[Illustration: _Plate 1._
_Drawn by F.F. Giraud. 1823._ _Engraved by J. Stewart._
_London. Published 1824, by Messrs. Longman, Hurst, Rees, Orme, Brown &
Green._]
In the usual manner of dissecting a side view of the pelvic viscera, an
unnatural bearing is given to several important parts, by the following
circumstances:—To assist the dissector a curved sound is previously
introduced into the urethra, the consequence of which is, that the canal
necessarily assumes whatever form the instrument may have. Views so taken
are therefore incorrect, and give an erroneous idea of the natural course
of the canal. The bladder and rectum are also excessively distended,
the former being inflated to its utmost, and the latter filled with
baked horse-hair. When the bladder is thus distended it rises out of the
pelvis; and if in the dissection, the abdominal muscles have been turned
aside, and the cellular connexions of the bladder much disturbed, its
rise is so considerable as to elevate the prostate gland, and thus give a
more horizontal bearing to the prostatic and membranous portions of the
urethra. The distending the rectum also adds to the erroneous impression,
by elevating the bladder, and thus bringing the base of the bladder,
prostate gland and membranous urethra into a nearly horizontal line.
Such a view is calculated to give a correct anatomical idea of the course
of the canal under retention of urine, and shews the propriety of using
a catheter with the curve recommended by Sir Astley Cooper. The relative
situation, however, of these parts is widely different when regarded in a
lithotomic point of view.
In a person prepared for the operation the rectum is emptied by purgative
medicine and an enema; and the bladder, which in a stone patient seldom
contains more than eight ounces of urine, occupies the hollow of the
flaccid or contracted rectum. Care has been taken not to distort these
parts by the introduction of an instrument into the urethra, nor by more
distention than was sufficient to preserve a general outline. To Mr.
Giraud, dresser to Sir Astley Cooper, I am indebted for the drawings;
the object of this plate being to represent the true bearing of the
parts concerned in Lithotomy, they were drawn of the natural size, by
measurement, from a young man, twenty-nine years of age, who died after
six days illness; and the dissection being completed within twelve hours
after his decease, the rigidity of death still remaining retained the
parts in situ.
_a._ Section of the left os pubis.
_b._ Articular surface of the sacrum.
_c._ Section of the left crus penis.
_d._ Bulb of the penis.
_e._ Membranous portion of the urethra.
_f._ Prostate gland; its posterior edge concealed by veins.
_g._ Base of the bladder sinking considerably below the level
of the prostate.
The relative bearing of the parts marked _e_, _f_, _g_, may be noticed,
in reference to the introduction of the instrument, as delineated in
Plate II.
When the pelvis is bent upon the lumbar vertebræ, and the shoulders of
the patient raised, as in the posture for Lithotomy, these parts will
have a rather more perpendicular bearing than even is in this view
represented.
_h._ The veins returning the blood from the vena magna ipsius
penis injected with wax, entering the pelvis under the pubic
arch, through the triangular ligament, in which the vein begins
to form a plexus, and concealing the posterior edge of the
prostate. In the Celsian operation, this part of the neck of
the bladder was cut laterally without dividing the prostate,
whence may be inferred the cause of its fatality. In the Gorget
operation, if the wound in the prostate is too small for the
calculus to pass, this part of the bladder is torn.
_i._ Triangular ligament, section of. This ligament connects
the membranous part of the urethra and prostate gland with
the arch of the pubes, protects the dorsal nerve, artery, and
veins, in their course to the dorsum penis, and serves the
purpose of a barrier between the perineum and the reticular
texture surrounding the bladder; it sends a process on each
side of the prostate gland, to cover the vesiculæ seminales.
The escape of urine after Lithotomy can only be productive
of mischief, by infiltrating the cells of the scrotum, or by
making its way upwards by the side of the bladder behind this
ligament, when the prostate has been torn from its connexions.
_k._ Rectus abdominis, section of.
_l._ Peritoneum reflected over the fundus and back part of the
bladder, and continued over the rectum.
_m._ Rectum partly distended by the introduction of a portion
of inflated ileum.
_n._ Accelerator urinæ reflected from the bulb, and discovering
the granular lobes of Cowpers’ gland between the bulb and
membranous urethra.
_o._ Muscle of the membranous part of the urethra reflected;
not forming a loop around the canal, but (as I have noticed in
many subjects), descending from the pubes, and attached to the
dense ligamento cellular structure which bounds the edge of the
accelerator urinæ; it is continuous with the levator ani.
_p._ Compressor prostatæ and levator ani partly reflected.
_q._ Section of pyriformis.
_r._ Vas deferens.
_s._ Vesiculæ seminalis, partly concealed by the veins
returning the blood from the prostate not in this subject
injected.
_t._ Ureter.
_u._ Small intestines turned over the abdominal muscles on the
right side, the latter having been left attached to the sternum
and ribs.
_w._ Lower part of the thorax.
_x._ Lumbar mass of muscles.
_y._ Anus.