Surgical Anatomy Part 42

Fig. 12, Plate 59.--In this case an instrument, d d, after pa.s.sing 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 pa.s.s 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 pa.s.sed in the course marked out.

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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 s.p.a.ce 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 ca.n.a.l. 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]

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Plate 60.--Figures 1, 2, 3, 4, 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 ca.n.a.l is bent upwards by the enlarged third lobe to such a degree as to form a right angle with the membranous part of the ca.n.a.l. A bougie is seen to perforate the third lobe, and this is the most frequent mode in which, under such circ.u.mstances, and with instruments of the usual imperfect form, access may be gained to the bladder for the relief of retention of urine. "The new pa.s.sage may in every respect be as efficient as one formed by puncture or incision in any other way." (Fergusson.)

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Plate 60.--Figure 6

Fig. 7, Plate 60.--The three lobes of the prostate, a, b, c, are equally enlarged. The prostatic ca.n.a.l is consequently much contracted and distorted, so that an instrument on being pa.s.sed into the bladder has made a false pa.s.sage 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 pa.s.sage till such time as this has a.s.sumed the cylindrical form of the instrument. If this be done, the new pa.s.sage will be the more likely to become permanent. It is ascertained that all false pa.s.sages and fistulae by which the urine escapes, become after a time lined with a membrane similar to that of the urethra. (Stafford.)

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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 ca.n.a.l upwards and to the right side.

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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 r.e.c.t.u.m, and by its projection in front, contracted the area of the prostatic ca.n.a.l, and thereby caused an obstruction in this part. Not unfrequently when a catheter is pa.s.sed 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.

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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 ca.n.a.l is almost completely obstructed, and an instrument has made a false pa.s.sage through the lobe a.

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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 pa.s.sage made by the catheter, d, through it, from its apex to its base. The proper ca.n.a.l is bent upwards from its usual position, which is that at present marked by the instrument in the false pa.s.sage.

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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 pa.s.sage of the instrument.

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Plate 60.--Figure 12.

Fig. 13, Plate 60.--The prostate, bc, is considerably enlarged anteriorly, b, in consequence of which the prostatic ca.n.a.l appears more horizontal even than natural. The catheter, d, occupying the ca.n.a.l 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.

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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 princ.i.p.al 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 s.e.x but has its a.n.a.logue in the opposite s.e.x; 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 a.n.a.logy becomes as fully manifested as that between the two quant.i.ties, a-b, and a+b the only difference which exists depends upon the subtraction or the addition of the quant.i.ty, b. The difference between a prostate and a uterus is simply one of quant.i.ty, 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 a.n.a.logue.

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 quant.i.tatively, 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 p.r.o.ne 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 a.s.sign 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 a.n.a.logy 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 quant.i.ty, 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 a.n.a.logical 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 pa.s.sage of urine from the bladder, but from this circ.u.mstance 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-encompa.s.sing 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.

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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 ca.n.a.l, 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 circ.u.mstance will, of course, favour the occurrence of the accident.

"False pa.s.sages (observes Mr. Benjamin Phillips) are less frequent here (in the membranous part of the urethra) than in the bulbous portion of the ca.n.a.l. The reason of this must be immediately evident: false pa.s.sages are ordinarily made in consequence of the difficulty experienced in the endeavour to pa.s.s 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 ca.n.a.l; consequently, the false pa.s.sage will be usually anterior to this latter point."--(On the Urethra, its Diseases. &c., p. 15.) ]