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.) ]
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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 ..
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
Plate 64,--Figure 3.