DESCRIPTION OF PLATE 47.
A. The aorta at its point of bifurcation.
B. The anterior superior iliac spine.
C. The symphysis pubis.
D. Poupart’s ligament, immediately above which are seen the circumflex ilii and epigastric arteries, with the vas deferens and spermatic vessels.
E E*. The right and left iliac muscles covered by the peritonaeum; the external cutaneous nerve is seen through the membrane.
F. The vena cava.
G G*. The common iliac arteries giving off the internal iliac branches on the sacro-iliac symphyses; g g, the right and left ureters.
H H*. The right and left common iliac veins.
I I*. The right and left external iliac arteries, each is crossed by the circumflex ilii vein.
K K *. The right and left external iliac veins.
L. The urinary bladder covered by the peritonaeum.
M. The rectum intestinum.
N. The profundus branch of the femoral artery.
O. The femoral vein; O, the saphena vein.
P. The anterior crural nerve.
Q. The sartorius muscle, cut.
S. The pectinaeus muscle.
T. The adductor longus muscle.
U. The gracilis muscle.
V. The tendinous sheath given off from the long adductor muscle, crossing the vessels, and becoming adherent to the vastus internus muscle.
W. The femoral artery. The letter is on the part where the vessel becomes first covered by the sartorius muscle.
Plate 47.
COMMENTARY ON PLATES 48 & 49.
THE RELATIVE ANATOMY OF THE MALE PELVIC ORGANS.
As the abdomen and pelvis form one general cavity, the organs contained in both regions are thereby intimately related. The viscera of the abdomen completely fill this region, and transmit to the pelvic organs all the impressions made upon them by the diaphragm and abdominal walls. The expansion of the lungs, the descent of the diaphragm, and the contraction of the abdominal muscles, cause the abdominal viscera to descend and compress the pelvic organs; and at the same time the muscles occupying the pelvic outlet, becoming relaxed or contracted, allow the perinaeum to be protruded or sustained voluntarily according to the requirements. Thus it is that the force originated in the muscular parietes of the thorax and abdomen is, while opposed by the counterforce of the perinæal muscles, brought so to bear upon the pelvic organs as to become the principal means whereby the contents of these are evacuated. The abdominal muscles are, during this act, the antagonists of the diaphragm, while the muscles which guard the pelvic outlet become at the time the antagonists of both. As the pelvic organs appear therefore to be little more than passive recipients of their contents, the voluntary processes of defecation and micturition may with more correctness be said to be performed rather for them than by them. The relations which they bear to the abdomen and its viscera, and their dependence upon these relations for the due performance of the processes in which they serve, are sufficiently explained by pathological facts. The same system of muscles comprising those of the thorax, abdomen and perinaeum, performs consentaneously the acts of respiration, vomiting, defecation and micturition. When the spinal cord suffers injury above the origin of the phrenic nerve, immediate death supervenes, owing to a cessation of the respiratory act. Considering, however, the effect of such an injury upon the pelvic organs alone, these may be regarded as being absolutely excluded from the pale of voluntary influence in consequence of the paralysis of the diaphragm, the abdominal and perinæal muscles. The expulsory power over the bladder and rectum being due to the opposing actions of these muscles above and below, if the cord be injured in the neck below the origin of the phrenic nerve, the inferior muscles becoming paralysed, the antagonism of muscular forces is thereby interrupted, and the pelvic organs are, under such circumstances, equally withdrawn from the sphere of volition. The antagonism of the abdominal muscles to the diaphragm being necessary, in order that the pelvic viscera may be acted upon, if the cord be injured in the lower dorsal region, so as to paralyse the abdominal walls and the perinæal muscles, the downward pressure of the diaphragm alone could not evacuate the pelvic organs voluntarily, for the abdominal muscles are now incapable of deflecting the line of force backwards and downwards through the pelvic axis; and the perinæal muscles being also unable to act in agreement, the contents of the viscera pass involuntarily. Again, as the muscular apparatus which occupies the pelvic outlet acts antagonistic to the abdomen and thorax, when by an injury to the cord in the sacral spine the perinæal apparatus alone becomes paralysed, its relaxation allows the thoracic and abdominal force to evacuate the pelvic organs involuntarily. It would appear, therefore, that the term “paralysis” of the bladder or rectum, when following spinal injuries, &c. &c. means, or should mean, only a paralytic state of the abdomino-pelvic muscular apparatus, entirely or in part. For, in fact, neither the bladder nor rectum ever acts voluntarily per se any more than the stomach does, and therefore the name “detrusor” urinae, as applied to the muscular coat investing the bladder, is as much a misnomer (if it be meant that the act of voiding the organ at will be dependent upon it) as would be the name “detrusor” applied to the muscular coat of the stomach, under the meaning that this were the agent in the spasmodic effort of vomiting.
The urinary bladder, G, Plate 49, (in the adult body,) occupies the true pelvic region when the organ is collapsed, or only partly distended. It is situated behind the pubic symphysis and in front of the rectum, C,—the latter lies between it and the sacrum, A. In early infancy, when the pelvis is comparatively small, the bladder is situated in the hypogastric region, with its summit pointing towards the umbilicus; as the bladder varies in shape, according to whether it be empty or full, its relations to neighbouring parts, especially to those in connexion with its summit, vary also considerably. When empty, the back and upper surface of the bladder collapse against its forepart, and in this state the organ lies flattened against the pubic symphysis. Whether the bladder be distended or not, the small intestines lie in contact with its upper surface, and compress it in the manner of a soft elastic cushion. When distended largely, its summit is raised above the pubic symphysis, the small intestines having yielded place to it, and in this state it can be felt by the hand laid upon the hypogastrium.
The shape of the bladder varies in different individuals. In some it is rounded, in others pyriform, in others peaked towards its summit. Its capacity varies also considerably at different ages and in different sexes. When distended, its long axis will be found to coincide with a line passing from a point midway between the navel and pubes to the point of the coccyx, the obliquity of this direction being greatest when the body is in the erect posture, for the intestines now gravitate upon it. When the body is recumbent, the bladder recedes somewhat from the pubes, and as the intestines do not now press upon it from above, it allows of being distended to a much greater degree without causing uneasiness, and a desire to void its contents.
The manner in which the bladder is connected to neighbouring parts is such as to admit of its full distension. Its summit, back, and upper sides are free and covered by the elastic peritonaeum, whilst its front, lower sides, and base are adherent to adjacent parts, and divested of the serous membrane. On tracing the peritonaeum from the front wall of the abdomen to its point of reflexion over the summit of the bladder, we find the membrane to be in this part so loosely adherent, that the bladder when much distended, raises the peritonaeum above the level of the upper margin of the pubic symphysis. In this state the organ may be punctured immediately above the pubic symphysis without endangering the serous sac. When the bladder is collapsed, the peritonaeum follows its summit below the level of the pubes, and in this position of the organ such an operation would be inadmissible, if indeed the necessity for it can now be conceived.
By removing the os innominatum, A D, Plate 48, together with the internal obturator, and levator ani muscles, which arise from its inner side, we obtain a lateral view, Plate 49, of the pelvic viscera, and of the vessels &c. connected with them. Those parts of the bladder, G, and the rectum, C, which are invested by the peritonaeum, are also now fully displayed. On tracing this membrane from before backwards, over the summit of the bladder, G, we find it descending deeply upon the posterior surface of the organ, before it becomes reflected so as to ascend over the forepart of the rectum. This duplicature of the serous membrane, H H, is named the recto-vesical pouch, and it is required to ascertain with all the exactness possible the level to which it descends, so as to avoid it in the operation of puncturing the bladder through the rectum. The serous pouch descends lower in some bodies than in others; but in all there exists a space, of greater or less dimensions, between it and the prostate, V, whereat the base of the bladder is in direct apposition with the rectum, W, the serous membrane not intervening.
When the peritonaeum is traced from one iliac fossa to the other, we find it sinking deeply into the hollow of the pelvis behind the bladder, so as to form the sides of the recto-vesical pouch; but when traced over the summit of the bladder, this organ is seen to have the membrane reflected upon it, almost immediately below the pelvic brim. At the situations where the peritonaeum becomes reflected in front, laterally, and behind, upon the sides of the bladder, the membrane is thrown into folds, which are named “false ligaments.” The pelvic fascia, in being reflected to the bladder from the front and sides of the pelvis, at a lower level than that of the peritonaeum, forms the “true ligaments.” In addition to these ligaments, which serve to keep the base and front of the bladder fixed in the pelvis, other structures, such as the ureters, K, the vasa deferentia, I, the hypogastric cords, the urachus, and the bloodvessels, embrace the organ in various directions, and act as bridles, to limit its expansion more or less in all directions, but least so towards its summit, which is always comparatively free.
The neck and outlet of the bladder, V, are situated at the anterior part of its base, and point towards the subpubic space. The prostate gland, V, surrounds its neck, and occupies a position behind and below the pubic arch, D, and in front of the rectum, W. The gland, V, being of a rounded form and dense structure, can be felt in this situation by the finger, passed upwards through the bowel. The prostate is suspended from the back of the pubic arch by the anterior true ligament of the bladder, and at its forepart, where the membranous portion of the urethra commences, this passes through the deep perinæal fascia, X. The anterior fibres of the levator ani muscle embrace the prostate on both its sides. Behind the base of the prostate, the ureter, K, is seen to enter the coats of the bladder obliquely, whilst the vas deferens, I, joined by the vesicula seminalis, L, penetrates the substance of the prostate, V, at its lower and back part, which lies in apposition with the rectum.
The rectum, W C, at its middle and upper parts, occupies the hollow of the sacrum, A Q, and is behind the bladder. The lower third of the rectum, W, not being covered by the peritonaeum, is that part on which the various surgical operations are performed. At its upper three-fifths, the rectum describes a curve corresponding to that of the sacrum; and if the bladder be full, its convex back part presses the bowel against the bone, causing its curve to be greater than if the bladder were empty and collapsed. This fact requires to be borne in mind, for, in order to introduce a bougie, or to allow a large injection to pass with freedom into the bowel, the bladder should be first evacuated. The coccygeal bones, Q, continuing in the curve of the sacrum, bear the rectum, W, forwards against the base of the bladder, and give to this part a degree of obliquity upwards and backwards, in respect to the perinaeum and anus. From the point where the prostate, V, lies in contact with the rectum, W, this latter curves downwards, and slightly backwards, to the anus, P. The prostate is situated at a distance of about an inch and a half or two inches from the anus—the distance varying according to whether the bladder and bowel be distended or not. [Footnote]
[Footnote: The distance between any two given parts is found to vary in different cases. “In subjects of an advanced age,” Mr. Stanley remarks, “a deep perinaeum, as it is termed, is frequently met with. This may be occasioned either by an unusual quantity of fat in the perinaeum, or by an enlarged prostate, or by the dilatation of that part of the rectum which is contiguous to the prostate and bladder. Under either of these circumstances, the prostate and bladder become situated higher in the pelvis than naturally, and consequently at a greater distance from the perinaeum.”—On the Lateral Operation of Lithotomy.]
The arteries of the bladder are derived from the branches of the internal iliac, S. The rectum receives its arteries from the inferior mesenteric and pudic. The veins which course upwards from the rectum are large and numerous, and devoid of valves. When these veins become varicose, owing to a stagnation of their circulation, produced from whatever cause, the bowel is liable to be affected with haemorrhoids or to assume a haemorrhagic tendency.
The pudic artery, S s, is a branch of the internal iliac. It passes from the pelvis by the great sciatic foramen, below the pyriformis muscle, and in company with the sciatic artery. The pudic artery and vein wind around the spine, E, of the ischium, where they are joined by the pudic nerve, derived from, T, the sacral plexus. The artery, in company with the nerve and vein, re-enters the pelvis by the small sciatic foramen, and gets under cover of a dense fibrous membrane (obturator fascia), between which and the obturator muscle, it courses obliquely downwards and forwards to the forepart of the perinaeum. At the place where the vessel re-enters the pelvis, it lies removed at an interval of an inch and a half from the perinaeum, but becomes more superficial as it approaches the subpubic space, N. The levator ani muscle separates the pudic vessels and nerves from the sides of the rectum and bladder. The principal branches given off from the pudic artery of either side, are (1st), the inferior hemorrhoidal, to supply the lower end of the rectum; (2nd), the transverse and superficial perinæal; (3rd), the artery of the bulb; (4th), that which enters the corpus cavernosum of the penis, N; and (5th), the dorsal artery of the penis. [Footnote] The branches given off from the pudic nerve correspond in number and place to those of the artery. Having now considered the relations of the pelvic organs in a lateral view, we are better prepared to understand these relations when seen at their perinæal aspect.
[Footnote: The pudic artery, or some one of its branches, occasionally undergoes marked deviations from the ordinary course. In Mr. Quain’s work, (“Anatomy of the Arteries,”) a case is represented in which the artery of the bulb arose from the pudic as far back as the tuber ischii, and crossed the line of incision made in the lateral operation of lithotomy. In another figure is seen a vessel (“accessory pudic”), which, passing between the base of the bladder and the levator ani muscle, crosses in contact with the left lobe of the prostate.]
DESCRIPTION OF PLATES 48 & 49.
PLATE 48.
A. The anterior superior iliac spine.
B. The anterior inferior iliac spine.
C. The acetabulum; c, the ligamentum teres.
D. The tuber ischii.
E. The spine of the ischium.
F. The pubic horizontal ramus.
G. The summit of the bladder covered by the peritonaeum.
H. The femoral artery.
I. The femoral vein.
K. The anterior crural nerve.
L. The thyroid ligament.
M. The spermatic cord.
N. The corpus cavernosum penis; n, its artery.
O. The urethra; o, the bulbus urethrae.
P. The sphincter ani muscle.
Q. The coccyx.
R. The sacro-sciatic ligament.
S. The pudic artery and nerve.
T. The sacral nerves.
U. The pyriformis muscle, cut.
V. The gluteal artery.
W. The small gluteus muscle.
Plate 48
PLATE 49.
A. The part of the sacrum which joins the ilium.
B. The external iliac artery, cut across.
C. The upper part of the rectum.
D. The ascending pubic ramus.
E. The spine of the ischium, cut.
F. The horizontal pubic ramus, cut.
G. The summit of the bladder covered by the peritonaeum; G *, its side, not covered by the membrane.
H H. The recto-vesical peritonaeal pouch,
I. The vas deferens.
K. The ureter.
L. The vesicula seminalis.
M, N, O, P, Q, R, S, T, U, refer to the same parts as in Plate 48.
V. The prostate.
W. The lower part of the rectum.
X. The deep perinæal fascia.
Plate 49
COMMENTARY ON PLATES 50 & 51.
THE SURGICAL DISSECTION OF THE SUPERFICIAL STRUCTURES OF THE MALE PERINAEUM.
The median line of the body is marked as the situation where the opposite halves unite and constitute a perfect symmetrical figure. Every structure—superficial as well as deep—which occupies the median line is either single, by the union of halves, or dual, by the cleavage and partition of halves. The two sides of the body being absolutely similar, the median line at which they unite is therefore common to both. Union along the median line is an occlusion taking place by the junction of sides; and every hiatus or opening, whether normal or abnormal, which happens at this line, signifies an omission in the process of central union. The sexual peculiarities are the results of the operation of this law, and all forms which are anomalous to either sex, may be interpreted as gradations in the same process of development; a few of these latter occasionally come under the notice of the surgeon.
The region which extends from the umbilicus to the point of the coccyx is marked upon the cutaneous surface by a central raphe dividing the hypogastrium, the penis, the scrotum, and the perinaeum respectively into equal and similar sides. The umbilicus is a cicatrix formed after the metamorphosis of a median foetal structure—the placental cord, &c. In the normal form, the meatus urinarius and the anus coincide with the line of the median raphe, and signify omissions at stated intervals along the line of central union. When between these intervals the process of union happens likewise to be arrested, malformations are the result; and of these the following are examples:—Extrusion of the bladder at the hypogastrium is caused by a congenital hiatus at the lower part of the linea alba, which is in the median line; Epispadias, which is an urethral opening on the dorsum of the penis; and Hypospadias, which is a similar opening on its under surface, are of the same nature—namely, omissions in median union. Hermaphrodism may be interpreted simply as a structural defect, compared to the normal form of the male, and as a structural excess compared to that of the female. Spina bifida is a congenital malformation or hiatus in union along the median line of the sacrum or loins. As the process of union along the median line may err by a defect or omission, so may it, on the other hand, err by an excess of fulfilment, as, for example, when the urethra, the vagina, or the anus are found to be imperforate. As the median line of union thus seems to influence the form of the hypogastrium, the genitals, and the perinaeum, the dissection of these parts has been conducted accordingly.
By removing the skin and subjacent adipose membrane from the hypogastrium, we expose the superficial fascia. This membrane, E E E*, Fig. 1, Plate 50, is, in the middle line, adherent to B, the linea alba, and thereby contributes to form the central depression which extends from the navel to the pubes. The adipose tissue, which in some subjects accumulates on either side of the linea alba, renders this depression more marked in them. At the folds of the groin the fascia is found adherent to Poupart’s ligament, and this also accounts for the depressions in both these localities. From the central linea alba to which the fascia adheres, outwards on either side to the folds of both groins, the membrane forms two distinct sacs, which droop down in front, so as to invest the testicles, E**, and penis in a manner similar to that of the skin covering these parts. As the two sacs of the superficial fascia join each other at the line B, coinciding with the linea alba, they form by that union the suspensory ligament of the penis, which is a structure precisely median.
The superficial fascia having invested the testicles each in a distinct sac, the adjacent sides of both these sacs, by joining together, form the median septum scroti, E, Fig. 2, Plate 50. In the perinaeum, Fig. 1, Plate 51, the fascia, A, may be traced from the back of the scrotum to the anus. In this region the membrane is found to adhere laterally to the rami of the ischium and pubes; whilst along the median perinæal line the two sacs of which the membrane is composed unite, as in the scrotum, and form an imperfect septum. In front of the anus, beneath the sphincter ani, the fascia degenerates into cellular membrane, one layer of which is spread over the adipose tissue in the ischio-rectal space, whilst its deeper and stronger layer unites with the deep perinæal fascia, and by this connexion separates the urethral from the anal spaces. The superficial fascia of the hypogastrium, the scrotum, and the perinaeum forming a continuous membrane, and being adherent to the several parts above noticed, may be regarded as a general double sac, which isolates the inguino-perinæal region from the femoral and anal regions, and hence it happens that when the urethra becomes ruptured, the urine which is extravasated in the perinaeum, is allowed to pass over the scrotum and the abdomen, involving these parts in consequent inflammation, whilst the thighs and anal space are exempt. The tunicae vaginales, which form the immediate coverings of the testicles, cannot be entered by the urine, as they are distinct sacs originally protruded from the abdomen. It is in consequence of the imperfect state of the inguino-perinæal septum of the fascia, that urine effused into one of the sacs is allowed to enter the other.
Like all the other structures which join on either side of the median line, the penis appears as a symmetrical organ, D D, Fig. 2, Plate 50. While viewed in section, its two corpora cavernosa are seen to unite anteriorly, and by this union to form a septum “pectiniforme;” posteriorly they remain distinct and lateral, F F, Fig. 2, Plate 51, being attached to the ischio-pubic rami as the crura penis. The urethra, B, Fig. 2, Plate 50, is also composed of two sides, united along the median line, but forming between them a canal by the cleavage and partition of the urethral septum. All the other structures of the perinaeum will be seen to be either double and lateral, or single and median, according as they stand apart from, or approach, or occupy the central line.
The perinaeum, Figs. 1, 2, Plate 51, is that space which is bounded above by the arch of the pubes, behind by C, the os coccygis, and the lower borders of, I I, the glutaei muscles and sacro-sciatic ligaments, and laterally by D D, the ischiatic tuberosities. The osseous boundaries can be felt through the integuments. Between the back of the scrotum and the anus the perinaeum swells on both sides of the raphe, A B, Fig. 3, Plate 50, and assumes a form corresponding with the bag of the superficial fascia which encloses the structures connected with the urethra. The anus is centrally situated in the depression formed between D D, the ischiatic tuberosities, and the double folds of the nates.
The perinaeum, Fig. 3, Plate 50, is, for surgical purposes, described as divisible into two spaces (anterior and posterior) by a transverse line drawn from one tuber ischii, D, to the other, D, and crossing in front of the anus. The anterior space, A D D, contains the urethra; the posterior space, D D C, contains the rectum. The central raphe, A B C, traverses both these spaces. The anterior or urethral space is (while viewed in reference to its osseous boundaries) triangular in shape, the apex being formed by the pubic symphysis beneath A, whilst two lines drawn from A to D D, would coincide with the ischio-pubic rami which form its sides. The raphe in the anterior space indicates the central position of the urethra, as may be ascertained by passing a sound into the bladder, when the shaft of the instrument will be felt prominently between the points A B. Behind the point B, the sound or staff sinks deeper in the perinaeum as it follows the curve of the urethra towards the bladder, and becomes overlaid by the bulb, &c.
The ischiatic tuberosities, D D, Fig. 3, Plate 50, are, in all subjects, sufficiently prominent to be felt through the integuments, &c.; and the line which, when drawn from one to the other, serves to divide the two perinæal spaces, forms the base of the anterior one. In well-formed subjects, the anterior space is equiangular, the base being equal to each side; but according as the tuberosities approach the median line, the base becomes narrowed, and the triangle is thereby rendered acute. These circumstances influence the direction in which the first incision in the lateral operation of lithotomy should be made. When the tuberosity of the left ischium stands well apart from the perinæal centre, the line of incision, B E, Fig. 3, Plate 50, is carried obliquely from above downwards and outwards; but in cases where the tuberosity approaches the centre, the incision must necessarily be made more vertical. The posterior perinæal space may be described on the surface by two lines drawn from D D, the ischiatic tuberosities, to C, the point of the coccyx, whilst the transverse line between D and D bounds it above.
By removing the integument and superficial fascia, we expose the superficial vessels and nerves, together with the muscles in the neighbourhood of the urethra and the anus. The accelerator urinae, E, Fig. 2, Plate 51, which embraces the urethra, and the sphincter ani, B C, which surrounds the anus, H, occupy the median line, and are divided each into halves by a central tendon, E B C, which traverses the perinaeum from before backwards, to the point of the coccyx. On either side of the anus, in the ischio-rectal space, D D, Fig. 1, Plate 51, is found a considerable quantity of granular adipose tissue, traversed by the inferior haemorrhoidal arteries and nerves-branches of the pudic artery and nerve.
In front of the anus are seen two small muscles (transversae perinaei), G G, Fig. 2, Plate 51, each arising from the tuber ischii of its own side, and the two becoming inserted into, B, the central tendon. These transverse muscles serve to mark the boundary between the anterior and posterior perinæal spaces. Behind each muscle is found a small artery, crossing to the median line. The left transverse muscle and artery are always divided in the lateral operation of lithotomy. On the outer sides of the anterior perinæal space are seen the erectores penis muscles, F F, overlaying the crura penis. Between each muscle and the accelerator urinae, the superficialis perinaei artery and nerve course forwards to the scrotum, &c.
The perinæal muscles having been brought fully into view, Plate 52, Fig. 1, their symmetrical arrangement on both sides of the median line at once strikes the attention. On either side of the anterior space appears a small angular interval, L, formed between B, the accelerator urinae, D, the erector penis, and E, the transverse muscle. Along the surface of this interval, the superficial perinæal artery and nerve are seen to pass forwards; and deep in it, beneath these, may also be observed, L, the artery of the bulb, arising from the pudic, and crossing inwards, under cover of the anterior layer of the membrane named the deep perinæal fascia. The first incision in the lateral operation of lithotomy is commenced over the inferior inner angle of this interval.
The muscles occupying the anterior perinæal space require to be removed, Fig. 1, Plate 53, in order to expose the urethra, B M, the crus penis, D, and the deep perinæal fascia. The fascia will be now seen stretched across the subpubic triangular space, reaching from one ischio-pubic ramus to the other, whilst by its lower border, corresponding with the line of the transversae perinaei muscles, it becomes continuous with the superficial fascia, in the manner before described. The deep perinæal fascia (triangular ligament) encloses between its two layers, C E, on either side of the urethra, the pudic artery, the artery of the bulb, Cowper’s glands, and some muscular fibres occasionally to be met with, to which the name “Compressor urethrae” has been assigned. At this stage of the dissection, as the principal vessels and parts composed of erectile tissue are now in view, their relative situations should be well noticed, so as to avoid wounding them in the several cutting operations required to be performed in their vicinity.
Along the median line (marked by the raphe) from the scrotum to the coccyx, and close to this line on either side, the vessels are unimportant as to size. The urethra lies along the middle line in the anterior perinæal space; the rectum occupies the middle in the posterior space. When either of these parts specially requires to be incised—the urethra for impassable stricture, &c., and the lower part of the rectum for fistula in ano—the operation may be performed without fear of inducing dangerous arterial haemorrhage. With the object of preserving from injury these important parts, deep incisions at, or approaching to, the middle line must be avoided. The outer (ischio-pubic) boundary of the perinaeum is the line along which the pudic artery passes. The anterior half of this boundary supports also the crus penis; hence, therefore, in order to avoid these, all deep incisions should be made parallel to, but removed to a proper distance from this situation. The structures placed at the middle line, B M F, Fig. 2, Plate 52, and those in connexion with the left perinæal boundary, D G L, require (in order to insure the safety of these parts) that the line of incision necessary to gain access to the neck of the bladder in lithotomy should be made through the left side of the perinaeum from a point midway between M, the bulb, and D, crus penis above, to a point, K, midway between the anus, F, and tuber ischii, G, below. As the upper end of this incision is commenced over the situation of the superficial perinæal artery and the artery of the bulb, the knife at this place should only divide the skin and superficial fascia. The lower end, K, just clears the outer side of the dilated lower part of the rectum. The middle of the incision is over the left lobe of the prostate gland and neck of the bladder, which parts, together with the membranous portion of the urethra, are still concealed by the deep perinæal fascia, the structures between its layers, and the anterior fibres of K, the levator ani muscle. The incision, if made in due reference to the relative situation of the parts above noticed, will leave them untouched; but when the pudic artery, or some one of its branches, deviates from its ordinary course and crosses the line of incision, a serious haemorrhage will ensue, despite the anatomical knowledge of the most experienced operator. When it is requisite to divide the superficial and deep sphincter ani as in the operation for complete fistula in ano, if the incision be made transversely in the ischio-rectal fossa, the haemorrhoidal arteries and nerves converging towards the anus will be the more likely to escape being wounded.
DESCRIPTION OF THE FIGURES OF PLATES 50 & 51.
PLATE 50.
FIGURE 1.
A. The umbilicus.
B. The linea alba.
C. The suspensory ligament of the penis.
D D. The two corpora cavernosa penis.
E E**. The hypogastric and scrotal superficial fascia.
F F. The spermatic cords.
FIGURE 2.
A. The umbilicus.
B. The urethra.
C*. The tunica vaginalis; c, the testicle invested by the tunic.
D D. The corpora cavernosa seen in section.
E. The scrotal raphe and septum scroti.
FIGURE 3.
A B. The perinæal raphè.
C. The place of the coccyx.
D D. The projections of the ischiatic tuberosities.
BE. The line of section in lithotomy.
Plate 50
PLATE 51.
FIGURE 1.
A. The superficial fascia covering the urethral space.
B. The sphincter ani.
C. The coccyx.
D D. The right and left ischiatic tuberosities.
H. The anus.
I I. The glutei muscles.
FIGURE 2.
A, B, C, D, H, I. The same parts as in Fig. 1.
E. The accelerator urinae muscle.
F F. Right and left erector penis muscle.
G G. Right and left transverse muscle.
Plate 51
COMMENTARY ON PLATES 52 & 53.
THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE MALE PERINAEUM.
THE LATERAL OPERATION OF LITHOTOMY.
The urethra, at its membranous part, M, Fig. 1, Plate 53, which commences behind the bulb, perforates the centre of the deep perinaeal fascia, E E, at about an inch and a half in front of F, the anus. The anterior layer of the fascia is continued forwards over the bulb, whilst the posterior layer is reflected backwards over the prostate gland.
Behind the deep perinaeal fascia, the anterior fibres of K, the levator ani muscle, arise from either side of the pubic symphysis posteriorly, and descend obliquely down wards and forwards, to be inserted into the sides of N N, the rectum above the anus. These fibres of the muscle, and the lower border of the fascia which covers them, lie immediately in front of the prostate, C C, Fig. 2, Plate 53, and must necessarily be divided in the operation of lithotomy. Previously to disturbing the lower end of the rectum from its natural position in the perinaeum, its close relation to the prostate and base of the bladder should be noticed. While the anus remains connected with the deep perinaeal fascia in front, the fibres of the levator ani muscle of the left side may be divided; and by now inserting the finger between them and the rectum, the left lobe of the prostate can be felt in apposition with the forepart of the bowel, an inch or two above the anus. It is owing to this connexion between these parts that the lithotomist has to depress the bowel, lest it be wounded, while the prostate is being incised. If either the bowel or the bladder, or both together, be over-distended, they are brought into closer apposition, and the rectum is consequently more exposed to danger during the latter stages of the operation. The prostate being in contact with the rectum, the surgeon is enabled to examine by the touch, per anum, the state of the gland. If the prostate be diseased and irregularly enlarged, the urethra, which passes through it, becomes, in general, so distorted, that the surgeon, after passing the catheter along the urethra as far as the prostate, will find it necessary to guide the point of the instrument into the bladder, by the finger introduced into the bowel. The middle or third lobe of the prostate being enlarged, bends the prostatic part of the urethra upwards. But when either of the lateral lobes is enlarged, the urethra becomes bent towards the opposite side.
By dividing the levator ani muscle on both sides of the rectum, F, Fig. 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.
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.
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.
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.
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.
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.
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.]
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.]
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.]
Plate 55—Figure 3
Fig. 1, Plate 56, represents by section the natural forms of the urethra and bladder. The general direction of the urethra measured during its relaxed state from the vesical orifice to the glans is usually described as having the form of the letter S laid procumbent to the right side [capital S rotated 90 degrees right] or to the left [capital S rotated 90 degrees left]. But as the anterior half of the canal is moveable, and liable thereby to obliterate the general form, while the posterior half is fixed, I shall direct attention to the latter half chiefly, since upon its peculiar form and relative position depends most of the difficulty in the performance of catheterism. The portion of the urethra which intervenes between the neck of the bladder, K, and the point E, where the penis is suspended from the front of the symphysis pubis by the suspensory ligament, assumes very nearly the form of a semicircle, whose anterior half looks towards the forepart, and whose posterior half is turned to the back of the pubis. The pubic arch, A, spans crossways, the middle of this part of the urethra, G, opposite the bulb H. The two extremes, F K, of this curve, and the lower part of the symphysis pubis, occupy in the adult the same antero-posterior level; and it follows, therefore, that the distance to which the urethra near its bulb, H, is removed from the pubic symphysis above must equal the depth of its own curve, which measures about an inch perpendicularly. The urethral aperture of the triangular ligament appears removed at this distance below the pubic symphysis, and that portion of the canal which lies behind the ligament, and ascends obliquely backwards and upwards to the vesical orifice on a level with the symphysis pubis in the adult should be remembered, as varying both in direction and length in individuals of the extremes of age. In the young, this variation is owing to the usual high position of the bladder in the pelvis, whilst in the old it may be caused by an enlarged state of the prostate. The curve of the urethra now described is permanent in all positions of the body, while that portion of the canal anterior to the point F, which is free, relaxed, and moveable, can by traction towards the umbilicus be made to continue in the direction of the fixed curve F K, and this is the general form which the urethra assumes when a bent catheter of ordinary shape is passed along the canal into the bladder. The length of the urethra varies at different ages and in different individuals, and its structure in the relaxed state is so very dilatable that it is not possible to estimate the width of its canal with fixed accuracy. As a general rule, the urethra is much more dilatable, and capable consequently of receiving an instrument of much larger bore in the aged than in the adult.
The three portions into which the urethra is described as being divisible, are the spongy, the membranous, and the prostatic. These names indicate the difference in the structure of each part. The spongy portion is the longest of the three, and extending from the glans to the bulb may be said on a rough, but for practical purposes, a sufficiently accurate estimate to comprise seven parts of the whole urethra, which measures nine. The membranous and prostatic portions measure respectively one part of the whole. These relative proportions of the three parts are maintained in different individuals of the same age, and in the same individual at different ages. The spongy part occupies the inferior groove formed between the two united corpora cavernosa of the penis, and is subcutaneous as far back as the scrotum under the pubes, between which point and the bulb it becomes embraced by the accelerator urinae muscle. The bulb and glans are expansions or enlargements of the spongy texture, and do not affect the calibre of the canal. When the spongy texture becomes injected with blood, the canal is rendered much narrower than otherwise. The canal of the urethra is uniform-cylindrical. The meatus is the narrowest part of it, and the prostatic part is the widest. At the point of junction between the membranous and spongy portions behind the bulb, the canal is described as being naturally constricted. Behind the meatus exists a dilatation (fossa navicularis), and opposite the bulb another (sinus of the bulb). Muscular fibres are said to enter into the structure of the urethra, but whether such be the case or not, it is at least very certain that they never prove an obstacle to the passage of instruments, or form the variety of stricture known as spasmodic. The urethra is lined by a delicate mucous membrane presenting longitudinal folds, which become obliterated by distention; and its entire surface is numerously studded with the orifices of mucous cells (lacunae), one of which, larger than the rest, appears on the upper side of the canal near the meatus. Some of these lacunae are nearly an inch long, and all of them open in an oblique direction forwards. Instruments having very narrow apices are liable to enter these ducts and to make false passages. The ducts of Cowper’s glands open by very minute orifices on the sides of the spongy urethra anterior to and near the bulb. On the floor of the prostatic urethra appears the crest of the veru montanum, upon which the two seminal ducts open by orifices directed forwards. On either side of the veru montanum the floor of the prostate may be seen perforated by the “excretory ducts” of this so-called gland. The part K, which is here represented as projecting from the floor of the bladder, near its neck, is named the “uvula vesicae,” (Lieutaud.) It is the same as that which is named the “third lobe of the prostate,” (Home.) The part does not appear as proper to the bladder in the healthy condition, Fig. 2, Plate 56. On either side of the point K may be seen the orifices, M M, of the ureters, opening upon two ridges of fibrous substance directed towards the uvula. These are the fibres which have been named by Sir Charles Bell as “the muscles of the ureters;” but as they do not appear in the bladder when in a state of health, I do not believe that nature ever intended them to perform the function assigned to them by this anatomist. And the same may be said of the fibres, which surrounding the vesical orifice, are supposed to act as the “sphincter vesicae.” The form of that portion of the base of the bladder which is named “trigone vesical” constitutes an equilateral triangle, and may be described by two lines drawn from the vesical orifice to both openings of the ureters, and another line reaching transversely between the latter. Behind the trigone a depression called “bas fond” is formed in the base of the bladder. Fig. 2, Plate 56, represents the prostate of a boy nine years of age. Fig. 3, Plate 56, represents that of a man aged forty years. A difference as to form and size, &c., is observable between both.
Plate 56—Figure 1, 2, 3
COMMENTARY ON PLATES 57 & 58.
CONGENITAL AND PATHOLOGICAL DEFORMITIES OF THE PREPUCE AND URETHRA.—STRICTURE AND MECHANICAL OBSTRUCTIONS OF THE URETHRA.
When any of the central organs of the body presents in a form differing from that which we term natural, or structurally perfect and efficient, if the deformity be one which results as a malformation, ascribable to an error in the law of development, it is always characterized as an excess or defect of the substance of the organ at, and in reference to, the median line. And when any of the canals which naturally open upon the external surface at the median line happens to deviate from its proper position, such deviation, if it be the result of an error in the law of development, always occurs, by an actual necessity, at the median line. On the contrary, though deformities which are the results of diseased action in a central organ may and do, in some instances, simulate those which occur by an error in the process of development, the former cannot bear a like interpretation with the latter, for those are the effects of ever-varying circumstances, whereas these are the effects of certain deviations in a natural process—a law, whose course is serial, gradational, and in the sequent order of a continuous chain of cause and effect.
Fig. 1, Plate 57, represents the prepuce in a state of congenital phymosis. The part hypertrophied and pendent projects nearly an inch in front of the meatus, and forms a canal, continued forwards from this orifice. As the prepuce in such a state becomes devoid of its proper function, and hence must be regarded, not only as a mere superfluity, but as a cause of impediment to the generative function of the whole organ, it should be removed by an operation.
Plate 57.—Figure 1.
Fig. 2, Plate 57, represents the prepuce in the condition of paraphymosis following gonorrhoeal inflammation. The part appears constricting the penis and urethra behind the corona glandis. This state of the organ is produced in the following-mentioned way:—the prepuce, naturally very extensible, becomes, while covering the glans, inflamed, thickened, and its orifice contracted. It is during this state withdrawn forcibly backwards over the glans, and in this situation, while being itself the first cause of constriction, it induces another—namely, an arrest to the venous circulation, which is followed by a turgescence of the glans. In the treatment of such a case, the indication is, first, to reduce by gradual pressure the size of the glans, so that the prepuce may be replaced over it; secondly, to lessen the inflammation by the ordinary means.
Plate 57.—Figure 2.
Fig. 3, Plate 57, exhibits the form of a gonorrhoeal phymosis. The orifice of the prepuce is contracted, and the tissue of it infiltrated. If in this state of the part, consequent upon diseased action, or in that of Fig. 1, which is congenital, the foreskin be retracted over the glans, a paraphymosis, like Fig. 2, will be produced.
Plate 57.—Figure 3.
Fig. 4, Plate 57, shows a form of phymosis in which the prepuce during inflammation has become adherent to the whole surface of the glans. The orifice of the prepuce being directly opposite the meatus, and the parts offering no obstruction to the flow of urine, an operation for separating the prepuce from the glans would not be required.
Plate 57.—Figure 4.
Fig. 5, Plate 57.—In this figure is represented the form of the penis of an adult, in whom the prepuce was removed by circumcision at an early age. The membrane covering the glans and the part which is cicatrised becomes in these cases dry, indurated, and deprived of its special sense.
Plate 57.—Figure 5.
Fig. 6, Plate 57.—In this figure the glans appears protruding through the upper surface of the prepuce, which is thickened and corrugated. This state of the parts was caused by a venereal ulceration of the upper part of the prepuce, sufficient to allow the glans to press through the aperture. The prepuce in this condition being superfluous, and acting as an impediment, should be removed by operation.
Plate 57.—Figure 6.
Fig. 7, Plate 57.—In this figure is shown a condition of the glans and prepuce resembling that last mentioned, and the effect of a similar cause. By the removal of the prepuce when in the position here represented, or in that of Fig. 6, the organ may be made to assume the appearance of Fig. 5.
Plate 57.—Figure 7.
Fig. 8, Plate 57, represents the form of a congenital hypospadias. The corpus spongiosum does not continue the canal of the urethra as far forwards as the usual position of the meatus, but has become defective behind the fraenum praeputii, leaving the canal open at this place. In a case of this kind an operation on the taliacotian principle might be tried in order to close the urethra where it presents abnormally patent.
Plate 57.—Figure 8.
Fig. 9, Plate 57, represents a congenital hypospadias, in which the canal of the urethra opens by two distinct apertures along the under surface of the corpus spongiosum at the middle line. A probe traverses both apertures. In such a case, if the canal of the urethra were perforate as far forwards as the meatus, and this latter in its normal position, the two false openings should be closed by an operation.
Plate 57.—Figure 9.
Fig. 10, Plate 57.—The urethra is here represented as having a false opening on its under surface behind the fraenum. The perforation was caused by a venereal ulcer. The meatus and urethra anterior to the false aperture remained perforate. Part of a bougie appears traversing the false opening and the meatus. In this state of the organ an attempt should be made to close the false aperture permanently.
Plate 57.—Figure 10.
Fig. 11, Plate 57, shows a state of the urethra similar to that of Fig. 10, and the effect of the same cause. Part of a bougie is seen traversing the false aperture from the meatus before to the urethra behind. In this case, as the whole substance of the corpus spongiosum was destroyed for half an inch in extent, the taliacotian operation, by which lost quantity is supplied, is the measure most likely to succeed in closing the canal.
Plate 57.—Figure 11
Fig. 12, Plate 57.—Behind the meatus, and on the right of the fraenum, is represented a perforation in the urethra, caused by a venereal ulcer. The meatus and the false opening have approached by the contraction of the cicatrix; in consequence of which, also, the apex of the glans is distorted towards the urethra; a bougie introduced by the meatus occupies the urethral canal.
Plate 57.—Figure 12.
Fig. 13, Plate 57.—In this figure the canal of the urethra appears turning upwards and opening at the median line behind the corona glandis. This state of the urethra was caused by a venereal ulcer penetrating the canal from the dorsum of the penis. The proper direction of the canal might be restored by obliterating the false passage, provided the urethra remained perforate in the direction of the meatus.
Plate 57.—Figure 13.
Fig. 14, Plate 57, exhibits the form of a congenital epispadias, in which the urethra is seen to open on the dorsal surface of the prepuce at the median line. The glans appears cleft and deformed. The meatus is deficient at its usual place. The prepuce at the dorsum is in part deficient, and bound to the glans around the abnormal orifice.
Plate 57.—Figure 14.
Fig. 15, Plate 57, represents in section a state of the parts in which the urethra opened externally by one fistulous aperture, a, behind the scrotum; and by another, b, in front of the scrotum. At the latter place the canal beneath the penis became imperforate for an inch in extent. Parts of catheters are seen to enter the urethra through the fistulous openings a b; and another instrument, c, is seen to pass by the proper meatus into the urethra as far as the point where this portion of the canal fails to communicate with the other. The under part of the scrotum presents a cleft corresponding with the situation of the scrotal septum. This state of the urinary passage may be the effect either of congenital deficiency or of disease. When caused by disease, the chief features in its history, taking these in the order of their occurrence, are, 1st, a stricture in the anterior part of the urethra; 2ndly, a rupture of this canal behind the stricture; 3rdly, the formation (on an abscess opening externally) of a fistulous communication between the canal and the surface of some part of the perinaeum; 4thly, the habitual escape of the urine by the false aperture; 5thly, the obliteration of the canal to a greater or less extent anterior to the stricture; 6thly, the parts situated near the urethral fistula become so consolidated and confused that it is difficult in some and impossible in many cases to find the situation of the urethra, either by external examination or by means of the catheter passed into the canal. The original seat of the stricture becomes so masked by the surrounding disease, and the stricture itself, even if found by any chance, is generally of so impassable a kind, that it must be confessed there are few operations in surgery more irksome to a looker-on than is the fruitless effort made, in such a state of the parts, by a hand without a guide, to pass perforce a blunt pointed instrument like a catheter into the bladder. In some instances the stricture is slightly pervious, the urine passing in small quantity by the meatus. In others, the stricture is rendered wholly imperforate, and the canal either contracted or nearly obliterated anteriorly through disuse. Of these two conditions, the first is that in which catheterism may be tried with any reasonable hope of passing the instrument into the bladder. In the latter state, catheterism is useless, and the only means whereby the urethra may be rendered pervious in the proper direction is that of incising the stricture from the perinaeum, and after passing a catheter across the divided part into the bladder, to retain the instrument in this situation till the wound and the fistulae heal and close under the treatment proper for this end. (Mr. Syme.)
Plate 57.—Figure 15.
Fig. 1, Plate 58.—In this figure the urethra appears communicating with a sac like a scrotum. A bougie is represented entering by the meatus, traversing the upper part of the sac, and passing into the membranous part of the urethra beyond. This case which was owing to a congenital malformation of the urethra, exhibits a dilatation of the canal such as might be produced behind a stricture wherever situated. The urine impelled forcibly by the whole action of the abdominal muscles against the obstructing part dilates the urethra behind the stricture, and by a repetition of such force the part gradually yields more and more, till it attains a very large size, and protrudes at the perinaeum as a distinct fluctuating tumour, every time that an effort is made to void the bladder. If the stricture in such a case happen to cause a complete retention of urine, and that a catheter cannot be passed into the bladder, the tumour should be punctured prior to taking measures for the removal of the stricture. (Sir B. Brodie.)
Plate 58.—Figure 1.
Fig. 2, Plate 58, represents two close strictures of the urethra, one of which is situated at the bulb, and the other at the adjoining membranous part. These are the two situations in which strictures of the organic kind are said most frequently to occur, (Hunter, Home, Cooper, Brodie, Phillips, Velpeau.) False passages likewise are mentioned as more liable to be made in these places than elsewhere in the urethral canal. These occurrences—the disease and the accident—would seem to follow each other closely, like cause and consequence. The frequency with which false passages occur in this situation appears to me to be chiefly owing to the anatomical fact, that the urethra at and close to the bulb is the most dependent part of the curve, F K, Fig. 1, Plate 56; and hence, that instruments descending to this part from before push forcibly against the urethra, and are more apt to protrude through it than to have their points turned so as to ascend the curve towards the neck of the bladder. If it be also true that strictures happen here more frequently than elsewhere, this circumstance will of course favour the accident. An additional cause why the catheter happens to be frequently arrested at this situation and to perforate the canal, is owing to the fact, that the triangular ligament is liable to oppose it, the urethral opening in this structure not happening to coincide with the direction of the point of the instrument. In the figure, part of a bougie traverses the urethra through both strictures and lodges upon the enlarged prostate. Another instrument, after entering the first stricture, occupies a false passage which was made in the canal between the two constricted parts.
Plate 58.—Figure 2.
Fig. 3, Plate 58.—A calculus is here represented lodging in the urethra at the bulb. The walls of the urethra around the calculus appear thickened. Behind the obstructing body the canal has become dilated, and, in front of it, contracted. In some instances the calculus presents a perforation through its centre, by which the urine escapes. In others, the urine makes its exit between the calculus and the side of the urethra, which it dilates. In this latter way the foreign body becomes loosened in the canal and gradually pushed forwards as far as the meatus, within which, owing to the narrowness of this aperture, it lodges permanently. If the calculus forms a complete obstruction to the passage of the urine, and its removal cannot be effected by other means, an incision should be made to effect this object.
Plate 58.—Figure 3.
Fig. 4, Plate 58, represents the neck of the bladder and neighbouring part of the urethra of an ox, in which a polypous growth is seen attached by a long pedicle to the veru montanum and blocking up the neck of the bladder. Small irregular tubercles of organized lymph, and tumours formed by the lacunae distended by their own secretion, their orifices being closed by inflammation, are also found to obstruct the urethral canal.
Plate 58.—Figure 4.
Fig. 5, Plate 58.—In this figure is represented a small calculus impacted in and dilating the membranous part of the urethra.
Plate 58.—Figure 5.
Fig. 6, Plate 58.—Two strictures are here shown to exist in the urethra, one of which is situated immediately in front of the bulb, and the other at a point midway between the bulb and the meatus.
Plate 58.—Figure 6.
Fig. 7, Plate 58.—A stricture is here shown situated at the bulb.
Plate 58.—Figure 7.
Fig. 8, Plate 58, represents a stricture of the canal in front of the bulb.
Plate 58.—Figure 8.
Fig. 9, Plate 58, represents the form of an old callous stricture half an inch long, situated midway between the bulb and the meatus. This is perhaps the most common site in which a stricture of this kind is found to exist. In some instances of old neglected cases the corpus spongiosum appears converted into a thick gristly cartilaginous mass, several inches in extent, the passage here being very much contracted, and chiefly so at the middle of the stricture. When it becomes impossible to dilate or pass the canal of such a stricture by the ordinary means, it is recommended to divide the part by the lancetted stilette. (Stafford.) Division of the stricture, by any means, is no doubt the readiest and most effectual measure that can be adopted, provided we know clearly that the cutting instrument engages fairly the part to be divided. But this is a knowledge less likely to be attained if the stricture be situated behind than in front of the triangular ligament.
Plate 58.—Figure 9.
Fig. 10, Plate 58, exhibits a lateral view of the muscular parts which surround the membranous portion of the urethra and the prostate; a, the membranous urethra embraced by the compressor urethrae muscle; b, the levator prostatae muscle; c, the prostate; d, the anterior ligament of the bladder.
Plate 58.—Figure 10.
Fig. 11, Plate 58.—A posterior view of the parts seen in Fig. 10; a, the urethra divided in front of the prostate; b b, the levator prostatae muscle; c c, the compressor urethrae; d d, parts of the obturator muscles; e e, the anterior fibres of the levator ani muscle; f g, the triangular ligament enclosing between its layers the artery of the bulb, Cowper’s glands, the membranous urethra, and the muscular parts surrounding this portion of the canal. The fact that the flow of urine through the urethra happens occasionally to be suddenly arrested, and this circumstance contrasted with the opposite fact that the organic stricture is of slow formation, originated the idea that the former occurrence arose from a spasmodic muscular contraction. By many this spasm was supposed to be due to the urethra being itself muscular. By others, it was demonstrated as being dependent upon the muscles which surround the membranous part of the urethra, and which act upon this part and constrict it. From my own observations I have formed the settled opinion that the urethra itself is not muscular. And though, on the one hand, I believe that this canal, per se, never causes by active contraction the spasmodic form of stricture, I am far from supposing, on the other, that all sudden arrests to the passage of urine through the urethra are solely attributable to spasm of the muscles which embrace this canal.
Plate 58.—Figure 11.
COMMENTARY ON PLATES 59 & 60.
THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND OTHER OBSTRUCTIONS OF THE URETHRA.—FALSE PASSAGES.—ENLARGEMENTS AND DEFORMITIES OF THE PROSTATE.
Impediments to the passage of the urine through the urethra may arise from different causes, such as the impaction of a small calculus in the canal, or any morbid growth (a polypus, &c.) being situated therein, or from an abscess which, though forming externally to the urethra, may press upon this tube so as either to obstruct it partially, by bending one of its sides towards the other, or completely, by surrounding the canal on all sides. These causes of obstruction may happen in any part of the urethra, but there are two others (the prostatic and the spasmodic) which are, owing to anatomical circumstances, necessarily confined to the posterior two-thirds of the urethra. The portion of the urethra surrounded by the prostate can alone be obstructed by this body when it has become irregularly enlarged, while the spasmodic stricture can only happen to the membranous portion of the urethra, and to an inch or two of the canal anterior to the bulb, these being the parts which are embraced by muscular structures. The urethra itself not being muscular, cannot give rise to the spasmodic form of stricture. But that kind of obstruction which is common to all parts of the urethra, and which is dependent, as well upon the structures of which the canal is uniformly composed, as upon the circumstance that inflammation may attack these in any situation and produce the same effect, is the permanent or organic stricture. Of this disease the forms are as various as the situations are, for as certainly as it may reasonably be supposed that the plastic lymph, effused in an inflamed state of the urethra from any cause, does not give rise to stricture of any special or particular form, exclusive of all others; so as certainly may it be inferred that, in a structurally uniform canal, inflammation points to no one particular place of it, whereat by preference to establish the organic stricture. The membranous part of the canal is, however, mentioned as being the situation most prone to the disease; but I have little doubt, nevertheless, that owing to general rules of this kind being taken for granted, upon imposing authority, many more serious evils (false passages, &c.) have been effected by catheterism than existed previous to the performance of this operation.[Footnote]
[Footnote: Home describes “a natural constriction of the urethra, directly behind the bulb, which is probably formed with a power of contraction to prevent,” &c. This is the part which he says is “most liable to the disease of stricture.” (Strictures of the Urethra.) Now, if anyone, even among the acute observing microscopists, can discern the structure to which Home alludes, he will certainly prove this anatomist to be a marked exception amongst those who, for the enforcement of any doctrine, can see any thing or phenomenon they wish to see. And, if Hunter were as the mirror from which Home’s mind was reflected, then the observation must be imputed to the Great Original. Upon the question, however, as to which is the most frequent seat of stricture, I find that both these anatomists do not agree, Hunter stating that its usual seat is just in front of the bulb, while Home regrets, as it were, to be obliged to differ from “his immortal friend,” and avers its seat to be an infinitesimal degree behind the bulb. Sir A. Cooper again, though arguing that the most usual situation of stricture is that mentioned by Hunter, names, as next in order of frequency, strictures of the membranous and prostatic parts of the urethra. Does it not appear strange now, how questions of this import should have occupied so much of the serious attention of our great predecessors, and of those, too, who at the present time form the vanguard of the ranks of science? Upon what circumstance, either anatomical or pathological, can one part of the urethra be more liable to the organic stricture than another?]
Figs. 1 and 2, Plate 59.—In these figures are presented seven forms of organic stricture occurring, in different parts of the urethra. In a, Fig. 1, the mucous membrane is thrown into a sharp circular fold, in the centre of which the canal, appears much contracted; a section of this stricture appears in b, Fig. 2. In b, Fig. 1, the canal is contracted laterally by a prominent fold of the mucous membrane at the opposite side. In c, Fig. 1, an organized band of lymph is stretched across the canal; this stricture is seen in section in c, Fig. 2. In e, Fig. 1, a stellate band of organized lymph, attached by pedicles to three sides of the urethra, divides the canal into three passages. In d, Fig. 1, the canal is seen to be much contracted towards the left side by a crescentic fold of the lining membrane projecting from the right. In f, the canal appears contracted by a circular membrane, perforated in the centre; a section of which is seen at a, Fig. 2. The form of the organic stricture varies therefore according to the three following circumstances:—1st. When lymph becomes effused within the canal upon the surface of the lining mucous membrane, and contracts adhesions across the canal. 2ndly. When lymph is effused external to the lining membrane, and projects this inwards, thereby narrowing the diameter of the canal. 3rdly. When the outer and inner walls of a part of the urethra are involved in the effused organizable matter, and on contracting towards each other, encroach at the same time upon the area of the canal. This latter state presents the form, which is known as the old callous tough stricture, extending in many instances for an inch or more along the canal. In cases where the urethra becomes obstructed by tough bands of substance, c e, which cross the canal directly, the points of flexible catheters, especially if these be of slender shape, are apt to be bent upon the resisting part, and on pressure being continued, the operator may be led to suppose that the instrument traverses the stricture, while it is most probably perforating the wall of the urethra. But in those cases where the diameter of the canal is circularly contracted, the stricture generally presents a conical depression in front, which, receiving the point of the instrument, allows this to enter the central passage unerringly. A stricture formed by a crescentic septum, such as is seen in b d, Fig. 1, offers a more effectual obstacle to the passage of a catheter than the circular septum like a f.
Plate 59. Figure 1
Plate 59. Figure 2
Fig. 3, Plate 59.—In this there are seen three separate strictures, a, b, c, situated in the urethra, anterior to the bulb. In some cases there are many more strictures (even to the number of six or seven) situated in various parts of the urethra; and it is observed that when one stricture exists, other slight tightnesses in different parts of the canal frequently attend it. (Hunter.) When several strictures occur in various parts of the urethra, they may occasion as much difficulty in passing an instrument as if the whole canal between the extreme constrictions were uniformly narrowed.
Plate 59.—Figure 3.
Fig. 4, Plate 59.—In this the canal is constricted at the point a, midway between the bulb and glans. A false passage has been made under the urethra by an instrument which passed out of the canal at the point f, anterior to the stricture a, and re-entered the canal at the point c, anterior to the bulb. When a false passage of this kind happens to be made, it will become a permanent outlet for the urine, so long as the stricture remains. For it can be of no avail that we avoid re-opening the anterior perforation by the catheter, so long as the urine prevented from flowing by the natural canal enters the posterior perforation. Measures should be at once taken to remove the stricture.
Plate 59.—Figure 4.
Fig. 5, Plate 59.—The stricture a appears midway between the bulb and glans, the area of the passage through the stricture being sufficient only to admit a bristle to pass. It would seem almost impossible to pass a catheter through a stricture so close as this, unless by a laceration of the part, combined with dilatation.
Plate 59.—Figure 5.
Fig. 6, Plate 59.—Two instruments, a, b, have made false passages beneath the mucous membrane, in a case where no stricture at all existed. The resistance which the instruments encountered in passing out of the canal having been mistaken, no doubt, for that of passing through a close stricture.
Plate 59.—Figure 6.
Fig. 7, Plate 59.—A bougie, b b, is seen to perforate the urethra anterior to the stricture c, situated an inch behind the glans, and after traversing the substance of the right corpus cavernosum d, for its whole length, re-enters the neck of the bladder through the body of the prostate.
Plate 59.—Figure 7.
Fig. 8, Plate 59.—A bougie, c c, appears tearing and passing beneath the lining membrane, d d, of the prostatic urethra. It is remarked that the origin of a false passage is in general anterior to the stricture. It may, however, occur at any part of the canal in which no stricture exists, if the hand that impels the instrument be not guided by a true knowledge of the form of the urethra; and perhaps the accident happening from this cause is the more general rule of the two.
Plate 59.—Figure 8.
Fig. 9, Plate 59.—Two strictures are represented here, the one, e, close to the bulb d, the other, f, an inch anterior to this part. In the prostate, a b, are seen irregularly shaped abscess pits, communicating with each other, and projecting upwards the floor of this body to such a degree, that the prostatic canal appears nearly obliterated.
Plate 59.—Figure 9.
Fig. 10, Plate 59.—Two bougies, d e, are seen to enter the upper wall of the urethra, c, anterior to the prostate, a b. This accident happens when the handle of a rigid instrument is depressed too soon, with the object of raising its point over the enlarged third lobe of the prostate.
Plate 59.—Figure 10.
Fig. 11, Plate 59.—Two instruments appear transfixing the prostate, of which body the three lobes, a, b, c, are much enlarged. The instrument d perforates the third lobe, a; while the instrument e penetrates the right lobe, c, and the third lobe, a. This accident occurs when instruments not possessing the proper prostatic bend are forcibly pushed forwards against the resistance at the neck of the bladder.
Plate 59.—Figure 11.
Fig. 12, Plate 59.—In this case an instrument, d d, after passing beneath part of the lining membrane, e e, anterior to the bulb, penetrates b, the right lobe of the prostate. A second instrument, c c, penetrates the left lobe. A third smaller instrument, f f, is seen to pass out of the urethra anterior to the prostate, and after transfixing the right vesicula seminalis external to the neck of the bladder, enters this viscus at a point behind the prostate. The resistance which the two larger instruments met with in penetrating the prostate, made it seem, perhaps, that a tight stricture existed in this situation, to match which the smaller instrument, f f, was afterwards passed in the course marked out.
Plate 59.—Figure 12.
Figs. 1 to 5, Plate 60, represent a series of prostates, in which the third lobe gradually increases in size. In Fig. 1, which shows the healthy state of the neck of the bladder, unmarked by the prominent lines which are said to bound the space named “trigone vesical,” or by those which indicate the position of the “muscles of the ureters,” the third lobe does not exist. In Fig. 2 it appears as the uvula vesicae, a. In Fig. 3 the part a is increased, and under the name now of third lobe is seen to contract and bend upwards the prostatic canal. In Fig. 4 the effect which the growth of the lobe, a, produces upon the form of the neck of the bladder becomes more marked, and the part presenting perforations, e e, produced by instruments, indicates that by its shape it became an obstacle to the egress of the urine as well as to the entrance of instruments. A calculus of irregular form is seen to lodge behind the third lobe, and to be out of the reach of the point of a sound, supposing this to enter the bladder over the apex of the lobe. In Fig. 5 the three lobes are enlarged, but the third is most so, and while standing on a narrow pedicle attached to the floor of the prostate, completely blocks up the neck of the bladder. [Footnote]
Plate 60.—Figure 1
Plate 60.—Figure 2
Plate 60.—Figure 3
Plate 60.—Figure 4
Plate 60.—Figure 5
[Footnote: On comparing this series of figures, it must appear that the third lobe of the prostate is the product of diseased action, in so far at least as an unnatural hypertrophy of a part may be so designated. It is not proper to the bladder in the healthy state of this organ, and where it does manifest itself by increase it performs no healthy function in the economy. When Home, therefore, described this part as a new fact in anatomy, he had in reality as little reason for so doing as he would have had in naming any other tumour, a thing unknown to normal anatomy. Langenbeck (Neue Bibl. b. i. p. 360) denies its existence in the healthy state. Cruveilhier (Anat. Pathog. liv. xxvii.) deems it incorrect to reckon a third lobe as proper to the healthy bladder.]
Fig. 6, Plate 60.—The prostatic canal is bent upwards by the enlarged third lobe to such a degree as to form a right angle with the membranous part of the canal. A bougie is seen to perforate the third lobe, and this is the most frequent mode in which, under such circumstances, and with instruments of the usual imperfect form, access may be gained to the bladder for the relief of retention of urine. “The new passage may in every respect be as efficient as one formed by puncture or incision in any other way.” (Fergusson.)
Plate 60.—Figure 6
Fig. 7, Plate 60.—The three lobes of the prostate, a, b, c, are equally enlarged. The prostatic canal is consequently much contracted and distorted, so that an instrument on being passed into the bladder has made a false passage through the third lobe. When a catheter is suspected to have entered the bladder by perforating the prostate, the instrument should be retained in the newly made passage till such time as this has assumed the cylindrical form of the instrument. If this be done, the new passage will be the more likely to become permanent. It is ascertained that all false passages and fistulae by which the urine escapes, become after a time lined with a membrane similar to that of the urethra. (Stafford.)
Plate 60.—Figure 7
Fig. 8, Plate 60.—The three lobes, a, b, c, of the prostate are irregularly enlarged. The third lobe, a a, projecting from below, distorts the prostatic canal upwards and to the right side.
Plate 60.—Figure 8.
Fig. 9, Plate 60.—The right lobe, a c c, of the prostate appears hollowed out so as to form the sac of an abscess which, by its projection behind, pressed upon the forepart of the rectum, and by its projection in front, contracted the area of the prostatic canal, and thereby caused an obstruction in this part. Not unfrequently when a catheter is passed along the urethra, for the relief of a retention of urine caused by the swell of an abscess in this situation, the sac becomes penetrated by the instrument, and, instead of urine, pus flows. The sac of a prostatic abscess frequently opens of its own accord into the neighbouring part of the urethra, and when this occurs it becomes necessary to retain a catheter in the neck of the bladder, so as to prevent the urine entering the sac.
Plate 60.—Figure 9.
Fig. 10, Plate 60.—The prostate presents four lobes of equal size, and all projecting largely around the neck of the bladder. The prostatic canal is almost completely obstructed, and an instrument has made a false passage through the lobe a.
Plate 60.—Figure 10.
Fig. 11, Plate 60.—The third lobe of the prostate is viewed in section, and shows the track of the false passage made by the catheter, d, through it, from its apex to its base. The proper canal is bent upwards from its usual position, which is that at present marked by the instrument in the false passage.
Plate 60.—Figure 11.
Fig. 12, Plate 60.—The prostatic lobes are uniformly enlarged, and cause the corresponding part of the urethra to be uniformly contracted, so as closely to embrace the catheter, d d, occupying it, and to offer considerable resistance to the passage of the instrument.
Plate 60.—Figure 12.
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.
Plate 61.—Figure 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.
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.
Plate 62.—Figure 3.
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.
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.”
Plate 62.—Figure 5.
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.
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.
Plate 63,—Figure 4.
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.
N. The short (posterior) saphena nerve, formed by the union of branches from the peronaeal and posterior tibial nerves.
O. The posterior tibial artery appearing from beneath the soleus muscle in the lower part of the leg.
P. The soleus muscle joining the tendo Achillis.
Q. The tendon of the flexor longus communis digitorum muscle.
R. The tendon of the flexor longus pollicis muscle.
S. The tendon of the peronaeus longus muscle.
T. The peronaeus brevis muscle.
U U. The internal annular ligament binding down the vessels, nerves, and tendons in the hollow behind the inner ankle.
V V. The tendo Achillis.
W. The tendon of the tibialis posticus muscle.
X. The venae comites of the posterior tibial artery.
PLATE 66.
A C D E F G H I indicate the same parts as in Plate 65.
B. The inner condyle of the femur.
K. The plantaris muscle lying upon the popliteal artery.
L. The popliteus muscle.
M M M. The tibia.
N N. The fibula.
O O. The posterior tibial artery.
P. The peronaeal artery.
Q R S T U V W. The parts shown in Plate 65.
X. The astragalus.
Plates 65, 66
COMMENTARY ON PLATES 67 & 68.
THE SURGICAL DISSECTION OF THE ANTERIOR CRURAL REGION, THE ANKLES, AND THE FOOT.
Beneath the integuments and subcutaneous adipose tissue on the fore part of the leg and foot, the fascia H H, Plate 67, Figure 2, is to be seen stretched over the muscles and sending processes between them, thus encasing each of these in a special sheath.
The fascia is here of considerable density. It is attached on the inner side of the leg to the spine of the tibia, D, Plate 67, Figure 2, and on the outer side it passes over the peronaeal muscles to those forming the calf. Between the extensor communis digitorum, B b, and the peronaeus longus, F, it sends in a strong process to be attached to the fibula, E. In front of the ankle joint, the fascia is increased in density, constituting a band (anterior annular ligament) which extends between the malleoli, forms sheaths for the several extensor tendons, and binds these down in front of the joint. From the lower border of the annular ligament, the fascia is continued over the dorsum of the foot, forming sheaths for the tendons and muscles of this part. Behind the inner malleolus, d, Plate 67, Figure 1, the fascia attached to this process and to the inner side of the os calcis appears as the internal annular ligament, which being broad and strong, forms a kind of arch, beneath which in special sheaths the flexor tendons, and the posterior tibial vessel and nerve, pass to the sole of the foot. On tracing the fascia from the front to the back of the leg, it will be seen to divide into two layers—superficial and deep; the former passes over the muscles of the calf and their common tendon (tendo Achillis) to which it adheres, while the latter passes between these muscles and the deep flexors. The deep layer is that which immediately overlies the posterior tibial and peronaeal vessels and nerves. While exposing the fascia on the forepart of the leg and dorsum of the foot, we meet with the musculo-cutaneous branch of the peronaeal nerve, which pierces the fascia at about the middle of the limb, and descends superficially in a direction between the fibula, and the extensor longus digitorum muscle, and after dividing into branches a little above the outer ankle, these traverse in two groups the dorsum of the foot, to be distributed to the integuments of the five toes. On the inner side of the tibia, D, Plate 67, Figure 1, will be seen the internal or long saphena vein, B B, which commencing by numerous branches on the dorsal surface of the foot ascends in front of the inner ankle, d, to gain the inner side of the leg, after which it ascends behind the inner side of the knee and thigh, till it terminates at the saphenous opening, where it joins the femoral vein. In its course along the lower part of the thigh, the leg and the foot, this vein is closely accompanied by the long saphenous nerve, derived from the anterior crural, and also by a group of lymphatics.
By removing the fascia from the front of the leg and foot, we expose the several muscles and tendons which are situated in these parts. In the upper part of the leg the tibialis anticus, A, Plate 67, Figure 2, and extensor-communis muscle, B, are adherent to the fascia which covers them, and to the intermuscular septum which divides them. In the lower part of the leg where these muscles and the extensor pollicis, C, terminate in tendons, a b c, they are readily separable from one another. The tibialis anticus lies along the outer side of the tibia, from which, and from the head of the fibula and interosseous ligament, it arises tendinous and fleshy. This muscle is superficial in its whole length; its tendon commencing about the middle of the leg, passes in a separate loose sheath of the annular ligament in front of the inner ankle, to be inserted into the inner side of the cuneiform bone and base of the metatarsal bone of the great toe. The extensor communis digitorum lies close to the outer side of the anterior tibial muscle, and arises from the upper three-fourths of the fibula, from the interosseous ligament and intermuscular septum. At the lower part of the leg, this muscle ends in three or four flat tendons, which pass through a ring of the annular ligament, and extending forwards, b b b b, over the dorsum of the foot, become inserted into the four outer toes. The peronaeus tertius or anterior, is that part of the common extensor muscle which is inserted into the base of the fifth metatarsal bone. On separating the anterior tibial and common extensor muscles, we find the extensor pollicis, C c, which, concealed between the two, arises from the middle of the fibula, and the interosseous ligament; its tendon passes beneath the annular ligament in front of the ankle joint, and after traversing the inner part of the dorsum of the foot, becomes inserted into the three phalanges of the great toe. Beneath the tendons of the extensor communis on the instep, will be seen the extensor digitorum brevis, K K, lying in an oblique direction, between the upper and outer part of the os calcis, from which it arises, and the four inner toes, into each of which it is inserted by a small flat tendon, which joins the corresponding tendon of the long common extensor.
The anterior tibial artery, L, Plate 67, Figure 2, extends from the upper part of the interosseous ligament which it perforates, to the bend of the ankle, whence it is continued over the dorsum of the foot. In the upper third of the leg, the anterior tibial artery lies deeply situated between the tibialis anticus, and flexor communis muscles. Here it will be found, close in front of the interosseous ligament, at about an inch and-a-half in depth from the anterior surface, and removed from the spine of the tibia at an interval equal to the width of the tibialis anticus muscle. In its course down the leg, the vessel passes obliquely from a point close to the inner side of the neck of the fibula, to midway between the ankles. In its descent, it becomes gradually more superficial. In the middle of the leg, the vessel passes between the extensor longus pollicis, and the tibialis anticus muscles. Above, beneath, and below the annular ligament, this artery will be found to pass midway between the extensor pollicis tendon, and those of the extensor communis, and to hold the same relation to these parts in traversing the dorsum of the foot, till it gains the interval between the two inner metatarsal bones, where it divides into two branches, one of which passes forwards in the first interdigital space, while the other sinks between the bones, to inosculate with the plantar arteries. The innermost tendon of the short common extensor crosses in front of the dorsal artery of the foot near its termination. Between the ankle and the first interosseous space the artery lies comparatively superficial, being here covered only by the skin and fascia and cellular membrane. Two veins accompany the anterior tibial artery and its continuation on the dorsum of the foot. The anterior tibial nerve, a branch of the peronaeal, joins the outer side of the artery, about the middle of the leg, and accompanies it closely in this position, till both have passed beneath the annular ligament. On the dorsum of the foot the nerve will be found to the inner side of the artery.
The branches of the anterior tibial artery are articular and muscular. From its upper end arises the recurrent branch which anastomoses in front of the knee with the articular branches of the popliteal artery. Near the ankle, arise on either side of the vessel two malleolar branches, internal and external, the former communicating with branches of the posterior tibial, the latter with those of the peronaeal. Numerous muscular branches arise, at short intervals, from the vessel in its passage down the leg. Tarsal, metatarsal, and small digital branches spring from the dorsal artery of the foot. The anterior tibial artery is rarely found to deviate from its usual course; in some cases it appears of less or of greater size than usual. When this vessel appears deficient, its place is usually supplied by some branch of the peronaeal or posterior tibial, which pierces the interosseous ligament from behind.
The anterior tibial artery when requiring a ligature to be applied to it in any part of its course, may be exposed by an incision, extending for three or four inches, (more or less, according to the depth of the vessel) along the outer border of the tibialis anticus muscle. The fibrous septum between this muscle and the extensor communis, will serve as a guide to the vessel in the upper third of the leg, where it lies deeply on the interosseous ligament. In the middle of the leg, the vessel is to be sought for between the anterior tibial and extensor longus pollicis muscles. In the lower part of the leg, and on the dorsum of the foot, it will be found between the extensor longus pollicis, and extensor communis tendons, the former being taken as a guide for the incision. In passing the ligature around this vessel at either of these situations, care is required to avoid including the venae comites and the accompanying nerve.
The sole of the foot is covered by a hard and thick integument, beneath which will be seen a large quantity of granulated adipose tissue so intersected by bands of fibrous structure as to form a firm, but elastic cushion, in the situations particularly of the heel and joints of the toes. On removing this structure, we expose the plantar fascia, B, Plate 68, Figure 1, extending from the os calcis, A, to the toes. This fascia is remarkably strong, especially its middle and outer parts, which serve to retain the arched form of the foot, and thereby to protect the plantar structures from superincumbent pressure during the erect posture. The superficial plantar muscles become exposed on removing the plantar fascia, to which they adhere. In the centre will be seen the thick fleshy flexor digitorum brevis muscle, B, arising from the inferior part of the os calcis, and passing forwards to divide into four small tendons, b b b b, for the four outer toes. On the inner side of the foot appears the abductor pollicis, D, arising from the inner side of the os calcis and internal annular ligament, and passing to be inserted with the flexor pollicis brevis, H, into the sesamoid bones and base of the first phalanx of the great toe. On the external border of the foot is situated the abductor minimi digiti, C, arising from the outer side of the os calcis, and passing to be inserted with the flexor brevis minimi digiti into the base of the first phalanx of the little toe. When the flexor brevis digitorum muscle is removed, the plantar arteries, L M, and nerves, are brought partially into view; and by further dividing the abductor pollicis, D, their continuity with the posterior tibial artery and nerves, K L, Plate 67, Figure 1, behind the inner ankle may be seen.
The plantar branches of the posterior tibial artery are the internal and external, both of which are deeply placed between the superficial and deep plantar muscles. The internal plantar artery is much the smaller of the two. The external plantar artery, L, Plate 68, Figure 1, is large, and seems to be the proper continuation of the posterior tibial. It corresponds, in the foot, to the deep palmar arch in the hand. Placed at first between the origin of the abductor pollicis and the calcaneum, the external plantar artery passes outwards between the short common flexor, B, and the flexor accessorius, E, to gain the inner borders of the muscles of the little toe; from this place it curves deeply inwards between the tendons of the long common flexor of the toes, F f f, and the tarso-metatarsal joints, to gain the outer side of the first metatarsal bone, H, Plate 68, Figure 2. In this course it is covered in its posterior half by the flexor brevis digitorum, and in its anterior half by this muscle, together with the tendons of the long flexor, F, Plate 68, Figure 1, of the toes and the lumbricales muscles, i i i i. From the external plantar artery are derived the principal branches for supplying the structures in the sole of the foot. The internal plantar nerve divides into four branches, for the supply of the four inner toes, to which they pass between the superficial and deep flexors. The external plantar nerve, passing along the inner side of the corresponding artery, sends branches to supply the outer toe and adjacent side of the next, and then passes, with the artery, between the deep common flexor tendon and the metatarsus, to be distributed to the deep plantar muscles.
The posterior tibial artery may be tied behind the inner ankle, on being laid bare in the following way:—A curved incision (the concavity forwards) of two inches in length, is to be made midway between the tendo Achillis and the ankle. The skin and superficial fascia having been divided, we expose the inner annular ligament, which will be found enclosing the vessels and nerve in a canal distinct from that of the tendons. Their fibrous sheath having been slit open, the artery will be seen between the venae comites, and with the nerve, in general, behind it.
When any of the arteries of the leg or the foot are wounded, and the haemorrhage cannot be commanded by compression, it will be necessary to search for the divided ends of the vessel in the wound, and to apply a ligature to both. The expediency of this measure must become fully apparent when we consider the frequent anastomoses existing between the collateral branches of the crural arteries, and that a ligature applied to any one of these above the seat of injury will not arrest the recurrent circulation through the vessels of the foot.
DESCRIPTION OF PLATES 67 & 68.
PLATE 67.
FIGURE 1. A. The tendon of the tibialis anticus muscle.
B B. The long saphena vein.
C C. The tendon of the tibialis posticus muscle.
D. The tibia; d, the inner malleolus.
E E. The tendon of the flexor longus digitorum muscle.
F. The gastrocnemius muscle; f, the tendo Achillis.
G. The soleus muscle.
H. The tendon of the plantaris muscle.
I I. The venae comites.
K K. The posterior tibial artery.
L L. The posterior tibial nerve.
FIGURE 2.
A. The tibialis anticus muscle; a, its tendon.
B. The extensor longus digitorum muscle; b b b b, its four tendons.
C C. The extensor longus pollicis muscle.
D D. The tibia.
E. The fibula; e, the outer malleolus.
F F. The tendon of the peronaeus longus muscle.
G G. The peronaeus brevis muscle; i, the peronaeus tertius.
H H. The fascia.
K. The extensor brevis digitorum muscle; k k, its tendons.
L L. The anterior tibial artery and nerve descending to the dorsum of the foot.
Plate 67, Figures 1, 2
PLATE 68.
FIGURE 1.
A. The calcaneum.
B. The plantar fascia and flexor brevis digitorum muscle cut; b b b, its tendons.
C. The abductor minimi digiti muscle.
D. The abductor pollicis muscle.
E. The flexor accessorius muscle.
F. The tendon of the flexor longus digitorum muscle, subdividing into f f f f, tendons for the four outer toes.
G. The tendon of the flexor pollicis longus muscle.
H. The flexor pollicis brevis muscle.
i i i i. The four lumbricales muscles.
K. The external plantar nerve.
L. The external plantar artery.
M. The internal plantar nerve and artery.
Plate 68, Figure 1
FIGURE 2.
A. The heel covered by the integument.
B. The plantar fascia and flexor brevis digitorum muscle cut; b b b, the tendons of the muscle.
C. The abductor minimi digiti.
D. The abductor pollicis.
E. The flexor accessorius cut.
F. The tendon of the flexor digitorum longus cut; f f f, its digital ends.
G. The tendon of the flexor pollicis.
H. The head of the first metatarsal bone.
I. The tendon of the tibialis posticus.
K. The external plantar nerve.
L L. The arch of the external plantar artery.
M M M M. The four interosseous muscles.
N. The external plantar nerve and artery cut.
Plate 68, Figure 2
CONCLUDING COMMENTARY. ON THE FORM AND DISTRIBUTION OF THE VASCULAR SYSTEM AS A WHOLE. ANOMALIES.—RAMIFICATION.—ANASTOMOSIS.
I.—The heart, in all stages of its development, is to the vascular system what the point of a circle is to the circumference—namely, at once the beginning and the end. The heart, occupying, it may be said, the centre of the thorax, circulates the blood in the same way, by similar channels, to an equal extent, in equal pace, and at the same period of time, through both sides of the body. In its adult normal condition, the heart presents itself as a double or symmetrical organ. The two hearts, though united and appearing single, are nevertheless, as to their respective cavities, absolutely distinct. Each heart consists again of two compartments—an auricle and a ventricle. The two auricles are similar in structure and form. The two ventricles are similar in the same respects. A septum divides the two auricles, and another—the two ventricles. Between the right auricle and ventricle, forming the right heart, there exists a valvular apparatus (tricuspid), by which these two compartments communicate; and a similar valve (bicuspid) admits of communication between the left auricle and ventricle. The two hearts being distinct, and the main vessels arising from each respectively being distinct likewise, it follows that the capillary peripheries of these vessels form the only channels through which the blood issuing from one heart can enter the other.
II.—As the aorta of the left heart ramifies throughout all parts of the body, and as the countless ramifications of this vessel terminate in an equal number of ramifications of the principal veins of the right heart, it will appear that between the systemic vessels of the two hearts respectively, the capillary anastomotic circulation reigns universal.
III.—The body generally is marked by the median line, from the vertex to the perinaeum, into corresponding halves. All parts excepting the main bloodvessels in the neighbourhood of the heart are naturally divisible by this line into equals. The vessels of each heart, in being distributed to both sides of the body alike, cross each other at the median line, and hence they are inseparable according to this line, unless by section. If the vessels proper to each heart, right and left, ramified alone within the limits of their respective sides of the body, then their capillary anastomosis could only take place along the median line, and here in such case they might be separated by median section into two distinct systems. But as each system is itself double in branching into both sides of the body, the two would be at the same time equally divided by vertical section. From this it will appear that the vessels belonging to each heart form a symmetrical system, corresponding to the sides of the body, and that the capillary anastomosis of these systemic veins and arteries is divisible into two great fields, one situated on either side of the median line, and touching at this line.
IV.—The vessels of the right heart do not communicate at their capillary peripheries, for its veins are systemic, and its arteries are pulmonary. The vessels of the left heart do not anastomose, for its veins are pulmonary, and its arteries are systemic. The arteries of the right and left hearts cannot anastomose, for the former are pulmonary, and the latter are systemic; and neither can the veins of the right and left hearts, for a similar reason. Hence, therefore, there can be, between the vessels of both hearts, but two provinces of anastomosis—viz., that of the lungs, and that of the system. In the lungs, the arteries of the right heart and the veins of the left anastomose. In the body generally (not excepting the lungs), the arteries of the left heart, and the veins of the right, anastomose; and thus in the pulmonary and the systemic circulation, each heart plays an equal part through the medium of its proper vessels. The pulmonary bear to the systemic vessels the same relation as a lesser circle contained within a greater; and the vessels of each heart form the half of each circle, the arteries of the one being opposite the veins of the other.
V.—The two hearts being, by the union of their similar forms, as one organ in regard to place, act, by an agreement of their corresponding functions, as one organ in respect to time. The action of the auricles is synchronous; that of the ventricles is the same; that of the auricles and ventricles is consentaneous; and that of the whole heart is rhythmical, or harmonious—the diastole of the auricles occurring in harmonical time with the systole of the ventricles, and vice versa. By this correlative action of both hearts, the pulmonary and systemic circulations take place synchronously; and the phenomena resulting in both reciprocate and balance each other. In the pulmonary circulation, the blood is aerated, decarbonized, and otherwise depurated; whilst in the systemic circulation, it is carbonized and otherwise deteriorated.
VI.—The circulation through the lungs and the system is carried on through vessels having the following form and relative position, which, as being most usual, is accounted normal. The two brachio-cephalic veins joining at the root of the neck, and the two common iliac veins joining in front of the lumbar vertebrae, form the superior and inferior venae cavae, by which the blood is returned from the upper and lower parts of the body to the right auricle, and thence it enters the right ventricle, by which it is impelled through the pulmonary artery into the two lungs; and from these it is returned (aerated) by the pulmonary veins to the left auricle, which passes it into the left ventricle, and by this it is impelled through the systemic aorta, which branches throughout the body in a similar way to the systemic veins, with which the aortic branches anastomose generally. On viewing together the system of vessels proper to each heart, they will be seen to exhibit in respect to the body a figure in doubly symmetrical arrangement, of which the united hearts form a duplex centre. At this centre, which is the theatre of metamorphosis, the principal abnormal conditions of the bloodvessels appear; and in order to find the signification of these, we must retrace the stages of development.
VII.—From the first appearance of an individualized centre in the vascular area of the human embryo, that centre (punctum saliens) and the vessels immediately connected with it, undergo a phaseal metamorphosis, till such time after birth as they assume their permanent character. In each stage of metamorphosis, the embryo heart and vessels typify the normal condition of the organ in one of the lower classes of animals. The several species of the organ in these classes are parallel to the various stages of change in the human organ. In its earliest condition, the human heart presents the form of a simple canal, similar to that of the lower Invertebrata, the veins being connected with its posterior end, while from its anterior end a single artery emanates. The canal next assumes a bent shape, and the vessels of both its ends become thereby approximated. The canal now being folded upon itself in heart-shape, next becomes constricted in situations, marking out the future auricle and ventricle and arterial bulb, which still communicate with each other. From the artery are given off on either side symmetrically five branches (branchial arches), which arch laterally from before, outwards and backwards, and unite in front of the vertebrae, forming the future descending aorta. In this condition, the human heart and vessels resemble the Piscean pipe. The next changes which take place consist in the gradual subdivision, by means of septa, of the auricle and ventricle respectively into two cavities. On the separation of the single auricle into two, while the ventricle as yet remains single, the heart presents that condition which is proper to the Reptilian class. The interauricular and interventricular septa, by gradual development from without inwards, at length meet and coalesce, thereby dividing the two cavities into four—two auricles and two ventricles—a condition proper to the Avian and Mammalian classes generally. In the centre of the interauricular septum of the human heart, an aperture (foramen ovale) is left as being necessary to the foetal circulation. While the septa are being completed, the arterial bulb also becomes divided by a partition formed in its interior in such a manner as to adjust the two resulting arteries, the one in connexion with the right, the other with the left ventricle. The right ventricular artery (pulmonary aorta) so formed, has assigned to it the fifth (posterior) opposite pair of arches, and of these the right one remaining pervious to the point where it gives off the right pulmonary branch, becomes obliterated beyond this point to that where it joins the descending aorta, while the left arch remains pervious during foetal life, as the ductus arteriosus still communicating with the descending aorta, and giving off at its middle the left pulmonary branch. The left ventricular artery (systemic aorta) is formed of the fourth arch of the left side, while the opposite arch (fourth right) is altogether obliterated. The third and second arches remain pervious on both sides, afterwards to become the right and left brachio-cephalic arteries. The first pair of arches, if not converted into the vertebral arteries, or the thyroid axes, are altogether metamorphosed. By these changes the heart and primary arteries assume the character in which they usually present themselves at birth, and in all probability the primary veins corresponded in form, number, and distribution with the arterial vessels, and underwent, at the same time, a similar mode of metamorphosis. One point in respect to the original symmetrical character of the primary veins is demonstrable—namely, that in front of the aortic branches the right and left brachio-cephalic veins, after joining by a cross branch, descend separately on either side of the heart, and enter (as two superior venae cavae) the right auricle by distinct orifices. In some of the lower animals, this double condition of the superior veins is constant, but in the human species the left vein below the cross branch (left brachio-cephalic) becomes obliterated, whilst the right vein (vena cava superior) receives the two brachio-cephalic veins, and in this condition remains throughout life. After birth, on the commencement of respiration, the foramen ovale of the interauricular septum closes, and the ductus arteriosus becomes impervious. This completes the stages of metamorphosis, and changes the course of the simple foetal circulation to one of a more complex order—viz., the systemic-pulmonary characteristic of the normal state in the adult body.
VIII.—Such being the phases of metamorphosis of the primary (branchial) arches which yield the vessels in their normal adult condition, we obtain in this history an explanation of the signification not only of such of their anomalies as are on record, but of such also as are potential in the law of development; a few of them will suffice to illustrate the meaning of the whole number:—lst, The interventricular as well as the interauricular septum may be arrested in growth, leaving an aperture in the centre of each; the former condition is natural to the human foetus, the latter to the reptilian class, while both would be abnormal in the human adult. 2nd. The heart may be cleft at its apex in the situation of the interventricular septum—a condition natural to the Dugong, A similar cleavage may divide the base of the heart in the situation of the interauricular septum. 3rd. The partitioning of the bulbus arteriosus may occur in such a manner as to assign to the two aortae a relative position, the reverse of that which they normally occupy—the pulmonary aorta springing from the left ventricle and the systemic aorta arising from the right, and giving off from its arch the primary branches in the usual order. [Footnote 1] 4th. As the two aortae result from a division of the common primary vessel (bulbus arteriosus), an arrest in the growth of the partition would leave them still as one vessel, which (supposing the ventricular septum remained also incomplete) would then arise from a single ventricle. 5th. The ductus arteriosus may remain pervious, and while co-existing with the proper aortic arch, two arches would then appear on the left side. 6th. The systemic normal aortic arch may be obliterated as far up as the innominate branch, and while the ductus arteriosus remains pervious, and leading from the pulmonary artery to the descending part of the aortic arch, this vessel would then present the appearance of a branch ascending from the left side and giving off the brachio-cephalic arteries. The right ventricular artery would then, through the medium of the ductus arteriosus, supply both the lungs and the system. Such a state of the vessels would require (in order that the circulation of a mixed blood might be carried on) that the two ventricles freely communicate. 7th. If the fourth arch of the right side remained pervious opposite the proper aortic arch, there would exist two aortic arches placed symmetrically, one on either side of the vertebral column, and, joining below, would include in their circle the trachea and oesophagus. 8th. If the fifth arch of the right side remained pervious opposite the open ductus arteriosus, both vessels would present a similar arrangement, as two symmetrical ducti arteriosi co-existing with symmetrical aortic arches. 9th. If the vessels appeared co-existing in the two conditions last mentioned, they would represent four aortic arches, two on either side of the vertebral column. 10th. If the fourth right arch, instead of the fourth left (aorta), remained pervious, the systemic aortic arch would then be turned to the right side of the vertebral column, and have the trachea and oesophagus on its left. 11th. When the bulbus arteriosus divides itself into three parts, the two lateral parts, in becoming connected with the left ventricle, will represent a double ascending systemic aorta, and having the pulmonary artery passing between them to the lungs. 12th. When of the two original superior venae cavae the right one instead of the left suffers metamorphosis, the vena cava superior will then appear on the left side of the normal aortic arch. [Footnote 2] Of these malformations, some are rather frequently met with, others very seldom, and others cannot exist compatible with life after birth. Those which involve a more or less imperfect discharge of the blood-aerating functions of the lungs, are in those degrees more or less fatal, and thus nature aborting as to the fitness of her creation, cancels it.
[Footnote 1: This physiological truth has, I find, been applied by Dr. R. Quain to the explanation of a numerous class of malformations connected with the origins of the great vessels from the heart, and of their primary branches. See The Lancet, vol. I. 1842.]
[Footnote 2: For an analysis of the occasional peculiarities of these primary veins in the human subject, see an able and original monograph in the Philosophical Transactions, Part 1., 1850, entitled, “On the Development of the Great Anterior Veins in Man and Mammalia.” By John Marshall, F.R.C.S., &c. ]
IX.—The portal system of veins passing to the liver, and the hepatic veins passing from this organ to join the inferior vena cava, exhibit in respect to the median line of the body an example of a-symmetry, since appearing on the right side, they have no counterparts on the left. As the law of symmetry seems to prevail universally in the development of organized beings, forasmuch as every lateral organ or part has its counterpart, while every central organ is double or complete, in having two similar sides, then the portal system, as being an exception to this law, is as a natural note of interrogation questioning the signification of that fact, and in the following observations, it appears to me, the answer may be found. Every artery in the body has its companion vein or veins. The inferior vena cava passes sidelong with the aorta in the abdomen. Every branch of the aorta which ramifies upon the abdominal parietes has its accompanying vein returning either to the vena cava or the vena azygos, and entering either of these vessels at a point on the same level as that at which itself arises. The renal vessels also have this arrangement. But all the other veins of the abdominal viscera, instead of entering the vena cava opposite their corresponding arteries, unite into a single trunk (vena portae), which enters the liver. The special purpose of this destination of the portal system is obvious, but the function of a part gives no explanation of its form or relative position, whether singular or otherwise. On viewing the vessels in presence of the general law of symmetrical development, it occurs to me that the portal and hepatic veins form one continuous system, which taken in the totality, represents the companion veins of the arteries of the abdominal viscera. The liver under this interpretation appears as a gland developed midway upon these veins, and dismembering them into a mesh of countless capillary vessels, (a condition necessary for all processes of secretion,) for the special purpose of decarbonizing the blood. In this great function the liver is an organ correlative or compensative to the lungs, whose office is similar. The secretion of the liver (bile) is fluidform; that of the lungs is aeriform. The bile being necessary to the digestive process, the liver has a duct to convey that product of its secretion to the intestines. The trachea is as it were the duct of the lungs. In the liver, then, the portal and hepatic veins being continuous as veins, the two systems, notwithstanding their apparent distinctness, caused by the intervention of the hepatic lobules, may be regarded as the veins corresponding with the arteries of the coeliac axis, and the two mesenteric. The hepatic artery and the hepatic veins evidently do not pair in the sense of afferent and efferent, with respect to the liver, both these vessels having destinations as different as those of the bronchial artery and the pulmonary veins in the lungs. The bronchial artery is attended by its vein proper, while the vein which corresponds to the hepatic artery joins either the hepatic or portal veins traversing the liver, and in this position escapes notice.[Footnote]
[Footnote: In instancing these facts, as serving under comparison to explain how the hepatic vessels constitute no radical exception to the law of symmetry which presides over the development and distribution of the vascular system as a whole, I am led to inquire in what respect (if in any) the liver as an organ forms an exception to this general law either in shape, in function, or in relative position. While seeing that every central organ is single and symmetrical by the union of two absolutely similar sides, and that each lateral pair of organs is double by the disunion of sides so similar to each other in all respects that the description of either side serves for the other opposite, it has long since seemed to me a reasonable inference that, since the liver on the right has no counterpart as a liver on the left, and that, since the spleen on the left has no counterpart as a spleen on the right, so these two organs (the liver and spleen) must themselves correspond to each other, and as such, express their respective significations. Under the belief that every exception (even though it be normal) to a general law or rule, is, like the anomaly itself, alone explicable according to such law, and expressing a fact not more singular or isolated from other parallel facts than is one form from another, or from all others constituting the graduated scale of being, I would, according to the light of this evidence alone, have no hesitation in stating that the liver and spleen, as opposites, represent corresponding organs, even though they appeared at first view more dissimilar than they really are. In support of this analogy of both organs, which is here, so far as I am aware, originally enunciated for anatomical science, I record the following observations:—1st. Between the opposite parts of the same organic entity (between the opposite leaves of the same plant, for example), nature manifests no such absolute difference in any case as exists between the leaf of a plant and of a book. 2ndly. When between two opposite parts of the same organic form there appears any differential character, this is simply the result of a modification or metamorphosis of one of the two perfectly similar originals or archetypes, but never carried out to such an extreme degree as to annihilate all trace of their analogy. 3rdly. The liver and the spleen are opposite parts; and as such, they are associated by arteries which arise by a single trunk (coeliac axis) from the aorta, and branch right and left, like indices pointing to the relationship between both these organs, in the same manner as the two emulgent arteries point to the opposite renal organs. 4thly. The liver is divided into two lobes, right and left; the left is less than the right; that quantity which is wanting to the left lobe is equal to the quantity of a spleen; and if in idea we add the spleen to the left lobe of the liver, both lobes of this organ become quantitatively equal, and the whole liver symmetrical; hence, as the liver plus the spleen represents the whole structural quantity, so the liver minus the spleen signifies that the two organs now dissevered still relate to each other as parts of the same whole. 5thly. The liver, as being three-fourths of the whole, possesses the duct which emanates at the centre of all glandular bodies. The spleen, as being one-fourth of the whole, is devoid of the duct. The liver having the duct, is functional as a gland, while the spleen having no duct, cannot serve any such function. If, in thus indicating the function which the spleen does not possess, there appears no proof positive of the function which it does, perhaps the truth is, that as being the ductless portion of the whole original hepatic quantity, it exists as a thing degenerate and functionless, for it seems that the animal economy suffers no loss of function when deprived of it. 6thly. In early foetal life, the left lobe of the liver touches the spleen on the left side; but in the process of abdominal development, the two organs become separated from each other right and left. 7thly. In animals devoid of the spleen, the liver appears of a symmetrical shape, both its lobes being equal; for that quantity which in other animals has become splenic, is in the former still hepatic. 8thly. In cases of transposition of both organs, it is the right lobe of the liver—that nearest the spleen, now on the right side—which is the smaller of the two lobes, proving that whichever lobe be in this condition, the spleen, as being opposite to it, represents the minus hepatic quantity. From these, among other facts, I infer that the spleen is the representative of the liver on the left side, and that as such, its signification being manifest, there exists no exception to the law of animal symmetry. “Tam miram uniformitatem in planetarum systemate, necessario fatendum est intelligentia et concilio fuisse effectam. Idemque dici possit de uniformitate illa quae est in corporibus animalium. Habent videlicet animalia pleraque omnia, bina latera, dextrum et sinistrum, forma consimili: et in lateribus illis, a posteriore quidem corporis sui parte, pedes binos; ab anteriori autem parte, binos armos, vel pedes, vel alas, humeris affixos: interque humeros collum, in spinam excurrens, cui affixum est caput; in eoque capite binas aures, binos oculos, nasum, os et linguam; similiter posita omnia, in omnibus fere animalibus.”—Newton, Optices, sive de reflex, &c. p. 411.]
X.—The heart, though being itself the recipient, the prime mover, and the dispenser of the blood, does not depend either for its growth, vitality, or stimulus to action, upon the blood under these uses, but upon the blood circulating through vessels which are derived from its main systemic artery, and disposed in capillary ramifications through its substance, in the manner of the nutrient vessels of all other organs. The two coronary arteries of the heart arise from the systemic aorta immediately outside the semilunar valves, situated in the root of this vessel, and in passing right and left along the auriculo-ventricular furrows, they send off some branches for the supply of the organ itself, and others by which both vessels anastomose freely around its base and apex. The vasa cordis form an anastomotic circulation altogether isolated from the vessels of the other thoracic organs, and also from those distributed to the thoracic parietes. The coronary arteries are accompanied by veins which open by distinct orifices (foramina Thebesii) into the right auricle. Like the heart itself, its main vessels do not depend for their support upon the blood conveyed by them, but upon that circulated by the small arteries (vasa vasorum) derived either from the vessel upon which they are distributed, or from some others in the neighbourhood. These little arteries are attended by veins of a corresponding size (venules) which enter the venae comites, thus carrying out the general order of vascular distribution to the minutest particular. Besides the larger nerves which accompany the main vessels, there are delicate filaments of the cerebro-spinal and sympathetic system distributed to their coats, for the purpose, as it is supposed, of governing their “contractile movements.” The vasa vasorum form an anastomosis as well upon the inner surface of the sheath as upon the artery contained in this part; and hence in the operation for tying the vessel, the rule should be to disturb its connexions as little as possible, otherwise its vitality, which depends upon these minute branches, will, by their rupture, be destroyed in the situation of the ligature, where it is most needed.
XI.—The branches of the systemic aorta form frequent anastomoses with each other in all parts of the body. This anastomosis occurs chiefly amongst the branches of the main arteries proper to either side. Those branches of the opposite vessels which join at the median line are generally of very small size. There are but few instances in which a large blood vessel crosses the central line from its own side to the other. Anastomosis at the median line between opposite vessels happens either by a fusion of their sides lying parallel, as for example (and the only one) that of the two vertebral arteries on the basilar process of the occipital bone; or else by a direct end-to-end union, of which the lateral pair of cerebral arteries, forming the circle of Willis, and the two labial arteries, forming the coronary, are examples. The branches of the main arteries of one side form numerous anastomoses in the muscles and in the cellular and adipose tissue generally. Other special branches derived from the parent vessel above and below the several joints ramify and anastomose so very freely over the surfaces of these parts, and seem to pass in reference to them out of their direct course, that to effect this mode of distribution appears to be no less immediate a design than to support the structures of which the joints are composed.
XII.—The innominate artery. When this vessel is tied, the free direct circulation through the principal arteries of the right arm, and the right side of the neck, head, and brain, becomes arrested; and the degree of strength of the recurrent circulation depends solely upon the amount of anastomosing points between the following arteries of the opposite sides. The small terminal branches of the two occipital, the two auricular, the two superficial temporal, and the two frontal, inosculate with each other upon the sides, and over the vertex of the head; the two vertebral, and the branches of the internal carotid, at the base and over the surface of the brain; the two facial with each other, and with the frontal above and mental below, at the median line of the face; the two internal maxillary by their palatine, pharyngeal, meningeal, and various other branches upon the surface of the parts to which they are distributed; and lastly, the two superior thyroid arteries inosculate around the larynx and in the thyroid body. By these anastomoses, it will be seen that the circulation is restored to the branches of the common carotid almost solely. In regard to the subclavian artery, the circulation would be carried on through the anastomosing branches of the two inferior thyroid in the thyroid body; of the two vertebral, in the cranium and upon the cervical vertebrae; of the two internal mammary, with each other behind the sternum, and with the thoracic branches of the axillary and the superior intercostal laterally; lastly, through the anastomosis of the ascending cervical with the descending branch of the occipital, and with the small lateral offsets of the vertebral.
XIII.—The common carotid arteries, Of these two vessels, the left one arising, in general, from the arch of the aorta, is longer than the right one by the measure of the innominate artery from which the right arises. When either of the common carotids is tied, the circulation will be maintained through the anastomosing branches of the opposite vessels as above specified. When the vertebral or the inferior thyroid branch arises from the middle of the common carotid, this vessel will have an additional source of supply if the ligature be applied to it below the origin of such branch. In the absence of the innominate artery, the right as well as the left carotid will be found to spring directly from the aortic arch.
XIV.—The subclavian arteries. When a ligature is applied to the inner third of this vessel within its primary branches, the collateral circulation is carried on by the anastomoses of the arteries above mentioned; but if the vertebral or the inferior thyroid arises either from the aorta or the common carotid, the sources of arterial supply in respect to the arm will, of course, be less numerous. When the outer portion of the subclavian is tied between the scalenus and the clavicle, while the branches arise from its inner part in their usual position and number, the collateral circulation in reference to the arm is maintained by the following anastomosing branches:—viz., those of the superficialis colli, and the supra and posterior scapular, with those of the acromial thoracic; the subscapular, and the anterior and posterior circumflex around the shoulder-joint, and over the dorsal surface of the scapula; and those of the internal mammary and superior intercostal, with those of the thoracic arteries arising from the axillary. Whatever be the variety as to their mode or place of origin, the branches emanating from the subclavian artery are constant as to their destination. The length of the inner portion of the right subclavian will vary according to the place at which it arises, whether from the innominate artery, from the ascending, or from the descending part of the aortic arch.
XV.—The axillary artery. As this vessel gives off throughout its whole length, numerous branches which inosculate principally with the scapular, mammary, and superior intercostal branches of the subclavian, it will be evident that, in tying it above its own branches, the anastomotic circulation will with much greater freedom be maintained in respect to the arm, than if the ligature be applied below those branches. Hence, therefore, when the axillary artery is affected with aneurism, thereby rendering it unsafe to apply a ligature to this vessel, it becomes not only pathologically, but anatomically, the more prudent measure to tie the subclavian immediately above the clavicle.
XVI.—The brachial artery, When this artery is tied immediately below the axilla, the collateral circulation will be weakly maintained, in consequence of the small number of anastomosing branches arising from it above and below the seat of the ligature. The two circumflex humeri alone send down branches to inosculate with the small muscular offsets from the middle of the brachial artery. When tied in the middle of the arm between the origins of the superior and inferior profunda arteries, the collateral circulation will depend chiefly upon the anastomosis of the former vessel with the recurrent branch of the radial, and of muscular branches with each other. When the ligature is applied to the lower third of the vessel, the collateral circulation will be comparatively free through the anastomoses of the two profundi and anastomotic branches with the radial, interosseous, and ulnar recurrent branches. If the artery happen to divide in the upper part of the arm into either of the branches of the forearm, or into all three, a ligature applied to any one of them will, of course, be insufficient to arrest the direct circulation through the forearm, if this be the object in view.
XVII.—The radial artery. If this vessel be tied in any part of its course, the collateral circulation will depend principally upon the free communications between it and the ulnar, through the medium of the superficial and deep palmar arches and those of the branches derived from both vessels, and from the two interossei distributed to the fingers and back of the hand.
XVIII.—The ulnar artery. When this vessel is tied, the collateral circulation will depend upon the anastomosis of the palmar arches, as in the case last mentioned. While the radial, ulnar, and interosseous arteries spring from the same main vessel, and are continuous with each other in the hand, they represent the condition of a circle of which, when either side is tied, the blood will pass in a current of almost equal strength towards the seat of the ligature from above and below—a circumstance which renders it necessary to tie both ends of the vessel in cases of wounds.
XIX.—The common iliac artery. When a ligature is applied to the middle of this artery, the direct circulation becomes arrested in the lower limb and side of the pelvis corresponding to the vessel operated on. The collateral circulation will then be carried on by the anastomosis of the following branches—viz., those of the lumbar, the internal mammary, and the epigastric arteries of that side with each other, and with their fellows in the anterior abdominal parietes; those of the middle and lateral sacral; those of the superior with the middle and inferior haemorrhoidal; those of the aortic and internal iliac uterine branches in the female; and of the aortic and external iliac spermatic branches in the male. The anastomoses of these arteries with their opposite fellows along the median line, are much less frequent than those of the arteries of the neck and head.
XX.—The external iliac artery. This vessel, when tied at its middle, will have its collateral circulation carried on by the anastomoses of the internal mammary with the epigastric; by those of the ilio-lumbar with the circumflex ilii; those of the internal circumflex femoris, and superior perforating arteries of the profunda femoris, with the obturator, when this branch arises from the internal iliac; those of the gluteal with the external circumflex; those of the latter with the sciatic; and those of both obturators, with each other, when arising—the one from the internal, the other from the external iliac. Not unfrequently either the epigastric, obturator, ilio-lumbar, or circumflex ilii, arises from the middle of the external iliac, in which case the ligature should be placed above such branch.
XXI.—The common femoral artery. On considering the circles of inosculation formed around the innominate bone between the branches derived from the iliac arteries near the sacro-iliac junction, and those emanating from the common femoral, above and below Poupart’s ligament, it will at once appear that, in respect to the lower limb, the collateral circulation will occur more freely if the ligature be applied to the main vessel (external iliac) than if to the common femoral below its branches.
XXII.—The superficial femoral artery. When a ligature is applied to this vessel at the situation where it is overlapped by the sartorius muscle, the collateral circulation will be maintained by the following arteries:—the long descending branches of the external circumflex beneath the rectus muscle, inosculate with the muscular branches of the anastomotica magna springing from the lower third of the main vessel; the three perforating branches of the profunda inosculate with the latter vessel, with the sciatic, and with the articular and muscular branches around the knee-joint.
XXIII.—The popliteal artery. When any circumstance renders it necessary to tie this vessel in preference to the femoral, the ligature should be placed above its upper pair of articular branches; for by so doing a freer collateral circulation will take place in reference to the leg. The ligature in this situation will lie between the anastomotic and articular arteries, which freely communicate with each other.
XXIV.—The anterior and posterior tibial and peronoeal arteries. As these vessels correspond to the arteries of the forearm, the observations which apply to the one set apply also to the other. [Footnote]
[Footnote: For a complete history of the general vascular system, see The Anatomy of the Arteries of the Human Body, by Richard Quain, F.R.S., &c., in which work, besides the results of the author’s own great experience and original observations, will be found those of Haller’s, Scarpa’s, Tiedemann’s, &c., systematically arranged with a view to operative surgery.]
THE END.