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 theultimate factin 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, anda+bthe 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 ofnihil supervacaneum nihil frutra, arrested in its development, and in such a character appears the prostate. This bodyis not a glandany 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 itselfper 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.Illustration: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 atd.The sinus of the bulb, being the lowest part of the urethral canal, is very liable to be distorted or perforated by the points of instruments descending upon it from above and before. [Footnote][Footnote: When a stricture exists immediately behind the bulb, this circumstance will, of course, favour the occurrence of the accident. “False passages (observes Mr. Benjamin Phillips) are less frequent here (in the membranous part of the urethra) than in the bulbous portion of the canal. The reason of this must be immediately evident: false passages are ordinarily made in consequence of the difficulty experienced in the endeavour to pass an instrument through the strictured portion of the tube. Stricture is most frequently seated at the point of junction between the bulbous and membranous portions of the canal; consequently, the false passage will be usually anterior to this latter point.”—(On the Urethra, its Diseases. &c., p. 15.) ]Illustration:Plate 61.—Figure 2Fig. 3, Plate 61.—A cyst,c, is seen to grow from the left side of the base of the prostate,a b, and to form an obstruction at the vesical orifice.Illustration:Plate 61.—Figure 3.Fig. 4, Plate 61.—A globular excrescence,a, appears blocking up the vesical orifice, and giving to this the appearance of a crescentic slit, corresponding to the shape of the obstructing body. The prostate,b b,is enlarged in both its lateral lobes. A small bougie,c,is placed in the prostatic canal and vesical opening.Illustration:Plate 61.—Figure 4Fig. 5, Plate 61.—The prostate,d, is considerably enlarged, and the vesical orifice is girt by a prominent ring,b b, from the right border of which the nipple-shaped body,a, projects and occupies the outlet. Owing to the retention of urine caused by this state of the prostate, the ureters,c c, have become very much dilated.Illustration:Plate 61.—Figure 5.Fig. 6, Plate 61.—The lateral lobes of the prostate,c c,are seen enlarged, and from the inner side and base of each, irregularly shaped masses,a, b, d,project, and bend the prostatic urethra first to the right side, then to the left. The part,a,resting upon the part,b, acts like a valve against the vesical outlet, which would become closed the tighter according to the degree of superincumbent pressure. A flexible catheter would, in such a case as this, be more likely, perhaps, to follow the sinuous course of the prostatic passage than a rigid instrument of metal.Illustration:Plate 61.—Figure 6.Fig. 7, Plate 61.—A globular mass,a,of large size, occupies the neck of the bladder, and gives the vesical orifice,c,a crescentic shape, convex towards the right side. The two lobes of the prostate,b,are much enlarged.Illustration:Plate 61.—Figure 7.Fig. 8, Plate 61.—The lateral lobes,b b,of the prostate are irregularly enlarged, and the urinary passage is bent towards the right side,c, from the membranous portion, which is central. Surmounting the vesical orifice,c, is seen the tuberculated mass,a, which being moveable, can be forced against the vesical orifice and thus produce complete retention of urine. In this case, also, a flexible catheter would be more suitable than a metallic one.Illustration:Plate 61.—Figure 8.Fig. 9, Plate 61.—The lateral lobes,b b, of the prostate are enlarged. The third lobe,a, projects at the neck of the bladder, distorting the vesical outlet. A small calculus occupies the prostatic urethra, and being closely impacted in this part of the canal, would arrest the progress of a catheter, and probably lead to the supposition that the instrument grated against a stone in the interior of the bladder, in which case it would be inferred that since the urine did not flow through the catheter no retention existed.Illustration:Plate 61.—Figure 9.Illustration: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.Illustration:Plate 61.—Figure 11.Fig. 12, Plate 61.—The prostate,c b, is enlarged and dilated, like a sac. Across the neck,a,of the bladder the prostate projects in an arched form, and is transfixed by the instrument,d. The prostate may assume this appearance, as well from instruments having been forced against it, as from an abscess cavity formed in its substance having received, from time to time, a certain amount of the urine, and retained this fluid under the pressure of strong efforts, made to void the bladder while the vesical orifice was closed above.Illustration:Plate 61.—Figure 12.Fig. 13, Plate 61.—The lateral lobes,d e, of the prostate are enlarged; and, occupying the position of the third lobe, appear as three masses,a b c,plicated upon each other, and directed towards the vesical orifice, which they close like valves. The prostatic urethra branches upwards into three canals, formed by the relative position of the parts,e, c, b, a, d,at the neck of the bladder. The ureters are dilated, in consequence of the regurgitation of the contents of the bladder during the retention which existed ..Illustration:Plate 61.—Figure 13.Fig. 1, Plate 62, exhibits the lobes of the prostate greatly increased in size. The part,a b,girds irregularly, and obstructs the vesical outlet, while the lateral lobes,c d,encroach upon the space of the prostatic canal. The walls of the bladder are much thickened.Illustration:Plate 62.—Figure 1.Fig. 2, Plate 62.—The three lobes,a, d, c,of the prostate are enlarged and of equal size, moulded against each other in such a way that the prostatic canal and vesical orifice appear as mere clefts between them. The three lobes are encrusted on their vesical surfaces with a thick calcareous deposit. The surface of the third lobe,a,which has been half denuded of the calcareous crust,b, in order to show its real character, appeared at first to be a stone impacted in the neck of the bladder, and of such a nature it certainly would seem to the touch, on striking it with the point of a sound or other instrument.Illustration:Plate 62.—Figure 2.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.Illustration: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.Illustration: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.”Illustration: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, betweena 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 pointc; 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 ofd 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 ofd d d, then the knife, following the staff, will open, not the bladder which contains the stone, but the sac, which, moreover, if it happen to be filled with urine regurgigated from the urethra, will render the deception more complete.Illustration:Plate 62.—Figure 6.Fig. 7, Plate 62.—The walls,a a, of the bladder, appear greatly thickened, and the ureters,b,dilated. The sides,c c c,of the prostate are thinned; and in the prostatic canal are two calculi,d d,closely impacted. In such a state of the parts it would be impossible to pass a catheter into the bladder for the relief of a retention of urine, or to introduce a staff as a guide to the knife in lithotomy. If, however, the staff can be passed as far as the situation of the stone, the parts may be held with a sufficient degree of steadiness to enable the operator to incise the prostate upon the stone.Illustration:Plate 62.—Figure 7.
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 theultimate factin 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, anda+bthe 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 ofnihil supervacaneum nihil frutra, arrested in its development, and in such a character appears the prostate. This bodyis not a glandany 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 itselfper 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.
Illustration:Plate 61.—Figure 1.
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 atd.The sinus of the bulb, being the lowest part of the urethral canal, is very liable to be distorted or perforated by the points of instruments descending upon it from above and before. [Footnote]
[Footnote: When a stricture exists immediately behind the bulb, this circumstance will, of course, favour the occurrence of the accident. “False passages (observes Mr. Benjamin Phillips) are less frequent here (in the membranous part of the urethra) than in the bulbous portion of the canal. The reason of this must be immediately evident: false passages are ordinarily made in consequence of the difficulty experienced in the endeavour to pass an instrument through the strictured portion of the tube. Stricture is most frequently seated at the point of junction between the bulbous and membranous portions of the canal; consequently, the false passage will be usually anterior to this latter point.”—(On the Urethra, its Diseases. &c., p. 15.) ]
Illustration:Plate 61.—Figure 2
Plate 61.—Figure 2
Fig. 3, Plate 61.—A cyst,c, is seen to grow from the left side of the base of the prostate,a b, and to form an obstruction at the vesical orifice.
Illustration:Plate 61.—Figure 3.
Plate 61.—Figure 3.
Fig. 4, Plate 61.—A globular excrescence,a, appears blocking up the vesical orifice, and giving to this the appearance of a crescentic slit, corresponding to the shape of the obstructing body. The prostate,b b,is enlarged in both its lateral lobes. A small bougie,c,is placed in the prostatic canal and vesical opening.
Illustration:Plate 61.—Figure 4
Plate 61.—Figure 4
Fig. 5, Plate 61.—The prostate,d, is considerably enlarged, and the vesical orifice is girt by a prominent ring,b b, from the right border of which the nipple-shaped body,a, projects and occupies the outlet. Owing to the retention of urine caused by this state of the prostate, the ureters,c c, have become very much dilated.
Illustration:Plate 61.—Figure 5.
Plate 61.—Figure 5.
Fig. 6, Plate 61.—The lateral lobes of the prostate,c c,are seen enlarged, and from the inner side and base of each, irregularly shaped masses,a, b, d,project, and bend the prostatic urethra first to the right side, then to the left. The part,a,resting upon the part,b, acts like a valve against the vesical outlet, which would become closed the tighter according to the degree of superincumbent pressure. A flexible catheter would, in such a case as this, be more likely, perhaps, to follow the sinuous course of the prostatic passage than a rigid instrument of metal.
Illustration:Plate 61.—Figure 6.
Plate 61.—Figure 6.
Fig. 7, Plate 61.—A globular mass,a,of large size, occupies the neck of the bladder, and gives the vesical orifice,c,a crescentic shape, convex towards the right side. The two lobes of the prostate,b,are much enlarged.
Illustration:Plate 61.—Figure 7.
Plate 61.—Figure 7.
Fig. 8, Plate 61.—The lateral lobes,b b,of the prostate are irregularly enlarged, and the urinary passage is bent towards the right side,c, from the membranous portion, which is central. Surmounting the vesical orifice,c, is seen the tuberculated mass,a, which being moveable, can be forced against the vesical orifice and thus produce complete retention of urine. In this case, also, a flexible catheter would be more suitable than a metallic one.
Illustration:Plate 61.—Figure 8.
Plate 61.—Figure 8.
Fig. 9, Plate 61.—The lateral lobes,b b, of the prostate are enlarged. The third lobe,a, projects at the neck of the bladder, distorting the vesical outlet. A small calculus occupies the prostatic urethra, and being closely impacted in this part of the canal, would arrest the progress of a catheter, and probably lead to the supposition that the instrument grated against a stone in the interior of the bladder, in which case it would be inferred that since the urine did not flow through the catheter no retention existed.
Illustration:Plate 61.—Figure 9.
Plate 61.—Figure 9.
Illustration:Plate 61.—Figure 10.
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.
Illustration:Plate 61.—Figure 11.
Plate 61.—Figure 11.
Fig. 12, Plate 61.—The prostate,c b, is enlarged and dilated, like a sac. Across the neck,a,of the bladder the prostate projects in an arched form, and is transfixed by the instrument,d. The prostate may assume this appearance, as well from instruments having been forced against it, as from an abscess cavity formed in its substance having received, from time to time, a certain amount of the urine, and retained this fluid under the pressure of strong efforts, made to void the bladder while the vesical orifice was closed above.
Illustration:Plate 61.—Figure 12.
Plate 61.—Figure 12.
Fig. 13, Plate 61.—The lateral lobes,d e, of the prostate are enlarged; and, occupying the position of the third lobe, appear as three masses,a b c,plicated upon each other, and directed towards the vesical orifice, which they close like valves. The prostatic urethra branches upwards into three canals, formed by the relative position of the parts,e, c, b, a, d,at the neck of the bladder. The ureters are dilated, in consequence of the regurgitation of the contents of the bladder during the retention which existed ..
Illustration:Plate 61.—Figure 13.
Plate 61.—Figure 13.
Fig. 1, Plate 62, exhibits the lobes of the prostate greatly increased in size. The part,a b,girds irregularly, and obstructs the vesical outlet, while the lateral lobes,c d,encroach upon the space of the prostatic canal. The walls of the bladder are much thickened.
Illustration:Plate 62.—Figure 1.
Plate 62.—Figure 1.
Fig. 2, Plate 62.—The three lobes,a, d, c,of the prostate are enlarged and of equal size, moulded against each other in such a way that the prostatic canal and vesical orifice appear as mere clefts between them. The three lobes are encrusted on their vesical surfaces with a thick calcareous deposit. The surface of the third lobe,a,which has been half denuded of the calcareous crust,b, in order to show its real character, appeared at first to be a stone impacted in the neck of the bladder, and of such a nature it certainly would seem to the touch, on striking it with the point of a sound or other instrument.
Illustration:Plate 62.—Figure 2.
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.
Illustration:Plate 62.—Figure 3.
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.
Illustration:Plate 62.—Figure 4.
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.”
Illustration:Plate 62.—Figure 5.
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, betweena 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 pointc; 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 ofd 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 ofd d d, then the knife, following the staff, will open, not the bladder which contains the stone, but the sac, which, moreover, if it happen to be filled with urine regurgigated from the urethra, will render the deception more complete.
Illustration:Plate 62.—Figure 6.
Plate 62.—Figure 6.
Fig. 7, Plate 62.—The walls,a a, of the bladder, appear greatly thickened, and the ureters,b,dilated. The sides,c c c,of the prostate are thinned; and in the prostatic canal are two calculi,d d,closely impacted. In such a state of the parts it would be impossible to pass a catheter into the bladder for the relief of a retention of urine, or to introduce a staff as a guide to the knife in lithotomy. If, however, the staff can be passed as far as the situation of the stone, the parts may be held with a sufficient degree of steadiness to enable the operator to incise the prostate upon the stone.
Illustration:Plate 62.—Figure 7.
Plate 62.—Figure 7.