THE DEVELOPMENT AND SURGICAL IMPORTANCE

OF THE RECTOURETHRALIS MUSCLE AND

DENONVILLIERS' FASCIA
MILEY B. WESSON
San Francisco

Received for publication July 28, 1922

The foundation of all perineal surgery is an exact knowledge

of the rectourethralis muscle and Denonvi1liers' fascia. Hazy
ideas of anatomical relations are indirectly responsible for. most
of the criticisms leveled at the perineal prostatectomy opera-
tion, since failure to properly divide the rectourethralis muscle
may result either in urinary incontinence or a rectourethral
fistula. The descriptions of the rectourethralis muscle in the
literature are very vague and indefinite, hence inexperienced
surgeons because of the small operative field and consequent
narrow margin of safety, occasionally have trouble in success-
fully exposing the prostate.
Denonvilliers' fascia, which lies between the rectum and
the prostate, can be split into two layers, and as a result the
didactic statement that it represents a fusion of the layers of
the fetal peritoneum has been generally accepted. At the sug-
gestion of Hugh H. Young this study was made to see if there
was any scientific basis for that theory. The work was begun
at the Brady Urological Institute, Johns Hopkins Hospital,
and completed in the Department of Urology, University of
California.
HISTORY

Denonvilliers (1), in 1836, enunciated the hypothesis that

the center or nucleus of the perineum is a prerectal raphe or
"aponeurosis prostato-peritonele." This fibrous plane is tri-
angular in shape with a truncated apex which blends with the
339
340 MILEY B. WESSON

superior layer of the triangular ligament, while the base is ad-

herent at the top to the inferior face of the peritoneum thereby
helping form the rectovesical cul-de-sac. The posterior layer
is in contact with the rectum, to which it is joined with very
loose cellular tissue, while from the superior face arise dense
cellular elongations which envelope the seminal vesicles, vasa-
deferentia and inferior extremities of the ureters.
In 1899, Cuneo and Veau (2) went a step further and stated
that the prostato-peritoneal aponeurosis of Denonvilliers was
formed by a fusion of the fetal peritoneum of the rectovesical
cul-de-sac, the two peritoneal layers combining and forming an
aponeurotic sheet with a complete correspondence of the ar-
rangement of the peritoneum in embryos of both sexes. Even
if the original fused layers disappeared they made the frame work
for later layers of fibers. As proof of this primitive fusion they
called attention to evidences of incomplete fusions such as vesico-
seminal cysts, perinea! hernias and the cul-de-sac of Douglas
in the female.
The following year Proust (3) stated that while the ideal
scheme was to admit the existence of a prerectal fascia forming
a nucleus of the perineum, as suggested by Denonvilliers (4)
the hypothesis unfortunately could not be reconciled with sur-
gical anatomy, for while it was easy to separate the coverings
of the prostate into anterior and posterior layers it was most
difficult to peel out the seminal vesicles, bladder and rectum.
Zuckerandl (5), Dixon (6, 7), Henle (8), Moullin (9, 10), Waldeyer
(11), and Richardson (12) agree in general with this view.
The existence of the rectourethralis muscle has been ignored
by most anatomists and those who mention it vary greatly in
their descriptions, as shown by the writings of Roux (13), Al-
barran (14, 15, 16), Fischer and Orth (17), Delbet (18), Proust
(19, 20, 21), Walker (22, 23), and Jackson (24).
MATERIAL AND METHODS

The material used for microscopic study is indicated in the

accompanying table and consists of serial sections of human
embryos obtained through the kindness of Director George S.
 TABLE 1

Specimens studied microscopically

z la
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8,a
~; ~f::;"l
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0

""~ A< wen

z
zz
i<"
0"'
~:
"'p

z8
""'
8.,
-=1p
~p:j
He,
mZ
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ZH
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I<
88
0 z
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_,,8 1;lcn ""en 0"
iiJcn ""' 8
--- - - -
mm. weeks
0
" 8

microns
"
--
,n

18.5 5 7 Not deter- 20 T Carmine Carnegie

mined
15.5 390 6 Not deter- 50 s H. and E. Carnegie
mined
19.8 1108 7 Female 40 T H. E. Au. and Carnegie
Or. G.
20.0 22 7 Male 50 T Carmine Carnegie
20.0 460 7 Female 40 T H. and E. Carnegie
20.0 462 7 Male 40 T Cochineal Carnegie
22.0 635b 7 Male 50 T Cochineal Carnegie
23.0 903c 7 Not deter- 40 T Cochineal Carnegie
mined
25.0 584a 7 Male 50 s Cochineal Carnegie
26.0 405 8 Male 40 s Cochineal Carnegie
26.0 895 8 Male 25 T Cochineal Carnegie
26.0 464 8 Male 100 s Cochineal Carnegie
27.0 875 8 Male 40 s Cochineal Carnegie
27.0 1458 8 Male 50 s H. E. Au. and Carnegie
Or. G.
30.0 75 9 Male 50 s Cochineal Carnegie
33.0 145 9 Male 50 s Cochineal Carnegie
37.8 1161 10 Male 50 T H. E. Au. and Carnegie
Or. G.
39.0 2514 10 Female 50 T Cochineal Carnegie
40.0 224 10 Male 50 and 100 s Cochineal Carnegie
46.0 1686 10 Male 100 s H. E. Au. and Carnegie
Or. G.
52.0 448 11 Male 25 and 100 s Cochineal Carnegie
67.0 1656 12 Male 200 s Cochineal Carnegie
80.0 34 13½ Male 50 T Cochineal Carnegie
80.3 768c 13½ Male 6 T H. and E. Carnegie
130.0 1018 17 Male 50 T H. and E. Carnegie
161.4 1049 20 Male 40 T H. and E. Carnegie
169.0 2577 20 Female 100 T H. E. Au. and Carnegie
Or. G.
176.0 2531 21 Male 100 T H. E. Au. and Carnegie
Or. G.
210.0 2402 24 Male 100 T H. E. Au. and Carnegie
Or. G.
221.0 1172 25 Male 15 T H. and E. Carnegie
253.0 2375 28 Male 100 T H. E. Au. and Carnegie
Or. G.

341
342 MILEY B. WESSON

Streeter from the collection of the Carnegie Institute of Embryol-

ogy. Microscopic measurements were made with a Spencer
ocular micrometer calibrated with a Zeiss micrometer stage
objective.
Specimens of the rectourethralis muscle were obtained at
operation, sectioned and stained with differential stains.
The macroscopic investigations consisted of dissections of
both preserved and fresh cadavers of infants and adults.
A glass model was constructed of the pelvis of a seven-months
fetus, cut transversely in sections 100 µ thick (specimen 2375,
Carnegie Institute of Embryology). An Edinger projection
apparatus was used, and the sections traced directly on glass
plates by means of various colored Higgins inks. Distortion
of the model was prevented by keeping the magnification ( X6.6)
in proportion to the thickness of the sections. The glass plates
were then stacked, divided into packs about 2 inches thick and
bound firmly with adhesive plaster. When mounted in a frame
with electric lights behind them they appeared as colored gelatin
molds in a glass case. A preparation of this kind is far superior
to a wax model for perineal studies, as it gives a transparent
presentation of an entire region, in this model showing ten
structures and their relationships, instead of an opaque repre-
sentation of a single organ.
EMBRYOLOGY OF THE PERINEUM

The primitive pelvis is divided into a ventral and dorsal half

by the fusion of the two urogenital folds which unite throughout
their whole length in the median line (fig. 1). This frontal
partition is termed the genital cord (25) and appears in embryos
between 19.4 and 20 mm., and when it fuses with the floor of
the body cavity the partition is complete. It was formerly
believed that sexual differences appeared with the formation
of the genital cord, but Spaulding (26) has recently shown
that they are present from the beginning. In females there is
a distinct vesico-uterine pouch between the genital cord and the
bladder, while in males the mesonephric folds approach one
another in the median line and unite at once with the wall of the
 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 343

bladder, the forerunner of the vesico-seminal vesicle pouch oc-

curring as a very shallow depression. In a 37.8 mm. embryo
the pouch was only 400 µ deep.
The coelom is lined with a layer of mesothelium which covers
the loose mesenchyme tissue. This is the primitive peritoneum,

FIG. L TRANSVERSE SECTION OF PELVIS 37 .8 MM. HUMAN EMBRYO

Showing the fusion of the genital ridges with the formation of the vesico-
seminal pouch. R, rectum; S, symphysis pubis; B, bladder; A, umbilical artery;
G, genital cord; WD, Wolffian duct; MD, Mullerian duct; Ur, ureter; T, testis;
P.C., peritoneal cavity; VSP, vesico-seminal pouch. (Embryo, Carnegie Insti-
tute 1161, slide 67, row 2, section 3.) X 54.

which is replaced later by mesothelial pavement (epithelial)

cells, supported by a basement membrane of connective tissue.
With the formation of the genital cord the peritoneum passes
over the bladder, dips into the vesico-uterine or vesico-seminal
vesicle pouch and then continues down over the dorsum to the
floor of the perineum and passes up about the rectum forming
344 MILEY B. WESSON

the rectovesical pouch. With the development of the fetus

this becomes compressed antero-posteriorly and relatively shallow
because of the approximation and fusion of the layers. There
is a marked increase in the amount of undifferentiated mesen-

. IJ11

. ",..,1 .,• · .. !J ~ r
. / •

- ........- ....-
._ ~

. .._ .
/' ~· 0
(\.I
. --....... '.
FIG. 2. TRANSVERSE SECTION THROUGH MOST DEPENDENT PORTION OF
PERITONEAL CAVITY OF 161.4 MM. HUMAN EMBRYO

Surrounding the rectum is a condensation of connective tissue forming a cuff,

in which the peritoneal cavity ends. The bottom of the utricle appears as a mass
of elastic tissue with the ejaculatory ducts at the sides. The condensations of
connective tissue between the prostate and the rectum represent the two layers
of Denonvilliers fascia. U, urethra; PC, peritoneal cavity; R, rectum.
(Embryo, Carnegie Institute 1049, slide 32, section 1.) X 17.
 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 345

chyme cells in the rectovesical space with definite condensations

about the prostate and rectum, which often forms a cuff about
the latter (fig. 2) enclosing the two layers of fetal peritoneum.
These layers always lie closer to the rectum than to the bladder.
The rectovesical pouch, which extends to the floor of the peri-
neum in a 15.5 mm. embryo, reaches just below the level of the

Fm. 3. SAGITTAL SECTION oF 25 MM. HuMAN EMBRYO

Showing a raphe formed by the fused layers of fetal peritoneum. The future
muscles of the region are represented by the condensations of loose mesenchyme
tissue; the raphe lies much closer to the rectum than to the site of the prostate.
U, urethra; R, rectum; PC, peritoneal cavity; ED, ejaculatory duct. (Embryo,
Carnegie Institute 584a, slide 14, row 1, section 1.) X 54.

verumontum in a 46-mm. specimen, at 80 mm. it ends directly

beneath the orifices of the ejaculatory ducts, and at 210 mm. the
level is the same, but at 240 mm. the base reaches only to the
middle of the seminal vesicles. In many of the specimens studied
the peritoneal pouch is asymmetrical being slightly deeper on one
side than the other.
THE JOURNAL OF UROLOGY, VOL. VIII, NO. 4
346 MILEY B. WESSON

When the peritoneal layers fuse, the mesothelium is absorbed

and disappears leaving only a bed of mesenchyme. In one 25
mm. embryo there was an apparent raphe (fig. 3), .as the absorp-

FIG. 4. SAGITTAL SECTION OF 26 MM. HUMAN EMBRYO

Showing incomplete. a bsorption of fetal peritoneal layers with formation of

"cysts ." The beginning of musculature formation is well advanced. R, rectum;
PC, peritoneal cavity; B, bladder; ED, e jaculatory duct. (Embryo, Carnegie
Institute 404, slide 12, row 2, section 2.) X 54.

tion was not complete; in other specimens showing incomplete

absorption the line of fusion was marked by isolated portions
simulating cysts (fig. 4)- all lying closer to the rectum than to
the prostate. In none of the older specimens (fig. 5), where
 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 347

differentiation is more complete, is there any evidence of the

persistence of the fused peritoneal layers as a raphe or cysts.
The rectourethralis muscle appears first as condensations of
mesenchyme tissue passing forward from the rectum to the site
of the membranous urethra. In a 26 mm. embryo it shows
clearly and the symmetrical rectovesical pouch is seen dipping

FIG. 5. SAGITTAL SECTION THROUGH PELVIS OF 67 MM. HUMAN EMBRYO

B, bladder; U, urethra; S, symphysis; P, prostate; PC, peritoneal cavity;

V, vas deferens; EVS, external vesical sphincter; RU, rectourethralis muscle;
R, rectum. (Embryo, Carnegie Institute 1656, slide 48.) X 18.5.

down on either side (fig. 6). In later stages it appears, below

the peritoneal pouch, as a triangular muscle sharply separated
laterally from the levator ani muscle (fig. 7).

GROSS ANATOMY OF PELVIC FASCIA

Because of the confused nomenclature, a brief description

of the gross anatomy of the pelvic fascia is necessary.
348 MILEY B. WESSON

The visceral pelvic fascia is a membranous diaphragm separat-

ing the pelvic cavity above from the perineum below and cover-
ing the upper surface of the levator ani muscles. This fascia
passing inward from the white line on either side forms the lateral
ligaments of the bladder, and at the junction of the bladder
and prostate it splits into two layers, one passing up around the

FIG. 6. TRANSVERSE SECTION THROUGH PERINEUM OF 26 MM. EMBRYO

Showing site of future rectourethralis muscle. The peritoneal cavity shows

at sides of rectum, but has disappeared in front. R, rectum; CS, corpus spongi-
osum; PC, peritoneal cavity; LA, levator ani muscle; OJ, obturator internus
muscle; Pu, pubis; Il, ilium; S, sacrum. (Embryo, Carnegie Institute 895, slide
63, row 1, section 3.) X 54.

bladder and the other down over the prostate. The former
splits into two layers on either side of the midline to enclose each
seminal vesicle and vas deferens, and then blending together
continue forward over the bladder to the pubis forming the an-
terior true ligaments. From that portion of the fascia overly-
ing the seminal vesicles and vasa deferentia arises the layer that
 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 349

forms the outer coat of the ejaculatory ducts and accompanies

them through the prostate (fig. 8).
The prostate has a capsule which consists of a comparatively
thin layer of fibrous tissue and involuntary muscle fibers closely
adherent to the gland and penetrating the substance, being

FIG. 7. TRANSVERSE SECTION THROUGH PROXIMAL PORTION OF POSTERIOR

URETHRA OF 221 MM. HUMAN EMBRYO

The rectourethralis muscle appears as a triangular sheet, separated from the

levator ani by a fascia. U, urethra; P, prostate tubule; EVS, external vesical
sphincter; LA, levator ani muscle; RU, rectourethralis muscle; R, rectum; SA,
sphincter ani, internal, muscle. (Embryo, Carnegie Institute 1172, slide 80.)
X 21.
350 MILEY B. WESSON

continuous with the glandular stroma it cannot be separated

from it without laceration of the gland tissue. It is analogous to
the fibrous capsule of the liver or spleen.
Denonvilliers' fascia, or the fascia between the prostate and
the rectum, consists of two layers, one covering the prostate

P .C.

Fm. 8. T RANSVERSE SECTION THROUGH POSTERIOR URETHRA, DISTAL To=VERU-

MONTANUM, OF 210 MM. HUMAN EMBRYO

A dense fascia surrounds the utricle and ejaculatory ducts separating them
from the prostatic tissue. U, urethra; Ut, utricle ; ED, ejaculatory duct; P, pros-
tate; PC, peritoneal cavity; D , Denonvilliers fascia . (Embryo, Carnegie Insti-
tute 2402, slide 245, section 2.) X 18.5.
 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 351

Fm. 9. SAGITTAL SECTION THROUGH PELVIS OF ADULTS

Showing diagramatically the relation existing between the external vesical

sphincter (EVS) and the rectourethralis muscle (RU); if the dissection follows
the posterior surface of this muscle the rectum will be opened, but if the muscle
is cut at its junction with the external vesical sphincter the rectum will drop back
and the prostate be exposed.
352 MILEY B. WESSON

and the other the rectum. These two layers meet above at
the vesico-prostatic junction, where they both spring from that
portion of the visceral fascia which may be said to stretch across
the pelvis between the urogenital apparatus and the rectum.
When the rectourethralis muscle is divided the incision should
likewise divide the posterior or rectal layer of Denonvilliers'

FIG. 10. TRANSVERSE SECTION PROXIMAL TO ORIGIN OF RECTOURETHRALIS

MUSCLE OF 130 MM. HUMAN EMBRYO

From the longitudinal layer on the anterior surface of therectum this bundle
of muscle has split off and is shown passing across the rectovesical space; EVS,
external vesical sphincter; RU, rectourethralis muscle; LA, levator ani muscle;
R, rectum. (Embryo, Carnegie Institute 1018, slide 168, row 2, section 3.) X 54.

fascia which is then pushed back with the rectum (fig.9). Thus
is formed the "espace decollable retroprostatique" or separable
space and the anterior layer of Denonvilliers' fascia or sheath of
the prostate is exposed. The t exture of this resistant membran-
ous layer resembles the dartos being made up of glistening fibrils
most pronounced in the midline.
 --------------------'----------'------'---'------

SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 353

GROSS ANATOMY OF THE RECTOURETHRALIS MUSCLE

The rectourethralis muscle is of primary importance to the

perineal surgeon since it is responsible for the acute anterior

FIG. 11. TRANSVERSE SECTION OF 130 MM. HUMAN EMBRYO

Showing insertion of rectourethralis in raphe of external vesical sphincter.

R, rectum; EVS, external vesical sphincter; RU, rectourethralis muscle; levator
ani muscle. (Embryo, Carnegie Institute 1018, slide 173, row 2, section 2.)
X 54.

flexure of the rectum and its approximation to the apex of the

prostate. It is formed by a bundle of muscle fibers which arise
from the anterior thickened longitudinal band of the rectum at
354 MILEY B. WESSON

the level of the verumontanum (fig. 10) and passing forward fuses
with the raphe of the external vesical sphincter (fig. 11). A
corresponding bundle passes from the posterior band to the coccyx
with the formation of the rectococcygeus muscle.
A study of the specimens of the rectourethralis muscle ob-
tained at operation and prepared with differential stains showed
smooth muscle fibers flowing into a bed of elastic tissue contain-
ing striated muscle. The striated fibers were part of the ex-
ternal vesical sphincter and the elastic tissue came from the raphe,
while the smooth muscle represented the fibers from the rectum.
DISCUSSION

Since fascia are merely condensations of connective tissue,

th ey have marked individual variations in density. From the
urological standpoint they are of interest not only as structural
supports but as protective partitions which control the course
of extravasations of urine and limit the spread of infections and
malignant growths. The dense anterior layer of Denonvilliers,
fascia is of primary importance in preventing cancer of the
rectum spreading anteriorly, and effectively confines early cancer
of the prostate, so that it can be entirely eradicated by means
of the radical perinea} prostatectomy.
The fascia which passes through the prostate enclosing the
ejaculatory ducts and utricle, protects them from injury when
the adenomata are removed perineally from the prostate gland.
A study of the glass model of the seven-months pelvis shows
several points of interest. The deep and superficial transverse
muscles are very thin and delicate while the rectourethralis
muscle is relatively heavy. It passes forward and downward
from the ant erior surface of the rectum and blends with the raphe
of the external vesical sphincter below the membranous urethera.
It shows clearly why if the surgeon fails to sever the muscle
at its insertion he will be punished for his carelessness by having
to cut through it at the bottom of a deep pocket or else if he dis-
sects far enough he will be led directly into the lumen of the
rectum.
Contrary to the generally a ccepted view, the levator animus-
cle lies lateral to the prostate and is definitely separated from it,
 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 355

and sends no fibers over its posterior surface either directly or

indirectly through the rectourethralis.
A study of the testicles, which lie in the inguinal canals is of
interest, since one is apparently normal while the other is ro-
tated end for end, so that the globus minor lies above while the
globus major is below. Apparently surh an embryological

Fm. 12. SAGITTAL SECTION, LATERAL TO MID-LINE OF 67 MM. HUMAN EMBRYO

Showing a Cowper's duct that enters the urethra near the meatus. B, bladder;
U, urethra; V, vas deferens; SV, seminal vesicle; P, prostate; PC, peritoneal
cavity; R, rectum; RU, rectourethralis muscle; S, symphysis pubis; CC, corpora
cavernosa; C, Cowper's gland; CD, Cowper's duct approaching urethra. (Embryo,
Carnegie Institute 1656, slide 46.) X 18.5.

anomaly can be responsible for torsion of the testicle which

manifests itself at a later stage of development.
In another specimen (fig. 12) was seen an abnormal Cowper's
duct-which enters the urethra near the coronary sulcus instead
of in the bulb. Such an anomaly is undoubtedly the forerunner
of a periurethral duct.
356 MILEY B. WESSON

SUMMARY

1. Denonvilliers' fascia is not formed by a fusion of the layers

of fetal peritoneum.
2. The fetal peritoneum in passing from the bladder to the
rectum, dips down between the bladder and the seminal vesicles
due to fusion of the genital cords, and then to the perineal floor
between the prostate and the rectum.
3. With development these two depressions become less
marked; first, by mechanical changes in outline which tend to
smooth out all irregularities; and second, approximation of the
layers followed by fusion and prompt reversion to undifferentiated
embryonic tissue or persistence for a short time of a pseudo-raphe
or an occasional cyst where apposition has not been perfect.
, 4. The rectum, at the level of the prostate, is surrounded by
a more or less definite cuff of connective tissue in which the
lowest part of the peritoneal cavity dips.
5. At no stage of development is the peritoneum in contact
with the prostate, it lying in all cases nearer to the rectum than
to the prostate.
6. The recto-prostatic space is filled at first with a synticium
or mass of embryonic connective tissue cells; eventually differ-
entiation occurs and there is a condensation of connective tissue
anteriorly and posteriorly. The anterior layer, covering the
prostate, is the thicker and the elastic tissue fibrils predom-
inate, thereby causing the characteristic shiny appearance of
"Denonvilliers' fascia."
7. A sheath of fascia surrounds the ejaculatory ducts and
utricle as they pass through the prostate.
8. The rectourethralis is a sheet of muscle arising from the
external longitudinal layer of the rectum and ending in the raphe
of the external vesical sphincter.
9. In exposing the prostate by the perineal route the recto-
urethralis muscle should be cut close to the central tendon, the
incision being sufficiently deep to sever the posterior or rectal
layer of Denonvilliers' fascia, and the dissection continued an-
teriorly to the muscle, for if the posterior layer is followed it
 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 357

leads directly into the rectum. 1f the incision is made anterior

to the central tendon the dissection leads first into the venous
bulb, and then through the external vesical sphincter. The
opening of the rectum is avoided, but there is a prolonged and
often permanent loss of vesical sphincter control.
REFERENCES
(1) DENONVILLIERs, C.: Anatomie du perfnee. Bull. et Mem. Soc. Anat. Par.,
1836, ii, 105-106.
(2) CUNEO, B., AND VEAU, V.: De la signification morphologique des aponeo-
roses perivesicales. J. de Anat. Par., 1899, xxxv, 235-245.
(3) PROUST, R.: Prostatectomie perineale totale. These, Par., 1900, 12.
(4) DENONVILLIERS, C.: Propositions et observations d'anatomie, de physi-
ologie et de pathologie. These De L'Ecole De Medecine, Par., 1837,
x, 285.
(5) ZucKERKANDL, 0.: Beitriige zur Lehre von den Briichen un Bereiches des
Douglasschen Raumes. Deutsche Ztschr. f. Chir., 1891, xxxi, 590-608.
(6) DIXON, A. F.: The form of the empty bladder and its connections with the
peritoneum: Together with a note on the form of the prostate. Jour.
Anat. and Physiol., 1900, xxxiv, 182-198.
(7) DrxoN, A. F., AND BIRMINGHAM, A.: The peritoneum of the pelvic cavity.
Jour. Anat. and Physiol., 1902, xxxvi, 127-142.
- (8) HENLE, J.: Handbuch der systematischen Anatomie des Menschen. Braun-
schweig, F. Vieweg u. Sohn, 1873, ii, 533-910.
(9) MouLLIN, C. M.: Enlargement of the prostate. Phila., P. Blakiston's
Son & Co., 1894.
(10) MouLLIN, C. M.: A contribution to the morphology of the prostate. Jour.
Anat and Physiol., 1895, xxix, 201-204.
(11) W ALDEYER, W.: Topographical sketch of the lateral wall of the pelvic cavity
with special reference to the ovarian groove. Jour. Anat. and Physiol.,
1898, xxxii, 1-11.
(12) RICHARDSON, W. G.: The development and anatomy of the prostate gland.
London, J. and A. Churchill, 1904.
(13) Roux, C.: Beitrage zur Kenntnis der Aftermuskulatur des Menschen.
Arch. f. Mikros. Anat., 1881, xix, 721-733.
(14) ALBARRAN, J.: Medecine Operatoire des Voies Urinaires. Par. Masson &
Cie, 1909, 740.
(15) ALBARRAN, J.: Maladies de la prostate, in Traite de Chirurgie. Par. Le
Dentu et Delbet, 1920, ix, 529.
(16) ALBARRAN, J., AND MoTz, B.: Contribution a l'etude de l'anatomie macro-
scopique de la prostate hypertrophie. Ann. d. mal. d. organes genito-
urin., 1902, xx, 769--817.
(17) FISCHER, A. W., AND ORTH, 0.: Die Chirurgie der Prostata. Ztschr. f.
Urol. Chir., 1920, v, 232-317.
(18) DELBET, P.: Vessie: in Traite d'Anatomie humaine. Par. Poirier and
Charpy, 1907, v, 74--240.
358 MILEY B. WESSON

(19) PROUST, R.: Le loge prostatique. Bull. et Mem. Soc. Anat. Par., 1902,
iv, 813-815.
(20) PROUST, R.: Technique de !'incision prerectale, appliquee a la chirurgie
genitale, chez l'homme. Centralbl. f. d. Krankh. d. Harn-u. Sex.-
Org., 1903, xiv, 52-62.
(21) GosSET ET PROUST: Le muscle recto-urethral. Son importance clans les
operations par voie perineale, en particulier clans la prostatectomie .
Bull. et Mem. Soc. Anat. Par., 1902, lxxvii, 425-436.
(22) WALKER, J. W. T.: On the surgical anatomy of the prostate. Jour. Anat.
and Physiol., 1905, 1906, xl, l&'J-209.
(23) WALKER, J. W. T.: Surgical diseases and injuries of the genito-urinary
organs. London, Cassell & Co., 1914, 667-739.
(24) JACKSON, C. M.: Digestive system: In Morris's human anatomy. Phila. ,
P. Blakiston's Son & Co., 1921, 1201.
(25) FELIX, W.: The development of the urogenital organs. Keibel and Mall
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(26) SPAULDING, M. H.: The development of the external genitalia in the human
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(27) In addition to the references already given, the following will be found
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CAMPBELL, W. F.: A text book of surgical anatomy. Phila., W. B. Saunders
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& Co., 1905, 30-46.
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HUGHES, J. S.: Diseases of the prostate gland. Dublin, Fannin & Co., 1870.
JOHNSON, F. P.: The later development of the urethra in the male. Jour.
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KALISCHER, 0.: Die Urogenitalmuskulatur des Dammes, etc. Berlin,
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LOCKWOOD, C. B.: The development and transition of the testis, normal
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MouLLIN, C. W. M.: Enlargement of the prostate. Phila., P. Blakiston's
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PICARD, H.: Traite des maladies de la prostate. Par., J.-B. Bailliere et
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FLESCHNER, H. G.: Zur Physiologie und Pathologie der Miktion. Ztschr.
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 SURGICAL IMPORTANCE OF RECTOURETHRALIS MUSCLE 359

RouvrLLOIS, H., ET FERREN, M.: Maladies de la Vessie. Encyclopedie

Francaise D'Urologie, Paris, 0. Doi:n et fils, 1914--1921, T. IV, 89-159.
SocuM, A.: Die Verletzungen und Krankheiten der Prostata. Stuttgart,
1902, 1-18.
STONEY, R. A.: The anatomy of the visceral pelvic fascia. Jour. Anat.
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THOMPSON, H.: The diseases of the prostate, their pathology and treatment.
Phila., C. Lea, 1873, 1-44.
WALLACE, C. S.: An anatomical criticism of the procedure known as total
prostatectomy. Brit. Med. Jour., 1904, i, 239-245.
WALLACE, C. S.: Prostatic enlargement. Lond., Oxford Univ. Press, 1907.
WATSON, F. S., AND CUNNINGHAM, J. H.: Diseases and surgery of the genito-
urinary system. Phila., Lea & Febriger, 1908, ii, 301.
WESSON, M. B.: Anatomical, embryological and physiological studies of
the trigon and neck of the bladder. Jour. Urol., June, 1920, iv, 279-315.
YouNG, H. H., AND WESSON, M. B.: The anatomy and surgery of the trigon.
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YOUNG, HUGH H.: Surgery of the prostate. Keen's Surgery, Phila., W. B.
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