2, Plate 53, and detaching and depressing this from the perinaeal
centre, the prostate, C C, and base of the bladder, P, are brought into
view. The pelvic fascia may be now felt reflected from the inner surface
of the levator ani muscle to the bladder at a level corresponding with
the base of the prostate, and the neck of the bladder in front, and the
vesiculae seminales, N N, laterally. In this manner the pelvic fascia
serves to insulate the perinaeal space from the pelvic cavity. The
prostate occupies the centre of the perinaeum. If the perinaeum were to
be penetrated at a point midway between the bulb of the urethra and the
anus, and to the depth of two inches straight backwards, the instrument
would transfix the apex of the gland. Its left lobe lies directly under
the middle of the line of incision which the lithotomist makes through
the surface; a fibrous membrane forms a capsule for the gland, and
renders its surface tough and unyielding, but its proper substance is
friable, and may be lacerated or dilated with ease, after having partly
incised its fibrous envelope. The membranous part of the urethra, M,
Fig. 2, Plate 53, enters the apex of the prostate, and traverses this
part in a line, nearer to the upper than to the under surface; and that
portion of the canal which the gland surrounds, is named prostatic. The
prostate is separated from the pudic artery by the levator ani muscle,
and from the artery of the bulb, by the deep perinaeal fascia and the
muscular fibres enclosed between its two layers.
The prostate being a median structure, is formed of two lobes, united at
the median line. The bulbus urethrae being also a median structure, is
occasionally found notched in the centre, and presenting a bifid
appearance. On the base of the bladder, P, Fig. 2, Plate 53, the two
vasa deferentia, Q Q, are seen to converge from behind forwards, and
enter the base of the gland; a triangular interval is thus formed
between the vasa, narrower before than behind, and at the middle of this
place the point of the trocar is to be passed (through the rectum,) for
the purpose of evacuating the contents of the bladder, when other
measures fail. When this operation is required to be performed, the
situation of the prostate is first to be ascertained through the bowel;
and at a distance of an inch behind the posterior border of the gland,
precisely in the median line, the distended base of the bladder may be
safely punctured. If the trocar pierce the bladder at this point, the
seminal vessels converging to the prostate from either side, and the
recto-vesical serous pouch behind, will escape being wounded. If the
prostate happen to be much enlarged, the relative position of the
neighbouring parts will be found disturbed, and in such case the bladder
can be punctured above the pubes with greater ease and safety. In cases
of impassable stricture, when extravasation of urine is threatened, or
has already occurred, the urethra should be opened in the perinaeum
behind the place where the stricture is situated, and this (in the
present instance) certainly seems to be the more effectual measure, for
at the same time that the stricture is divided, the contents of the
bladder may be evacuated through the perinaeum. If the membranous part
of the urethra be that where the stricture exists, a staff with a
central groove is to be passed as far as the strictured part, and having
ascertained the position of the instrument by the finger in the bowel,
the perinaeum should be incised, at the middle line, between the bulb of
the urethra and the anus. The urethra in this situation will be found to
curve backwards at the depth of an inch or more from the surface. The
point of the staff is now to be felt for, and the urethra is to be
incised upon it. The bistoury is next to be carried backwards through
the stricture till it enters that part of the urethra (usually dilated
in such cases) which intervenes between the seat of obstruction and the
neck of the bladder.
The lateral operation of lithotomy is to be performed according to the
above described anatomical relations of the parts concerned. The bowel
being empty and the bladder moderately full, a staff with a groove in
its left side is to be passed by the urethra into the bladder. The
position and size of the prostate is next to be ascertained by the left
fore-finger in the rectum. Having now explored the surface of the
perinaeum in order to determine the situation of the left tuberosity and
ischio-pubic ramus, in relation to the perinaeal middle line, the staff
being held steadily against the symphysis pubis, the operator proceeds
to divide the skin and superficial fascia on the left side of the
perinaeum, commencing the incision on the left of the raphe about an
inch in front of the anus, and carrying it downwards and outwards midway
between the anus and ischiatic tuberosity, to a point below these parts.
The left fore-finger is then to be passed along the incision for the
purpose of parting the loose cellular tissue; and any of the more
resisting structures, such as the transverse and levator ani muscles,
are to be divided by the knife. Deep in the forepart of the wound, the
position of the staff is now to be felt for, and the structures which
cover the membranous portion of the urethra are to be cautiously
divided. Recollecting now that the artery of the bulb passes anterior to
the staff in the urethra on a level with the bulb, the vessel is to be
avoided by inserting the point of the knife in the groove of the staff
as far backwards--that is, as near the apex of the prostate--as
possible. The point of the knife having been inserted in the groove of
the staff, the bowel is then to be depressed by the left fore-finger;
and now the knife, with its back to the staff, and its edge lateralized
(towards the lower part of the left tuber ischii), is to be pushed
steadily along the groove in the direction of the staff, and made to
divide the membranous part of the urethra and the anterior two-thirds of
the left lobe of the prostate. The gland must necessarily be divided to
this extent if the part of the urethra which it surrounds be traversed
by the knife. The extent to which the prostate is divided depends upon
the degree of the angle which the knife, passing along the urethra,
makes with the staff. The greater this angle is, the greater the extent
to which the gland will be incised. The knife being next withdrawn, the
left fore-finger is to be passed through the opening into the bladder,
and the parts are to be dilated by the finger as it proceeds, guided by
the staff. The staff is now to be removed while the point of the finger
is in the neck of the bladder, and the forceps is to be passed into the
bladder along the finger as a guide. The calculus, now in the grip of
the forceps, is to be extracted by a slow undulating motion.
The general rules to be remembered and adopted in performing the
operation of lithotomy are as follow:--1st, The incision through the
skin and sub-cutaneous cellular membrane should be freely made, in order
that the stone may be easily extracted and the urine have ready egress.
The incision which (judging from the anatomical relations of the parts)
appears to be best calculated to effect these objects, is one which
would extend from a point an inch above the anus to a point in the
posterior perinaeal space an inch or more below the anus. The wound thus
made would depend in relation to the neck of the bladder; the important
parts, vessels, &c., in the anterior perinaeal space would be avoided
where the incision, if extended upwards, would have no effect whatever
in facilitating the extraction of the stone or the egress of the urine;
and what is also of prime importance, the external opening would
directly correspond with the incision through the prostate and neck of
the bladder. 2nd, After the incision through the skin and superficial
fascia is made, the operator should separate as many of the deeper
structures as will admit of it, by the finger rather than by the knife;
and especially use the knife cautiously towards the extremities of the
wound, so as to avoid the artery of the bulb, and the bulb itself in the
upper part, and the rectum below. The pudic artery will not be
endangered if the deeper parts be divided by the knife, with its edge
directed downwards and outwards, while its point slides securely along
the staff in the prostate. 3rd, The prostate should be incised
sparingly, for, in addition to the known fact that the gland when only
partly cut admits of dilatation to a degree sufficient to admit the
passage of even a stone of large size, it is also stated upon high
authority that by incising the prostate and neck of the bladder to a
length equal to the diameter of the stone, such a proceeding is more
frequently followed with disastrous results, owing to the circumstance
that the pelvic fascia being divided at the place where it is reflected
upon the base of the gland and the side and neck of the bladder, allows
the urine to infiltrate the cellular tissue of the pelvis. [Footnote]
[Footnote: "The object in following this method," Mr. Liston observes,
"is to avoid all interference with the reflexion of the ilio-vesical
fascia from the sides of the pelvic cavity over the base of the gland
and side of the bladder. If this natural boundary betwixt the external
and internal cellular tissue is broken up, there is scarcely a
possibility of preventing infiltration of the urine, which must almost
certainly prove fatal. The prostate and other parts around the neck of
the bladder are very elastic and yielding, so that without much solution
of their continuity, and without the least laceration, the opening can
be so dilated as to admit the fore-finger readily through the same
wound; the forceps can be introduced upon this as a guide, and they can
also be removed along with a stone of considerable dimensions, say from
three to nearly five inches in circumference, in one direction, and from
four to six in the largest."--Practical Surgery, page 510. This doctrine
(founded, no doubt, on Mr. Liston's own great experience) coincides with
that first expressed by Scarpa, Le Cat, and others. Sir Benjamin Brodie,
Mr. Stanley, and Mr. Syme are also advocates for limited incisions,
extending no farther than a partial division of the prostate, the rest
being effected by dilatation. The experience, however, of Cheselden,
Martineau, and Mr. S. Cooper, inclined them in favour of a rather free
incision of the prostate and neck of the bladder proportioned to the
size of the calculus, so that this may be extracted freely, without
lacerating or contusing the parts, "and," says the distinguished
lithotomist Klein, "upon this basis rests the success of my operations;
and hence I invariably make it a rule to let the incision be rather too
large than too small, and never to dilate it with any blunt instrument
when it happens to be too diminutive, but to enlarge it with a knife,
introduced, if necessary, several times."--Practische Ansichten der
Bedeutendsten Chirurgische Operationen. Opinions of the highest
authority being thus opposed, in reference to the question whether free
or limited incisions in the neck of the bladder are followed
respectively by the greater number of fatal or favourable results, and
these being thought mainly to depend upon whether the pelvic fascia be
opened or not, one need not hesitate to conclude, that since facts seem
to be noticed in support of both modes of practice equally, the issue of
the cases themselves must really be dependent upon other circumstances,
such as the state of the constitution, the state of the bladder, and the
relative position of the internal and external incisions. "Some
individuals (observes Sir B. Brodie) are good subjects for the
operation, and recover perhaps without a bad symptom, although the
operation may have been very indifferently performed. Others may be
truly said to be bad subjects, and die, even though the operation be
performed in the most perfect manner. What is it that constitutes the
essential difference between these two classes of cases? It is,
according to my experience, the presence or absence of organic
disease."--Diseases of the Urinary Organs.]
The position in which the staff is held while the membranous urethra and
prostate are being divided should be regulated by the operator himself.
If he requires the perinaeum to be protruded and the urethra directed
towards the place of the incision, he can effect this by depressing the
handle of the instrument a little towards the right groin, taking care
at the same time that the point is kept beyond the prostate in the
interior of the bladder.
DESCRIPTION OF THE FIGURES OF PLATES 52 & 53.
PLATE 52.
FIGURE 1.
A. The urethra.
B. Accelerator urinae muscle.
C. Central perinaeal tendon.
D D. Right and left erector penis muscle.
E E. The transverse muscles.
F. The anus.
G G. The ischiatic tuberosities.
H. The coccyx.
I I. The glutei muscles.
K K. The levator ani muscle.
L. The left artery of the bulb.
[Illustration: Abdomen, showing blood vessels and other internal organs.]
Plate 52.--Figure 1
FIGURE 2.
A, D, F, G, H, I, K, L refer to the same parts as in Fig. 1, Plate 52.
B. The urethra.
C. Cowper's glands between the two layers of--
E. The deep perinaeal fascia.
M. The bulb of the urethra.
[Illustration: Abdomen, showing blood vessels and other internal organs.]
Plate 52.--Figure 2
PLATE 53.
FIGURE 1.
A, B, C, E, F, G, H, I, K, L refer to the same parts as in Fig. 2, Plate
52.
D D. The two crura penis.
M. The urethra in section
N N. The rectum.
O. The sacro-sciatic ligament.
[Illustration: Abdomen, showing blood vessels and other internal organs.]
Plate 53.--Figure 1
FIGURE 2.
A, B, D, G, H, I, K, L, O refer to the same parts as in Fig. 1, Plate 53.
C C. The two lobes of the prostate.
F. The rectum turned down.
M. The membranous part of the urethra.
N N. The vesiculae seminales.
P. The base of the bladder.
Q Q. The two vasa deferentia.
[Illustration: Abdomen, showing blood vessels and other internal organs.]
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.
[Illustration: Abdomen, showing blood vessels and other internal organs.]
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.
[Illustration: Abdomen, showing blood vessels and other internal organs.]
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.]
[Illustration: Abdomen, showing blood vessels and other internal organs.]
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.]
[Illustration: Abdomen, showing blood vessels and other internal organs.]
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.]
[Illustration: Abdomen, showing blood vessels and other internal organs.]
Plate 55--Figure 3