472 APPLIED ANATOMY. 



that the sound will not reach to the bladder. To avoid this it should be grasped 

 lower down toward the scrotum. The urethra is so flexible and loose that straight 

 instruments, such as cystoscopes, can readily be passed by skilful hands. In hyper- 

 trophy of the prostate, long instruments, with big curves if of metal, are essential. 

 Many rubber catheters are too short for this purpose. In passing small, filiform bougies 

 they are to be directed at first toward the floor of the urethra to avoid the lacunae on 

 the roof. If they do catch they are allowed to remain and so prevent the ones sub- 

 sequently introduced catching in the same place. The vascular net-work in the sub- 

 mucous tissue bleeds readily and the skill evinced by the surgeon in passing urethral 

 instruments is in inverse ratio to the amount of bleeding produced. 



Otis claimed that a penis 3 in. in circumference had a normal urethra admitting 

 a No. 30, French scale, sound; 3^ in. No. 32; 3^ in. No. 34; 3^ in - No - 3 6 > and 

 4 in. No. 38. White and Martin state that a 3 in. circumference admits a No. 26 

 to No. 28; 3^ in. Nos. 28 to 30; 3^ in. Nos. 30 to 32; 3^ in. Nos. 32 to 34; and 

 a 4 in. Nos. 34 to 36. We agree with the latter, and often the meatus though 

 normal in appearance must be incised to admit the above sizes. The distensibility 

 of the urethra is such, especially in its deeper portions, that after incision of the meatus 

 very large sounds can be introduced. For this reason urethrotomes should not 

 cut to the full size. Teevan's urethrotome only cuts up to 22 French and the 

 additional size is obtained by stretching with sounds. This instrument in one case 

 was made to cut to 26 French but death followed from hemorrhage and a return was 

 made to No. 22. It cuts on the roof, and the dorsal artery of the penis or the artery 

 to the bulb was probably divided. To avoid hemorrhage, deep strictures are treated 

 by dilatation or external urethrotomy and penile strictures only are cut internally. 

 Keegan has shown that the calibre of the urethra in small children is sufficient to 

 allow the use of the lithotrite and so avoid a cutting operation. 



Spasmodic stricture results from contraction of the urethral muscles due to some 

 irritation. This irritation may be from the urine, from organic stricture, fissure of 

 the anus, hemorrhoids, etc. It causes retention of urine, which can be relieved by 

 passing a full-sized catheter, or by hot baths, etc. Notice the firmness with which 

 the urethra grasps a sound as it is withdrawn. 



Traumatic Stricture. This is usually located in the bulbous portion, just in 

 front of the triangular ligament. The urethra is compressed between the pubic bone 

 and the vulnerating body. It is treated by passing in a full-sized catheter either 

 with or without the aid of a perineal incision. 



THE MALE PERINEUM. 



The name perineum -in its broad sense is applied to the structures of the outlet 

 of the pelvis, superficial to the levator ani muscle. In its restricted anatomical sense 

 it is applied to the subpubic triangle as far back as a line joining the anterior portions 

 of the tuberosities. In its clinical sense it is the space between the anus and scrotum 

 in the male and anus and vulva in the female. 



Bony Landmarks. On examining the pelvic outlet the symphysis pubis is 

 seen anteriorly with the descending rami of the pubes and ascending rami of the 

 ischia on the sides, leading to the tuberosities. Posteriorly is seen the coccyx, with 

 the spines of the ischia on each side comparatively close to it. The greater sacro- 

 sciatic ligament runs from the sacrum to the tuberosity of the ischium, the lesser 

 from the sacrum to the spine of the ischium. Taken together a diamond-shaped 

 space is formed. In the female the pubic arch is wider, the tuberosities further 

 apart, the spines of the ischia do not project so markedly inward, and the coccyx 

 is more movable. 



Perineal and Ischiorectal Regions. A line drawn from the anterior por- 

 tion of one tuberosity to that of the opposite side passes 1.25 cm. (^4 in.) in front 

 of the anus, and divides the outlet into the urogenital triangle or perineum in front, 

 and the anal triangle or ischiorectal region behind. 



Urogenital Triangle. The urogenital triangle has the symphysis in front, 

 the ischiopubic rami as far back as the anterior portion of the tuberosities on the 



