Practical pathology

by Aldred Scott Warthin

Fig. 45.—Section of male pelvic organs. Arrows mark line of incisions through prostate and rectum. (After Nauwerck.)

When the external genitals cannot be removed, the testicles can be examined by enlarging the inguinal rings and canal, and forcing each testicle up from below, through the ring. The gland is then sectioned and, after examination, returned to the scrotum. The anterior wall of the bladder is then separated from the pubis and the tissues about rectum and prostate loosened until the hand can completely encircle the rectum and prostate. These organs and the bladder are then pulled up firmly toward the head of the cadaver, and with the cartilage-knife hugging the pubic bone the rectum is cut just above the internal sphincter, and the urethra just anteriorly to the prostate. When it is desired to get as much of the penis as possible, its attachments to the pubis are cut from the pelvic side, and the body of the penis pulled up into the pelvis, while the skin of the organ is loosened as far as the glans. The body of the penis may be severed from the glans or the glans may be freed from the prepuce and removed with the entire organ, leaving only the skin to be used for the restoration of the part. After the rectum and urethra are severed, the mass of pelvic organs is stripped up to the brim of the pelvis and removed, as given above. They are examined upon the board, opening first the rectum, then the seminal vesicles, prostatic urethra, bladder and prostate. The prostatic urethra and anterior bladder-wall are cut with the small probe-pointed shears, while the prostate is cut transversely with the long section-knife.

The bladder, prostate and seminal vesicles may be examined in situ, or separated from the rectum and examined outside of the body. The anterior wall of the bladder is freed from the pubis, and the lateral connections of the prostate separated. The bladder is then opened in its anterior wall by an incision from its fundus into the prostatic portion of the urethra. The prostate is then cut transversely at about its middle, the cut extending entirely through the organ. The fore-finger of the left hand is then hooked underneath the prostate, and the bladder stripped forcibly from the rectum, upward toward the pelvic brim. The base of the bladder is thus brought up into view, exposing the seminal vesicles, which are examined by transverse incisions.

In the employment of any one of these methods, the urine, if it is to be saved for examination, should first be drawn through a catheter. This is also the cleanest way of emptying the bladder, particularly when it is greatly distended. The employment of force to squeeze the urine out of the bladder through the urethra is not advisable when there is any disease of bladder or urethra present.

Fig. 46.—Section of female pelvic organs. Urinary bladder bisected and vagina opened in anterior median line. Arrows show direction of incisions. (After Nauwerck.)

2. Female Pelvis. The contents of the pelvis and the external genitalia are removed from the female cadaver in the same way as in the male. The anterior wall of the bladder is first freed from the pubis and the tissues separated around and behind the rectum so that the hand can be carried around the vagina and rectum. When the external genitalia are to be removed with the internal organs, an encircling incision is made on both sides of the external genitals, beginning above at the termination of the main incision at the beginning of the anterior commissure, and meeting behind the anus. The external genitals are then dissected away from the arch of the pubis until the knife can be passed up beneath the symphysis and the attachments to the posterior border of the arch cut on both sides, so that the vulva can be pulled up beneath the pelvic arch, putting the perineum on the stretch. The posterior portion of the encircling incision is then deepened until the entire mass of external genitals and anus can be stripped up with the internal organs to the brim of the pelvis, where they are held up perpendicularly and any remaining attachments of peritoneum and blood-vessels cut, care being taken to cut outside of the ovaries and tubes. The mass thus removed is laid on the board with rectum uppermost and the latter opened first. The organs are then turned over, and the urethra and bladder opened in the anterior median line with the probe-pointed shears. The vagina and uterus are then opened in the anterior median line, bisecting the urethra and bladder. A heavy pair of shears having one blunt-pointed blade should be used. If it is desired to save the bladder and urethra, they can be dissected over to the right, or the vaginal wall can be cut on its left side. When the cervical canal will not admit the scissors the uterus may be cut in the median line with a knife. The horns may then be opened with the scissors. Additional cuts may be made into the uterine wall as desired (tumors, placental site, etc.). The tubes may be sounded from the abdominal extremity and then opened for their entire length with the fine probe-pointed shears, or they may be examined by means of transverse cuts. The ovaries are held with their flat surfaces between thumb and index-finger and then sectioned in the plane of greatest dimension from the convex border to the hilus. The broad ligaments, parametrium, parovarium and lymphnodes are examined by means of cuts made parallel with the sides of the uterus.

When the external genitals cannot be removed, the vagina and rectum, after they have been freed from the surrounding tissues, are put on the stretch toward the head of the body and cut through as close to the pubic outlet as possible. When this is carefully done it is possible to secure the inner labia and the urethra intact. The rectum is cut as close to the anus as possible. The organs are then stripped up to the brim of the pelvis, then held up perpendicularly while the remaining connections are severed. The organs thus removed are examined on the board in the same manner as given above. When the organs cannot be removed from the body, the bladder and urethra are examined by an anterior median incision after they have been freed from the symphysis. The uterus and vagina are then cut with the knife in the anterior median line, either through the bladder or after the latter has been dissected away. The ovaries, tubes and broad ligaments are then examined as directed above. The uterus and vagina may also be dissected from the rectum and opened by a posterior median incision. This method is used in medicolegal examinations.

To facilitate the removal of the genital organs in either sex a symphysiotomy may be performed and the pubic arch pulled apart, or a portion of the pubis may be cut out with the saw.