Surgical Anatomy Part 44

Plate 62.--Figure 4, 5.

Fig. 5, Plate 62.--The prostate, a a, is greatly enlarged, and projects high in the bladder, the walls of the latter, b b, being very much thickened. The ureters, c, are dilated, and perforations made by instruments are seen in the prostate. The prostatic ca.n.a.l 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 circ.u.mstance occasions what is termed a "deep perinaeum."

Fig. 6, Plate 62.--The lower half, c, b, f, of the prostate, having become the seat of abscess, appears hollowed out in the form of a sac.

This sac is separated from the bladder by a horizontal septum, e e, the proper base of the bladder, g g. The prostatic urethra, between a e, has become vertical in respect to the membranous part of the ca.n.a.l, 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 pa.s.sed 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 ca.n.a.l 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 pa.s.s, 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 r.e.c.t.u.m 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.

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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 ca.n.a.l are two calculi, d d, closely impacted. In such a state of the parts it would be impossible to pa.s.s 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 pa.s.sed 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.

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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 p.u.b.eS.

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 ma.s.s through an opening at the median line of the hypogastrium; that in which the r.e.c.t.u.m terminates in the bladder posteriorly; and that in which the foetal urachus remains pervious as a uniform ca.n.a.l, or a.s.sumes 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 p.u.b.es, at the perinaeum, or into the r.e.c.t.u.m, 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 ca.n.a.l.[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, a.s.sumes 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 pa.s.sage 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 const.i.tutional 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 princ.i.p.al 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 const.i.tutes the disease, since in this form it cannot be pa.s.sed. 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 s.e.xes,) why the lithic sediment should present in the form of concrement in some and not in others? The princ.i.p.al, if not the sole, cause of this seems to me to be obstruction to the free egress of the urine along the natural pa.s.sage. Aged individuals of the male s.e.x, in whom the prostate is p.r.o.ne 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 ca.n.a.l. 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.

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Plate 63,--Figure 1.

FIG. 2, Plate 63.--The prostate, 2, 3, is enlarged, and the middle lobe, 2, appears bending the prostatic ca.n.a.l 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.

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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 r.e.c.t.u.m. 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 p.u.b.es.

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Plate 63,--Figure 3, 4.

FIG. 4, Plate 63.--The vesical orifice is obstructed by two portions, 3, 4, of the prostate, projecting upwards, one from each of its lateral lobes, 6, 6. The bladder is thickened and fasciculated, and from its summit projects a double sac, 1, 2, which is invested by the peritonaeum.

FIG. 5, Plate 63.--The prostatic ca.n.a.l 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.

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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 r.e.c.t.u.m lay in contact with the base of the bladder between the two sacs.

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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 ca.n.a.l, and becomes a complete bar to the pa.s.sage 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.

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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.

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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 circ.u.mstances combine to this effect--while the renal secretion continues to pa.s.s into the ureters from above, the contents of the bladder under abdominal pressure are forced regurgitating into them from below, through their orifices.

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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.

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