The urinary bladder, G, Plate 49, (in the adult body,) occupies the true pelvic region when the organ is collapsed, or only partly distended. It is situated behind the pubic symphysis and in front of the rectum, C,—the latter lies between it and the sacrum, A. In early infancy, when the pelvis is comparatively small, the bladder is situated in the hypogastric region, with its summit pointing towards the umbilicus; as the bladder varies in shape, according to whether it be empty or full, its relations to neighbouring parts, especially to those in connexion with its summit, vary also considerably. When empty, the back and upper surface of the bladder collapse against its forepart, and in this state the organ lies flattened against the pubic symphysis. Whether the bladder be distended or not, the small intestines lie in contact with its upper surface, and compress it in the manner of a soft elastic cushion. When distended largely, its summit is raised above the pubic symphysis, the small intestines having yielded place to it, and in this state it can be felt by the hand laid upon the hypogastrium.

The shape of the bladder varies in different individuals. In some it is rounded, in others pyriform, in others peaked towards its summit. Its capacity varies also considerably at different ages and in different sexes. When distended, its long axis will be found to coincide with a line passing from a point midway between the navel and pubes to the point of the coccyx, the obliquity of this direction being greatest when the body is in the erect posture, for the intestines now gravitate upon it. When the body is recumbent, the bladder recedes somewhat from the pubes, and as the intestines do not now press upon it from above, it allows of being distended to a much greater degree without causing uneasiness, and a desire to void its contents.

The manner in which the bladder is connected to neighbouring parts is such as to admit of its full distension. Its summit, back, and upper sides are free and covered by the elastic peritonaeum, whilst its front, lower sides, and base are adherent to adjacent parts, and divested of the serous membrane. On tracing the peritonaeum from the front wall of the abdomen to its point of reflexion over the summit of the bladder, we find the membrane to be in this part so loosely adherent, that the bladder when much distended, raises the peritonaeum above the level of the upper margin of the pubic symphysis. In this state the organ may be punctured immediately above the pubic symphysis without endangering the serous sac. When the bladder is collapsed, the peritonaeum follows its summit below the level of the pubes, and in this position of the organ such an operation would be inadmissible, if indeed the necessity for it can now be conceived.

By removing the os innominatum, A D, Plate 48, together with the internal obturator, and levator ani muscles, which arise from its inner side, we obtain a lateral view, Plate 49, of the pelvic viscera, and of the vessels &c. connected with them. Those parts of the bladder, G, and the rectum, C, which are invested by the peritonaeum, are also now fully displayed. On tracing this membrane from before backwards, over the summit of the bladder, G, we find it descending deeply upon the posterior surface of the organ, before it becomes reflected so as to ascend over the forepart of the rectum. This duplicature of the serous membrane, H H, is named the recto-vesical pouch, and it is required to ascertain with all the exactness possible the level to which it descends, so as to avoid it in the operation of puncturing the bladder through the rectum. The serous pouch descends lower in some bodies than in others; but in all there exists a space, of greater or less dimensions, between it and the prostate, V, whereat the base of the bladder is in direct apposition with the rectum, W, the serous membrane not intervening.

When the peritonaeum is traced from one iliac fossa to the other, we find it sinking deeply into the hollow of the pelvis behind the bladder, so as to form the sides of the recto-vesical pouch; but when traced over the summit of the bladder, this organ is seen to have the membrane reflected upon it, almost immediately below the pelvic brim. At the situations where the peritonaeum becomes reflected in front, laterally, and behind, upon the sides of the bladder, the membrane is thrown into folds, which are named "false ligaments." The pelvic fascia, in being reflected to the bladder from the front and sides of the pelvis, at a lower level than that of the peritonaeum, forms the "true ligaments." In addition to these ligaments, which serve to keep the base and front of the bladder fixed in the pelvis, other structures, such as the ureters, K, the vasa deferentia, I, the hypogastric cords, the urachus, and the bloodvessels, embrace the organ in various directions, and act as bridles, to limit its expansion more or less in all directions, but least so towards its summit, which is always comparatively free.

The neck and outlet of the bladder, V, are situated at the anterior part of its base, and point towards the subpubic space. The prostate gland, V, surrounds its neck, and occupies a position behind and below the pubic arch, D, and in front of the rectum, W. The gland, V, being of a rounded form and dense structure, can be felt in this situation by the finger, passed upwards through the bowel. The prostate is suspended from the back of the pubic arch by the anterior true ligament of the bladder, and at its forepart, where the membranous portion of the urethra commences, this passes through the deep perinaeal fascia, X. The anterior fibres of the levator ani muscle embrace the prostate on both its sides. Behind the base of the prostate, the ureter, K, is seen to enter the coats of the bladder obliquely, whilst the vas deferens, I, joined by the vesicula seminalis, L, penetrates the substance of the prostate, V, at its lower and back part, which lies in apposition with the rectum.

The rectum, W C, at its middle and upper parts, occupies the hollow of the sacrum, A Q, and is behind the bladder. The lower third of the rectum, W, not being covered by the peritonaeum, is that part on which the various surgical operations are performed. At its upper three-fifths, the rectum describes a curve corresponding to that of the sacrum; and if the bladder be full, its convex back part presses the bowel against the bone, causing its curve to be greater than if the bladder were empty and collapsed. This fact requires to be borne in mind, for, in order to introduce a bougie, or to allow a large injection to pass with freedom into the bowel, the bladder should be first evacuated. The coccygeal bones, Q, continuing in the curve of the sacrum, bear the rectum, W, forwards against the base of the bladder, and give to this part a degree of obliquity upwards and backwards, in respect to the perinaeum and anus. From the point where the prostate, V, lies in contact with the rectum, W, this latter curves downwards, and slightly backwards, to the anus, P. The prostate is situated at a distance of about an inch and a half or two inches from the anus—the distance varying according to whether the bladder and bowel be distended or not. [Footnote]

[Footnote: The distance between any two given parts is found to vary in different cases. "In subjects of an advanced age," Mr. Stanley remarks, "a deep perinaeum, as it is termed, is frequently met with. This may be occasioned either by an unusual quantity of fat in the perinaeum, or by an enlarged prostate, or by the dilatation of that part of the rectum which is contiguous to the prostate and bladder. Under either of these circumstances, the prostate and bladder become situated higher in the pelvis than naturally, and consequently at a greater distance from the perinaeum."—On the Lateral Operation of Lithotomy.]

The arteries of the bladder are derived from the branches of the internal iliac, S. The rectum receives its arteries from the inferior mesenteric and pudic. The veins which course upwards from the rectum are large and numerous, and devoid of valves. When these veins become varicose, owing to a stagnation of their circulation, produced from whatever cause, the bowel is liable to be affected with haemorrhoids or to assume a haemorrhagic tendency.

The pudic artery, S s, is a branch of the internal iliac. It passes from the pelvis by the great sciatic foramen, below the pyriformis muscle, and in company with the sciatic artery. The pudic artery and vein wind around the spine, E, of the ischium, where they are joined by the pudic nerve, derived from, T, the sacral plexus. The artery, in company with the nerve and vein, re-enters the pelvis by the small sciatic foramen, and gets under cover of a dense fibrous membrane (obturator fascia), between which and the obturator muscle, it courses obliquely downwards and forwards to the forepart of the perinaeum. At the place where the vessel re-enters the pelvis, it lies removed at an interval of an inch and a half from the perinaeum, but becomes more superficial as it approaches the subpubic space, N. The levator ani muscle separates the pudic vessels and nerves from the sides of the rectum and bladder. The principal branches given off from the pudic artery of either side, are (1st), the inferior hemorrhoidal, to supply the lower end of the rectum; (2nd), the transverse and superficial perinaeal; (3rd), the artery of the bulb; (4th), that which enters the corpus cavernosum of the penis, N; and (5th), the dorsal artery of the penis. [Footnote] The branches given off from the pudic nerve correspond in number and place to those of the artery. Having now considered the relations of the pelvic organs in a lateral view, we are better prepared to understand these relations when seen at their perinaeal aspect.

[Footnote: The pudic artery, or some one of its branches, occasionally undergoes marked deviations from the ordinary course. In Mr. Quain's work, ("Anatomy of the Arteries,") a case is represented in which the artery of the bulb arose from the pudic as far back as the tuber ischii, and crossed the line of incision made in the lateral operation of lithotomy. In another figure is seen a vessel ("accessory pudic"), which, passing between the base of the bladder and the levator ani muscle, crosses in contact with the left lobe of the prostate.]

DESCRIPTION OF PLATES 48 & 49.

PLATE 48.

A. The anterior superior iliac spine.

B. The anterior inferior iliac spine.

C. The acetabulum; c, the ligamentum teres.

D. The tuber ischii.

E. The spine of the ischium.

F. The pubic horizontal ramus.

G. The summit of the bladder covered by the peritonaeum.

H. The femoral artery.

I. The femoral vein.

K. The anterior crural nerve.

L. The thyroid ligament.

M. The spermatic cord.

N. The corpus cavernosum penis; n, its artery.

O. The urethra; o, the bulbus urethrae.

P. The sphincter ani muscle.

Q. The coccyx.

R. The sacro-sciatic ligament.

S. The pudic artery and nerve.

T. The sacral nerves.

U. The pyriformis muscle, cut.

V. The gluteal artery.

W. The small gluteus muscle.



Plate 48

PLATE 49.

A. The part of the sacrum which joins the ilium.

B. The external iliac artery, cut across.

C. The upper part of the rectum.

D. The ascending pubic ramus.

E. The spine of the ischium, cut.

F. The horizontal pubic ramus, cut.

G. The summit of the bladder covered by the peritonaeum; G *, its side, not covered by the membrane.

H H. The recto-vesical peritonaeal pouch,

I. The vas deferens.

K. The ureter.

L. The vesicula seminalis.

M, N, O, P, Q, R, S, T, U, refer to the same parts as in Plate 48.

V. The prostate.

W. The lower part of the rectum.

X. The deep perinaeal fascia.



Plate 49



COMMENTARY ON PLATES 50 & 51.

THE SURGICAL DISSECTION OF THE SUPERFICIAL STRUCTURES OF THE MALE PERINAEUM.

The median line of the body is marked as the situation where the opposite halves unite and constitute a perfect symmetrical figure. Every structure—superficial as well as deep—which occupies the median line is either single, by the union of halves, or dual, by the cleavage and partition of halves. The two sides of the body being absolutely similar, the median line at which they unite is therefore common to both. Union along the median line is an occlusion taking place by the junction of sides; and every hiatus or opening, whether normal or abnormal, which happens at this line, signifies an omission in the process of central union. The sexual peculiarities are the results of the operation of this law, and all forms which are anomalous to either sex, may be interpreted as gradations in the same process of development; a few of these latter occasionally come under the notice of the surgeon.

The region which extends from the umbilicus to the point of the coccyx is marked upon the cutaneous surface by a central raphe dividing the hypogastrium, the penis, the scrotum, and the perinaeum respectively into equal and similar sides. The umbilicus is a cicatrix formed after the metamorphosis of a median foetal structure—the placental cord, &c. In the normal form, the meatus urinarius and the anus coincide with the line of the median raphe, and signify omissions at stated intervals along the line of central union. When between these intervals the process of union happens likewise to be arrested, malformations are the result; and of these the following are examples:—Extrusion of the bladder at the hypogastrium is caused by a congenital hiatus at the lower part of the linea alba, which is in the median line; Epispadias, which is an urethral opening on the dorsum of the penis; and Hypospadias, which is a similar opening on its under surface, are of the same nature—namely, omissions in median union. Hermaphrodism may be interpreted simply as a structural defect, compared to the normal form of the male, and as a structural excess compared to that of the female. Spina bifida is a congenital malformation or hiatus in union along the median line of the sacrum or loins. As the process of union along the median line may err by a defect or omission, so may it, on the other hand, err by an excess of fulfilment, as, for example, when the urethra, the vagina, or the anus are found to be imperforate. As the median line of union thus seems to influence the form of the hypogastrium, the genitals, and the perinaeum, the dissection of these parts has been conducted accordingly.

By removing the skin and subjacent adipose membrane from the hypogastrium, we expose the superficial fascia. This membrane, E E E*, Fig. 1, Plate 50, is, in the middle line, adherent to B, the linea alba, and thereby contributes to form the central depression which extends from the navel to the pubes. The adipose tissue, which in some subjects accumulates on either side of the linea alba, renders this depression more marked in them. At the folds of the groin the fascia is found adherent to Poupart's ligament, and this also accounts for the depressions in both these localities. From the central linea alba to which the fascia adheres, outwards on either side to the folds of both groins, the membrane forms two distinct sacs, which droop down in front, so as to invest the testicles, E**, and penis in a manner similar to that of the skin covering these parts. As the two sacs of the superficial fascia join each other at the line B, coinciding with the linea alba, they form by that union the suspensory ligament of the penis, which is a structure precisely median.

The superficial fascia having invested the testicles each in a distinct sac, the adjacent sides of both these sacs, by joining together, form the median septum scroti, E, Fig. 2, Plate 50. In the perinaeum, Fig. 1, Plate 51, the fascia, A, may be traced from the back of the scrotum to the anus. In this region the membrane is found to adhere laterally to the rami of the ischium and pubes; whilst along the median perinaeal line the two sacs of which the membrane is composed unite, as in the scrotum, and form an imperfect septum. In front of the anus, beneath the sphincter ani, the fascia degenerates into cellular membrane, one layer of which is spread over the adipose tissue in the ischio-rectal space, whilst its deeper and stronger layer unites with the deep perinaeal fascia, and by this connexion separates the urethral from the anal spaces. The superficial fascia of the hypogastrium, the scrotum, and the perinaeum forming a continuous membrane, and being adherent to the several parts above noticed, may be regarded as a general double sac, which isolates the inguino-perinaeal region from the femoral and anal regions, and hence it happens that when the urethra becomes ruptured, the urine which is extravasated in the perinaeum, is allowed to pass over the scrotum and the abdomen, involving these parts in consequent inflammation, whilst the thighs and anal space are exempt. The tunicae vaginales, which form the immediate coverings of the testicles, cannot be entered by the urine, as they are distinct sacs originally protruded from the abdomen. It is in consequence of the imperfect state of the inguino-perinaeal septum of the fascia, that urine effused into one of the sacs is allowed to enter the other.

Like all the other structures which join on either side of the median line, the penis appears as a symmetrical organ, D D, Fig. 2, Plate 50. While viewed in section, its two corpora cavernosa are seen to unite anteriorly, and by this union to form a septum "pectiniforme;" posteriorly they remain distinct and lateral, F F, Fig. 2, Plate 51, being attached to the ischio-pubic rami as the crura penis. The urethra, B, Fig. 2, Plate 50, is also composed of two sides, united along the median line, but forming between them a canal by the cleavage and partition of the urethral septum. All the other structures of the perinaeum will be seen to be either double and lateral, or single and median, according as they stand apart from, or approach, or occupy the central line.

The perinaeum, Figs. 1, 2, Plate 51, is that space which is bounded above by the arch of the pubes, behind by C, the os coccygis, and the lower borders of, I I, the glutaei muscles and sacro-sciatic ligaments, and laterally by D D, the ischiatic tuberosities. The osseous boundaries can be felt through the integuments. Between the back of the scrotum and the anus the perinaeum swells on both sides of the raphe, A B, Fig. 3, Plate 50, and assumes a form corresponding with the bag of the superficial fascia which encloses the structures connected with the urethra. The anus is centrally situated in the depression formed between D D, the ischiatic tuberosities, and the double folds of the nates.

The perinaeum, Fig. 3, Plate 50, is, for surgical purposes, described as divisible into two spaces (anterior and posterior) by a transverse line drawn from one tuber ischii, D, to the other, D, and crossing in front of the anus. The anterior space, A D D, contains the urethra; the posterior space, D D C, contains the rectum. The central raphe, A B C, traverses both these spaces. The anterior or urethral space is (while viewed in reference to its osseous boundaries) triangular in shape, the apex being formed by the pubic symphysis beneath A, whilst two lines drawn from A to D D, would coincide with the ischio-pubic rami which form its sides. The raphe in the anterior space indicates the central position of the urethra, as may be ascertained by passing a sound into the bladder, when the shaft of the instrument will be felt prominently between the points A B. Behind the point B, the sound or staff sinks deeper in the perinaeum as it follows the curve of the urethra towards the bladder, and becomes overlaid by the bulb, &c.

The ischiatic tuberosities, D D, Fig. 3, Plate 50, are, in all subjects, sufficiently prominent to be felt through the integuments, &c.; and the line which, when drawn from one to the other, serves to divide the two perinaeal spaces, forms the base of the anterior one. In well-formed subjects, the anterior space is equiangular, the base being equal to each side; but according as the tuberosities approach the median line, the base becomes narrowed, and the triangle is thereby rendered acute. These circumstances influence the direction in which the first incision in the lateral operation of lithotomy should be made. When the tuberosity of the left ischium stands well apart from the perinaeal centre, the line of incision, B E, Fig. 3, Plate 50, is carried obliquely from above downwards and outwards; but in cases where the tuberosity approaches the centre, the incision must necessarily be made more vertical. The posterior perinaeal space may be described on the surface by two lines drawn from D D, the ischiatic tuberosities, to C, the point of the coccyx, whilst the transverse line between D and D bounds it above.

By removing the integument and superficial fascia, we expose the superficial vessels and nerves, together with the muscles in the neighbourhood of the urethra and the anus. The accelerator urinae, E, Fig. 2, Plate 51, which embraces the urethra, and the sphincter ani, B C, which surrounds the anus, H, occupy the median line, and are divided each into halves by a central tendon, E B C, which traverses the perinaeum from before backwards, to the point of the coccyx. On either side of the anus, in the ischio-rectal space, D D, Fig. 1, Plate 51, is found a considerable quantity of granular adipose tissue, traversed by the inferior haemorrhoidal arteries and nerves-branches of the pudic artery and nerve.

In front of the anus are seen two small muscles (transversae perinaei), G G, Fig. 2, Plate 51, each arising from the tuber ischii of its own side, and the two becoming inserted into, B, the central tendon. These transverse muscles serve to mark the boundary between the anterior and posterior perinaeal spaces. Behind each muscle is found a small artery, crossing to the median line. The left transverse muscle and artery are always divided in the lateral operation of lithotomy. On the outer sides of the anterior perinaeal space are seen the erectores penis muscles, F F, overlaying the crura penis. Between each muscle and the accelerator urinae, the superficialis perinaei artery and nerve course forwards to the scrotum, &c.

The perinaeal muscles having been brought fully into view, Plate 52, Fig. 1, their symmetrical arrangement on both sides of the median line at once strikes the attention. On either side of the anterior space appears a small angular interval, L, formed between B, the accelerator urinae, D, the erector penis, and E, the transverse muscle. Along the surface of this interval, the superficial perinaeal artery and nerve are seen to pass forwards; and deep in it, beneath these, may also be observed, L, the artery of the bulb, arising from the pudic, and crossing inwards, under cover of the anterior layer of the membrane named the deep perinaeal fascia. The first incision in the lateral operation of lithotomy is commenced over the inferior inner angle of this interval.

The muscles occupying the anterior perinaeal space require to be removed, Fig. 1, Plate 53, in order to expose the urethra, B M, the crus penis, D, and the deep perinaeal fascia. The fascia will be now seen stretched across the subpubic triangular space, reaching from one ischio-pubic ramus to the other, whilst by its lower border, corresponding with the line of the transversae perinaei muscles, it becomes continuous with the superficial fascia, in the manner before described. The deep perinaeal fascia (triangular ligament) encloses between its two layers, C E, on either side of the urethra, the pudic artery, the artery of the bulb, Cowper's glands, and some muscular fibres occasionally to be met with, to which the name "Compressor urethrae" has been assigned. At this stage of the dissection, as the principal vessels and parts composed of erectile tissue are now in view, their relative situations should be well noticed, so as to avoid wounding them in the several cutting operations required to be performed in their vicinity.

Along the median line (marked by the raphe) from the scrotum to the coccyx, and close to this line on either side, the vessels are unimportant as to size. The urethra lies along the middle line in the anterior perinaeal space; the rectum occupies the middle in the posterior space. When either of these parts specially requires to be incised—the urethra for impassable stricture, &c., and the lower part of the rectum for fistula in ano—the operation may be performed without fear of inducing dangerous arterial haemorrhage. With the object of preserving from injury these important parts, deep incisions at, or approaching to, the middle line must be avoided. The outer (ischio-pubic) boundary of the perinaeum is the line along which the pudic artery passes. The anterior half of this boundary supports also the crus penis; hence, therefore, in order to avoid these, all deep incisions should be made parallel to, but removed to a proper distance from this situation. The structures placed at the middle line, B M F, Fig. 2, Plate 52, and those in connexion with the left perinaeal boundary, D G L, require (in order to insure the safety of these parts) that the line of incision necessary to gain access to the neck of the bladder in lithotomy should be made through the left side of the perinaeum from a point midway between M, the bulb, and D, crus penis above, to a point, K, midway between the anus, F, and tuber ischii, G, below. As the upper end of this incision is commenced over the situation of the superficial perinaeal artery and the artery of the bulb, the knife at this place should only divide the skin and superficial fascia. The lower end, K, just clears the outer side of the dilated lower part of the rectum. The middle of the incision is over the left lobe of the prostate gland and neck of the bladder, which parts, together with the membranous portion of the urethra, are still concealed by the deep perinaeal fascia, the structures between its layers, and the anterior fibres of K, the levator ani muscle. The incision, if made in due reference to the relative situation of the parts above noticed, will leave them untouched; but when the pudic artery, or some one of its branches, deviates from its ordinary course and crosses the line of incision, a serious haemorrhage will ensue, despite the anatomical knowledge of the most experienced operator. When it is requisite to divide the superficial and deep sphincter ani as in the operation for complete fistula in ano, if the incision be made transversely in the ischio-rectal fossa, the haemorrhoidal arteries and nerves converging towards the anus will be the more likely to escape being wounded.

DESCRIPTION OF THE FIGURES OF PLATES 50 & 51.

PLATE 50.

FIGURE 1.

A. The umbilicus.

B. The linea alba.

C. The suspensory ligament of the penis.

D D. The two corpora cavernosa penis.

E E**. The hypogastric and scrotal superficial fascia.

F F. The spermatic cords.

FIGURE 2.

A. The umbilicus.

B. The urethra.

C*. The tunica vaginalis; c, the testicle invested by the tunic.

D D. The corpora cavernosa seen in section.

E. The scrotal raphe and septum scroti.

FIGURE 3.

A B. The perinaeal raphe.

C. The place of the coccyx.

D D. The projections of the ischiatic tuberosities.

BE. The line of section in lithotomy.



Plate 50; Figure 2, Figure 3, Figure 1.

PLATE 51.

FIGURE 1.

A. The superficial fascia covering the urethral space.

B. The sphincter ani.

C. The coccyx.

D D. The right and left ischiatic tuberosities.

H. The anus.

I I. The glutei muscles.

FIGURE 2.

A, B, C, D, H, I. The same parts as in Fig. 1.

E. The accelerator urinae muscle.

F F. Right and left erector penis muscle.

G G. Right and left transverse muscle.



Plate 51; Figure 2, Figure 1.



COMMENTARY ON PLATES 52 & 53.

THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE MALE PERINAEUM.

THE LATERAL OPERATION OF LITHOTOMY.

The urethra, at its membranous part, M, Fig. 1, Plate 53, which commences behind the bulb, perforates the centre of the deep perinaeal fascia, E E, at about an inch and a half in front of F, the anus. The anterior layer of the fascia is continued forwards over the bulb, whilst the posterior layer is reflected backwards over the prostate gland.

Behind the deep perinaeal fascia, the anterior fibres of K, the levator ani muscle, arise from either side of the pubic symphysis posteriorly, and descend obliquely down wards and forwards, to be inserted into the sides of N N, the rectum above the anus. These fibres of the muscle, and the lower border of the fascia which covers them, lie immediately in front of the prostate, C C, Fig. 2, Plate 53, and must necessarily be divided in the operation of lithotomy. Previously to disturbing the lower end of the rectum from its natural position in the perinaeum, its close relation to the prostate and base of the bladder should be noticed. While the anus remains connected with the deep perinaeal fascia in front, the fibres of the levator ani muscle of the left side may be divided; and by now inserting the finger between them and the rectum, the left lobe of the prostate can be felt in apposition with the forepart of the bowel, an inch or two above the anus. It is owing to this connexion between these parts that the lithotomist has to depress the bowel, lest it be wounded, while the prostate is being incised. If either the bowel or the bladder, or both together, be over-distended, they are brought into closer apposition, and the rectum is consequently more exposed to danger during the latter stages of the operation. The prostate being in contact with the rectum, the surgeon is enabled to examine by the touch, per anum, the state of the gland. If the prostate be diseased and irregularly enlarged, the urethra, which passes through it, becomes, in general, so distorted, that the surgeon, after passing the catheter along the urethra as far as the prostate, will find it necessary to guide the point of the instrument into the bladder, by the finger introduced into the bowel. The middle or third lobe of the prostate being enlarged, bends the prostatic part of the urethra upwards. But when either of the lateral lobes is enlarged, the urethra becomes bent towards the opposite side.

By dividing the levator ani muscle on both sides of the rectum, F, Fig. 2, Plate 53, and detaching and depressing this from the perinaeal centre, the prostate, C C, and base of the bladder, P, are brought into view. The pelvic fascia may be now felt reflected from the inner surface of the levator ani muscle to the bladder at a level corresponding with the base of the prostate, and the neck of the bladder in front, and the vesiculae seminales, N N, laterally. In this manner the pelvic fascia serves to insulate the perinaeal space from the pelvic cavity. The prostate occupies the centre of the perinaeum. If the perinaeum were to be penetrated at a point midway between the bulb of the urethra and the anus, and to the depth of two inches straight backwards, the instrument would transfix the apex of the gland. Its left lobe lies directly under the middle of the line of incision which the lithotomist makes through the surface; a fibrous membrane forms a capsule for the gland, and renders its surface tough and unyielding, but its proper substance is friable, and may be lacerated or dilated with ease, after having partly incised its fibrous envelope. The membranous part of the urethra, M, Fig. 2, Plate 53, enters the apex of the prostate, and traverses this part in a line, nearer to the upper than to the under surface; and that portion of the canal which the gland surrounds, is named prostatic. The prostate is separated from the pudic artery by the levator ani muscle, and from the artery of the bulb, by the deep perinaeal fascia and the muscular fibres enclosed between its two layers.

The prostate being a median structure, is formed of two lobes, united at the median line. The bulbus urethrae being also a median structure, is occasionally found notched in the centre, and presenting a bifid appearance. On the base of the bladder, P, Fig. 2, Plate 53, the two vasa deferentia, Q Q, are seen to converge from behind forwards, and enter the base of the gland; a triangular interval is thus formed between the vasa, narrower before than behind, and at the middle of this place the point of the trocar is to be passed (through the rectum,) for the purpose of evacuating the contents of the bladder, when other measures fail. When this operation is required to be performed, the situation of the prostate is first to be ascertained through the bowel; and at a distance of an inch behind the posterior border of the gland, precisely in the median line, the distended base of the bladder may be safely punctured. If the trocar pierce the bladder at this point, the seminal vessels converging to the prostate from either side, and the recto-vesical serous pouch behind, will escape being wounded. If the prostate happen to be much enlarged, the relative position of the neighbouring parts will be found disturbed, and in such case the bladder can be punctured above the pubes with greater ease and safety. In cases of impassable stricture, when extravasation of urine is threatened, or has already occurred, the urethra should be opened in the perinaeum behind the place where the stricture is situated, and this (in the present instance) certainly seems to be the more effectual measure, for at the same time that the stricture is divided, the contents of the bladder may be evacuated through the perinaeum. If the membranous part of the urethra be that where the stricture exists, a staff with a central groove is to be passed as far as the strictured part, and having ascertained the position of the instrument by the finger in the bowel, the perinaeum should be incised, at the middle line, between the bulb of the urethra and the anus. The urethra in this situation will be found to curve backwards at the depth of an inch or more from the surface. The point of the staff is now to be felt for, and the urethra is to be incised upon it. The bistoury is next to be carried backwards through the stricture till it enters that part of the urethra (usually dilated in such cases) which intervenes between the seat of obstruction and the neck of the bladder.

The lateral operation of lithotomy is to be performed according to the above described anatomical relations of the parts concerned. The bowel being empty and the bladder moderately full, a staff with a groove in its left side is to be passed by the urethra into the bladder. The position and size of the prostate is next to be ascertained by the left fore-finger in the rectum. Having now explored the surface of the perinaeum in order to determine the situation of the left tuberosity and ischio-pubic ramus, in relation to the perinaeal middle line, the staff being held steadily against the symphysis pubis, the operator proceeds to divide the skin and superficial fascia on the left side of the perinaeum, commencing the incision on the left of the raphe about an inch in front of the anus, and carrying it downwards and outwards midway between the anus and ischiatic tuberosity, to a point below these parts. The left fore-finger is then to be passed along the incision for the purpose of parting the loose cellular tissue; and any of the more resisting structures, such as the transverse and levator ani muscles, are to be divided by the knife. Deep in the forepart of the wound, the position of the staff is now to be felt for, and the structures which cover the membranous portion of the urethra are to be cautiously divided. Recollecting now that the artery of the bulb passes anterior to the staff in the urethra on a level with the bulb, the vessel is to be avoided by inserting the point of the knife in the groove of the staff as far backwards—that is, as near the apex of the prostate—as possible. The point of the knife having been inserted in the groove of the staff, the bowel is then to be depressed by the left fore-finger; and now the knife, with its back to the staff, and its edge lateralized (towards the lower part of the left tuber ischii), is to be pushed steadily along the groove in the direction of the staff, and made to divide the membranous part of the urethra and the anterior two-thirds of the left lobe of the prostate. The gland must necessarily be divided to this extent if the part of the urethra which it surrounds be traversed by the knife. The extent to which the prostate is divided depends upon the degree of the angle which the knife, passing along the urethra, makes with the staff. The greater this angle is, the greater the extent to which the gland will be incised. The knife being next withdrawn, the left fore-finger is to be passed through the opening into the bladder, and the parts are to be dilated by the finger as it proceeds, guided by the staff. The staff is now to be removed while the point of the finger is in the neck of the bladder, and the forceps is to be passed into the bladder along the finger as a guide. The calculus, now in the grip of the forceps, is to be extracted by a slow undulating motion.

The general rules to be remembered and adopted in performing the operation of lithotomy are as follow:—1st, The incision through the skin and sub-cutaneous cellular membrane should be freely made, in order that the stone may be easily extracted and the urine have ready egress. The incision which (judging from the anatomical relations of the parts) appears to be best calculated to effect these objects, is one which would extend from a point an inch above the anus to a point in the posterior perinaeal space an inch or more below the anus. The wound thus made would depend in relation to the neck of the bladder; the important parts, vessels, &c., in the anterior perinaeal space would be avoided where the incision, if extended upwards, would have no effect whatever in facilitating the extraction of the stone or the egress of the urine; and what is also of prime importance, the external opening would directly correspond with the incision through the prostate and neck of the bladder. 2nd, After the incision through the skin and superficial fascia is made, the operator should separate as many of the deeper structures as will admit of it, by the finger rather than by the knife; and especially use the knife cautiously towards the extremities of the wound, so as to avoid the artery of the bulb, and the bulb itself in the upper part, and the rectum below. The pudic artery will not be endangered if the deeper parts be divided by the knife, with its edge directed downwards and outwards, while its point slides securely along the staff in the prostate. 3rd, The prostate should be incised sparingly, for, in addition to the known fact that the gland when only partly cut admits of dilatation to a degree sufficient to admit the passage of even a stone of large size, it is also stated upon high authority that by incising the prostate and neck of the bladder to a length equal to the diameter of the stone, such a proceeding is more frequently followed with disastrous results, owing to the circumstance that the pelvic fascia being divided at the place where it is reflected upon the base of the gland and the side and neck of the bladder, allows the urine to infiltrate the cellular tissue of the pelvis. [Footnote]

[Footnote: "The object in following this method," Mr. Liston observes, "is to avoid all interference with the reflexion of the ilio-vesical fascia from the sides of the pelvic cavity over the base of the gland and side of the bladder. If this natural boundary betwixt the external and internal cellular tissue is broken up, there is scarcely a possibility of preventing infiltration of the urine, which must almost certainly prove fatal. The prostate and other parts around the neck of the bladder are very elastic and yielding, so that without much solution of their continuity, and without the least laceration, the opening can be so dilated as to admit the fore-finger readily through the same wound; the forceps can be introduced upon this as a guide, and they can also be removed along with a stone of considerable dimensions, say from three to nearly five inches in circumference, in one direction, and from four to six in the largest."—Practical Surgery, page 510. This doctrine (founded, no doubt, on Mr. Liston's own great experience) coincides with that first expressed by Scarpa, Le Cat, and others. Sir Benjamin Brodie, Mr. Stanley, and Mr. Syme are also advocates for limited incisions, extending no farther than a partial division of the prostate, the rest being effected by dilatation. The experience, however, of Cheselden, Martineau, and Mr. S. Cooper, inclined them in favour of a rather free incision of the prostate and neck of the bladder proportioned to the size of the calculus, so that this may be extracted freely, without lacerating or contusing the parts, "and," says the distinguished lithotomist Klein, "upon this basis rests the success of my operations; and hence I invariably make it a rule to let the incision be rather too large than too small, and never to dilate it with any blunt instrument when it happens to be too diminutive, but to enlarge it with a knife, introduced, if necessary, several times."—Practische Ansichten der Bedeutendsten Chirurgische Operationen. Opinions of the highest authority being thus opposed, in reference to the question whether free or limited incisions in the neck of the bladder are followed respectively by the greater number of fatal or favourable results, and these being thought mainly to depend upon whether the pelvic fascia be opened or not, one need not hesitate to conclude, that since facts seem to be noticed in support of both modes of practice equally, the issue of the cases themselves must really be dependent upon other circumstances, such as the state of the constitution, the state of the bladder, and the relative position of the internal and external incisions. "Some individuals (observes Sir B. Brodie) are good subjects for the operation, and recover perhaps without a bad symptom, although the operation may have been very indifferently performed. Others may be truly said to be bad subjects, and die, even though the operation be performed in the most perfect manner. What is it that constitutes the essential difference between these two classes of cases? It is, according to my experience, the presence or absence of organic disease."—Diseases of the Urinary Organs.]

The position in which the staff is held while the membranous urethra and prostate are being divided should be regulated by the operator himself. If he requires the perinaeum to be protruded and the urethra directed towards the place of the incision, he can effect this by depressing the handle of the instrument a little towards the right groin, taking care at the same time that the point is kept beyond the prostate in the interior of the bladder.

DESCRIPTION OF THE FIGURES OF PLATES 52 & 53.

PLATE 52.

FIGURE 1.

A. The urethra.

B. Accelerator urinae muscle.

C. Central perinaeal tendon.

D D. Right and left erector penis muscle.

E E. The transverse muscles.

F. The anus.

G G. The ischiatic tuberosities.

H. The coccyx.

I I. The glutei muscles.

K K. The levator ani muscle.

L. The left artery of the bulb.



Plate 52.—Figure 1

FIGURE 2.

A, D, F, G, H, I, K, L refer to the same parts as in Fig. 1, Plate 52.

B. The urethra.

C. Cowper's glands between the two layers of—

E. The deep perinaeal fascia.

M. The bulb of the urethra.



Plate 52.—Figure 2

PLATE 53.

FIGURE 1.

A, B, C, E, F, G, H, I, K, L refer to the same parts as in Fig. 2, Plate 52.

D D. The two crura penis.

M. The urethra in section

N N. The rectum.

O. The sacro-sciatic ligament.



Plate 53.—Figure 1

FIGURE 2.

A, B, D, G, H, I, K, L, O refer to the same parts as in Fig. 1, Plate 53.

C C. The two lobes of the prostate.

F. The rectum turned down.

M. The membranous part of the urethra.

N N. The vesiculae seminales.

P. The base of the bladder.

Q Q. The two vasa deferentia.



Plate 53.—Figure 2.



COMMENTARY ON PLATES 54, 55, & 56.

THE SURGICAL DISSECTION OF THE MALE BLADDER AND URETHRA.— LATERAL AND BILATERAL LITHOTOMY COMPARED.

Having examined the surgical relations of the bladder and adjacent structures, in reference to the lateral operation of lithotomy, it remains to reconsider these same parts as they are concerned in the bilateral operation and in catheterism.

Fig. 1, Plate 54, represents the normal relations of the more important parts concerned in lithotomy as performed at the perinaeal region. The median line, AA, drawn from the symphysis pubis above, to the point of the coccyx below, is seen to traverse vertically the centres of the urethra, the prostate, the base of the bladder, the anus, and the rectum. These several parts are situated at different depths from the perinaeal surface. The bulb of the urethra and the lower end of the bowel are on the same plane comparatively superficial. The prostate lies between these two parts, and on a plane deeper than they. The base of the bladder is still more deeply situated than the prostate; and hence it is that the end of the bowel is allowed to advance so near the pendent bulb, that those parts are in a great measure concealed by these. As the apex of the prostate lies an inch (more or less) deeper than the bulb, so the direction of the membranous urethra, which intervenes between the two, is according to the axis of the pelvic outlet; the prostatic end of the membranous urethra being deeper than the part near the bulb. The scalpel of the lithotomist, guided by the staff in this part of the urethra, is made to enter the neck of the bladder deeply in the same direction. On comparing the course of the pudic arteries with the median line, A A, we find that they are removed from it at a wider interval below than above; and also that where the vessels first enter the perinaeal space, winding around the spines of the ischia, they are much deeper in this situation (on a level with the base of the bladder) than they are when arrived opposite the bulb of the urethra. The transverse line B B, drawn in front of the anus from one tuber ischii to the other, is seen to divide the perinaeum into the anterior and posterior spaces, and to intersect at right angles the median line A A. In the same way the line B B divides transversely both pudic arteries, the front of the bowel, the base of the prostate, and the sides of the neck of the bladder. Lateral lithotomy is performed in reference to the line A A; the bilateral operation in regard to the line B B. In order to avoid the bulb and rectum at the median line, and the pudic artery at the outer side of the perinaeum, the lateral incisions are made obliquely in the direction of the lines CD. In the bilateral operation the incision necessary to avoid the bulb of the urethra in front, the rectum behind, and the pudic arteries laterally, is required to be made of a semicircular form, corresponding with the forepart of the bowel; the cornua of the incision being directed behind. In the lateral operation, the incision C through the integument, crosses at an acute angle the deeper incision D, which divides the neck of the bladder, the prostate, &c. The left lobe of the prostate is divided obliquely in the lateral operation; both lobes transversely in the bilateral.



Plate 54, Figure 1.

Fig. 2, Plate 54.—If the artery of the bulb happen to arise from the pudic opposite the tuber ischii, or if the inferior hemorrhoidal arteries be larger than usual, these vessels crossing the lines of incision in both operations will be divided. If the superficial lateral incision C, Fig. 1, be made too deeply at its forepart, the artery of the bulb, even when in its usual place, will be wounded; and if the deep lateral incision D be carried too far outwards, the trunk of the pudic artery will be severed. These accidents are incidental in the bilateral operation also, in performing which it should be remembered that the bulb is in some instances so large and pendulous, as to lie in contact with the front of the rectum.



Plate 54, Figure 2.

Fig. 1, Plate 55.—When the pudic artery crosses in contact with the prostate, F, it must inevitably be divided in either mode of operation. Judging from the shape of the prostate, I am of opinion that this part, whether incised transversely in the line B B, or laterally in the line D, will exhibit a wound in the neck of the bladder of equal dimensions. When the calculus is large, it is recommended to divide the neck of the bladder by an incision, combined of the transverse and the lateral. The advantages gained by such a combination are, that while the surface of the section made in the line D is increased by "notching" the right lobe of the prostate in the direction of the line B, the sides of both sections are thereby rendered more readily separable, so as to suit with the rounded form of the calculus to be extracted. These remarks are equally applicable as to the mode in which the superficial perinaeal incision should be made under the like necessity. If the prostate be wholly divided in either line of section, the pelvic fascia adhering to the base of this body will be equally subject to danger. By incising the prostate transversely, B B, the seminal ducts, G H, which enter the base of this body, are likewise divided; but by the simple lateral incision D being made through the forepart of the left lobe, F, these ducts will escape injury. [Footnote] On the whole, therefore, the lateral operation appears preferable to the bilateral one.

[Footnote: As to the mode in which the superficial and deep incisions in lateral lithotomy should be made, a very eminent operating surgeon remarks—"a free incision of the skin I consider a most important feature in the operation; but beyond this the application of the knife should, in my opinion, be extremely limited. In so far as I can perceive, there should be no hesitation in cutting any part of the gland which seems to offer resistance, with the exception, perhaps, of its under surface, where the position of the seminal ducts, and other circumstances, should deter the surgeon from using a cutting instrument."—Wm. Fergusson, Practical Surgery, 3d Am. Ed., p. 610.]



Plate 55—Figure 1.

Fig. 2, Plate 55.—The muscular structures surrounding the membranous urethra and the neck of the bladder, and which are divided in lithotomy, have been examined from time to time by anatomists with more than ordinary painstaking, owing to the circumstance that they are found occasionally to offer, by spasmodic contraction, an obstacle to the passage of the catheter along the urethral canal. These muscles do not appear to exist in all subjects alike. In some, they are altogether wanting; in others, a few of them only appear; in others, they seem to be not naturally separable from the larger muscles which are always present. Hence it is that the opinions of anatomists respecting their form, character, and even their actual existence, are so conflicting, not only against each other, but against nature. In Fig. 2, Plate 55, I have summed together all the facts recorded concerning them, [Footnote] and on comparing these facts with what I have myself observed, the muscles seem to me to assume originally the form and relative position of the parts B C D E F viewed in their totality. Each of these parts of muscular structure arises from the ischio-pubic ramus, and is inserted at the median line A A. They appear to me, therefore, to be muscles of the same category, which, if all were present, would assume the serial order of B C D E F. When one or more of them are omitted from the series, there occurs anatomical variety, which of course occasions variety in opinion, fruitless though never ending. By that interpretation of the parts which I here venture to offer, and to which I am guided by considerations of a higher law of formation, I encompass and bind together, as with a belt, all the dismembered parts of variety, and of these I construct a uniform whole. Forms become, when not viewed under comparison, as meaningless hieroglyphics, as the algebraic symbols a + c - d = 11 are when the mind is devoid of the power of calculation.

[Footnote: The part C is that alone described by Santorini, who named it "elevator urethrae," as passing beneath the urethra. The part B is that first observed and described by Mr. Guthrie as passing above the urethra. The part F represents the well-known "transversalis perinaei," between which and the part C there occasionally appears the part E, supposed to be the "transversalis alter" of Albinus, and also the part D, which is the "ischio bulbosus" of Cruveilhier. It is possible that I may not have given one or other of these parts its proper name, but this will not affect their anatomy.]



Plate 55—Figure 2

Fig. 3, Plate 55.—The membranous urethra A is also in some instances embraced by two symmetrical fasciculi of muscular fibres B B, which arising from the posterior and lower part of the symphysis pubis, descend on either side of the canal and join beneath it. The muscles B C, Fig. 2, Plate 55, are between the two layers of the deep perinaeal fascia, while the muscle B B, Fig. 3, Plate 55, lies like the forepart of the levator ani, C C, behind this structure and between it and the anterior ligaments of the bladder. [Footnote] As to the interpretation of the muscle, I, myself, am inclined to believe that it is simply a part of the levator ani, and for these reasons—1st, it arises from the pubic symphysis, and is inserted into the perinaeal median line with the levator ani; 2nd, the fibres of both muscles overlie the forepart of the prostate, and present the same arrangement in parallel order; 3rd, the one is not naturally separable from the other.

[Footnote: This is the muscle, B B, which is described by Santorini as the "levator prostatae;" by Winslow as "le prostatique superieur;" by Wilson as the "pubo-urethrales;" by Muller as not existing; by Mr. Guthrie as forming (when existing), with the parts B C, Fig. 2, Plate 55, his "compressor isthmi urethrae;" and by M. Cruveilhier as being part of the levator ani muscle. "As in one case," (observes Mr. Quain,) "I myself saw a few vertical muscular fibres connected with the transverse compressor, it has been thought best to retain the muscle in the text."—Dr. Quain's Anat., Am. Ed. vol. ii. p. 539.]



Plate 55—Figure 3

Fig. 1, Plate 56, represents by section the natural forms of the urethra and bladder. The general direction of the urethra measured during its relaxed state from the vesical orifice to the glans is usually described as having the form of the letter S laid procumbent to the right side [capital S rotated 90 degrees right] or to the left [capital S rotated 90 degrees left]. But as the anterior half of the canal is moveable, and liable thereby to obliterate the general form, while the posterior half is fixed, I shall direct attention to the latter half chiefly, since upon its peculiar form and relative position depends most of the difficulty in the performance of catheterism. The portion of the urethra which intervenes between the neck of the bladder, K, and the point E, where the penis is suspended from the front of the symphysis pubis by the suspensory ligament, assumes very nearly the form of a semicircle, whose anterior half looks towards the forepart, and whose posterior half is turned to the back of the pubis. The pubic arch, A, spans crossways, the middle of this part of the urethra, G, opposite the bulb H. The two extremes, F K, of this curve, and the lower part of the symphysis pubis, occupy in the adult the same antero-posterior level; and it follows, therefore, that the distance to which the urethra near its bulb, H, is removed from the pubic symphysis above must equal the depth of its own curve, which measures about an inch perpendicularly. The urethral aperture of the triangular ligament appears removed at this distance below the pubic symphysis, and that portion of the canal which lies behind the ligament, and ascends obliquely backwards and upwards to the vesical orifice on a level with the symphysis pubis in the adult should be remembered, as varying both in direction and length in individuals of the extremes of age. In the young, this variation is owing to the usual high position of the bladder in the pelvis, whilst in the old it may be caused by an enlarged state of the prostate. The curve of the urethra now described is permanent in all positions of the body, while that portion of the canal anterior to the point F, which is free, relaxed, and moveable, can by traction towards the umbilicus be made to continue in the direction of the fixed curve F K, and this is the general form which the urethra assumes when a bent catheter of ordinary shape is passed along the canal into the bladder. The length of the urethra varies at different ages and in different individuals, and its structure in the relaxed state is so very dilatable that it is not possible to estimate the width of its canal with fixed accuracy. As a general rule, the urethra is much more dilatable, and capable consequently of receiving an instrument of much larger bore in the aged than in the adult.

The three portions into which the urethra is described as being divisible, are the spongy, the membranous, and the prostatic. These names indicate the difference in the structure of each part. The spongy portion is the longest of the three, and extending from the glans to the bulb may be said on a rough, but for practical purposes, a sufficiently accurate estimate to comprise seven parts of the whole urethra, which measures nine. The membranous and prostatic portions measure respectively one part of the whole. These relative proportions of the three parts are maintained in different individuals of the same age, and in the same individual at different ages. The spongy part occupies the inferior groove formed between the two united corpora cavernosa of the penis, and is subcutaneous as far back as the scrotum under the pubes, between which point and the bulb it becomes embraced by the accelerator urinae muscle. The bulb and glans are expansions or enlargements of the spongy texture, and do not affect the calibre of the canal. When the spongy texture becomes injected with blood, the canal is rendered much narrower than otherwise. The canal of the urethra is uniform-cylindrical. The meatus is the narrowest part of it, and the prostatic part is the widest. At the point of junction between the membranous and spongy portions behind the bulb, the canal is described as being naturally constricted. Behind the meatus exists a dilatation (fossa navicularis), and opposite the bulb another (sinus of the bulb). Muscular fibres are said to enter into the structure of the urethra, but whether such be the case or not, it is at least very certain that they never prove an obstacle to the passage of instruments, or form the variety of stricture known as spasmodic. The urethra is lined by a delicate mucous membrane presenting longitudinal folds, which become obliterated by distention; and its entire surface is numerously studded with the orifices of mucous cells (lacunae), one of which, larger than the rest, appears on the upper side of the canal near the meatus. Some of these lacunae are nearly an inch long, and all of them open in an oblique direction forwards. Instruments having very narrow apices are liable to enter these ducts and to make false passages. The ducts of Cowper's glands open by very minute orifices on the sides of the spongy urethra anterior to and near the bulb. On the floor of the prostatic urethra appears the crest of the veru montanum, upon which the two seminal ducts open by orifices directed forwards. On either side of the veru montanum the floor of the prostate may be seen perforated by the "excretory ducts" of this so-called gland. The part K, which is here represented as projecting from the floor of the bladder, near its neck, is named the "uvula vesicae," (Lieutaud.) It is the same as that which is named the "third lobe of the prostate," (Home.) The part does not appear as proper to the bladder in the healthy condition, Fig. 2, Plate 56. On either side of the point K may be seen the orifices, M M, of the ureters, opening upon two ridges of fibrous substance directed towards the uvula. These are the fibres which have been named by Sir Charles Bell as "the muscles of the ureters;" but as they do not appear in the bladder when in a state of health, I do not believe that nature ever intended them to perform the function assigned to them by this anatomist. And the same may be said of the fibres, which surrounding the vesical orifice, are supposed to act as the "sphincter vesicae." The form of that portion of the base of the bladder which is named "trigone vesical" constitutes an equilateral triangle, and may be described by two lines drawn from the vesical orifice to both openings of the ureters, and another line reaching transversely between the latter. Behind the trigone a depression called "bas fond" is formed in the base of the bladder. Fig. 2, Plate 56, represents the prostate of a boy nine years of age. Fig. 3, Plate 56, represents that of a man aged forty years. A difference as to form and size, &c., is observable between both.



Plate 56—Figure 1, 2, 3



COMMENTARY ON PLATES 57 & 58.

CONGENITAL AND PATHOLOGICAL DEFORMITIES OF THE PREPUCE AND URETHRA.—STRICTURE AND MECHANICAL OBSTRUCTIONS OF THE URETHRA.

When any of the central organs of the body presents in a form differing from that which we term natural, or structurally perfect and efficient, if the deformity be one which results as a malformation, ascribable to an error in the law of development, it is always characterized as an excess or defect of the substance of the organ at, and in reference to, the median line. And when any of the canals which naturally open upon the external surface at the median line happens to deviate from its proper position, such deviation, if it be the result of an error in the law of development, always occurs, by an actual necessity, at the median line. On the contrary, though deformities which are the results of diseased action in a central organ may and do, in some instances, simulate those which occur by an error in the process of development, the former cannot bear a like interpretation with the latter, for those are the effects of ever-varying circumstances, whereas these are the effects of certain deviations in a natural process—a law, whose course is serial, gradational, and in the sequent order of a continuous chain of cause and effect.

Fig. 1, Plate 57, represents the prepuce in a state of congenital phymosis. The part hypertrophied and pendent projects nearly an inch in front of the meatus, and forms a canal, continued forwards from this orifice. As the prepuce in such a state becomes devoid of its proper function, and hence must be regarded, not only as a mere superfluity, but as a cause of impediment to the generative function of the whole organ, it should be removed by an operation.



Plate 57.—Figure 1.

Fig. 2, Plate 57, represents the prepuce in the condition of paraphymosis following gonorrhoeal inflammation. The part appears constricting the penis and urethra behind the corona glandis. This state of the organ is produced in the following-mentioned way:—the prepuce, naturally very extensible, becomes, while covering the glans, inflamed, thickened, and its orifice contracted. It is during this state withdrawn forcibly backwards over the glans, and in this situation, while being itself the first cause of constriction, it induces another—namely, an arrest to the venous circulation, which is followed by a turgescence of the glans. In the treatment of such a case, the indication is, first, to reduce by gradual pressure the size of the glans, so that the prepuce may be replaced over it; secondly, to lessen the inflammation by the ordinary means.



Plate 57.—Figure 2.

Fig. 3, Plate 57, exhibits the form of a gonorrhoeal phymosis. The orifice of the prepuce is contracted, and the tissue of it infiltrated. If in this state of the part, consequent upon diseased action, or in that of Fig. 1, which is congenital, the foreskin be retracted over the glans, a paraphymosis, like Fig. 2, will be produced.



Plate 57.—Figure 3.

Fig. 4, Plate 57, shows a form of phymosis in which the prepuce during inflammation has become adherent to the whole surface of the glans. The orifice of the prepuce being directly opposite the meatus, and the parts offering no obstruction to the flow of urine, an operation for separating the prepuce from the glans would not be required.



Plate 57.—Figure 4.

Fig. 5, Plate 57.—In this figure is represented the form of the penis of an adult, in whom the prepuce was removed by circumcision at an early age. The membrane covering the glans and the part which is cicatrised becomes in these cases dry, indurated, and deprived of its special sense.



Plate 57.—Figure 5.

Fig. 6, Plate 57.—In this figure the glans appears protruding through the upper surface of the prepuce, which is thickened and corrugated. This state of the parts was caused by a venereal ulceration of the upper part of the prepuce, sufficient to allow the glans to press through the aperture. The prepuce in this condition being superfluous, and acting as an impediment, should be removed by operation.



Plate 57.—Figure 6.

Fig. 7, Plate 57.—In this figure is shown a condition of the glans and prepuce resembling that last mentioned, and the effect of a similar cause. By the removal of the prepuce when in the position here represented, or in that of Fig. 6, the organ may be made to assume the appearance of Fig. 5.



Plate 57.—Figure 7.

Fig. 8, Plate 57, represents the form of a congenital hypospadias. The corpus spongiosum does not continue the canal of the urethra as far forwards as the usual position of the meatus, but has become defective behind the fraenum praeputii, leaving the canal open at this place. In a case of this kind an operation on the taliacotian principle might be tried in order to close the urethra where it presents abnormally patent.



Plate 57.—Figure 8.

Fig. 9, Plate 57, represents a congenital hypospadias, in which the canal of the urethra opens by two distinct apertures along the under surface of the corpus spongiosum at the middle line. A probe traverses both apertures. In such a case, if the canal of the urethra were perforate as far forwards as the meatus, and this latter in its normal position, the two false openings should be closed by an operation.



Plate 57.—Figure 9.

Fig. 10, Plate 57.—The urethra is here represented as having a false opening on its under surface behind the fraenum. The perforation was caused by a venereal ulcer. The meatus and urethra anterior to the false aperture remained perforate. Part of a bougie appears traversing the false opening and the meatus. In this state of the organ an attempt should be made to close the false aperture permanently.



Plate 57.—Figure 10.

Fig. 11, Plate 57, shows a state of the urethra similar to that of Fig. 10, and the effect of the same cause. Part of a bougie is seen traversing the false aperture from the meatus before to the urethra behind. In this case, as the whole substance of the corpus spongiosum was destroyed for half an inch in extent, the taliacotian operation, by which lost quantity is supplied, is the measure most likely to succeed in closing the canal.



Plate 57.—Figure 11

Fig. 12, Plate 57.—Behind the meatus, and on the right of the fraenum, is represented a perforation in the urethra, caused by a venereal ulcer. The meatus and the false opening have approached by the contraction of the cicatrix; in consequence of which, also, the apex of the glans is distorted towards the urethra; a bougie introduced by the meatus occupies the urethral canal.



Plate 57.—Figure 12.

Fig. 13, Plate 57.—In this figure the canal of the urethra appears turning upwards and opening at the median line behind the corona glandis. This state of the urethra was caused by a venereal ulcer penetrating the canal from the dorsum of the penis. The proper direction of the canal might be restored by obliterating the false passage, provided the urethra remained perforate in the direction of the meatus.



Plate 57.—Figure 13.

Fig. 14, Plate 57, exhibits the form of a congenital epispadias, in which the urethra is seen to open on the dorsal surface of the prepuce at the median line. The glans appears cleft and deformed. The meatus is deficient at its usual place. The prepuce at the dorsum is in part deficient, and bound to the glans around the abnormal orifice.



Plate 57.—Figure 14.

Fig. 15, Plate 57, represents in section a state of the parts in which the urethra opened externally by one fistulous aperture, a, behind the scrotum; and by another, b, in front of the scrotum. At the latter place the canal beneath the penis became imperforate for an inch in extent. Parts of catheters are seen to enter the urethra through the fistulous openings a b; and another instrument, c, is seen to pass by the proper meatus into the urethra as far as the point where this portion of the canal fails to communicate with the other. The under part of the scrotum presents a cleft corresponding with the situation of the scrotal septum. This state of the urinary passage may be the effect either of congenital deficiency or of disease. When caused by disease, the chief features in its history, taking these in the order of their occurrence, are, 1st, a stricture in the anterior part of the urethra; 2ndly, a rupture of this canal behind the stricture; 3rdly, the formation (on an abscess opening externally) of a fistulous communication between the canal and the surface of some part of the perinaeum; 4thly, the habitual escape of the urine by the false aperture; 5thly, the obliteration of the canal to a greater or less extent anterior to the stricture; 6thly, the parts situated near the urethral fistula become so consolidated and confused that it is difficult in some and impossible in many cases to find the situation of the urethra, either by external examination or by means of the catheter passed into the canal. The original seat of the stricture becomes so masked by the surrounding disease, and the stricture itself, even if found by any chance, is generally of so impassable a kind, that it must be confessed there are few operations in surgery more irksome to a looker-on than is the fruitless effort made, in such a state of the parts, by a hand without a guide, to pass perforce a blunt pointed instrument like a catheter into the bladder. In some instances the stricture is slightly pervious, the urine passing in small quantity by the meatus. In others, the stricture is rendered wholly imperforate, and the canal either contracted or nearly obliterated anteriorly through disuse. Of these two conditions, the first is that in which catheterism may be tried with any reasonable hope of passing the instrument into the bladder. In the latter state, catheterism is useless, and the only means whereby the urethra may be rendered pervious in the proper direction is that of incising the stricture from the perinaeum, and after passing a catheter across the divided part into the bladder, to retain the instrument in this situation till the wound and the fistulae heal and close under the treatment proper for this end. (Mr. Syme.)



Plate 57.—Figure 15.

Fig. 1, Plate 58.—In this figure the urethra appears communicating with a sac like a scrotum. A bougie is represented entering by the meatus, traversing the upper part of the sac, and passing into the membranous part of the urethra beyond. This case which was owing to a congenital malformation of the urethra, exhibits a dilatation of the canal such as might be produced behind a stricture wherever situated. The urine impelled forcibly by the whole action of the abdominal muscles against the obstructing part dilates the urethra behind the stricture, and by a repetition of such force the part gradually yields more and more, till it attains a very large size, and protrudes at the perinaeum as a distinct fluctuating tumour, every time that an effort is made to void the bladder. If the stricture in such a case happen to cause a complete retention of urine, and that a catheter cannot be passed into the bladder, the tumour should be punctured prior to taking measures for the removal of the stricture. (Sir B. Brodie.)



Plate 58.—Figure 1.

Fig. 2, Plate 58, represents two close strictures of the urethra, one of which is situated at the bulb, and the other at the adjoining membranous part. These are the two situations in which strictures of the organic kind are said most frequently to occur, (Hunter, Home, Cooper, Brodie, Phillips, Velpeau.) False passages likewise are mentioned as more liable to be made in these places than elsewhere in the urethral canal. These occurrences—the disease and the accident—would seem to follow each other closely, like cause and consequence. The frequency with which false passages occur in this situation appears to me to be chiefly owing to the anatomical fact, that the urethra at and close to the bulb is the most dependent part of the curve, F K, Fig. 1, Plate 56; and hence, that instruments descending to this part from before push forcibly against the urethra, and are more apt to protrude through it than to have their points turned so as to ascend the curve towards the neck of the bladder. If it be also true that strictures happen here more frequently than elsewhere, this circumstance will of course favour the accident. An additional cause why the catheter happens to be frequently arrested at this situation and to perforate the canal, is owing to the fact, that the triangular ligament is liable to oppose it, the urethral opening in this structure not happening to coincide with the direction of the point of the instrument. In the figure, part of a bougie traverses the urethra through both strictures and lodges upon the enlarged prostate. Another instrument, after entering the first stricture, occupies a false passage which was made in the canal between the two constricted parts.



Plate 58.—Figure 2.

Fig. 3, Plate 58.—A calculus is here represented lodging in the urethra at the bulb. The walls of the urethra around the calculus appear thickened. Behind the obstructing body the canal has become dilated, and, in front of it, contracted. In some instances the calculus presents a perforation through its centre, by which the urine escapes. In others, the urine makes its exit between the calculus and the side of the urethra, which it dilates. In this latter way the foreign body becomes loosened in the canal and gradually pushed forwards as far as the meatus, within which, owing to the narrowness of this aperture, it lodges permanently. If the calculus forms a complete obstruction to the passage of the urine, and its removal cannot be effected by other means, an incision should be made to effect this object.



Plate 58.—Figure 3.

Fig. 4, Plate 58, represents the neck of the bladder and neighbouring part of the urethra of an ox, in which a polypous growth is seen attached by a long pedicle to the veru montanum and blocking up the neck of the bladder. Small irregular tubercles of organized lymph, and tumours formed by the lacunae distended by their own secretion, their orifices being closed by inflammation, are also found to obstruct the urethral canal.



Plate 58.—Figure 4.

Fig. 5, Plate 58.—In this figure is represented a small calculus impacted in and dilating the membranous part of the urethra.



Plate 58.—Figure 5.

Fig. 6, Plate 58.—Two strictures are here shown to exist in the urethra, one of which is situated immediately in front of the bulb, and the other at a point midway between the bulb and the meatus.



Plate 58.—Figure 6.

Fig. 7, Plate 58.—A stricture is here shown situated at the bulb.



Plate 58.—Figure 7.

Fig. 8, Plate 58, represents a stricture of the canal in front of the bulb.



Plate 58.—Figure 8.

Fig. 9, Plate 58, represents the form of an old callous stricture half an inch long, situated midway between the bulb and the meatus. This is perhaps the most common site in which a stricture of this kind is found to exist. In some instances of old neglected cases the corpus spongiosum appears converted into a thick gristly cartilaginous mass, several inches in extent, the passage here being very much contracted, and chiefly so at the middle of the stricture. When it becomes impossible to dilate or pass the canal of such a stricture by the ordinary means, it is recommended to divide the part by the lancetted stilette. (Stafford.) Division of the stricture, by any means, is no doubt the readiest and most effectual measure that can be adopted, provided we know clearly that the cutting instrument engages fairly the part to be divided. But this is a knowledge less likely to be attained if the stricture be situated behind than in front of the triangular ligament.



Plate 58.—Figure 9.

Fig. 10, Plate 58, exhibits a lateral view of the muscular parts which surround the membranous portion of the urethra and the prostate; a, the membranous urethra embraced by the compressor urethrae muscle; b, the levator prostatae muscle; c, the prostate; d, the anterior ligament of the bladder.



Plate 58.—Figure 10.

Fig. 11, Plate 58.—A posterior view of the parts seen in Fig. 10; a, the urethra divided in front of the prostate; b b, the levator prostatae muscle; c c, the compressor urethrae; d d, parts of the obturator muscles; e e, the anterior fibres of the levator ani muscle; f g, the triangular ligament enclosing between its layers the artery of the bulb, Cowper's glands, the membranous urethra, and the muscular parts surrounding this portion of the canal. The fact that the flow of urine through the urethra happens occasionally to be suddenly arrested, and this circumstance contrasted with the opposite fact that the organic stricture is of slow formation, originated the idea that the former occurrence arose from a spasmodic muscular contraction. By many this spasm was supposed to be due to the urethra being itself muscular. By others, it was demonstrated as being dependent upon the muscles which surround the membranous part of the urethra, and which act upon this part and constrict it. From my own observations I have formed the settled opinion that the urethra itself is not muscular. And though, on the one hand, I believe that this canal, per se, never causes by active contraction the spasmodic form of stricture, I am far from supposing, on the other, that all sudden arrests to the passage of urine through the urethra are solely attributable to spasm of the muscles which embrace this canal.



Plate 58.—Figure 11.



COMMENTARY ON PLATES 59 & 60.

THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND OTHER OBSTRUCTIONS OF THE URETHRA.—FALSE PASSAGES.—ENLARGEMENTS AND DEFORMITIES OF THE PROSTATE.

Impediments to the passage of the urine through the urethra may arise from different causes, such as the impaction of a small calculus in the canal, or any morbid growth (a polypus, &c.) being situated therein, or from an abscess which, though forming externally to the urethra, may press upon this tube so as either to obstruct it partially, by bending one of its sides towards the other, or completely, by surrounding the canal on all sides. These causes of obstruction may happen in any part of the urethra, but there are two others (the prostatic and the spasmodic) which are, owing to anatomical circumstances, necessarily confined to the posterior two-thirds of the urethra. The portion of the urethra surrounded by the prostate can alone be obstructed by this body when it has become irregularly enlarged, while the spasmodic stricture can only happen to the membranous portion of the urethra, and to an inch or two of the canal anterior to the bulb, these being the parts which are embraced by muscular structures. The urethra itself not being muscular, cannot give rise to the spasmodic form of stricture. But that kind of obstruction which is common to all parts of the urethra, and which is dependent, as well upon the structures of which the canal is uniformly composed, as upon the circumstance that inflammation may attack these in any situation and produce the same effect, is the permanent or organic stricture. Of this disease the forms are as various as the situations are, for as certainly as it may reasonably be supposed that the plastic lymph, effused in an inflamed state of the urethra from any cause, does not give rise to stricture of any special or particular form, exclusive of all others; so as certainly may it be inferred that, in a structurally uniform canal, inflammation points to no one particular place of it, whereat by preference to establish the organic stricture. The membranous part of the canal is, however, mentioned as being the situation most prone to the disease; but I have little doubt, nevertheless, that owing to general rules of this kind being taken for granted, upon imposing authority, many more serious evils (false passages, &c.) have been effected by catheterism than existed previous to the performance of this operation.[Footnote]

[Footnote: Home describes "a natural constriction of the urethra, directly behind the bulb, which is probably formed with a power of contraction to prevent," &c. This is the part which he says is "most liable to the disease of stricture." (Strictures of the Urethra.) Now, if anyone, even among the acute observing microscopists, can discern the structure to which Home alludes, he will certainly prove this anatomist to be a marked exception amongst those who, for the enforcement of any doctrine, can see any thing or phenomenon they wish to see. And, if Hunter were as the mirror from which Home's mind was reflected, then the observation must be imputed to the Great Original. Upon the question, however, as to which is the most frequent seat of stricture, I find that both these anatomists do not agree, Hunter stating that its usual seat is just in front of the bulb, while Home regrets, as it were, to be obliged to differ from "his immortal friend," and avers its seat to be an infinitesimal degree behind the bulb. Sir A. Cooper again, though arguing that the most usual situation of stricture is that mentioned by Hunter, names, as next in order of frequency, strictures of the membranous and prostatic parts of the urethra. Does it not appear strange now, how questions of this import should have occupied so much of the serious attention of our great predecessors, and of those, too, who at the present time form the vanguard of the ranks of science? Upon what circumstance, either anatomical or pathological, can one part of the urethra be more liable to the organic stricture than another?]

Figs. 1 and 2, Plate 59.—In these figures are presented seven forms of organic stricture occurring, in different parts of the urethra. In a, Fig. 1, the mucous membrane is thrown into a sharp circular fold, in the centre of which the canal, appears much contracted; a section of this stricture appears in b, Fig. 2. In b, Fig. 1, the canal is contracted laterally by a prominent fold of the mucous membrane at the opposite side. In c, Fig. 1, an organized band of lymph is stretched across the canal; this stricture is seen in section in c, Fig. 2. In e, Fig. 1, a stellate band of organized lymph, attached by pedicles to three sides of the urethra, divides the canal into three passages. In d, Fig. 1, the canal is seen to be much contracted towards the left side by a crescentic fold of the lining membrane projecting from the right. In f, the canal appears contracted by a circular membrane, perforated in the centre; a section of which is seen at a, Fig. 2. The form of the organic stricture varies therefore according to the three following circumstances:—1st. When lymph becomes effused within the canal upon the surface of the lining mucous membrane, and contracts adhesions across the canal. 2ndly. When lymph is effused external to the lining membrane, and projects this inwards, thereby narrowing the diameter of the canal. 3rdly. When the outer and inner walls of a part of the urethra are involved in the effused organizable matter, and on contracting towards each other, encroach at the same time upon the area of the canal. This latter state presents the form, which is known as the old callous tough stricture, extending in many instances for an inch or more along the canal. In cases where the urethra becomes obstructed by tough bands of substance, c e, which cross the canal directly, the points of flexible catheters, especially if these be of slender shape, are apt to be bent upon the resisting part, and on pressure being continued, the operator may be led to suppose that the instrument traverses the stricture, while it is most probably perforating the wall of the urethra. But in those cases where the diameter of the canal is circularly contracted, the stricture generally presents a conical depression in front, which, receiving the point of the instrument, allows this to enter the central passage unerringly. A stricture formed by a crescentic septum, such as is seen in b d, Fig. 1, offers a more effectual obstacle to the passage of a catheter than the circular septum like a f.