Chapter C: C. The two lobes of the prostate (1)

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.

Plate 59.--Figure 1, Figure 2.

Fig. 3, Plate 59.--In this there are seen three separate strictures, a, b, c, situated in the urethra, anterior to the bulb. In some cases there are many more strictures (even to the number of six or seven) situated in various parts of the urethra; and it is observed that when one stricture exists, other slight tightnesses in different parts of the canal frequently attend it. (Hunter.) When several strictures occur in various parts of the urethra, they may occasion as much difficulty in passing an instrument as if the whole canal between the extreme constrictions were uniformly narrowed.

Plate 59.--Figure 3.

Fig. 4, Plate 59.--In this the canal is constricted at the point a, midway between the bulb and glans. A false passage has been made under the urethra by an instrument which passed out of the canal at the point f, anterior to the stricture a, and re-entered the canal at the point c, anterior to the bulb. When a false passage of this kind happens to be made, it will become a permanent outlet for the urine, so long as the stricture remains. For it can be of no avail that we avoid re-opening the anterior perforation by the catheter, so long as the urine prevented from flowing by the natural canal enters the posterior perforation. Measures should be at once taken to remove the stricture.

Plate 59.--Figure 4.

Fig. 5, Plate 59.--The stricture a appears midway between the bulb and glans, the area of the passage through the stricture being sufficient only to admit a bristle to pass. It would seem almost impossible to pass a catheter through a stricture so close as this, unless by a laceration of the part, combined with dilatation.

Plate 59.--Figure 5.

Fig. 6, Plate 59.--Two instruments, a, b, have made false passages beneath the mucous membrane, in a case where no stricture at all existed. The resistance which the instruments encountered in passing out of the canal having been mistaken, no doubt, for that of passing through a close stricture.

Plate 59.--Figure 6.

Fig. 7, Plate 59.--A bougie, b b, is seen to perforate the urethra anterior to the stricture c, situated an inch behind the glans, and after traversing the substance of the right corpus cavernosum d, for its whole length, re-enters the neck of the bladder through the body of the prostate.

Plate 59.--Figure 7.

Fig. 8, Plate 59.--A bougie, c c, appears tearing and passing beneath the lining membrane, d d, of the prostatic urethra. It is remarked that the origin of a false passage is in general anterior to the stricture. It may, however, occur at any part of the canal in which no stricture exists, if the hand that impels the instrument be not guided by a true knowledge of the form of the urethra; and perhaps the accident happening from this cause is the more general rule of the two.

Plate 59.--Figure 8.

Fig. 9, Plate 59.--Two strictures are represented here, the one, e, close to the bulb d, the other, f, an inch anterior to this part. In the prostate, a b, are seen irregularly shaped abscess pits, communicating with each other, and projecting upwards the floor of this body to such a degree, that the prostatic canal appears nearly obliterated.

Plate 59.--Figure 9.

Fig. 10, Plate 59.--Two bougies, d e, are seen to enter the upper wall of the urethra, c, anterior to the prostate, a b. This accident happens when the handle of a rigid instrument is depressed too soon, with the object of raising its point over the enlarged third lobe of the prostate.

Plate 59.--Figure 10.

Fig. 11, Plate 59.--Two instruments appear transfixing the prostate, of which body the three lobes, a, b, c, are much enlarged. The instrument d perforates the third lobe, a; while the instrument e penetrates the right lobe, c, and the third lobe, a. This accident occurs when instruments not possessing the proper prostatic bend are forcibly pushed forwards against the resistance at the neck of the bladder.

Plate 59.--Figure 11.

Fig. 12, Plate 59.--In this case an instrument, d d, after passing beneath part of the lining membrane, e e, anterior to the bulb, penetrates b, the right lobe of the prostate. A second instrument, c c, penetrates the left lobe. A third smaller instrument, f f, is seen to pass out of the urethra anterior to the prostate, and after transfixing the right vesicula seminalis external to the neck of the bladder, enters this viscus at a point behind the prostate. The resistance which the two larger instruments met with in penetrating the prostate, made it seem, perhaps, that a tight stricture existed in this situation, to match which the smaller instrument, f f, was afterwards passed in the course marked out.

Plate 59.--Figure 12.

Figs. 1 to 5, Plate 60, represent a series of prostates, in which the third lobe gradually increases in size. In Fig. 1, which shows the healthy state of the neck of the bladder, unmarked by the prominent lines which are said to bound the space named "trigone vesical," or by those which indicate the position of the "muscles of the ureters," the third lobe does not exist. In Fig. 2 it appears as the uvula vesicae, a. In Fig. 3 the part a is increased, and under the name now of third lobe is seen to contract and bend upwards the prostatic canal. In Fig. 4 the effect which the growth of the lobe, a, produces upon the form of the neck of the bladder becomes more marked, and the part presenting perforations, e e, produced by instruments, indicates that by its shape it became an obstacle to the egress of the urine as well as to the entrance of instruments. A calculus of irregular form is seen to lodge behind the third lobe, and to be out of the reach of the point of a sound, supposing this to enter the bladder over the apex of the lobe. In Fig. 5 the three lobes are enlarged, but the third is most so, and while standing on a narrow pedicle attached to the floor of the prostate, completely blocks up the neck of the bladder. [Footnote]

Plate 60.--Figures 1, 2, 3, 4, 5

[Footnote: On comparing this series of figures, it must appear that the third lobe of the prostate is the product of diseased action, in so far at least as an unnatural hypertrophy of a part may be so designated. It is not proper to the bladder in the healthy state of this organ, and where it does manifest itself by increase it performs no healthy function in the economy. When Home, therefore, described this part as a new fact in anatomy, he had in reality as little reason for so doing as he would have had in naming any other tumour, a thing unknown to normal anatomy. Langenbeck (Neue Bibl. b. i. p. 360) denies its existence in the healthy state. Cruveilhier (Anat. Pathog. liv. xxvii.) deems it incorrect to reckon a third lobe as proper to the healthy bladder.]

Fig. 6, Plate 60.--The prostatic canal is bent upwards by the enlarged third lobe to such a degree as to form a right angle with the membranous part of the canal. A bougie is seen to perforate the third lobe, and this is the most frequent mode in which, under such circumstances, and with instruments of the usual imperfect form, access may be gained to the bladder for the relief of retention of urine. "The new passage may in every respect be as efficient as one formed by puncture or incision in any other way." (Fergusson.)

Plate 60.--Figure 6

Fig. 7, Plate 60.--The three lobes of the prostate, a, b, c, are equally enlarged. The prostatic canal is consequently much contracted and distorted, so that an instrument on being passed into the bladder has made a false passage through the third lobe. When a catheter is suspected to have entered the bladder by perforating the prostate, the instrument should be retained in the newly made passage till such time as this has assumed the cylindrical form of the instrument. If this be done, the new passage will be the more likely to become permanent. It is ascertained that all false passages and fistulae by which the urine escapes, become after a time lined with a membrane similar to that of the urethra. (Stafford.)

Plate 60.--Figure 7

Fig. 8, Plate 60.--The three lobes, a, b, c, of the prostate are irregularly enlarged. The third lobe, a a, projecting from below, distorts the prostatic canal upwards and to the right side.

Plate 60.--Figure 8.

Fig. 9, Plate 60.--The right lobe, a c c, of the prostate appears hollowed out so as to form the sac of an abscess which, by its projection behind, pressed upon the forepart of the rectum, and by its projection in front, contracted the area of the prostatic canal, and thereby caused an obstruction in this part. Not unfrequently when a catheter is passed along the urethra, for the relief of a retention of urine caused by the swell of an abscess in this situation, the sac becomes penetrated by the instrument, and, instead of urine, pus flows. The sac of a prostatic abscess frequently opens of its own accord into the neighbouring part of the urethra, and when this occurs it becomes necessary to retain a catheter in the neck of the bladder, so as to prevent the urine entering the sac.

Plate 60.--Figure 9.

Fig. 10, Plate 60.--The prostate presents four lobes of equal size, and all projecting largely around the neck of the bladder. The prostatic canal is almost completely obstructed, and an instrument has made a false passage through the lobe a.

Plate 60.--Figure 10.

Fig. 11, Plate 60.--The third lobe of the prostate is viewed in section, and shows the track of the false passage made by the catheter, d, through it, from its apex to its base. The proper canal is bent upwards from its usual position, which is that at present marked by the instrument in the false passage.

Plate 60.--Figure 11.

Fig. 12, Plate 60.--The prostatic lobes are uniformly enlarged, and cause the corresponding part of the urethra to be uniformly contracted, so as closely to embrace the catheter, d d, occupying it, and to offer considerable resistance to the passage of the instrument.

Plate 60.--Figure 12.