Part 42 (1/2)

Fig. 12, Plate 59.--In this case an instrument, d d, after pa.s.sing beneath part of the lining membrane, e e, anterior to the bulb, penetrates b, the right lobe of the prostate. A second instrument, c c, penetrates the left lobe. A third smaller instrument, f f, is seen to pa.s.s out of the urethra anterior to the prostate, and after transfixing the right vesicula seminalis external to the neck of the bladder, enters this viscus at a point behind the prostate. The resistance which the two larger instruments met with in penetrating the prostate, made it seem, perhaps, that a tight stricture existed in this situation, to match which the smaller instrument, f f, was afterwards pa.s.sed in the course marked out.

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Plate 59.--Figure 12.

Figs. 1 to 5, Plate 60, represent a series of prostates, in which the third lobe gradually increases in size. In Fig. 1, which shows the healthy state of the neck of the bladder, unmarked by the prominent lines which are said to bound the s.p.a.ce named ”trigone vesical,” or by those which indicate the position of the ”muscles of the ureters,” the third lobe does not exist. In Fig. 2 it appears as the uvula vesicae, a.

In Fig. 3 the part a is increased, and under the name now of third lobe is seen to contract and bend upwards the prostatic ca.n.a.l. In Fig. 4 the effect which the growth of the lobe, a, produces upon the form of the neck of the bladder becomes more marked, and the part presenting perforations, e e, produced by instruments, indicates that by its shape it became an obstacle to the egress of the urine as well as to the entrance of instruments. A calculus of irregular form is seen to lodge behind the third lobe, and to be out of the reach of the point of a sound, supposing this to enter the bladder over the apex of the lobe. In Fig. 5 the three lobes are enlarged, but the third is most so, and while standing on a narrow pedicle attached to the floor of the prostate, completely blocks up the neck of the bladder. [Footnote]

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Plate 60.--Figures 1, 2, 3, 4, 5

[Footnote: On comparing this series of figures, it must appear that the third lobe of the prostate is the product of diseased action, in so far at least as an unnatural hypertrophy of a part may be so designated. It is not proper to the bladder in the healthy state of this organ, and where it does manifest itself by increase it performs no healthy function in the economy. When Home, therefore, described this part as a new fact in anatomy, he had in reality as little reason for so doing as he would have had in naming any other tumour, a thing unknown to normal anatomy. Langenbeck (Neue Bibl. b. i. p. 360) denies its existence in the healthy state. Cruveilhier (Anat. Pathog. liv. xxvii.) deems it incorrect to reckon a third lobe as proper to the healthy bladder.]

Fig. 6, Plate 60.--The prostatic ca.n.a.l is bent upwards by the enlarged third lobe to such a degree as to form a right angle with the membranous part of the ca.n.a.l. A bougie is seen to perforate the third lobe, and this is the most frequent mode in which, under such circ.u.mstances, and with instruments of the usual imperfect form, access may be gained to the bladder for the relief of retention of urine. ”The new pa.s.sage may in every respect be as efficient as one formed by puncture or incision in any other way.” (Fergusson.)

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Plate 60.--Figure 6

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

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Plate 60.--Figure 7

Fig. 8, Plate 60.--The three lobes, a, b, c, of the prostate are irregularly enlarged. The third lobe, a a, projecting from below, distorts the prostatic ca.n.a.l upwards and to the right side.

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Plate 60.--Figure 8.

Fig. 9, Plate 60.--The right lobe, a c c, of the prostate appears hollowed out so as to form the sac of an abscess which, by its projection behind, pressed upon the forepart of the r.e.c.t.u.m, and by its projection in front, contracted the area of the prostatic ca.n.a.l, and thereby caused an obstruction in this part. Not unfrequently when a catheter is pa.s.sed along the urethra, for the relief of a retention of urine caused by the swell of an abscess in this situation, the sac becomes penetrated by the instrument, and, instead of urine, pus flows.

The sac of a prostatic abscess frequently opens of its own accord into the neighbouring part of the urethra, and when this occurs it becomes necessary to retain a catheter in the neck of the bladder, so as to prevent the urine entering the sac.

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Plate 60.--Figure 9.

Fig. 10, Plate 60.--The prostate presents four lobes of equal size, and all projecting largely around the neck of the bladder. The prostatic ca.n.a.l is almost completely obstructed, and an instrument has made a false pa.s.sage through the lobe a.

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Plate 60.--Figure 10.