UNGER CORNELL UNIVERSITY LIBRARY Cornell University Library QM 531.M12 1857 Plates of Macllse's Surgcal anatomy, wit 3 1924 024 791 752 .,»,.,.. Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924024791752 THE PLATES OF MACLISE'S SURGICAL ANATOMY, WITH THE DESCRIPTIONS. FEOM THE ENGLISH EDITION. WITH AN ADDITIONAL PLATE FROM BOUGERY. EDITED BY E. U. PIPER, M. D. PRINTEB IN OIL COLORS, , AFTER BAXTER'S PROCESS. BOSTON: PUBLISHED BY JOHN P. JEWETT AND COMPANY. CLEVELAND, OHIO : HENRY P- B. JEWETT. M.DCCC.LVII. Kntereil according to Act of ('onpees, in the yoni: 1857, by JOHN P. JEWETT AXD 00511' AXY, In the Clevis's office of the Di-triet Court for the District nf Massachusetts. IJTIIOTYrKD UY C0WLE3 AND CO>a»AI., .'■'V. /"'^"s^^^' ■ *- SURGICAL ANATOMY. PLATE 19. DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND INFANTILE INGUINAL HERNIA, AND OF HYDROCELE. Plate 19. Fig. 1. — The descent of the testicle from the loins to the scrotum. — The foetal abdomen and scrotum form one general cavity, and are composed of parts wMch are structurally identical. The cutaneous, fascial, muscu- lar, and membranous layers of the abdominal parietes are continued into those of the scrotum. At the fifth month of fcetal hfe, the testicle, 3, is situated in the loins beneath the kidney, 2. The testicle is then numbered amongst the abdominal viscera, and, like these, it is developed external to the peritonseal membrane, ■which forms an envelope for it. At the back and sides of the testicle, where the peri- tonaeum is reflected from it, a small membranous fold or mesentery (mesorchium, Seiler) is formed, and between the layers of this the nerves and vessels enter the organ, the nerves being derived from the neighboring sympathetic ganglia (aortic plexus), while the arteries and veins spring directly from the main abdominal blood vessels. It being predetermined that the testicle, 3, should migrate from the loins to the scrotum, 6 a, 7, at a period included between the sixth and ninth month, certain structural changes are at this time already effected for its sure and easy passage. By the time that the testis, 5, is about to enter the inter- nal inguinal ring, 6 a, (seventh or eighth month), a pro- cess or pouch of the peritonseal membrane (processus vagi- nalis) has already descended through this aperture into the scrotum, and the testicle follows it. The descent of the testis is effected by a very slow and gradual process of change. (Tout va par degrSs dans la nature, et rien par sauts. — Bonnet.) But how, or by what distinct and active structural agent, this descent is effected, or whether there does exist, in fact, any such agent as that which anatomists name " gubernacukmi testis," are questions which appear to me by no means settled.* The general lining membrane of the fcetal abdomen is composed of two layers — an outer one of fibrous, and an inner one of serous structure. Of these two layers, the abdominal viscera form for themselves a double envelope.f The testis in the loins has a covering from both mem- branes, and is still found to be inclosed by both, even when it has descended to the scrotum. The two coverings of fibro-serous structure which surrounded the testis in the *Dr. Carpenter (Principles of Human Physiology) remarks, that " the cause of this descent is not very clear. It can scarcely be due merely, as some have supposed, to the contraction of the gubemacu- lum, since that does not contain any fibrous structure until after the lowering of the testis has commenced." Dr. Sharpey (Quaiu's Anatomy, 5th edition) observes, that " the office of the gubemacu- lum is yet imperfectly understood." The opinions of these two distiuguished physiologists will doubtless be regarded as an impartial estimate of the results of the researches prosecuted in reference to these questions by Haller, Camper, Hunter, Arnaud, Lobstein, Meckel, Paletta, Wrisberg, Vicq d'Azyr, Brugnone, Tumiati, Seiler, Girardi, Cooper, BeU, Weber, Cams, Cloquet, Ctirling, and others. . !From my own observations, I am led to believe that no such mus- cular structure as a gubernaculum exists, and therefore that the descent of the testis is the effect of another cause. Leaving these matters, however, to the consideration of the physiologist, it is suf- ficient for the surgeon to know that the testis in its transition derives certain coverings from the parietes of the groin, and that a commu- nication is thereby established between the scrotal and abdominal cavities. t Langenbeck describes the peritonseum as consisting of two lay- ers ; one external and fibrous, another internal and serous. By the first, he means, I presume, that membrane of which the transversalis and iliac fascise are parts. (See Comment, de Periton. Structtira, etc.) PLATE 19. loins become respectively the tunica albuginea and tunica vaginalis when the gland occupies the scrotal cavity. Plate 119, Fig. 2. — The testicle in the scrotum. — When the testicle, 5, descends into the scrotum, 7, which happens in general at the time of birth, the abdomino- scrotal fibro-serous membrane, 6 a, 6 c?, is still continuous at the internal ring, 6 5. From this point downwards to a level with the upper border of the testicle, the canal of communication between the scrotal cavity and the abdo- men becomes elongated and somewhat constricted. At this part, the canal itself consists, like the abdominal mem- brane above and the scrotal membrane below, of a fibrous and serous layer, the latter enclosed within the former. The serous lining of this canal is destined to be obliterated, while the outer fibrous membrane is designed to remain in its primitive condition. When the serous canal contracts and degenerates to the form of a simple cord, it leaves the fibrous canal still continuous above with the fibrous mem- brane (transversalis fascia) of the abdomen, and below with the fibrous envelope (tunica albuginea) of the testis ; and at the adult period, this fibrous canal is known as the internal spermatic sheath, or infundibulifoi-m fascia en- closing the remains of the serous canal, together with the spermatic vessels, &c. Plate 19, Fig. 3. — The serous tunica vaginalis is separated from the peritonceum. — When the testicle, 7, has descended to the scrotum, the serous tube or lining of the inguinal canal and cord, 6 5, 6 c, closes and degener- ates into a simple cord, (infantile spermatic cord,) and thereby the peritonseal sac, 6 a, becomes distinct from the serous tunica vaginalis, 6 d. But the fibrous tube, or outer envelope of the inguinal canal, remains still pervious, and continues in this condition throughout life. In the adult, we recognise this fibrous tube as the infundibuliform fascia of the cord, or as forming the fascia propria of an external inguinal hernia. The anterior part of the fibrous sper- matic tube descends from the fascia transversahs ; the posterior part is continuous with the fascia iliaca. In relation to the testicle, the posterior part will be seen to be reflected over the body of the gland as the tunica albuginea, while the anterior part blends with the cellular tissue of the front wall of the scrotum. The tunica vagi- nalis, 6 d, is now traceable as a distinct sac,* closed on all sides, and reflected from the fore part of the testicle, above and below, to the posterior aspect of the front wall of the scrotum. Plate 19, Fig. 4. — The abdomino-scrotal serous lining *Mr. Owen states that the Chimpanzee alone, amongst bnite animals, has the tunica vaginalis as a distinct sac. remains continuous id the internal ring, and a congenital hydrocele is formed. — When the serous spermatic tube, G J, 6 c, remains pervious and continuous above with the peritonaeum, 6 a, and below with the serous tunica vagi- nalis, 6 d, the serous fluid of the abdomen will naturally gravitate to the most depending part — viz., the tunica vaginalis ; and thus a hydrocele is formed. This kind of hydrocele is named congenital, owing to the circumstance that the natural process of obliteration, by which the peri- tonajum becomes separated from the tunica vaginalis, has been, from some cause, arrested.* As long as the canal of communication, 6 5, 6 c, between the tunica vaginalis, 6 d, and the peritonaeum 6 a, remains pervious, which it may be throughout life, this form of hydrocele is, of course, liable to occur. It may be diagnosed from diseased en- largements of the testicle, by its transparency, its fluctua- tion, and its smooth, uniform fulness and shape, besides ' its being of less weight than a diseased testis of the same size would be. It may be distinguished from the common form of hydrocele of the isolated tunica vaginahs by the fact, that pressure made on the scrotum will cause the fluid to pass freely into the general cavity of the perito- nfeum. As the fluid distends the tunica vaginalis, 6 c, 6 rf, in front of the testis, this organ will of course lie towards the back of the scrotum, and therefore, if it be found necessary to evacuate the fluid, the puncture may be made with most safety in front of the scrotum. If ascites should form in an adult in whom the tunica vaginalis stOl com- municates with the peritonajal sac, the fluid which accu- mulates in the latter membrane will also distend the former, and all the collected fluid may be evacuated by tapping the scrotum. When a hydrocele is found to be congenital, it must be at once obvious that to inject irritating fluids into the tunica vaginalis (the radical cure) is inadmissible. In an adult, free from all structural disease, and in whom a congenital hydrocele is occasioned by the gravitation of the ordinary serous secretion of the peritonseum, a cure may be effected by causing the obliteration of the serous spermatic canal by the pressure of a truss. When a con- genital hydrocele happens in an infant in whom the testi- cle, 5, Fig. 1, Plate 19, is arrested in the inguinal canal,t * The serous spennatic tube remains open in all quadrupeds; but their natvu"al prono position renders them secure against hydrocele or hernial protrusion. It is interesting to notice how in man, and the most anthropo-morphous animals, where the erect position would subject these to the frequent accident of hydrocele or hernia, nature causes the serous spermatic tube to close. t In many quadrupeds (the Rodentia and Mouotremes ) the testes remain within the abdomen. In the Elephant, the testes always PLATE 19. if pressure be made on this passage with a view of causing its closure, the testicle will be prevented from descending. Plate 19, Fig. 5. — The serous spermatic canal closes imperfectly, so as to become sacculated, and thus a hydro- cele of the cord is formed. — After the testicle, 7, has descended to the scrotum, the sides of the serous tube, or lining of the inguinal canal and cord, 6 5, 6 c, may become adherent at intervals ; and the intervening sacs of serous membrane continuing to secrete their proper fluid, wUl occasion a hydrocele of the cord. This form of hydro- cele will differ according to the varieties in the manner of closure ; and these may take place in the following modes : let, if the serous tube close only at the internal ring, 6 a, while the lower part of it, 6 5, 6 c, remains pervious, and communicating with the tunica vaginalis, 6 t?, a hydrocele wiU be formed of a corresponding shape ; 2d, if the tube close at the upper part of the testicle, 6 c, thus isolating the tunica vaginalis, 6 d, whUe the upper part, 6 h, remains pervious, and the internal ring, 6 a, open, and communi- cating with the peritonajal sac, a hydrocele of the cord will happen distinct from the tunica vaginalis ; or this latter may be, at the same time, distended with fluid, if the disposition of the subject be favorable to the formation of dropsy ; 3d, the serous tube may close at the internal ring, form sacculi along the cord, and close again at the top of the testicle, thus separating the tunica vaginalis from the abdomen, and thereby several isolated hydro- celes may be formed. If in this condition of the parts we puncture one of the sacs for the evacuation of its con- tents, the others, owing to their separation, will remain distended. Plate 19, Fig. 6. — Hydrocele of the isolated tuni- ca vaginalis. — When the serous spermatic tube, 6 5, 6 c, becomes obliterated, according to the normal rule, after the descent of the testicle, 7, the tunica vaginalis, 6 d, is then a distinct serous sac. If a hydrocele form in this sac, it may be distinguished from the congenital variety by its remaining undiminished in bulk when the subject assumes the horizontal position, or when pressure is made on the tumor, for its contents cannot now be forced into the abdomen. The testicle, 7, holds the same position in this as it does in the congenital hydrocele.* The radical occupy their original position beneath the liidneys, in the loins. Human adults are occasionally found to be " testiconde ; " the testes being situated below ihe kidneys, or at some part between this posi- tion and the internal inguinal ring. Sometimes only one of the testes descends to the scrotum. * When a hydrocele is interposed between the eye and a strong light, the testis appears as an opaque body at the back of the tunica cure may be performed here without endangering the peritonseal sac. Congenital hydrocele is of a cylindri- cal shape ; and this is mentioned as distinguishing it from isolated hydrocele of the tunica vaginalis, which is pyri- form ; but this mark wUl fail when the cord is at the same time distended, as it may be, in the latter form of the complaint. Plate 19, Fig. 7. — The serous spermatic tube re- maining pervious, a congenital hernia is formed. — When the testicle, 7, has descended to the scrotum, if the com- munication between the peritonEeum, 6 a, and the tunica vaginalis, 6 c, be not obliterated, a fold of the intestine, 13, will follow the testicle, and occupy the cavity of the tunica vaginalis, 6 d. In this form of hernia (hernia tunicEe vaginalis, Cooper), the intestine is in front of, and in immediate contact with, the testicle. The intestine may descend lower than the testicle, and envelope this organ so completely as to render its position very obscure to the touch. This form of hernia is named congenital, since it occurs in the same condition of the parts as is found in congenital hydrocele, — viz: the inguinal ring remaining unclosed. It may occur at any period of life, so long as the original congenital defect remains. It may be distinguished from hydrocele by its want of transpa- rency and fluctuation. The impulse which is communi- cated to the hand applied to the scrotum of a person affected with scrotal hernia, when he is made to cough, is also felt in the case of congenital hydrocele. But in hydrocele of the separate tunica vaginalis, such impulse is not perceived. Congenital hernia and hydrocele may co-exist ; and, in this case, the diagnostic signs which are proper to each, when occurring separately, wiU be so min- gled as to render the precise nature of the case obscure. Plate 19, Figure 8. — Infantile hernia. — When the serous spermatic tube becomes merely closed, or obliter- ated at the inguinal ring, 6 b, the lower part of it, 6 c, is pervious, and communicating with the tunica vaginalis, vaginalis. But this position of the organ is, from several causes, liable to vary. The testis may have become morbidly adherent to the front wall of the serous sac, in which case the hydi'ocele will dis- tend the sac laterally. Or the testis may be so transposed in the scrotum, that, whilst the gland occupies its front part, the distended tunica vaginalis is turned behind. The tunica vaginalis, like the serous spermatic tube, may, in consequence of inflammatory fibrin- ous effusion, become sacculated-multilocular, in which case, if a hydrocele form, the position of the testis will vary accordingly. — See Sir Astley Cooper's work, ( " Anatomy and Diseases of the Testis, " ) Morton's " Surgical Anatomy ; " Mr. CurUng's " Trea- tise on Diseases of the Testis ; " and also his article " Testicle," in the Cyclopsedia of Anatomy and Physiology. PLATE 19. G d. In consequence of the closure of the tube at the inguinal ring, if a hernia now occur, it cannot enter the tunica vaginalis, and come into actual contact with the testicle. The hernia, 13, therefore, when about to force the peritonaeum, 6 a, near the closed ring, 6 h, takes a dis- tinct sac or investment from this membrane. This hernial sac, 6 e, will vary as to its position in regard to the tunica vaginalis, 6 d, according to the place whereat it dilates the peritoneeum at the ring. The peculiarity of this hernia, as distinguished from the congenital form, is owing to the scrotum containing two sacs, — the tunica vaginalis and the proper sac of the hernia ; whereas, in the congenital variety, the tunica vaginalis itself becomes the hernial sac by a direct reception of the naked intestine. If in infan- tile hernia a hydrocele should form in the tunica vaginalis, the fluid will also distend the pervious serous spermatic tube, 6 c, as far up as the closed internal ring, 6 h, and will thus invest and obscure the descending herniary sac, 13. This form of hernia is named infantile {Hey), owing to the congenital defect in that process, whereby the serous tube lining the cord is normally obliterated. Such a form of hernia may occur at the adult age for the first time, but it is still the consequence of original default. Plate 19, Figure 9. — Oblique inguinal hernia in the adult. — This variety of hernia occurs not in consequence of any congenital defect, except inasmuch as the natural weakness of the inguinal wall opposite the internal ring may be attributed to this cause. The serous spermatic tube has been normally obliterated for its whole length between the internal ring and the tunica vaginalis ; but the fibrous tube, or spermatic fascia, is open at the internal ring where it joins the transversalis fascia, and remains pervious as far down as the testicle. The intestine, 13, forces and distends the upper end of the closed serous tube ; and as this is now wholly obliterated, the herniary sac, 6 c, derived anew from the inguiQal peritonseum, enters the fibrous tube, or sheath of the cord, and descends it as far as the tunica vaginalis, 6 d, but does not enter this sac, as it is already closed. "When we compare this hernia. Fig. 9, Plate 19, with the infantUe variety. Fig. 8, Plate 19, we find that they agree in so far as the intesti- nal sac is distinct from the tunica vaginalis ; whereas the difference between them is caused by the fact of the serous cord remaining in part pervious in the infantile hernia ; and on comparing Figure 9, Plate 19, with the congenital variety, Figure 7, Plate 19, we see that the intestine has acquired a new sac in the former, whereas, in the latter, the intestine entered the tunica vaginalis. The variable position of the testicle in Figs. 7, 8, and 9, Plate 19, is owing to the variety in the anatomical circumstances under which these hernise have happened. Slao. V 7"' .>^. f ^m. // \ PLATE 22. currence happen to loop round the inner side of the neck of the sac, supposing this to be the seat of stricture, what amount of anatomical knowledge, at the call of the most dexterous operator, can render the vessel safe from danger ? The taxis, in a case of crural hernia, should be con- ducted in accordance with anatomical principles. The fascia lata, Poupart's ligament, and the abdominal aponeu- rosis, are to be relaxed by bending Hie thigh inwards to the hypogastrium. By this measure, the falciform pro- cess, 6, is also relaxed ; but I doubt whether the situation occupied by Gimbemat's ligament allows this part to be influenced by any position of the limb or abdomen. The hernia is then to be drawn from its place above Poupart's ligament, (if it have advanced so far,) and when brought opposite the saphenous opening, gentle pressure made out- wards, upwards, and backwards, so as to slip it beneath the margin of the falciform process, will best serve for its reduction. "When this cannot be effected by the taxis, and the stricture still remains, the cutting operation is required. The precise seat of the stricture cannot be known ex- cept during the operation. But it is to be presumed that the sac and contained intestine suffer constriction through- out the whole length of the canal.* Previously to the milliers de cadavres, ne me permet pas de dire qu'elle se rencontre un fois sur trois, ni siir cinq, ni meme sur dix, mais bien seulement sur quinze a vingt." Monro (Obs. on Crural Hernia) states this condition of tbe obturator artery to be as 1 in 20-30. Mi-. Quain (Anatomy of the Arteries) gives, as the resiilt of his observations, the proportion to be as 1 in 3 1-2, and in this estimate he agrees to a great extent ivith tlie observations of Cloquet and Hesselbach. Numerical tables have also been di-awn up to show the relative fre- quency in vrhioh the obturator descends on tlie outer and inner borders of the crural ring and neck of the sac. Su- A. Cooper never met with an example where the vessel passed on the inner side of the sac, and from this alone it may be inferred that such a position of the vessel is very rare. It is generally admitted that the obturator artery, when derived from the epigastric, passes down much more frequently between the iliac vein and outer border of the ring. The researches of anatomists (Monro and others) in reference to this point have given rise to the question, " What determines the position of the obturator artery with respect to the femoral ring ■? " It ap- pears to me to be one of those questions which do not admit of a precise answer by any mode of mathematical computation ; and even if it did, where then is the practical inference ? * " The seat of the stricture is not the same in all cases, though, in by far the greater number of instances, the constriction is relieved by the division upwards and inwards of the falciform process of the fascia lata, and the lunated edge of Gimbemat's ligament, where they join with each other. In some instances, it will be the fibres of the deep crescentic (femoral) arch ; in others, again, the neok of the sac itself, and produced by a thickening and contraction of the commencement of the operation, the urinary bladder should be emptied; for this organ, in its distended state, rises above the level of the pubic bone, and may thus be endan- gered by the incision through the stricture — especially if Gimbemat's ligament be the structure which causes it. An incision commencing a little way above Poupart's ligament, is to be carried vertically over the hernia, parallel with, but to the inner side of its median line. This incision divides the skin and subcutaneous adipose membrane, which latter varies considerably in quantity in several individuals. One or two small arteries (superficial pubic, etc.) may be divided, and some lymphatic bodies exposed. On cautiously turning aside the incised adipose membrane contained between the two layers of the super- ficial fascia, the fascia propria, 9, Figs. 10, 11, Plate 22, of the hernia is exposed. This envelope, besides varying in thickness in two or more cases, may be absent altogether. The fascia closely invests the sac, 1 2 ; but sometimes a layer of fatty substance interposes between the two cover- ings, and resembles the omentum so much, that the oper- ator may be led to doubt whether or not the sac has been already opened. The fascia is to be cautiously slit open on a director ; and now the sac comes in view. The her- nia having been drawn outwards, so as to separate it from the inner wall of the crural canal, a director * is next to be passed along the interval thus left, the groove of the instrument being turned to the pubic side. The position of the director is now between the neck of the sac and the inner wall of the canal. The extent to which the director passes up in the canal will vary according to the suspected level of the stricture. A probe-pointed bistoury is now to be slid along the directoi", and with its edge turned up- wards and inwards, according to the seat of stricture, the following mentioned parts- are to be divided — viz., the falciform process, 6 ; the inner wall of the canal, which is continuous with the fascia propria, 9 ; Gimbemat's liga- ment, 8 ; and the conjoined tendon, 4 ; where this is in- serted with the ligament into the pectineal ridge. By this mode of incision, which seems to be all-sufiicient for the liberation of the stricture external to the neck of the sac, subserous and peritonseal membranes where they lie within the cir- cumference of the crural ring.'' — Morton (Surgical Anatomy of the Groin, p. 148> tThe finger is the safest director; for at the same time that it guides the knife it feels the stricture and protects the bowel. As all the stmctures which are liable to become the seat of stricture — viz., the falciform process, Gimbemat's ligament, and the conjoined ten- don, lie in very close apposition, a very short incision made upwards and inwards is all that is required. PLATE 22. we avoid Ponpart's ligament ; and thereby the spermatic cord, 3, and epigastric artery, 1, are not endangered. The crural caniil being thus laid open on its inner side, and the constricting fibrous bands being severed, the sac may now be gently manipulated, so as to restore it and its contents to the cavity of the abdomen ; but if any impediment to the reduction still remain, the cause, in all probability, arises either from the neck of the sac having become strongly adherent to the crural ring, or from the bowel being bound by bands 'of false membrane to the sac. In either case, it will be necessary to open the sac, and ex- amine its contents. The neck of the sac is then to be exposed by an incision carried through the integument across the upper end of the first incision, and parallel with Poupart's ligament. The neck is then to be divided on its inner side, and the exposed intestine may now be restored to the abdomen. DESCRIPTION OF PLATE 23. i. The aorta at its point of bifurcation. 2. THe anterior superior iliac spine. 3. The symphysis pubis. 4. Poupart's ligament, immediately above which are seen the circumflex ilii and epigastric arteries, with the vas deferens and spermatic vessels. 5, 5. The right and left iliac muscles covered by the peritonseum ; the external cutaneous nerve is seen through the membrane. 6. The vena cava. 7, 7. The common iliac arteries giving off the internal iliac branches on the sacro-iliac symphyses ; 7*, 7*, the right and left ureters. 8, 8. The right and left common iliac veins. 9, 9. . The right and left external ihac arteries, each is crossed by the circumflex ilii vein. 10. 10. The right and left external iliac veins. 11. The urinary bladder covered by the peritonseum. 12. The rectum intestinum. 13. The profundus branch of the femoral artery. 14. The femoral vein ; 14*, the saphena vein. 15. The anterior crural nerve. 16. The sartorius muscle, cut. 17. The pectinseus muscle. 18.' The adductor longus muscle. 19. The gracilis muscle. 20. The tendinous sheath given off from the long adduc- tor muscle, crossing the vessels, and becoming ad- herent to the vastus intemus muscle. 21. The femoral artery. The figure is on the part where the vessel becomes first covered by the sar- torius muscle. DESCRIPTION OF PLATE 23. 1. The aorta at its point of bifurcation. 2. The anterior superior iliac spine. 3. The symphysis pubis. 4. Poupart's ligament, immediately above which are seen the circumflex ilii and epigastric arteries, with the vas deferens and spermatic vessels. 5. 5. The right and left iliac muscles covered by the peritonaeum ; the external cutaneous nerve is seen through the membrane. 6. The vena cava. 7. 7. The common iliac arteries giving off the internal iliac branches on the sacro-iliac symphyses ; 7*, 7*, the right and left ureters. 8. 8. The right and left common iliac veins. 9. 9. ■ The right and left external iUac arteries, each is crossed by the circumflex ilii vein. 10. 10. The right and left external iliac veins. 11. The urinary bladder covered by the peritonaeum. 12. The rectum intestinum. 13. The profundus branch of the femoral artery. 14. The femoral vein ; 14*, the saphena vein. 15. The anterior crural nerve. 16. The sartorius muscle, cut. 17. The pectinseus muscle. 18. The adductor longus muscle. 19. The gracilis muscle. 20. The tendinous sheath given off from the long adduc- tor muscle, crossing the vessels, and becoming ad- herent to the vastus internus muscle. 21. The femoral artery. The figure is on the part where the vessel becomes first covered by the sar- torius muscle. DESCRIPTION OF PLATE 24 FiGUKE 1. 1. The anterior superior iliac spine. 2. The anterior inferior iliac spine. 3. The acetabulum ; 3*, the ligamentum teres. 4. The tuber ischii. 5. The spine of the ischium. 6. The pubic horizontal ramus. [nasum. 7. The summit of the bladder covered by the perito- 8. The femoral artery. 9. The femoral vein. 10. The anterior crural nerve. 11. The thyroid ligament. 12. The spermatic cord. 13. The corpus cavernosum penis ; and its artery. 14. The urethra ; 14*, the bulbous urethrse. 15. The sphincter ani muscle. 16. The coccyx. 17. The sacro-sciatic ligament. 18. The pudic artery and nerve. 19. The sacral nerves. 20. The pyriformis muscle, cut. 21. The gluteal artery. 22. The small gluteus muscle. Figure 2. 1. The part of the sacrum which joins the ilium. 2. The external iliac artery, cut across. 3. The ujjper part of the rectum. 4. The ascending pubic ramus. 5. The spine of the ischium cut. 6. The horizontal pubic ramus, cut. 7. The summit of the bladder covered by the perito- neum ; 7*, its side, not covered by the membrane. 8. The recto-vesical peritonaial pouch. 9. The vas deferens. 10. The ureter. 11. The vesicula seminalis. 12. 13, 14, 15, 16, 17, 18, 19, 20, refer to the same parts as in Fig. 1. 2 1 . The prostate. 22. The lower part of the rectum. 23. The deep periupeal fascia. \\> n iU mJ^"""'^' DESCRIPTION OF PLATE 25. FiGCllE 1. 1. The umbilicus. 2. The linea alba. 3. The suspensory ligament of the penis. 4. The two corpora cavernosa penis. 5. The hypogastric and scrotal superficial fascia. 6. The spermatic cords. Figure 2. 1. The umbilicus. 3. The uretlu-a. 4. The tunica vaginalis ; 4, on the left side, the testicle invested by the tunic. •5. The corpora cavernosa seen in section. 6. The scrotal raphe and septum scroti. Figure .T. 1, i. The perinseal raphe. 3. Tlie place of the coccyx. 4. The projections of the ischiatic tuberosities. 5. 6. The line of section in lithotomy. Figure 4. 1. The superficial fascia covering the urethral space. 2. The sphincter ani. 3. The coccyx. 4. The right and left ischiatic tuberosities. 8. The anus. 9. The glutei muscles. Figure 5. 1, 2, 3, 4, 5, 6. The same parts as in Fig. 4. 7. The accelerator urinoe muscle. 8. The anus. DESCRIPTION OF PLATE 26. Figure 1. 1. The urethra. i. Accelerator urinoe muscle. 3. Central perinaeal tendon. (4. Right and left erector penis muscle. \ The transverse muscles. 6; The anus. 7i The ischiatic tuberosities. 8. The coccyx. 9. The glutei muscles. 10. The levator ani muscle. 11. The artery of the bulb. Figure 2. 1, 4, 6, 7, 8, 9, 10, 11, refer to the same parts as in Fig. 1. 3. Cowper's glands between the two layers of — 5. The deep perineal fascia. Figure 3. 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, refer to the same parts as in Fig. 2. 4. The two crura penis. 12. The urethra in section. 13. The rectum. 14. The sacro-sciatic ligament. Figure 4. 1, 2, 4, 7, 8, 9, 10, 11, 14, refer to the same parts as in Fig. 3. 3. The two lobes of the prostate. 16. The rectum turned down. 12. The membranous part of the urethra. 13. The vesicula3 seminales. 15. The base of the bladder. G. The two vasa deferentia. PLATE 27. THE SURGICAL DISSECTION OP THE MALE BLADDER AND URETHRA. — LATERAL AND BILATERAL LITHOTOMY COMPARED. Fig. 1 represents tlie normal relations of the more important parts concerned in lithotomy as performed at the perineal region. The median line, a a, 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 perinaaal surface. The bulb of the urethra and the lower end of the bowel are on the same plane compara- tively 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 ad- vance 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 inter- venes 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 ure- thra, 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 perinasal 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 perinseum 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 periniEum, the lateral incisions are made obliquely in the direction of the lines C d. In the bilateral operation the incision necessary to avoid the bulb of the urethra in front, tlie 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 lat- eral 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, etc. The left lobe of the prostate is divided obliquely in the lateral oper- ation ; both lobes transversely in the bilateral. Fig. 2. — If the artery of the bulb happens 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. Fig. 3. — "When the pudic artery crosses in contact with the prostate, r, 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, wUl 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 sec- tion 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 cal- culus to be extracted. These remarks are equally appli- cable as to the mode in which the superficial perinaeal PLATE 127. incision should be made under the like iiece^sily. If the prostate be icholhj divided in either line of section, the pelvio fascia adiiering to the base of this body will be equally subject to danger. i;_y incising the prostate trans- versely, B B, the seminal ducts, G ii, 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.* On the whole, there- fore, the lateral operation appears preferable to the bila- teral one. Fig. 4. — The muscular structures surrounding the membranous urethra and the neck of the bladder, and which are divided in lithotomy, ha\-e been examined from time to time by anatomists with more than ordinary pains- taking, owing to the circumstance tliat they are found occasionally to offer, by spasmodic contraction, an obstacle to the passage of the calbeler along the urethral canal. These muscles do not appear to cxi.-.t in all subjects ahke. 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 pres- ent. Hence it is that the opinions of anatomists respecting their form, character, and even their actual existence, ai-e so conflicting, not only against each other, but against nature. In Fig. 4, I have summed together all the facts recorded concerning them,t 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 musculai' structure arises from the ischio-pubic ramus, and is inserted at the median line a a. They ap- pear to me, therefore, to be muscles of the same category, * As to the mode in which the superficial and deep incisions in lateral lithotomy should be made, a very eminent ojjerating surgeon remarks : " A free incision of the skin I consider a most important feature in the operation ; but beyond this tlio application of tlie knife should, in my opinion, bo 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, witli 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. Pergusson, Practical Sargenj, 3d Am. Ed., ,p. CIO. t Tlio part c is that alone described by Santorini, who named it " clcv.itov tircihia'." as passing beneath the urethra. The part n is which, if all were present, would assume the serial order of B c D ic F. "Wlien 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 hieio- gl}'phics as the algebraic s3'mbols, n-[-c — d^ 11, are when the mind is devoid of the power of calculation. Fig. .'). — Tlic membranous urethra a is also in some instances embraced by two symmetrical fascicidi of mus- cular fibres b b, which, arising from the posterior and lower part of the svmphysis pubis, descend on either ?ide of the canal and join beneath it. The muscles b c, Fig. 4, are between the two layers of the deep perinatal fascia, while the muscle b b, Fig. .">, lies like the fore part of the levator ani, c c, behind this structure and between it and the anterior ligaments of the bladder.* As to the interpreta- tion 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 perinatal median line with the levator ani ; 2nd, the fibres of both muscles overlie the Ibrepart of the pros- tate, and present the same arrangement in parallel order; 3rd, the one i?- not naturally separable from the other. that first observed and described I>y Sir. Guthrie as ]inssing above the urethra. The pai-t f represents the well-known " transvcrsalis pcrinoei," between which and the part c there oecasionnlly appears the paj-t E, supposed to be the "transvcrsalis alter" of Albinus, and also the part D, which is the "iscliio bulbosits " of Criiveiliiier. It is possible that I may not have given one or otlicr of these parts its proper name, Iml: this will not allcet their anatomy. * Tills is the nui>rle, b b, whicli is (lcseril>ed I'v Santorini as the "levator prostatic; " by Winsleiw as " le prostalique snpcricur; " by Wilson as the " pubo-urethrales ; " by MuUor as not existing; by Mr. Guthrie as forming (when existing), with the parts n o, Fig. 2, Plate .T.'), his " compressor isthmi urothraj ; " and by Jl. Cruveilhier as being part of the levator ani muscle, "As in one ease," (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. Qnaiu's Anal., Am. Ki1.,yoI. it., p. .MO. PLATE 28. Fig. 1 represents by section the natural fonns of the urethra and bladder. The general direction of the nrethra, ; measured during its relaxed statg from the vesical orifice to the glans, is usually described as having the form of the ' letter S laid procumbent to the right side w or to the left CO. 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 inter- venes between the neck of the bladder, 10, and the point 5, where the penis is suspended from the front of the sym- I physis pubis by the suspensory ligament, assumes very nearly the form of a semicircle, whose anterior half looks toward the forepart, and whose posterior half is turned to the back of the pubis. The pubic arch, 1, spans cross- ways the middle of this part of the urethra, 2, opposite the bulb, 8. The two extremes, 6 10, 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, 8, is J removed from the pubic symphysis above, must equal the depth of its own curve, which measures about an inch per- pendicularly. 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 i the ligament, and ascends obliquely backwards and up- wards 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 6, which is free, relaxed, and move- able, can by traction towards the umbilicus be made to continue in the direction of the fixed curve, 6 10, 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 difierent 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 capa- ble 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 difierent 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 urinse muscle. The bulb and glans are expansions or enlarge- ments of the spongy texture, and do not afl^ect 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-cylindri- cal. The meatus is the narrowest part of it, and the pros- tatic 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 op- posite 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 cer- tain 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 numer- ously studded with the orifices of mucous cells (lacunse), 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 PLATE 29. CONGENITAL AND PATHOLOGICAL DEFORMITIES OP THE PREPUCE AND URETHRA. STRICTURE AND MECHANICAL OBSTRUCTIONS OF THE URETHRA. WiiE^r any of the central organs of the boily presents in a form differing from that which we term natural, or struc- turally 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 devi- ation, if it be the result of an error in the law of develop- ment, 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 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, ))ut as a cause of impediment to the generative function of the whole organ, it should be removed by an operation. Fig. 2 represents the prepuce in the condition oi" para- phymosis following gonorrhceal inflammation. The part appears constricting tlie 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, in- flamed, 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 cf 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. Fig. 3 exhibits the form of a gonorrhceal 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. Fig. 4 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 ob- struction to the flow of urine, an operation for separating the prepuce from the glans would not be required. Fig. 5. — In this figure is represented the form of the penis of an adult, in wliom the prepuce was removed by circumcision at an early age. The membrane covering the glans, and the part which is cicatrized, becomes in these cases dry, indurated, and deprived of its special sense. Fig. 6. — In this figure the glans appears protruding through the upper surface of the prepuce, which is thick- ened and corrugated. This state of the parts was caused by a venereal ulceration of the upper part of the prepuce, sufficient to aUow the glans to press through the aperture. The prepuce in this condition being superfluous, and acting as an impediment, should be removed by operation. Fig. 7. — 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 prepifce when in the position here represented, or in that of Fig. 6, the organ may be made to assume the appearance of Fig. 5. Fig. 8 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 frasnum prasputii, leaving the canal open at this place. In a case of this kind, an operation on the taliacotian principle might be PLATE 29. sac, and passing into the membranous part of the urethra "beyond. This case, which was owing to a congenital mal- formation 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 perinseum as a distinct fluctuating tumor, every time that an effort is made to void the bladder. If the stricture in such a case happens to cause a complete retention of urine, and that a catheter cannot be passed into the bladder, the tumor should be punctured prior to taking measures for the re- moval of the stricture. (Sir B. Brodie.) Fig. 17 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 fre- quently to occur, (Hunter, Home, Cooper, Brodie, Phillips, Velpeau.) False passages likewise are mentioned as more liable to be made in these places than elsevyhere 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, 8 10, Fig. 1, Plate 28 ; 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 wiU of course favor 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 ure- thral 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. Fig. 18. — A. calculus is here represented lodging in the urethra at the bulb. The walls of the urethra around the calculus appear thickened. Behind the obstracting body the canal has become dilated, and, in front of it, con- tracted. In some instances the calculus presents a per- foration 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 obstruc- tion to the passage of the urine, and its removal cannot be effected by other means, an incision should be made to effect this object. Fig. 19 represents the neck of the bladder and neigh- boring part of the urethra of an ox, in which a polypous growth is seen attached by a long pedicle to the veru mon- tanum and blocking up the neck of the bladder. Small irregular tubercles of organized lymph, and tumors formed by the lacunae distended by their own secretion, their ori- fices being closed by inflammation, are also found to ob- struct the urethral canal. Fig. 20. — In this figure is represented a small calculus impacted in and dilating the membranous part of the urethra. Fig. 21. — 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. Fig. 22. — A stricture is here shown situated at the bulb. Fig. 23 represents a stricture of the canal in front of the bulb. Fig. 24 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 en- gages fairly the part to be divided. But this is a knowl- edge less likely to be attained if the stricture be situated behind than in front of the triangular ligament. Fig. 25 exhibits a lateral view of the muscular parts which surround the membranous portion of the urethra PLATE 30. THE VARIOUS FORMS AND POSITIONS OP STRICTURES AND OTHER OBSTRUCTIONS OP THE URETHRA. — FALSE PASSAGES. — ENLARGEMENTS AND DEFORMITIES OP THE PROSTATE. Impediments to the passage of the urine through the urethra may arise fi'om different causes, such as the impac- tion of a small calculus in the canal, or any morbid growth (a polypus, etc.) 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 par- tially, 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 ure- thra, but there are two others (the prostatic and the spas- modic) which are, owing to anatomical circumstances, ne- cessarily 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 struc- tures. 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 cir- cumstance that inflammation may attack these in any situ- ation and produce the same effect, is the permanent or organic stricture. Of this disease the forms are as vari- ous as the situations are, for as certainly as it may reason- ably be supposed that the plastic lymph, effused in an in- flamed state of the urethra from any cause, does not give rise to stricture of any special or particular form, exclu- sive 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 estab- lish 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, etc.) have been effected by catheterism than existed previous to the performance of this oper- ation.* Figs. 1 and 2. — In these figures are presented seven forms of organic stricture occurring in different parts of the urethra. In 1, 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 2, Fig. 2. In 2, Fig. 1, the canal is contracted laterally by a prominent fold of the mucous membrane at the opposite side. In 3, Fig. 1, an organ- ized band of lymph is stretched across the canal ; this stricture is seen in section 3, Fig. 2. In 6, Fig. 1, a stel- late band of organized lymph, attached by pedicles to three sides of the urethra, divides the canal into three passages. In 4, Fig. 1, the canal is seen to be much con- tracted towards the left side by a crescentic fold of the lining membrane projecting from the right. In 6, the canal appears contracted by a circular membrane, perfo- * Home describes " a natural constriction of the urethra, directly behind the bulb, which is probably formed with a power of contrac- tion to prevent," etc. This is the part which he says is " most lia- ble to the disease of stricture." (Strictures of the Urethra.) Now, if any one, even among the acute observing microscopists, can dis- cern 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 anato- mists 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 ? PLATJ^ 30. the bulb, penetrates, 2, tlie right lobe of the prostate. A second instrument, 3 3, penetrates the left lobe. A third smaller instrument, 6 6, 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, en- ters this viscus at a point behind the prostate. The resist- ance which the two larger instruments met with in pen- etrating the prostate made it seem, perhaps, that a tight stricture existed in this situation, to match which the smaller instrument, 6 6, was afterwards passed in the course marked out. Figs. 13 to 17, represent a series of prostates, in which the third lobe gradually increases in size. In Fig. 13, 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 indi- cate the position of the " muscles of the ureters," the third lobe does not exist. In Fig. 16 it appears as the uvula vesicas, 1. In Fig. 15 the part 1 is increased, and under the name now of third lobe is seen to contract and bend upwards the prostatic canal. In Fig. 16 the effect which the growth of the lobe, 1, produces upon the form of the neck of the bladder becomes more marked, and the part presenting perforations, 5 5, 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 instru- ments. A calculus of irregular form is seen to lodge be- hind the third lobe, and to be out of reach of the point of a sound, supposing this to enter the bladder over the apex of the lobe. In Fig. 17 the three lobes are enlarged, but the third is most so, and, while standing on a narrow ped- icle attached to the floor of the prostate, completely blocks up the neck of the bladder.* Fig. 18. — 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 * 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 tumor, a thing unknown to normal anatomy. Langenbeclc [Neuo Bibl. b. i p. 360] denies its exislence in the healthy state. Cruveilhier [Anat. Pathog. Hv. xxvii.] deems it incorrect to reckon a third lobe as proper to the healthy bladder. urine. " The new passage may in every respect be as efficient as one formed by puncture or incision in any other way." (Fergusson.) Fig. 19. — The three lobes of the prostate, 8, 2, 5, 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 fistulse by which the urine escapes, become after a time lined with a membrane simi- lar to that of the urethra. (Stafford.) Fig. 20. — The three lobes, 1, 2, 3, of the prostate are irregularly enlarged. The third lobe, 1 1, projecting from below, distorts the prostatic canal upwards and to the right side. Fig. 21. — The right lobe, 1, 2, 3, of the prostate ap- pears hollowed out so as to form the sac of an abscess which, by its projection behind, pressed upon the fore part of the rectum, and by its projection in front, contracted the area of the prostatic canal, and thereby caused an ob- struction 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 situa- tion, the sac becomes penetrated by the instrument, and, instead of urine, pus flows. The sac of a prostatic ab- scess frequently opens of its own accord into the neigh- boring 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. Fig. 22. — The pi-ostate presents four lobes of equal size, and all projecting largely around the neck of the bladder. The prostatic canal is almost completely ob- structed, and an instrument has made a false passage through the lobe, 1. Fig. 23. — The third lobe of the prostate is viewed in section, and shows the track of the false passage made by the catheter, 4, 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. Fig. 24. — The prostatic lobes are uniformly enlarged, and cause the corresponding part of the urethra to be uni- formly contracted, so as closely to embrace the catheter, 6, 6, occupying it, and to offer considerable resistance to the passage of the instrument. PLATE 31. DEFORMITIES OP THE PROSTATE. — DISTORTIONS AND OBSTRUCTIONS OF THE PROSTATIC URETHRA. The prostate is liable to such frequent and varied de- formities, 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 interpre- tation 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 expla- nation 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 — 5, and a + i, the only dif- ference 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 frustra, 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 accom- panying figures even witn a surgical bearing, I remark that the prostatic or rudimentary uterus, like a germ not wholly bhghted, is prone to an occasional sprouting or in- crease beyond its prescribed dimensions — a hyperl rophy in barren imitation, as it were, of gestation.* * This expression of the fact to which I allude will not, I trust, be Fig. 1. — The prostate, 1 2, is here represented thinned in its walls above and below. The lower wall is dilated 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 situ- ated 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 coccy- geal bone and a vertebra, the only difference which exists is one of quantity, and that hence arises the functional difference. A pros- tate 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 Imown to enable us to form a judgment of the bad consequences of its dis- eased state. When the part becomes morbi,dly 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, perfonns 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 urin- ary 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 ("pros- tatic 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 in- terpretation of the prostate, which I believe to be true to nature, will last perhaps till siich time as the microscopists shall discover in its "secretion" some species of mannikins, such as may pair with those which they term spci-matozoa, PLATE 31. ment, 4. 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 re- ceived, 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. Fig. 13. — The lateral lobes, 4 5, of the prostate are enlarged ; and, occupying the position of the third lobe, appear as three masses, 12 3, 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, 5 3 2 1 4, at the neck of the bladder. The ure- ters are dilated, in consequence of the regurgitation of the contents of the bladder during the retention which existed. Fig. 14 exhibits the lobes of the prostate greatly in- creased in size. The part, 1 2, girds irregularly, and obstructs the vesical outlet, while the lateral lobes, 3 4, encroach upon the space of the prostatic canal. The walls of the bladder are much thickened. Fig. 15. — The three lobes, 1 2 3, of the prostate are enlarged and of equal size, moulded against each other in such a way that the prostatic canal and vesical orifice ap- pear as mere clefts between them. The three lobes are incrusted on their vesical surfaces with a thick calcareous deposit. The surface of the third lobe, 1, which has been half denuded of the calcareous crust, 2, 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. Fig. 16 represents the prostate with its three lobes en- larged, 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. Fig. 17. — The prostate presents four lobes, 12 3 4, 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 pros- tate have been perforated by instruments, passed for the retention of urine which existed. A stricturing band, 5, is seen to cross the membranous part of the canal. Fig. 18. — The prostate, 1 1, is greatly enlarged, and projects high in the bladder, the walls of the latter, 2 2, being very much thickened. The ureters, 3, are dilated, and perforations made by instruments are seen in the pros- tate. 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, ihe incisions wUl 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" hap- pen to have surmounted the prostate, the incision, in order to divide the whole vertical thickness of this body, wiU require to be made very deeply from the perinaaal surface, and this circumstance occasions what is termed a " deep perinseum." Fig. 19. — The lower half, 3 2 6, of the prostate, hav- ing 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, 5 5, the proper base of the bladder, 7 7. The prostatic urethra, between 1 5, has become ver- tical 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, 3 ; 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, 1*. The bladder and sac do not communicate, but the urethra is a canal common to both. In a case of this sort it be- comes evident that, although symptoms may strongly indi- cate either a retention of urine, or the presence of a stone in the bladder, any instrument taking the position and direction of 4 4, 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 lithot- omy in such a state of the parts, the staff" occupy the situ- ation of 4 4 4, 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 regur- gitated from the urethra, will render the deception more complete. PLATE 32. DEFORMITIES OP 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 defi- cient in front, and has become everted and protruded hke 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 ura- chus 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 situa- tions, 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 over-distended with its contents, and while incapable of voiding these, from some permanent obstruction in the urethral canal.* The bladder is liable to become saccu- * On considering these cases of physical impediments to the pas- sage of urine from tlie vesical reservoir through the urethral conduit, it seems to me as if these were sufficient to account for the forma- tion of stone in the bladder, or any other part of the urinary appa- ratus, without the necessity of ascribing it to a constitutional disease, such as that named the Uthic 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 accord- ing 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 Uthic 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 witliin some part of the urinary appa- ratus alone constitutes the disease, since in this form it cannot be passed. On viewing tlie subject in this light, the question tliat springs directly is, (while the lithic diathesis is common to individu- als of all ages and both sexes,) why the lithic sediment should pre- lated 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 sit- uation ; 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, how- ever 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 perito- na3um ; 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. Fig. 1. — 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 oc- sent 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 tlie male sex, in whom the prostate is prone to en- largement, and the urethra to organic stricture, are hence more sub- ject 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 ob- struction exists, lithic concretions take place in the urinary appara- tus 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 che matter, will favor the formation of stone. PLATE 32. cal 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. Fig. 13. — The prostatic canal is contracted by the lateral lobes, 4 5 ; resting upon these, appear three cal culi, 12 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 ascer tainable by the sound. Fig. 14. — The three prostatic lobes are enlarged, and appear contracting the vesical orifice. In the walls of the bladder are imbedded 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. Fig. 15. — 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. Fig. 16. — 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 de- posit from the urine. Fig. 17 represents, in section, the relative position of the parts concerned in catheterism.* 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 perinteum is brought fully into view, and its structures are made to assume a fixed relative position. The opera- tor, 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 instru- ment. By stretching the urethra, we render its sides suf- * It may be necessary for me to state that, with the exception of this figure (which is obviously a plan, but suflficiently accurate for the pui-poses it is intended to serve) all the others representing patho- logical conditions and congenital defonnities 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. ficiently tense for facilitating the passage of iLe instru- ment, and the orifices of the lacunse become closed. While the instrument is being passed along this part of the canal, its point should be directed fairly towards the urethral opening, C*, 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 liga- ment. 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 perinseal curve, 3 6 8, and is closely embraced by the middle fibres of the accelerator urinas muscle. 2d, It is immediately succeeded by the commencement of the membranous urethra, which, while being naturally nar- rower than other parts, is also the more usual seat of or- ganic stricture, and is subject to spasmodic constriction by the fibres of the compressor urethras. 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 ure'thra 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 engag- ing 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 ren- dered 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, 3*, 3. In order that the point of the instrument may freely traverse the urethra in this direction, its handle, 1*, requires to be depressed, 2*, 3*, slowly towards the perinseum, and at the same time to be impelled steadily back in the line, 4*, 4*, 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 oth- erwise required, so that its point may surmount the obsta- cle. But since the suspensory hgament of the penis, 10, and the perinasal structures, prevent the handle being de- pressed beyond a certain degree, which is insufficient for the object to be attained, the instrument should possess the prostatic curve, 3*, compared with 3*, 2*. In the event of its being impossible to pass a catheter by the urethra, in cases of retention of urine threatening DESClilPTION OF PLATE 33 Figure 1. 1. Tendon of the gracilis muscle. 2. The fascia lata. 3. Tendon of the semimembranosus muscle. 4. Tendon of the semitendinosus muscle. 5. The two heads of the gastrocnemius muscle. 6. The popliteal artery. 7. The popliteal vein joined by the short saphena vein. 9. The middle branch of the sciatic nerve. 8. The outer (peronseal) branch of the sciatic nerve. 10. The posterior tibial nerve continued from the middle branch of the sciatic, and extending to 10, behind the inner ankle. 11. The posterior (short) saphena vein. 12. The fascia covering the gastrocnemius muscle. 13. The short (posterior) saphena nerve, formed by the union of branches from the peronseal and posterior tibial nerves. 14. The posterior tibial artery appearing from beneath the soleus muscle in the lower part of the leg. 15. The soleus muscle joining the tendo Achilhs. 16. The tendon of the flexor longus communis digitorum muscle. 17. The tendon of the flexus longus pollicis muscle. 18. The tendon of the peronseus longus muscle. 19. The peronseus brevis muscle. 20. The internal annular ligament binding down the ves- sels, nerves, and tendons in the hollow behind the inner ankle. 21. The tendo AchiUis. 22. The tendon of the tibialis posticus muscle. 23. The venoe comites of the posterior tibial artery. Figure 2. « 1, 3, 4, 5, 6, 7, 8, 9, indicate the same parts as in Fig. 1. 2. The inner condyle of the femur. 10. The plantaris muscle lying upon the popliteal artery. 11. The popliteus muscle. 13. The tibia. 14. The fibula. 15. The posterior tibial artery. 1 6. The peronseal artery. 17. 18, 19, 20, 21, 22, 23. The pai-ts shown in Fig. 1. 24. The astragalus. DESCEIPTION OF PLATE 34. Figure 1. 1. The tendon of the tibialis anticus muscle. 2. The long saphena vein. 3. The tendon of the tibialis posticus muscle. 4. The tibia ; d, the inner malleolus. 5. The tendon of the flexor longus digitorum muscle. 6. The gastrocnemius muscle ; /, the tendo Achillis. 7. The soleus muscle. 8. The tendon of the plantaris muscle. 9. The vensB comites. 10. The posterior tibial artery. 11. The posterior tibial nerve. Figure 2. 1. The tibialis anticus muscle ; a, its tendon. 2. Tbe extensor longus digitorum muscle ; i J J i, its four tendons. 3. The extensor lopgug naWicis muscle. 4. The tibia. * ' 5. The fibula ; e, the outer malleolus. 6. The tendon of the peronseus longus muscle. 7. The peronseus brevis muscle ; i, the peronseus tertius. 8. The fascia. [dons. 10. The extensor brevis digitorum muscle ; k Ic, its ten- 11. The anterior tibial artery and nerve descending to the dorsum of the foot. DESCRIPTION- OF PIwVTE 35. Figure 1. 7. 8. i i 10. 11. 12. The calcaneum. The plantar fascia and flexor brevis digitorum muscle cut ; h h b, its tendons. The abductor minimi digiti muscle. The abductor pollicis muscle. The flexor accessorius muscle. The tendtin of the flexor longus digitorum muscle, subdividing into ffff, tendons for the four outer toes. The tendon of the flexor pollicis longus muscle. The flexor pollicis brevis muscle. (■ i. The four lumbricales muscles. The external plantar nerve. The external plantar artery. The internal plantar nerve and artery. •,.^ •'■ Figure 2. 1. The heel covered by the integument. 2. The plantar fascia and flexor brevis digitorum muscle cut ; h b h, the tendons of the muscle. 3. The abductor minimi digiti. 4. The abductor pollicis. 5. The flexor aeepiSfeftrius cut. 6. The tendon of tlie flexor digitorum longus cut ; /'//, its digital ends. 7. The tendon of the flexor pollicis. 8. The head of the first metatarsal bone. 9. The tendon of the tibialis posticus. 10. The external plantar nerve. 11. The arch of the external plantar artery. 12. The four interosseous muscles. 13. The external plantar nerve and artery cut. DESCRIPTION OF PLATE 36. FROM BOURGERY. THE NECK. 1st. Suprahyoid Eeoion. A. Parotid gland. B. Submaxillary gland. 1. Submental artery and vein, accompanied by lymphatic ganglions passing over the surface of the mylo-hyoid muscle. C. Place of the maxillary belly of the digastric muscle, which has been removed ; the sheath is seen behind and at the sides. 2d. Subhyoid Region. D. Place of the sterno-hyoid, at the bottom of which are seen the sterno-thyroid and thyro-hyoid muscles, E. Scapulo-hyoid, uncovered. Beyond, in its continu- ation, it is seen through the transparent sheath of the stemo-mastoid muscle. From F to F is seen the place of the stemo-mastoid muscle, the body of which has been dissected out, leaving the posterior part of its sheath ; a part of the upper por- tion of the muscle is preserved. The external jugular vein (2) is seen crossing this space diagonally. In the space occupied by the muscle, the vessels and nerves belonging to it are shown, and behind its transpa- rent sheath are seen, 3. The primitive carotid artery ; i. Tlie internal jugular vein ; also the origin of the thyroid vessels, and numerous lymphatic vessels and nerves. THE ARMPIT. The arm being elevated. The figure shows the armpit, properly so called, and the parts adjacent. 1. The axillary cavity, situated be- tween the great pectoral muscle before, the teres major and the great dorsal behind ; 2. The region of the axil- lary vessels seen behind the sheaths of the pectoral mus- cles; 3. Internal and superior brachial region. 1st. Hollow of the Armpit. F. 5. Mass of lymphatic ganglions, imbedded in adipose tissue. It is isolated by a layer of the sheath of the great pectoral from the region of the axillary vessels. The hollow of the armpit is traversed by the inferior scapular vessels, 6, the thoracic vessels, 7, and by the infe- rior branches of the plexus of nerves which accompany them. G. Superior extremity of the great dorsal muscle, with its vessels and nerves, a portion of which, as may be seen, has been dissected out. H. a portion of the sheath of the great dorsal muscle, which limits the axillary cavity behind. I. Space occupied by the great pectoral muscle, the sheath of which limits the axillary cavity before and on the inside. Superiorly, as may be seen, it passes before the great vessels and nerves. In going backward, it unites with their sheaths, and receives from without the brachial aponeurosis, and forms the only true line of demarcation between the subclavicular region and superior internal brachial region. K, Fold of the brachial aponeurosis, which is seen to jqjn th8 'tendons of the great dorsal and great pectoral miTscles, adhering to the roots of the great vessels, and limiting the depth of the axilla abo^ r.. 2d. SUBCLATIOULAR REGION. The place of the great pectoral muscle is shown, and also that of the little pectoral muscle, portions of both being dissected away to show the vessels. The deltoid muscle is cut off negf ij^capular attachment. 8. Axillary, ad*^,/ 9. Axillary vein, a little drawn downward, te tweover the nerves. 10. Trunk of the ex- ternal cutaneous nerve, before which may be seen a branch of the median. II. One of the roots of the median nerve. 12, 12. Acromio-thoracic vessels with the nerves, which are distributed to the pectoral muscles. 13. Cephalic vein. L. Subclavian muscle inclosed in its sheath. 3d. Internal Superior Brachial Region. INI. Portion of the place of the biceps muscle, the two extremities of which are left. In this space are seen the vessels and nerves belonging to it, and beneath, through the transparent sheath, the deltoid muscle. ' N. Surface of the triceps, covered by the" posterior brachial aponeurosis, which is inserted upon the tendons of the great dorsal and the teres major. This surface is traversed by the internal cutaneous brachial branches of the second and third pairs of inter- costal nerves. ' 14. Brachial artery. 15. Internal humeral vein. 16. Basilic vein. 17. Musculo-cutaneous nerve. 18. Median nerve. 19. Internal cutaneous nerve. 20. Ulnar nerve. The radial nerve and the external collateral vessels are not seen in this arrangement of the figure.