PLATE I.
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.