Chapter C: C. The two lobes of the prostate (2)

Fig. 13, Plate 60.--The prostate, bc, is considerably enlarged anteriorly, b, in consequence of which the prostatic canal appears more horizontal even than natural. The catheter, d, occupying the canal lies nearly straight. The lower wall, c, of the prostate is much diminished in thickness. A nipple-shaped process, a, is seen to be attached by a pedicle to the back of the upper part, b, of the prostate, and to act like a stopper to the neck of the bladder. The body a being moveable, it will be perceived how, while the bladder is distended with urine, the pressure from above may block up the neck of the organ with this part, and thus cause complete retention, which, on the introduction of a catheter, becomes readily relieved by the instrument pushing the obstructing body aside.

Plate 60.--Figure 13.

COMMENTARY ON PLATES 61 & 62.

DEFORMITIES OF THE PROSTATE.--DISTORTIONS AND OBSTRUCTIONS OF THE PROSTATIC URETHRA.

The prostate is liable to such frequent and varied deformities, the consequence of diseased action, whilst, at the same time, its healthy function (if it have any) in the male body is unknown, that it admits at least of one interpretation which may, according to fact, be given of it--namely, that of playing a principal part in effecting some of the most distressing of "the thousand natural ills that flesh is heir to." But heedless of such a singular explanation of a final cause, the practical surgeon will readily confess the fitting application of the interpretation, such as it is, and rest contented with the proximate facts and proofs. As physiologists, however, it behooves us to look further into nature, and search for the ultimate fact in her prime moving law. The prostate is peculiar to the male body, the uterus to the female. With the exception of these two organs there is not another which appears in the one sex but has its analogue in the opposite sex; and thus these two organs, the prostate and the uterus, appear by exclusion of the rest to approach the test of comparison, by which their analogy becomes as fully manifested as that between the two quantities, a-b, and a+b the only difference which exists depends upon the subtraction or the addition of the quantity, b. The difference between a prostate and a uterus is simply one of quantity, such as we see existing between the male and the female breast. The prostate is to the uterus absolutely what a rudimentary organ is to its fully developed analogue. The one, as being superfluous, is in accordance with nature's law of nihil supervacaneum nihil frutra, arrested in its development, and in such a character appears the prostate. This body is not a gland any more than is the uterus, but both organs being quantitatively, and hence functionally different, I here once more venture to call down an interpretation of the part from the unfrequented bourne of comparative anatomy, and turning it to lend an interest to the accompanying figures even with a surgical bearing, I remark that the prostatic or rudimentary uterus, like a germ not wholly blighted, is prone to an occasional sprouting or increase beyond its prescribed dimensions--a hypertrophy in barren imitation, as it were, of gestation. [Footnote]

[Footnote: This expression of the fact to which I allude will not, I trust, be extended beyond the limits I assign to it. Though I have every reason to believe, that between the prostate of the male and the uterus of the female, the same amount of analogy exists, as between a coccygeal ossicle and the complete vertebral form elsewhere situated in the spinal series, I am as far from regarding the two former to be in all respects structurally or functionally alike, as I am from entertaining the like idea in respect to the two latter. But still I maintain that between a prostate and a uterus, as between a coccygeal bone and a vertebra, the only difference which exists is one of quantity, and that hence arises the functional difference. A prostate is part of a uterus, just as a coccygeal bone is part (the centrum) of a vertebra. That this is the absolute signification of the prostate I firmly believe, and were this the proper place, I could prove it in detail, by the infallible rule of analogical reasoning. John Hunter has observed that the use of the prostate was not sufficiently known to enable us to form a judgment of the bad consequences of its diseased state. When the part becomes morbidly enlarged, it acts as a mechanical impediment to the passage of urine from the bladder, but from this circumstance we cannot reasonably infer, that while of its normal healthy proportions, its special function is to facilitate the egress of the urine, for the female bladder, though wholly devoid of the prostate, performs its own function perfectly. It appears to me, therefore, that the real question should be, not what is the use of the prostate? but has it any proper function? If the former question puzzled even the philosophy of Hunter, it was because the latter question must be answered in the negative. The prostate has no function proper to itself per se. It is a thing distinct from the urinary apparatus, and distinct likewise from the generative organs. It may be hypertrophied or atrophied, or changed in texture, or wholly destroyed by abscess, and yet neither of the functions of these two systems of organs will be impaired, if the part while diseased act not as an obstruction to them. In texture the prostate is similar to an unimpregnated uterus. In form it is, like the uterus, symmetrical. In position it corresponds to the uterus. The prostate has no ducts proper to itself. Those ducts which are said to belong to it (prostatic ducts) are merely mucous cells, similar to those in other parts of the urethral lining membrane. The seminal ducts evidently do not belong to it. The texture of the prostate is not such as appears in glandular bodies generally. In short, the facts which prove what it is not, prove what it actually is--namely, a uterus arrested in its development, and as a sign of that all-encompassing law in nature, which science expresses by the term "unity in variety." This interpretation of the prostate, which I believe to be true to nature, will last perhaps till such time as the microscopists shall discover in its "secretion" some species of mannikins, such as may pair with those which they term spermatozoa.]

Fig. 1, Plate 61.--The prostate, a b, is here represented thinned in its walls above and below. The lower wall is dilated into a pouch caused by the points of misdirected instruments in catheterism having been rashly forced against it.

Plate 61.--Figure 1.

Fig. 2, Plate 61.--The prostate, a b, is here seen to be somewhat more enlarged than is natural. A tubercle, b, surmounts the lower part, c, of the prostate, and blocks up the vesical orifice. Catheters introduced by the urethra for retention of urine which existed in this case, have had their points arrested at the bulb, and on being pushed forwards in this direction, have dilated the bulb into the form of a pouch, seen at d. The sinus of the bulb, being the lowest part of the urethral canal, is very liable to be distorted or perforated by the points of instruments descending upon it from above and before. [Footnote]

[Footnote: When a stricture exists immediately behind the bulb, this circumstance will, of course, favour the occurrence of the accident. "False passages (observes Mr. Benjamin Phillips) are less frequent here (in the membranous part of the urethra) than in the bulbous portion of the canal. The reason of this must be immediately evident: false passages are ordinarily made in consequence of the difficulty experienced in the endeavour to pass an instrument through the strictured portion of the tube. Stricture is most frequently seated at the point of junction between the bulbous and membranous portions of the canal; consequently, the false passage will be usually anterior to this latter point."--(On the Urethra, its Diseases. &c., p. 15.) ]

Plate 61.--Figure 2

Fig. 3, Plate 61.--A cyst, c, is seen to grow from the left side of the base of the prostate, a b, and to form an obstruction at the vesical orifice.

Plate 61.--Figure 3.

Fig. 4, Plate 61.--A globular excrescence, a, appears blocking up the vesical orifice, and giving to this the appearance of a crescentic slit, corresponding to the shape of the obstructing body. The prostate, b b, is enlarged in both its lateral lobes. A small bougie, c, is placed in the prostatic canal and vesical opening.

Plate 61.--Figure 4

Fig. 5, Plate 61.--The prostate, d, is considerably enlarged, and the vesical orifice is girt by a prominent ring, b b, from the right border of which the nipple-shaped body, a, projects and occupies the outlet. Owing to the retention of urine caused by this state of the prostate, the ureters, c c, have become very much dilated.

Plate 61.--Figure 5.

Fig. 6, Plate 61.--The lateral lobes of the prostate, c c, are seen enlarged, and from the inner side and base of each, irregularly shaped masses, a, b, d, project, and bend the prostatic urethra first to the right side, then to the left. The part, a, resting upon the part, b, acts like a valve against the vesical outlet, which would become closed the tighter according to the degree of superincumbent pressure. A flexible catheter would, in such a case as this, be more likely, perhaps, to follow the sinuous course of the prostatic passage than a rigid instrument of metal.

Plate 61.--Figure 6.

Fig. 7, Plate 61.--A globular mass, a, of large size, occupies the neck of the bladder, and gives the vesical orifice, c, a crescentic shape, convex towards the right side. The two lobes of the prostate, b, are much enlarged.

Plate 61.--Figure 7.

Fig. 8, Plate 61.--The lateral lobes, b b, of the prostate are irregularly enlarged, and the urinary passage is bent towards the right side, c, from the membranous portion, which is central. Surmounting the vesical orifice, c, is seen the tuberculated mass, a, which being moveable, can be forced against the vesical orifice and thus produce complete retention of urine. In this case, also, a flexible catheter would be more suitable than a metallic one.

Plate 61.--Figure 8.

Fig. 9, Plate 61.--The lateral lobes, b b, of the prostate are enlarged. The third lobe, a, projects at the neck of the bladder, distorting the vesical outlet. A small calculus occupies the prostatic urethra, and being closely impacted in this part of the canal, would arrest the progress of a catheter, and probably lead to the supposition that the instrument grated against a stone in the interior of the bladder, in which case it would be inferred that since the urine did not flow through the catheter no retention existed.

Plate 61.--Figure 9, 10.

Fig. 10, Plate 61.--Both lateral lobes, b c, of the prostate appear much increased in size. A large irregular shaped mass, a, grows from the base of the right lobe, and distorts the prostatic canal and vesical orifice. When the lobes of the prostate increase in size in this direction, the prostatic canal becomes much more elongated than natural, and hence the instrument which is to be passed for relieving the existing retention of urine should have a wide and long curve to correspond with the form of this part of the urethra. [Footnote]

[Footnote: Both lobes of the prostate are equally liable to chronic enlargement. Home believed the left lobe to be oftener increased in size than the right. Wilson (on the Male Urinary and Genital Organs) mentions several instances of the enlargement of the right lobe. No reason can be assigned why one lobe should be more prone to hypertrophy than the other, even supposing it to be matter of fact, which it is not. But the observations made by Cruveilhier (Anat. Pathol.), that the lobulated projections of the prostate always take place internally at its vesical aspect, is as true as the manner in which he accounts for the fact is plausible. The dense fibrous envelope of the prostate is sufficient to repress its irregular growth externally.]

Fig. 11, Plate 61.--Both lobes of the prostate are enlarged, and from the base of each a mass projects prominently around the vesical orifice, a b. The prostatic urethra has been moulded to the shape of the instrument, which was retained in it for a considerable time.

Plate 61.--Figure 11.

Fig. 12, Plate 61.--The prostate, c b, is enlarged and dilated, like a sac. Across the neck, a, of the bladder the prostate projects in an arched form, and is transfixed by the instrument, d. The prostate may assume this appearance, as well from instruments having been forced against it, as from an abscess cavity formed in its substance having received, from time to time, a certain amount of the urine, and retained this fluid under the pressure of strong efforts, made to void the bladder while the vesical orifice was closed above.

Plate 61.--Figure 12.

Fig. 13, Plate 61.--The lateral lobes, d e, of the prostate are enlarged; and, occupying the position of the third lobe, appear as three masses, a b c, plicated upon each other, and directed towards the vesical orifice, which they close like valves. The prostatic urethra branches upwards into three canals, formed by the relative position of the parts, e, c, b, a, d, at the neck of the bladder. The ureters are dilated, in consequence of the regurgitation of the contents of the bladder during the retention which existed ..

Plate 61.--Figure 13.

Fig. 1, Plate 62, exhibits the lobes of the prostate greatly increased in size. The part, a b, girds irregularly, and obstructs the vesical outlet, while the lateral lobes, c d, encroach upon the space of the prostatic canal. The walls of the bladder are much thickened.

Plate 62.--Figure 1.

Fig. 2, Plate 62.--The three lobes, a, d, c, of the prostate are enlarged and of equal size, moulded against each other in such a way that the prostatic canal and vesical orifice appear as mere clefts between them. The three lobes are encrusted on their vesical surfaces with a thick calcareous deposit. The surface of the third lobe, a, which has been half denuded of the calcareous crust, b, in order to show its real character, appeared at first to be a stone impacted in the neck of the bladder, and of such a nature it certainly would seem to the touch, on striking it with the point of a sound or other instrument.

Plate 62.--Figure 2, 3.

Fig. 3, Plate 62, represents the prostate with its three lobes enlarged, and the prostatic canal and vesical orifice narrowed. The walls of the bladder are thickened, fasciculated, and sacculated; the two former appearances being caused by a hypertrophy of the vesical fibres, while the latter is in general owing to a protrusion of the mucous membrane between the fasciculi.

Fig. 4, Plate 62.--The prostate presents four lobes, a, b, c, d, each being of large size, and projecting far into the interior of the bladder, from around the vesical orifice which they obstruct. The bladder is thickened, and the prostatic canal is elongated. The urethra and the lobes of the prostate have been perforated by instruments, passed for the retention of urine which existed. A stricturing band, e, is seen to cross the membranous part of the canal.

Plate 62.--Figure 4, 5.

Fig. 5, Plate 62.--The prostate, a a, is greatly enlarged, and projects high in the bladder, the walls of the latter, b b, being very much thickened. The ureters, c, are dilated, and perforations made by instruments are seen in the prostate. The prostatic canal being directed almost vertically, and the neck of the bladder being raised nearly as high as the upper border of the pubic symphysis, it must appear that if a stone rest in the bas fond of the bladder, a sound or staff cannot reach the stone, unless by perforating the prostate; and if, while the staff occupies this position, lithotomy be performed, the incisions will not be required to be made of a greater depth than if the prostate were of its ordinary proportions. On the contrary, if the staff happen to have surmounted the prostate, the incision, in order to divide the whole vertical thickness of this body, will require to be made very deeply from the perinaeal surface, and this circumstance occasions what is termed a "deep perinaeum."

Fig. 6, Plate 62.--The lower half, c, b, f, of the prostate, having become the seat of abscess, appears hollowed out in the form of a sac. This sac is separated from the bladder by a horizontal septum, e e, the proper base of the bladder, g g. The prostatic urethra, between a e, has become vertical in respect to the membranous part of the canal, in consequence of the upward pressure of the abscess. The sac opens into the urethra, near the apex of the prostate, at the point c; and a catheter passed along the urethra has entered the orifice of the sac, the interior of which the instrument traverses, and the posterior wall of which it perforates. The bladder contains a large calculus, i. The bladder and sac do not communicate, but the urethra is a canal common to both. In a case of this sort it becomes evident that, although symptoms may strongly indicate either a retention of urine, or the presence of a stone in the bladder, any instrument taking the position and direction of d d, cannot relieve the one or detect the other; and such is the direction in which the instrument must of necessity pass, while the sac presents its orifice more in a line with the membranous part of the urethra than the neck of the bladder is. The sac will intervene between the rectum and the bladder; and on examination of the parts through the bowel, an instrument in the sac will readily be mistaken for being in the bladder, while neither a calculus in the bladder, nor this organ in a state of even extreme distention, can be detected by the touch any more than by the sound or catheter. If, while performing lithotomy in such a state of the parts, the staff occupy the situation of d d d, then the knife, following the staff, will open, not the bladder which contains the stone, but the sac, which, moreover, if it happen to be filled with urine regurgigated from the urethra, will render the deception more complete.

Plate 62.--Figure 6.

Fig. 7, Plate 62.--The walls, a a, of the bladder, appear greatly thickened, and the ureters, b, dilated. The sides, c c c, of the prostate are thinned; and in the prostatic canal are two calculi, d d, closely impacted. In such a state of the parts it would be impossible to pass a catheter into the bladder for the relief of a retention of urine, or to introduce a staff as a guide to the knife in lithotomy. If, however, the staff can be passed as far as the situation of the stone, the parts may be held with a sufficient degree of steadiness to enable the operator to incise the prostate upon the stone.

Plate 62.--Figure 7.

COMMENTARY ON PLATES 63 & 64.

DEFORMITIES OF THE URINARY BLADDER.--THE OPERATIONS OF SOUNDING FOR STONE, OF CATHETERISM AND OF PUNCTURING THE BLADDER ABOVE THE PUBES.

The urinary bladder presents two kinds of deformity--viz., congenital and pathological. As examples of the former may be mentioned that in which the organ is deficient in front, and has become everted and protruded like a fungous mass through an opening at the median line of the hypogastrium; that in which the rectum terminates in the bladder posteriorly; and that in which the foetal urachus remains pervious as a uniform canal, or assumes a sacculated shape between the summit of the bladder and the umbilicus. The pathological deformities are, those in which vesical fistulae, opening either above the pubes, at the perinaeum, or into the rectum, have followed abscesses or the operation of puncturing the bladder in these situations, and those in which the walls of the organ appear thickened and contracted, or thinned and expanded, or sacculated externally, or ridged internally, in consequence of its having been subjected to abdominal pressure while overdistended with its contents, and while incapable of voiding these from some permanent obstruction in the urethral canal.[Footnote] The bladder is liable to become sacculated from two causes--from a hernial protrusion of its mucous membrane through the separated fasciculi of its fibrous coat, or from the cyst of an abscess which has formed a communication with the bladder, and received the contents of this organ. Sacs, when produced in the former way, may be of any number, or size, or in any situation; when caused by an abscess, the sac is single, is generally formed in the prostate, or corresponds to the base of the bladder, and may attain to a size equalling, or even exceeding, that of the bladder itself. The sac, however formed, will be found lined by mucous membrane. The cyst of an abscess, when become a recipient for the urine, assumes after a time a lining membrane similar to that of the bladder. If the sac be situated at the summit or back of the bladder, it will be found invested by peritonaeum; but, whatever be its size, structure, or position, it may be always distinguished from the bladder by being devoid of the fibrous tunic, and by having but an indirect relation to the vesical orifice.

[Footnote: On considering these cases of physical impediments to the passage of urine from the vesical reservoir through the urethral conduit, it seems to me as if these were sufficient to account for the formation of stone in the bladder, or any other part of the urinary apparatus, without the necessity of ascribing it to a constitutional disease, such as that named the lithic diathesis by the humoral pathologists.

The urinary apparatus (consisting of the kidneys, ureters, bladder, and urethra) is known to be the principal emunctory for eliminating and voiding the detritus formed by the continual decay of the parts comprising the animal economy. The urine is this detritus in a state of solution. The components of urine are chemically similar to those of calculi, and as the components of the one vary according to the disintegration occurring at the time in the vital alembic, so do those of the other. While, therefore, a calculus is only as urine precipitated and solidified, and this fluid only as calculous matter suspended in a menstruum, it must appear that the lithic diathesis is as natural and universal as structural disintegration is constant and general in operation. As every individual, therefore, may be said to void day by day a dissolved calculus, it must follow that its form of precipitation within some part of the urinary apparatus alone constitutes the disease, since in this form it cannot be passed. On viewing the subject in this light, the question that springs directly is, (while the lithic diathesis is common to individuals of all ages and both sexes,) why the lithic sediment should present in the form of concrement in some and not in others? The principal, if not the sole, cause of this seems to me to be obstruction to the free egress of the urine along the natural passage. Aged individuals of the male sex, in whom the prostate is prone to enlargement, and the urethra to organic stricture, are hence more subject to the formation of stone in the bladder, than youths, in whom these causes of obstruction are less frequent, or than females of any age, in whom the prostate is absent, and the urethra simple, short, readily dilatable, and seldom or never strictured. When an obstruction exists, lithic concretions take place in the urinary apparatus in the same manner as sedimentary particles cohere or crystallize elsewhere. The urine becoming pent up and stagnant while charged with saline matter, either deposits this around a nucleus introduced into it, or as a surplus when the menstruum is insufficient to suspend it. The most depending part of the bladder is that where lithic concretions take place; and if a sacculus exist here, this, becoming a recipient for the matter, will favour the formation of stone.] [End Footnote]

FIG. 1, Plate 63.--The lateral lobes of the prostate, 3, 4, are enlarged, and contract the prostatic canal. Behind them the third lobe of smaller size occupies the vesical orifice, and completes the obstruction. The walls of the bladder have hence become fasciculated and sacculated. One sac, 1, projects from the summit of the bladder; another, 2, containing a stone, projects laterally. When a stone occupies a sac, it does not give rise to the usual symptoms as indicating its presence, nor can it be always detected by the sound.

Plate 63,--Figure 1.

FIG. 2, Plate 63.--The prostate, 2, 3, is enlarged, and the middle lobe, 2, appears bending the prostatic canal to an almost vertical position, and obstructing the vesical orifice. The bladder, 1, 1, 1, is thickened; the ureters, 7, are dilated; and a large sac, 6, 6, projects from the base of the bladder backwards, and occupies the recto-vesical fossa. The sac, equal in size to the bladder, communicates with this organ by a small circular opening, 8, situated between the orifices of the ureters. The peritonaeum is reflected from the summit of the bladder to that of the sac. A catheter, 4, appears perforating the third lobe of the prostate, 2, and entering the sac, 5, through the base of the bladder, below the opening, 8. In a case of this kind, a catheter occupying the position 4, 5, would, while voiding the bladder through the sac, make it seem as if it really traversed the vesical orifice. If a stone occupied the bladder, the point of the instrument in the sac could not detect it, whereas, if a stone lay within the sac, the instrument, on striking it here, would give the impression as if it lay within the bladder.

Plate 63,--Figure 2.

FIG. 3, Plate 63.--The urethra being strictured, the bladder has become sacculated. In the bas fond of the bladder appears a circular opening, 2, leading to a sac of large dimensions, which rested against the rectum. In such a case as this, the sac, occupying a lower position than the base of the bladder, must first become the recipient of the urine, and retain this fluid even after the bladder has been evacuated, either voluntarily or by means of instruments. If, in such a state of the parts, retention of urine called for puncturation, it is evident that this operation would be performed with greater effect by opening the depending sac through the bowel, than by entering the summit of the bladder above the pubes.

Plate 63,--Figure 3, 4.

FIG. 4, Plate 63.--The vesical orifice is obstructed by two portions, 3, 4, of the prostate, projecting upwards, one from each of its lateral lobes, 6, 6. The bladder is thickened and fasciculated, and from its summit projects a double sac, 1, 2, which is invested by the peritonaeum.

FIG. 5, Plate 63.--The prostatic canal is constricted and bent upwards by the third lobe. The bladder is thickened, and its base is dilated in the form of a sac, which is dependent, and upon which rests a calculus. An instrument enters the bladder by perforating the third lobe, but does not come into contact with the calculus, owing to the low position occupied by this body.

Plate 63,--Figure 5.

FIG. 6, Plate 63.--Two sacs appear projecting on either side of the base of the bladder. The right one, 5, contains a calculus, 6; the left one, of larger dimensions, is empty. The rectum lay in contact with the base of the bladder between the two sacs.

Plate 63,--Figure 6.

FIG. 7, Plate 63.--Four calculi are contained in the bladder. This organ is divided by two septa, 2, 4, into three compartments, each of which, 1, 3, 5, gives lodgment to a calculus; and another, 6, of these bodies lies impacted in the prostatic canal, and becomes a complete bar to the passage of a catheter. Supposing lithotomy to be performed in an instance of this kind, it is probable that, after the extraction of the calculi, 6, 5, the two upper ones, 3, 1, would, owing to their being embedded in the walls of the bladder, escape the forceps.

Plate 63,--Figure 7.

FIG. 8, Plate 63.-Two large polypi, and many smaller ones, appear growing from the mucous membrane of the prostatic urethra and vesical orifice, and obstructing these parts. In examining this case during life by the sound, the two larger growths, 1, 2, were mistaken by the surgeon for calculi. Such a mistake might well be excused if they happened to be encrusted with lithic matter.

Plate 63,--Figure 8.

FIG. 9, Plate 63.--The base of the bladder, 8, 8, appears dilated into a large uniform sac, and separated from the upper part of the organ by a circular horizontal fold, 2, 2. The ureters are also dilated. The left ureter, 3, 4, opens into the sac below this fold, while the right ureter opens above it into the bladder. In all cases of retention of urine from permanent obstruction of the urethra, the ureters are generally found more or less dilated. Two circumstances combine to this effect--while the renal secretion continues to pass into the ureters from above, the contents of the bladder under abdominal pressure are forced regurgitating into them from below, through their orifices.

Plate 63,--Figure 9.

FIG. 1, Plate 64.--The bladder, 6, appears symmetrically sacculated. One sac, 1, is formed at its summit, others, 3, 2, project laterally, and two more, 5, 4, from its base. The ureters, 7, 7, are dilated, and enter the bladder between the lateral and inferior sacs.

Plate 64,--Figure 1.

Fig. 2, Plate 64.--The prostate is greatly enlarged, and forms a narrow ring around the vesical orifice. Through this an instrument, 12, enters the bladder. The walls of the bladder are thickened and sacculated. On its left side appear numerous sacs, 2, 3, 4, 5, 6, 7, 8, and on the inner surface of its right side appear the orifices of as many more. On its summit another sac is formed. The ureters, 9, are dilated.

Plate 64,--Figure 2.

FIG. 3, Plate 64.--The prostate is enlarged, its canal is narrowed, and the bladder is thickened and contracted. A calculus, 1, 2, appears occupying nearly the whole vesical interior. The incision in the neck of the bladder in lithotomy must necessarily be extensive, to admit of the extraction of a stone of this size.

Plate 64,--Figure 3.

FIG. 4, Plate 64.--The prostatic canal is contracted by the lateral lobes, 4, 5; resting upon these, appear three calculi, 1, 2, 3, which nearly fill the bladder. This organ is thickened and fasciculated. In cases of this kind, and that last mentioned, the presence of stone is readily ascertainable by the sound.

Plate 64,--Figure 4.

FIG. 5, Plate 64.--The three prostatic lobes are enlarged, and appear contracting the vesical orifice. In the walls of the bladder are embedded several small calculi, 2, 2, 2, 2, which, on being struck with the convex side of a sound, might give the impression as though a single stone of large size existed. In performing lithotomy, these calculi would not be within reach of the forceps.

Plate 64,--Figure 5.

FIG. 6, Plate 64.--Two sacculi, 4, 5, appear projecting at the middle line of the base of the bladder, between the vasa deferentia, 7, 7, and behind the prostate, in the situation where the operation of puncturing the bladder per anum is recommended to be performed in retention of urine.

Plate 64,--Figure 6.

FIG. 7, Plate 64.--A sac, 4, is situated on the left side of the bladder, 3, 3, immediately above the orifice of the ureter. In the sac was contained a mass of phosphatic calculus. This substance is said to be secreted by the mucous lining of the bladder, while in a state of chronic inflammation, but there seems nevertheless very good reason for us to believe that it is, like all other calculous matter, a deposit from the urine.

Plate 64,--Figure 7.

FIG. 8, Plate 64, represents, in section, the relative position of the parts concerned in catheterism. [Footnote] In performing this operation, the patient is to be laid supine; his loins are to be supported on a pillow; and his thighs are to be flexed and drawn apart from each other. By this means the perinaeum is brought fully into view, and its structures are made to assume a fixed relative position. The operator, standing on the patient's left side, is now to raise the penis so as to render the urethra, 8, 8, 8, as straight as possible between the meatus, a, and the bulb, 7. The instrument (the concavity of its curve being turned to the left groin) is now to be inserted into the meatus, and while being gently impelled through the canal, the urethra is to be drawn forwards, by the left hand, over the instrument. By stretching the urethra, we render its sides sufficiently tense for facilitating the passage of the instrument, and the orifices of the lacunae become closed. While the instrument is being passed along this part of the canal, its point should be directed fairly towards the urethral opening, 6*, of the triangular ligament, which is situated an inch or so below the pubic symphysis, 11. With this object in view, we should avoid depressing its handle as yet, lest its point be prematurely tilted up, and rupture the upper side of the urethra anterior to the ligament. As soon as the instrument has arrived at the bulb, its further progress is liable to be arrested, from these causes:--1st, This portion of the canal is the lowest part of its perinaeal curve, 3, 6, 8, and is closely embraced by the middle fibres of the accelerator urinae muscle. 2nd, It is immediately succeeded by the commencement of the membranous urethra, which, while being naturally narrower than other parts, is also the more usual seat of organic stricture, and is subject to spasmodic constriction by the fibres of the compressor urethrae. 3d, The triangular ligament is behind it, and if the urethral opening of the ligament be not directly entered by the instrument, this will bend the urethra against the front of that dense structure. On ascertaining these to be the causes of resistance, the instrument is to be withdrawn a little in the canal, so as to admit of its being readjusted for engaging precisely the opening in the triangular ligament. As this structure, 6, is attached to the membranous urethra, 6*, which perforates it, both these parts may be rendered tense, by drawing the penis forwards, and thereby the instrument may be guided towards and through the aperture. The instrument having passed the ligament, regard is now to be paid to the direction of the pelvic portion of the canal, which is upwards and backwards to the vesical orifice, 3, d, 3. In order that the point of the instrument may freely traverse the urethra in this direction, its handle, a, requires to be depressed, b c, slowly towards the perinaeum, and at the same time to be impelled steadily back in the line d, d, through the pubic arch, 11. If the third lobe of the prostate happen to be enlarged, the vesical orifice will accordingly be more elevated than usual. In this case, it becomes necessary to depress the instrument to a greater extent than is otherwise required, so that its point may surmount the obstacle. But since the suspensory ligament of the penis, 10, and the perinaeal structures prevent the handle being depressed beyond a certain degree, which is insufficient for the object to be attained, the instrument should possess the prostatic curve, c c, compared with c b.

[Footnote: It may be necessary for me to state that, with the exception of this figure (which is obviously a plan, but sufficiently accurate for the purposes it is intended to serve) all the others representing pathological conditions and congenital deformities of the urethra, the prostate, and the bladder, have been made by myself from natural specimens in the museums and hospitals of London and Paris.]

Plate 64,--Figure 8.

In the event of its being impossible to pass a catheter by the urethra, in cases of retention of urine threatening rupture, the base or the summit of the bladder, according as either part may be reached with the greater safety to the peritonaeal sac, will require to be punctured. If the prostate be greatly and irregularly enlarged, it will be safer to puncture the bladder above the pubes, and here the position of the organ in regard to the peritonaeum, 1, becomes the chief consideration. The shape of the bladder varies very considerably from its state of collapse, 3, 3, 5, to those of mediate, 3, 3, 2, 1, and extreme distention, 3, 3, 4. This change of form is chiefly effected by the expansive elevation of its upper half, which is invested by the peritonaeum. As the summit of the bladder falls below, and rises above the level of the upper margin of the pubic symphysis, it carries the peritonaeum with it in either direction. While the bladder is fully expanded, 4, there occurs an interval between the margin of the symphysis pubis and the point of reflexion of the peritonaeum, from the recti muscles, to the summit of the viscus. At this interval, close to the pubes, and in the median line, the trocar may be safely passed through the front wall of the bladder. The instrument should, in all cases, be directed downwards and backwards, h, h, in a line pointing to the hollow of the sacrum.

COMMENTARY ON PLATES 65 & 66.

THE SURGICAL DISSECTION OF THE POPLITEAL SPACE AND THE POSTERIOR CRURAL REGION.

On comparing the bend of the knee with the bend of the elbow, as evident a correspondence can be discerned between these two regions, as exists between the groin and the axilla.

Behind the knee-joint, the muscles which connect the leg with the thigh enclose the space named popliteal. When the integuments and subcutaneous substance are removed from this place, the dense fascia lata may be seen binding these muscles so closely together as to leave but a very narrow interval between them at the mesial line. On removing this fascia, B B M M, Plate 65, the muscles part asunder, and the popliteal space as usually described is thereby formed. This region now presents of a lozenge-shaped form, B J D K, of which the widest diameter, D J, is opposite the knee-joint. The flexor muscles, C D J, in diverging from each other as they pass down from the sides of the thigh to those of the upper part of the leg, form the upper angle of this space; whilst its lower angle is described by the two heads of the gastrocnemius muscle, E E, arising inside the flexors, from the condyles of the femur. The popliteal space is filled with adipose substance, in which are embedded several lymphatic bodies and through which pass the principal vessels and nerves to the leg.

In the dissection of the popliteal space, the more important parts first met with are the branches of the great sciatic nerve. In the upper angle of the space, this nerve will be found dividing into the peronaeal, I, and posterior tibial branches, H K. The peronaeal nerve descends close to the inner margin of the tendon, J, of the biceps muscle; and, having reached the outer side of the knee, I*, Plate 66, below the insertion of the tendon into the head of the fibula, winds round the neck of this bone under cover of the peronaeus longus muscle, S, to join the anterior tibial artery. The posterior tibial nerve, H K, Plate 65, descends the popliteal space midway to the cleft between the heads of the gastrocnemius; and, after passing beneath this muscle, to gain the inner side of the vessels, H*, Plate 66, it then accompanies the posterior tibial artery. On the same plane with and close to the posterior tibial nerve in the popliteal space, will be seen the terminal branch of the lesser sciatic nerve, together with a small artery and vein destined for distribution to the skin and other superficial parts on the back of the knee. Opposite the heads of the gastrocnemius, the peronaeal and posterior tibial nerves give off each a branch, both of which descend along the mesial line of the calf, and joining near the upper end of the tendo Achillis, the single nerve here, N, Plate 65, becomes superficial to the fascia, and thence descends behind the outer ankle to gain the external border of the foot, where it divides into cutaneous branches and others to be distributed to the three or four outer toes. In company with this nerve will be seen the posterior saphena vein, L, which, commencing behind the outer ankle, ascends the mesial line of the calf to join the popliteal vein, G, in the cleft between the heads of the gastrocnemius.

On removing next the adipose substance and lymphatic glands, we expose the popliteal vein and artery. The relative position of these vessels and the posterior tibial nerve, may now be seen. Between the heads of the gastrocnemius, the nerve, H, giving off large branches to this muscle, lies upon the popliteal vein, G, where this is joined by the posterior saphena vein. Beneath the veins lies the popliteal artery, F. On tracing the vessels and nerve from this point upwards through the popliteal space, we find the nerve occupying a comparatively superficial position at the mesial line, while the vessels are directed upwards, forwards, and inwards, passing deeply, as they become covered by the inner flexor muscles, C D, to the place where they perforate the tendon of the adductor magnus on the inner side of the lower third of the femur.

The popliteal artery, F, Plate 66, being the continuation of the femoral, extends from the opening in the great adductor tendon at the junction of the middle and lower third of the thigh, to the point where it divides, in the upper, and back part of the leg, at the lower border of the popliteus muscle, L, into the anterior and posterior tibial branches. In order to expose the vessel through this extent, we have to divide and reflect the heads of the gastrocnemius muscle, E E, and to retract the inner flexors. The popliteal artery will now be seen lying obliquely over the middle of the back of the joint. It is deeply placed in its whole course. Its upper and lower thirds are covered by large muscles; whilst the fascia and a quantity of adipose tissue overlies its middle. The upper part of the artery rests upon the femur, its middle part upon the posterior ligament of the joint, and its lower part upon the popliteus muscle. The popliteal vein, G; adheres to the artery in its whole course, being situated on its outer side above, and posterior to it below. The vein is not unfrequently found to be double; one vein lying to either side of the artery, and both having branches of communication with each other, which cross behind the artery. In some instances the posterior saphena vein, instead of joining the popliteal vein, ascends superficially to terminate in some of the large veins of the thigh. Numerous lymphatic vessels accompany the superficial and deep veins into the popliteal space, where they join the lymphatic bodies, which here lie in the course of the artery.

The branches derived from the popliteal artery are the muscular and the articular. The former spring from the vessel opposite those parts of the several muscles which lie in contact with it; the latter are generally five in number--two superior, two inferior, and one median. The two superior articular branches arise from either side of the artery, and pass, the one beneath the outer, the other beneath the inner flexors, above the knee-joint; and the two inferior pass off from it, the one internally, the other externally, beneath the heads of the gastrocnemius below the joint; while the middle articular enters the joint through the posterior ligament. The two superior and inferior articular branches anastomose freely around the knee behind, laterally, and in front, where they are joined by the terminal branches of the anastomotic, from the femoral, and by those of the recurrent, from the anterior tibial. The main vessel, having arrived at the lower border of the popliteus muscle, divides into two branches, of which one passes through the interosseous ligament to become the anterior tibial; while the other, after descending a short way between the bones of the leg, separates into the peronaeal and posterior tibial arteries. In some rare instances the popliteal artery is found to divide above the popliteus muscle into the anterior, or the posterior tibial, or the peronaeal.

The two large muscles, (gastrocnemius and soleus,) forming the calf of the leg, have to be removed together with the deep fascia in order to expose the posterior tibial, and peronaeal vessels and nerves. The fascia forms a sheath for the vessels, and binds them close to the deep layer of muscles in their whole course down the back of the leg. The point at which the main artery, F, Plate 66, gives off the anterior tibial, is at the lower border of the popliteus muscle, on a level with N, the neck of the fibula; that at which the artery again subdivides into the peronaeal, P, and posterior tibial branches, O, is in the mesial line of the leg, and generally on a level with the junction of its upper and middle thirds. From this place the two arteries diverge in their descent; the peronaeal being directed along the inner border of the fibula towards the back of the outer ankle; while the posterior tibial, approaching the inner side of the tibia, courses towards the back of the inner ankle. The gastrocnemius and soleus muscles overlie both arteries in their upper two thirds; but as these muscles taper towards the mesial line where they end in the tendo Achillis, V V, Plate 65, they leave the posterior tibial artery, O, with its accompanying nerve and vein, uncovered in the lower part of the leg, except by the skin and the superficial and deep layers of fasciae. The peronaeal artery is deeply situated in its whole course. Soon after its origin, it passes under cover of the flexor longus pollicis, R, a muscle of large size arising from the lower three fourths of the fibula, N, and will be found overlapped by this muscle on the outer border of the tendo Achillis, as low down as the outer ankle. The two arteries are accompanied by venae comites, which, with the short saphena vein, form the popliteal vein. The posterior tibial artery is closely followed by the posterior tibial nerve. In the popliteal space, this nerve crosses to the inner side of the posterior tibial artery, where both are about to pass under the gastrocnemius muscle, to which they give large branches. Near the middle of the leg, the nerve recrosses the artery to its outer side and in this relative position both descend to a point about midway between the inner ankle and calcaneum, where they appear having the tendons of the tibialis posticus and flexor longus digitorum to their inner side and the tendon of the flexor longus pollicis on their outer side. Numerous branches are given off from the nerve and artery to the neighbouring parts in their course.

The varieties of the posterior crural arteries are these--the tibial vessel, in some instances, is larger than usual, while the peronaeal is small, or absent; and, in others, the peronaeal supplies the place of the posterior tibial, when the latter is diminished in size. The peronaeal has been known to take the position of the posterior tibial in the lower part of the leg, and to supply the plantar arteries. In whatever condition the two vessels may be found, there will always be seen ramifying around the ankle-joint, articular branches, which anastomose freely with each other and with those of the anterior tibial.

The popliteal artery is unfavourably circumstanced for the application of a ligature. It is very deeply situated, and the vein adheres closely to its posterior surface. Numerous branches (articular and muscular) arise from it at short intervals; and these, besides being a source of disturbance to a ligature, are liable to be injured in the operation, in which case the collateral circulation cannot be maintained after the main vessel is tied. There is a danger, too, of injuring the middle branch of the sciatic nerve, in the incisions required to reach the artery; and, lastly, there is a possibility of this vessel dividing higher up than usual. Considering these facts in reference to those cases in which it might be supposed necessary to tie the popliteal artery--such cases, for example, as aneurism of either of the crural arteries, or secondary haemorrhages occurring after amputations of the leg at a time when the healing process was far advanced and the bleeding vessels inaccessible,--it becomes a question whether it would not be preferable to tie the femoral, rather than the popliteal artery. But when the popliteal artery itself becomes affected with aneurism, and when, in addition to the anatomical circumstances which forbid the application of a ligature to this vessel, we consider those which are pathological,--such as the coats of the artery being here diseased, the relative position of the neighbouring parts being disturbed by the tumour, and the large irregular wound which would be required to isolate the disease, at the risk of danger to the health from profuse suppuration, to the limb from destruction of the collateral branches, or to the joint from cicatrization, rendering it permanently bent,--we must acknowledge at once the necessity for tying the femoral part of the main vessel.

When the popliteal artery happens to be divided in a wound, it will be required to expose its bleeding orifices, and tie both these in the wound. For this purpose, the following operation usually recommended for reaching the vessel may be necessary. The skin and fascia lata are to be incised in a direction corresponding to that of the vessel. The extent of the incision must be considerable, (about three inches,) so as the more conveniently to expose the artery in its deep situation. On laying bare the outer margin of the semi-membranosus muscle, while the knee is straight, it now becomes necessary to flex the joint, in order that this muscle may admit of being pressed inwards from over the vessel. The external margin of the wound, including the middle branch of the sciatic nerve, should be retracted outwards, so as to ensure the safety of that nerve, while room is gained for making the deeper incisions. The adipose substance, which is here generally abundant, should now be divided, between the mesial line and the semimembranosus, till the sheath of the vessels be exposed. The sheath should be incised at its inner side, to avoid wounding the popliteal vein. The pulsation of the artery will now indicate its exact position. As the vein adheres firmly to the coats of the artery, some care is required to separate the two vessels, so as to pass the ligature around each end of the artery from without inwards, while excluding the vein. While this operation is being performed in a case of wound of the popliteal artery, the haemorrhage may be arrested by compressing the femoral vessel, either against the femur or the os pubis.

In the operation for tying the posterior tibial artery near its middle, an incision of three or four inches in extent is to be made through the skin and fascia, in a line corresponding with the inner posterior margin of the tibia and the great muscles of the calf. The long saphena vein should be here avoided. The origins of the gastrocnemius and soleus muscles require to be detached from the tibia, and then the knee is to be flexed and the foot extended, so as to allow these muscles to be retracted from the plane of the vessels. This being done, the deep fascia which covers the artery and its accompanying nerve is next to be divided. The artery will now appear pulsating at a situation an inch from the edge of the tibia. While the ligature is being passed around the artery, due care should be taken to exclude the venae comites and the nerve.

DESCRIPTION OF PLATES 65 & 66.

PLATE 65.

A. Tendon of the gracilis muscle.

B B. The fascia lata.

C C. Tendon of the semimembranosus muscle.

D. Tendon of the semitendinosus muscle.

E E. The two heads of the gastrocnemius muscle.

F. The popliteal artery.

G. The popliteal vein joined by the short saphena vein.

H. The middle branch of the sciatic nerve.

I. The outer (peronaeal) branch of the sciatic nerve.

K. The posterior tibial nerve continued from the middle branch of the
sciatic, and extending to K, behind the inner ankle.

L. The posterior (short) saphena vein.

M M. The fascia covering the gastrocnemius muscle.