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Title: A Short Treatise on the Section of the Prostate Gland in Lithotomy
Author: Key, Charles Aston
Language: English
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                                    A
                             SHORT TREATISE
                                 ON THE
                     SECTION OF THE PROSTATE GLAND,
                                   IN
                               LITHOTOMY.

                            F. WARR, PRINTER,
                   RED LION PASSAGE, RED LION SQUARE.



                                    A
                             SHORT TREATISE
                                 ON THE
                      SECTION OF THE PROSTATE GLAND
                                   IN
                               LITHOTOMY;

       WITH AN EXPLANATION OF A SAFE AND EASY METHOD OF CONDUCTING
                   THE OPERATION ON THE PRINCIPLES OF
                               CHESELDEN.

                      _ILLUSTRATED BY ENGRAVINGS._

                            BY C. ASTON KEY,
             SURGEON TO GUY’S HOSPITAL, AND TO THE MAGDALEN.

    “Occupons-nous maintenant d’un Lithotomiste bien plus célèbre
    qui mérite la reconnoissance de son siècle et celle des siècles
    à venir; je veux dire Cheselden.”

                                                          DESCHAMPS.

                                 LONDON:
     LONGMAN, HURST, REES, ORME, BROWN, AND GREEN, PATERNOSTER ROW:
   S. HIGHLEY, 74, FLEET STREET; T. & G. UNDERWOOD, 32, FLEET STREET;
            AND E. COX & SON, ST. THOMAS’S STREET, SOUTHWARK.
                               MDCCCXXIV.



TO

SIR ASTLEY COOPER, BART., F.R.S.,

SURGEON TO THE KING, AND TO GUY’S HOSPITAL,

THE FOLLOWING PAGES ARE INSCRIBED BY HIS SINCERE FRIEND AND GRATEFUL
PUPIL.


In selecting the Name that graces the head of this page, I am influenced,
not only by feelings as a surgeon, to render a slight tribute to
unrivalled professional reputation, but also by gratitude for the many
acts of friendship I have personally received at his hands.

Educated under his eye, I am proud to acknowledge, that I consider myself
indebted to his professional instructions, and to his excellent advice,
for whatever information and advancement I possess; and I am sensible,
that in no way more satisfactory to him can I repay his kindness, than by
unceasing labor in a science which it is his constant study to improve,
and by endeavours to attain a respectable character in a profession of
which he constitutes the brightest ornament.

                                                            C. ASTON KEY.

_18, St. Helen’s Place, April, 1824._



PREFACE.


To Cheselden Operative Surgery is indebted for one of the most important
improvements, that the whole range of the profession can present. The
certainty and safety with which a most painful disease can be relieved,
stamps the lateral operation of Lithotomy as a bold and highly rewarded
effort of genius,—as a present of inestimable value to suffering
humanity,—and as a just cause of triumph to our national feelings as
surgeons.

It has now undergone the test of nearly a century, and, like all
improvements of real value, it has past through its ordeal with increased
rather than diminished credit.

Connected with a school that gave birth to the present lateral operation,
and deeply impressed with the conviction of its superiority over every
other mode of operating in this disease, I need offer no apology for
reviewing what appears to me to be the true principle of the operation.

A review of this kind is perhaps the more required at the present time,
when attempts are made by English, as well as Continental surgeons, to
revive a mode of operating that presents no advantage under ordinary
circumstances,—that was discarded by Cheselden,—and needs an equal test
of time and experience to shew its comparative merit. If want of success
in the lateral operation has thus led to its abandonment, it becomes a
question, how far it may be traced to a neglect of those principles which
guided Cheselden. To such as are laying aside lateral Lithotomy; the
following observations, by recalling their attention to his principles,
may prove useful; to those who still continue to practice it, they may,
by throwing a few lights on the subject, be interesting; and to the
younger members of the profession, by explaining a new and simple method
of performing the operation, they may perhaps be not entirely devoid of
instruction.



A SHORT TREATISE ON LITHOTOMY.


In the performance of surgical operations, it is the paramount duty of
the surgeon, a duty rendered doubly indispensable, both as the feelings
of humanity and the improvement of the profession are concerned, not to
deviate from the rules which have been found efficient in the hands of
experienced and dexterous operators; nor to suggest any important change
in the mechanism of an operation that can be at variance with principles
established on the firm basis of experience.

After the records recently laid before the public by two able and
successful Lithotomists,[1] it may appear superfluous, or even
presumptuous in me, to clothe in the formal garb of a publication the
observations which the following pages contain. To disarm the severity of
the critic, however, and to invite those who shrink, and frequently with
reason, at the idea of innovation on established practice, I may premise,
that it is not intended to change in any one respect the principles
of the lateral operation, but merely to suggest an easier mode of
accomplishing the same object. Indeed, I trust I shall be able to shew,
that the proposed method will enable the surgeon to adhere more closely
to the operation as first proposed and practised by the great Cheselden.

If more satisfactory proof of the superiority of his operation be
required than his success from the year 1731 at St. Thomas’s Hospital,
where he cut fifty-two patients and lost only two, the extraordinary
zeal of all the surgeons of Europe to acquaint themselves with his plan,
and the desire evinced by surgeons of the highest fame closely to follow
his steps, would alone characterise it as a safe and simple operation.
It must however be confessed that his method, as practised by himself,
required a greater share of anatomical knowledge than at that time fell
to the lot of the generality of persons educated even for the higher
branches of the profession; this gave rise to slight changes in the
operation, which were thought to be improvements; among these ranks the
introduction of the Cutting-Gorget, first used by Sir Cæsar Hawkins, and
receiving various modifications under successive operators down to the
present day. The employment of the Gorget in the division of the prostate
gland, has been stigmatized as substituting mechanism for skill; if that
were the only remark that could apply to this instrument, it would be
rather an argument in its favor than an objection to its general use, as
the success of the operation would depend less on individual dexterity.
But the objection to it in my opinion is, that, from the manner in which
it is introduced into the bladder, it cannot divide the parts according
to Cheselden’s operation. To explain this defect in the Gorget, it is
necessary to understand the direction of Cheselden’s incisions.

In his first operation he adhered to the plan of Frère Jacques, and Raw;
but, from the ill success attending it, he was soon induced to lay it
aside. He then practised the operation, which, from the lateral division
of the prostate gland, has since been denominated the Lateral Operation.
This, his second operation, is thus described by Douglas in his appendix.

“His knife entered first the muscular part of the urethra, which he
divided laterally, from the pendulous part of its bulb to the apex, or
first point of the prostate gland, and from thence directed his knife
upward and backward all the way to the bladder.”

Morand, to whom Cheselden communicated the particulars of his operation,
describes it as follows:—

“Je fais d’abord une incision aux tégumens, aussi longue qu’il est
possible, en commençant près de l’éndroit où elle finit au grand
appareil; je continue de couper de haut en bas entre les muscles
accélérateur de l’urine et érecteur de la verge, et à côté de l’intestin
rectum. Je tâte ensuite pour trouver la sonde, et je coupe dessus,
le long de la glande prostate, continuant jusqu’à la vessie, en
assujettissant le rectum en bas pendant tout le temps de l’operation.”[2]

Deschamps gives the following account:—“L’incision des tégumens faite,
il continue de couper de haut en bas entre les muscles accélérateur et
érecteur de la verge, et à côté de l’intestin rectum; il s’assure ensuite
de la situation de la sonde sur la quelle il coupe le long de la glande
prostate jusqu’à la vessie, ayant soin d’assujettir le rectum en bas,
pendant toute l’operation, avec un ou deux doigts de la main gauche.”[3]

The first of these accounts is certainly not very perspicuous, or, as
Deschamps says, “à la verité bien imparfaite.” It is evident, however,
that the edge of the knife must have been turned obliquely towards the
rectum in the division of the prostate gland; and also that the gland
must have been divided, not at its upper part where it is thinnest, but
through its thickest and depending part. If the cutting edge were not
carried very obliquely downwards, the rectum would have run no risk of
being wounded; nor would he have changed his operation in consequence of
having twice cut the gut, as he himself confessed to Morand. For though
Douglas does not assign the reason for his giving up the operation,
but merely says that, “Mr. Cheselden has for very good reasons laid
this method aside, and substituted another very different in its room,
which he now practices with very great applause,” &c.; yet, with the
ingenuousness that always accompanies talent, he confessed having wounded
the rectum more than once: “Le chirurgien Anglais, malgré la direction
très oblique qu’il donnoit à son incision, avoue l’avoir interessé plus
d’une fois.”[4]

Though he abandoned this mode of conducting the incision, he still
adhered to the principle which guided him, namely, making a very free
incision, by the side of the rectum, and dividing the prostate very low
down.

The following descriptions of his third and last operation will impress
the mind of every person, that his incision of the prostate could not be
horizontal, but must have been inclined towards the rectum, even more
than in his second operation.

The operation appears to have been as follows:—An assistant holding a
long and curved staff, Cheselden, with a pointed convex edged knife, made
his usual large external incision through the muscles of the bulb and
crus penis, and part of the levator ani, till he could feel with the fore
finger of his left hand the prostate gland, at the same time keeping the
rectum down and preventing it being endangered: then pressing his finger
behind the prostate, and feeling the groove of the staff, he turned the
edge of his knife upward, pierced the cervix vesicæ, till the edge rested
in the groove; and completed the division of the prostate and membranous
part of the urethra by withdrawing the knife towards himself.

Douglas describes it in the following manner:—“Having cut the fat pretty
deep, especially near the intestinum rectum, covered by the sphincter and
levator ani, he puts the fore finger of his left hand into the wound,
and keeps it there till the internal incision is quite finished; first
to direct the point of his knife into the groove of his staff, which
he now feels with the end of his finger, and likewise to hold down the
intestinum rectum, by the side of which his knife is to pass, and so
prevent its being wounded. This inward incision is made with more caution
and more leisure than the former.”

“His knife first enters the rostrated or straight part of his catheter,
through the side of the bladder, immediately above the prostate, and
afterward the point of it continuing to run in the same groove in a
direction downwards and forwards, or towards himself, he divides that
part of the sphincter of the bladder that lies upon that gland, and
then he cuts the outside of one half of it obliquely according to the
direction and whole length of the urethra, that runs within it, and
finishes his internal incision by dividing the muscular portion of the
urethra on the convex part of his staff. When he began to practice this
method he cut the very same parts the contrary way, &c.”[5]

Deschamps, noticing the above description of Cheselden’s operation,
speaks clearly as to the prostate being cut low down: “Il dirige son
bistourie le long de la sonde vers la partie inferieure et laterale
de la vessie derriere la glande prostate, et au dessus des vesicules
seminales.”[6] With regard to the edge of the knife, Deschamps says that
the rectum runs no risk of being wounded in the division of the prostate:
“le tranchant de l’instrument etant dirigé en haut et s’eloignant par
consequent de l’intestin.”[7]

Cheselden, in his last edition of his anatomy, thus describes his
incision. “I first make as long an incision as I can, beginning near the
place where the old operation ends, and cutting down between the musculus
accelerator urinæ and erector penis, and by the side of the intestinum
rectum: I then feel for the staff, holding down the gut all the while
with one or two fingers of my left hand, and cut upon it in that part of
the urethra which lies beyond the corpora cavernosa urethræ, and in the
prostate gland, _cutting from below upwards to avoid the gut_.”[8]

Mr. John Bell’s remarks in his description of this operation are
concise:—“He struck his knife into the great hollow under the tuber
ischii, entered it into the body of the bladder immediately behind the
gland, and drawing the knife towards him, cut the whole substance of the
gland, and even a part of the urethra;” or, in other words, “cut the same
parts the contrary way,” alluding to this operation as contrasted with
the second.[9]

Mr. Sharp, giving instruction on the same subject, says, “The wound must
be carried deep between the muscles till the prostate can be felt, when
searching for the staff, and fixing it properly, if it has slipped, you
must turn the edge of your knife upwards, and cut the whole length of the
gland from within outwards.”[10] When speaking of the knife he remarks,
“That the back of the knife being blunt is a security against wounding
the rectum _when we cut the neck of the bladder from below upwards_.”

The concurring testimony of those most likely to be acquainted with the
true principles of Cheselden’s operation fully establishes the fact,
which to me seems an important one, namely: that the prostate gland was
divided in a manner very different from the direction in which the Gorget
cuts it. Cheselden’s aim evidently was, to divide the prostate in the
depending part of the left lobe, with a considerable inclination towards
the rectum. The most dexterous operator with the Gorget cannot effect
this: the direction which the Gorget takes is the very reverse of this;
it is directed to be inclined upwards, by which the upper surface of the
gland only is sliced off, and the major part of the gland remains whole.

In the quotations given above, two points are clearly made out:—first,
that the edge of the knife was turned upward; and, secondly, that the
knife was in this position carried into the neck of the bladder behind
the prostate gland.

With the preceding account of what I conceive to be the intent of
Cheselden’s operation, I have deemed it right to preface the following
observations, in the hope that what I have to offer on the subject will
not be construed into a deviation from, but rather a closer approximation
to that desirable object than can be attained by the employment of the
instruments commonly used.

The form of the staff has always appeared to me, to present the greatest
difficulty in executing the operation on the true principles of the
Lateral Lithotomy.[11] At the part where it serves the purpose of a
director it is curved; a form certainly least adapted to convey a cutting
instrument with safety where the eye of the operator cannot follow it;
and whether the knife or Gorget be used, difficulties, though of a
different kind, present themselves. When the former is propelled along
the groove of the curved staff, as in Mr. Martineau’s operation, the
edge must be turned, if not directly downward, at least not sufficiently
towards the left side of the patient to effect the necessary division
of the prostate gland; unless the operator be skilful enough to turn
the blade and divide the lobe of the gland, in doing which he is obliged
to make two incisions, as Mr. Martineau has observed. “I introduce,”
says that gentleman in his valuable paper in the Medico Chirurgical
Transactions, “the point of my knife into the groove of my staff as low
down as I can, and cut the membranous part of the urethra, continuing my
knife through the prostate into the bladder; when, instead of enlarging
the wound downwards, and thus endangering the rectum, I turn the blade
towards the ischium and make a lateral enlargement of the wound in
withdrawing my knife. I thus avoid cutting over and over again, which
often does mischief, but can give no advantage over the two incisions,
which I generally depend upon, unless in very large subjects, when a
little further dissection may be required.”

While quoting this gentleman’s description I take the opportunity of
mentioning that I had the pleasure of seeing him operate at Norwich
in the Summer of 1818, and from his deservedly high character as a
successful Lithotomist, I was induced to pay most minute attention
to the several steps of his operation; and I am satisfied from my
own observation, as well as from his words, that he conducts his
incisions of the several parts precisely on the principles laid down by
Cheselden. The depth, extent, and direction of his external incision,
and the division of the prostate gland, appear to me to accord in every
particular with the operation of the great Lithotomist. What more
satisfactory proof can be required of the imprudence of quitting a path
chalked out to us by one able surgeon, and trodden with unparalleled
success by another; a path sanctioned by that most unerring of all tests,
experience; and rendered still more secure by the light which anatomy
throws upon it.

In the use of the Gorget, a more unpleasant feeling is experienced by
the operator; namely, the danger of the beak slipping from the groove of
the curved staff; a danger, not imaginary, but with reason insisted upon
ever since Hawkins’s first introduction of the Cutting-Gorget, as well
by its strenuous advocates as by its enemies. The operator has to attend
to two sensations, the running of the beak along the staff’s groove, and
the resistance afforded by the prostate gland; while he is overcoming the
latter he becomes unconscious of the former, and at the time he impales
the prostate, loses all certainty of the beak being within the groove;
this difficulty depends as much on the curve of the staff as on the
nature of the Cutting-Gorget, and is one that every candid surgeon must
acknowledge frequently to have experienced.

The first impediment a surgeon meets with, is the giving the first
impetus to the Gorget; by raising his hand, he is aware of the hazard
he runs of the blade slipping between the gut and the prostate; by
depressing it, he is in danger of thrusting the beak at right angles
against the staff, so that the Gorget cannot run along the groove; and
not unfrequently in the efforts of the surgeon to propel it onwards, the
beak is nearly broken off the Gorget’s blade, and the staff is withdrawn
with a bent back. These accidents I have witnessed; and by those who
have seen much of Gorget Lithotomy, such occurrences will be recognised
as by no means uncommon. Mr. John Bell so happily illustrates the nicety
required in the introduction of this instrument, that for the sake of
the point the high colouring will be forgiven. “The operator holds the
staff steady for a moment, then moving the Gorget with his right hand,
feels by the left when the beak runs fairly and smoothly in the groove;
then, the two hands acting in concert with each other, the operator
balances the staff and Gorget, and, by making the two hands feel each
other, prepares them for co-operating in the most critical moment of
driving in the Gorget; and when all is prepared for driving home the
Gorget into the bladder, the surgeon depresses the handle of the staff,
so as to carry the point of it deep into the cavity of the bladder; his
staff stands at this moment at right angles with the patient’s body; he
rises from his seat, stands over the patient for an instant of time,
balancing the staff and Gorget once more, and feeling once more that the
beak is fairly in the groove, he runs it home into the bladder.” Mr.
Martineau speaks forcibly on the tact necessary to introduce the Gorget
along the curve of the staff, and to prevent it slipping:—“To perform
this part of the operation with dexterity, I would recommend every young
operator to practice the directing of the Gorget in the groove of his
staff when he holds them in his hand, and he will perceive how easily the
beak may slip out, if the convex part of the staff be not familiar to his
observation.”[12]

It should be borne in mind, that Cheselden never used the staff as a
director in the manner it is used at the present day. His left hand
being employed in holding the gut down, an assistant kept the instrument
fixed, while Cheselden divided the parts upon the groove of the staff in
withdrawing his knife.

To the Gorget exclusively belongs the merit of first employing the staff
in the modern light of a director. Is it surprising that the blind should
err in a crooked path?

In addition to the hazard and difficulty with which the introduction
of the Gorget is beset, a reflecting surgeon has only to consider its
anatomical imperfections (if I may be allowed the expression), to
convince himself of the impossibility of performing the operation à la
Cheselden. For this purpose he should be aware of the manner in which
the Gorget performs its part of the operation. In its introduction the
operator is directed to give the beak a slight inclination upwards, to
avoid the risk of slipping between the bladder and rectum; a direction
so contrary to the anatomical bearing of the parts he has to divide, as
necessarily to thrust the staff upwards against the arch of the pubes,
and thus to make the several sections too high; giving rise to the
following unavoidable evils:—

First. The cutting edge of the Gorget is conducted so high under the
narrow angle of the pubic arch, as to incur a great risk of wounding the
pudic artery; a frequent consequence of the introduction of the Gorget in
adults, being, as is well known to surgeons, a profuse gush of arterial
blood; and, what is more material, not unfrequently great difficulty in
restraining the hæmorrhage after the operation.

Secondly. In the section of the prostate, the Gorget is carried upward
through the large plexus of veins which surround the upper surface of the
gland, by which long continued venous hæmorrhage is produced, filling
the opening into the bladder with coagula, and preventing the ready exit
of urine, both by the wound and penis; thus producing the infiltrations
of urine into the cellular membrane, which frequently cause so much
irritation after Lithotomy.

Thirdly. The section of the prostate is made in a direction most
unfavourable to the extraction of a calculus. Instead of the free
incision made through the depending lobe of the gland by Cheselden, the
Gorget merely slices off the upper and narrowest part, leaving the body
of the gland, which affords so much resistance to a stone, untouched.
This slicing of the gland never affords room enough for a large calculus
to pass, and, in the violent efforts to extract it, either the bladder
is torn laterally, or, what is worse, the prostate is dragged towards
the external wound, and its ligamento cellular connexion with the
arch and ramus of the pubes destroyed. When the operation is properly
performed, that is, when the wound in the prostate is sufficient for
the passage of the calculus, the connexion between the prostate and the
arch of the pubes remains; and affords an opposing barrier, when the
finger is attempted to be thrust upwards by the side of the bladder. The
consequences attending the destruction of the attachment of the prostate
are worthy of consideration.

Fourthly. To be fully aware of the mischief attending this laceration
of the prostatic connexions, a knowledge of the cause of death after
Lithotomy is necessary. It is a prevailing opinion, that stone patients
die of peritonitis, brought on by the injury done to the bladder during
the operation; a mistake which, though not leading to any serious error
in the after-treatment, is so far attended with mischief, inasmuch as it
misleads the mind of the surgeon from the true source of the fatal event.
I will not venture the assertion, that inflammation of the peritoneum
is never a sequela of Lithotomy, but that it is an extremely rare
occurrence, and still more rarely the cause of death, examinations post
mortem have fully convinced me. During the ten years I have been at our
hospitals, I have never yet seen an unsuccessful case examined after the
operation, in which inflammation of the peritoneum could be regarded as
the cause of death; and as invariably I have found that one circumstance
was uniformly present, namely, suppurative inflammation of the reticular
texture surrounding the bladder. Those who are unaccustomed to morbid
examinations may be inclined to be sceptical on this point, and may think
that an injury done to the prostate and neck of the bladder, by a cutting
instrument, would be productive of more serious evil to the constitution,
than a laceration of reticular texture. Some also may probably look on
this explanation as a refinement of modern surgery, and one not borne
out by facts; the fact, however, is indisputable; and analogy will bear
us out in attributing the highest constitutional symptoms to active
suppuration of cellular tissue. In injuries of the scalp, if the wound
has penetrated the tendon of the occipito frontalis, we expect extensive
suppuration, not from the injury to the tendon, quoad tendon, but from
the laceration or other injury done to the cellular membrane between the
tendon and pericranium. In like manner wounds of fasciæ, whether of the
hand, foot, or other parts of the extremities, are dangerous in their
consequences, not from the injury done to the tendinous fibres, but
from the exquisitely acute inflammatory action set up in the subjacent
cellular tissue. This reticular membrane may be regarded as an infinite
number of serous cavities, communicating with each other, and presenting
an incalculable extent of surface. Inflammation spreading rapidly through
these cells will quickly affect a surface much greater than that of the
peritoneum, and I have witnessed symptoms as acute, pain as severe, and
the peculiar depression attending peritonitis as marked in the reticular
inflammation, as in the most acute and fatal case of inflammation of
the abdominal cavity. The instances I have met with of the texture
surrounding the bladder being affected with suppurative inflammation,
and terminating fatally, whether arising from Lithotomy or operations
for fistulæ in perinæo, are sufficiently numerous to allow me thus to
generalize on the subject, and afford a very useful lesson to those who
endeavour to profit by examinations after death. In the inspection of
those who die after Lithotomy, it is not sufficient to look into the
peritoneal cavity, to open the bladder, or to examine the state of the
wound; the peritoneum lining the lower part of the abdominal muscles
should be stripped off, and the source of evil will then be laid open.
The finger will enter a quantity of brick-dust coloured pus in the
cellular substance around the bladder, and if considerable force has been
used in the extraction of the stone, will readily find its way towards
the wound in the perineum; the barrier between the adipose structure of
the perineum and the reticular texture of the pelvis being broken down,
the suppurative inflammation spreads rapidly along the latter, and may be
traced in some cases, between the peritoneum and abdominal muscles, as
high as the umbilicus; in one case I have seen it extend to the diaphragm.

Lastly. Every surgeon who operates with the Gorget is under the
apprehension of it slipping between the bladder and rectum: if the beak
slips from the groove before it has entered the bladder, it is supposed
to have passed between the gut and the prostate. From the bearing of the
Gorget during its introduction, I always entertained some doubt as to
this being the direction which the Gorget takes under such circumstances.
In the only instance in which I have had an opportunity of ascertaining
the real course of the Gorget in this accident, I found that the
instrument, which was supposed to have passed between the bladder and
rectum, had taken a very different course; it had slipped from the groove
of the staff, had been propelled under the arch of the pubes, and had
entered the reticular texture above, and to the left side of the bladder.
I believe this to be the usual course of the Gorget, when it slips out of
the staff: to force it between the bladder and rectum, the beak must be
thrust downwards, a direction which is never given to the instrument in
passing it into the bladder.

A reference to the plate of the side view of the pelvis, will illustrate
the several defective points in the Gorget operation to which I have
adverted.

With a view to obviate the evils attending the employment of the
Gorget and curved staff, and, at the same time, to adhere closely to
the operation of Cheselden, I use a straight director, which I find to
answer all the purposes of a common staff, to be entirely free from its
objections, and to combine advantages which a curved instrument cannot
possess.[13]

I was first led to try an instrument of this form on the dead subject, by
the following accidental occurrence. Being called upon to examine a child
who had died with stone in its bladder, I was desirous of performing the
operation, before making any examination of the body; and having neither
staff, Gorget, nor stone-knife with me, I was obliged to operate with
a common director, a scalpel, and dressing forceps; and I was forcibly
struck with the facility with which the director conducted the knife into
the bladder.

The introduction of this instrument (_see plate_), is not attended with
any difficulty; it enters the bladder of the adult, or infant, with as
much facility as one of the accustomed form. When held in the position
for the first incision of the operation it might strike a surgeon, in
the habit of using a common staff, that the point of the director was
not in the bladder, an objection that, if correct, would justly condemn
it as a dangerous instrument. To satisfy my own doubt on the subject
when first I used it, I cut open the bladder, while an assistant held
the director in the position delineated in plate 2; and in every subject
on which I tried it, I found the extremity projecting some way into the
base of the bladder. In plate 2 will be found a correct view of the
bladder, with the instrument passed into it. At first I had the extremity
made straight, but thinking that in depressing the handle it might be
caught by a projecting fold in the bladder, which would considerably
embarrass the operator, I had the point slightly curved upwards, and as
the knife is never introduced so far into the bladder as to reach the
curve, it will cause no difficulty in its introduction. The groove is
made somewhat deeper than in the common staff, to prevent any risk of the
knife slipping out. The extremity is not grooved, but rounded like a
common sound, to prevent abrasion of the prostate or mucous lining of the
bladder. The handle is somewhat larger, to afford a better purchase to
the hand of the operator.

The advantage of a straight over a curved line as a conductor to a
cutting instrument, is too obvious to require any comment; but its chief
superiority consists in allowing the surgeon to turn the groove in any
direction he may wish. Before carrying the knife into the prostate,
the groove, which has been held downwards for the first incision, may
be turned in any oblique line towards the patient’s left side that the
operator may think preferable for the division of the prostate. Nor does
it preclude the use of the Gorget: this instrument may be propelled along
the straight groove with more safety than in the curved staff. To those
who have been used to the Gorget it may be difficult to lay it aside;
and its employment is certainly less objectionable with the straight
director than with the common staff. When the Gorget is employed, the
corresponding motion of the left hand is not required to carry it into
the bladder; the director should be held perfectly quiet while the Gorget
is propelled along its groove. The danger of passing it out of the
groove of the director is diminished, if not entirely removed, from which
circumstance alone the surgeon gains much additional confidence, and,
consequently, the patient much benefit.

The knife resembles in form a common scalpel, but is longer in the blade,
and is slightly convex in the back near the point, to enable it to run
with more facility in the groove of the director. The scalpel blade
has this advantage over the common beaked lithotome, that the external
incision can be made with the same instrument as the section of the
prostate gland, thus rendering a change of instrument unnecessary. There
is less danger also of any membrane getting between the groove and the
knife, as the point of the cutting edge, being buried in the groove, will
divide whatever lies before it, which is not done by a beaked instrument.
The opening made in the prostate, and also in the perineal muscles, can,
in some measure, be regulated by the angle which the knife makes with
the director as it enters the bladder. In the majority of cases it will
merely be necessary to pass the knife along the director, and, having
cut the prostate, to withdraw it without carrying it out of the groove;
varying the angle according to the age of the patient, the width of the
pelvis, and size of the stone. As the direction in which the prostate
should be divided (in order to adhere to Cheselden’s operation), is
obliquely downwards and outwards, the increasing the angle at which the
knife enters the bladder will incur no risk of wounding the pudic artery.
When the stone is unusually large, it will be necessary to dilate the
prostate in withdrawing the knife.

This want of power to regulate the size of the incision is an objection
to which the Gorget is acknowledged to be open. Whether the stone be
large or small, the same opening, and that a small one, must serve in
either case; and, if the stone be large, the operator cannot avoid
employing violence in its extraction.

As not more dexterity is required to introduce this knife upon the
director than every surgeon, however unused to Lithotomy, possesses, it
is almost needless to caution against the employment of undue force in
the section of the prostate. The knife may be conducted with deliberate
care into the bladder, the resistance afforded by the prostate will be
readily felt, and the hand of the operator should be checked as soon as
he feels the prostate has given way. It will be evident that the most
important part of the operation is thus divested of that blind force,
which renders it hazardous in the hands of the most dexterous, as well as
of the most unskilful Lithotomist.

I had, for a considerable time past, been in the habit of operating on
the dead subject with the instruments I have described; but until very
lately I had no opportunity of trying them on the living subject. To Sir
Astley Cooper’s kindness I am indebted for the opportunity, who allowed
me to operate on a boy, that had been sent from the country into Guy’s
Hospital for the purpose of submitting to the operation.

The mode of conducting the operation is as follows:—

An assistant holding the director, with the handle somewhat inclined
towards the operator,[14] the external incision of the usual extent is
made with the knife, until the groove is opened, and the point of the
knife rests fairly in the director, which can be readily ascertained
by the sensation communicated; the point being kept steadily against
the groove, the operator with his left hand takes the handle of the
director, and lowers it till he brings the handle to the elevation
described in plate 3, keeping his right hand fixed; then with an easy,
simultaneous movement of both hands, the groove of the director and the
edge of the knife are to be turned obliquely towards the patient’s left
side; the knife having the proper bearing is now ready for the section
of the prostate; at this time the operator should look to the exact line
the director takes, in order to carry the knife safely and slowly along
the groove; which may now be done without any risk of the point slipping
out. The knife may then be either withdrawn along the director, or the
parts further dilated, according to the circumstances I have adverted to.
Having delivered his knife to the assistant, the operator takes the staff
in his right hand, and passing the fore finger of his left along the
director through the opening in the prostate, withdraws the director, and
exchanging it for the forceps, passes the latter upon his finger into the
cavity of the bladder.

In extracting the calculus, should the aperture in the prostate prove
too small, and a great degree of violence be required to make it pass
through the opening, it is advisable always to dilate with the knife,
rather than expose the patient to the inevitable danger consequent upon
laceration.

In the case, on which the operation was first performed, the instruments
in every respect answered my expectations. Not the slightest impediment
was experienced in getting quickly into the bladder. The stone, which was
large for a child of between four and five years old, is here delineated
to shew the free incision which the mere passing of the knife along the
director, and withdrawing it without dilating, will make. The stone was
readily extracted, and the boy recovered without the intervention of a
bad symptom.

The operation was performed in the presence of Mr. Travers, Mr. Green,
and Mr. Tyrrell, Surgeons to St. Thomas’s Hospital.


FINIS.



    I have deemed it right to defer this publication to the present
    period, in order to have the sanction of further experience
    as to the success and facility of this mode of operating, and
    also to demonstrate to the Gentlemen at present attending our
    Hospitals its ready application in practice. Its advantages
    have been fully confirmed in respect to the quickness,
    facility, and event of the operation.



PLATES AND EXPLANATIONS.


PLATE I.

[Illustration: _Plate 1._

_Drawn by F.F. Giraud. 1823._ _Engraved by J. Stewart._

_London. Published 1824, by Messrs. Longman, Hurst, Rees, Orme, Brown &
Green._]

In the usual manner of dissecting a side view of the pelvic viscera, an
unnatural bearing is given to several important parts, by the following
circumstances:—To assist the dissector a curved sound is previously
introduced into the urethra, the consequence of which is, that the canal
necessarily assumes whatever form the instrument may have. Views so taken
are therefore incorrect, and give an erroneous idea of the natural course
of the canal. The bladder and rectum are also excessively distended,
the former being inflated to its utmost, and the latter filled with
baked horse-hair. When the bladder is thus distended it rises out of the
pelvis; and if in the dissection, the abdominal muscles have been turned
aside, and the cellular connexions of the bladder much disturbed, its
rise is so considerable as to elevate the prostate gland, and thus give a
more horizontal bearing to the prostatic and membranous portions of the
urethra. The distending the rectum also adds to the erroneous impression,
by elevating the bladder, and thus bringing the base of the bladder,
prostate gland and membranous urethra into a nearly horizontal line.

Such a view is calculated to give a correct anatomical idea of the course
of the canal under retention of urine, and shews the propriety of using
a catheter with the curve recommended by Sir Astley Cooper. The relative
situation, however, of these parts is widely different when regarded in a
lithotomic point of view.

In a person prepared for the operation the rectum is emptied by purgative
medicine and an enema; and the bladder, which in a stone patient seldom
contains more than eight ounces of urine, occupies the hollow of the
flaccid or contracted rectum. Care has been taken not to distort these
parts by the introduction of an instrument into the urethra, nor by more
distention than was sufficient to preserve a general outline. To Mr.
Giraud, dresser to Sir Astley Cooper, I am indebted for the drawings;
the object of this plate being to represent the true bearing of the
parts concerned in Lithotomy, they were drawn of the natural size, by
measurement, from a young man, twenty-nine years of age, who died after
six days illness; and the dissection being completed within twelve hours
after his decease, the rigidity of death still remaining retained the
parts in situ.

    _a._ Section of the left os pubis.

    _b._ Articular surface of the sacrum.

    _c._ Section of the left crus penis.

    _d._ Bulb of the penis.

    _e._ Membranous portion of the urethra.

    _f._ Prostate gland; its posterior edge concealed by veins.

    _g._ Base of the bladder sinking considerably below the level
    of the prostate.

The relative bearing of the parts marked _e_, _f_, _g_, may be noticed,
in reference to the introduction of the instrument, as delineated in
Plate II.

When the pelvis is bent upon the lumbar vertebræ, and the shoulders of
the patient raised, as in the posture for Lithotomy, these parts will
have a rather more perpendicular bearing than even is in this view
represented.

    _h._ The veins returning the blood from the vena magna ipsius
    penis injected with wax, entering the pelvis under the pubic
    arch, through the triangular ligament, in which the vein begins
    to form a plexus, and concealing the posterior edge of the
    prostate. In the Celsian operation, this part of the neck of
    the bladder was cut laterally without dividing the prostate,
    whence may be inferred the cause of its fatality. In the Gorget
    operation, if the wound in the prostate is too small for the
    calculus to pass, this part of the bladder is torn.

    _i._ Triangular ligament, section of. This ligament connects
    the membranous part of the urethra and prostate gland with
    the arch of the pubes, protects the dorsal nerve, artery, and
    veins, in their course to the dorsum penis, and serves the
    purpose of a barrier between the perineum and the reticular
    texture surrounding the bladder; it sends a process on each
    side of the prostate gland, to cover the vesiculæ seminales.
    The escape of urine after Lithotomy can only be productive
    of mischief, by infiltrating the cells of the scrotum, or by
    making its way upwards by the side of the bladder behind this
    ligament, when the prostate has been torn from its connexions.

    _k._ Rectus abdominis, section of.

    _l._ Peritoneum reflected over the fundus and back part of the
    bladder, and continued over the rectum.

    _m._ Rectum partly distended by the introduction of a portion
    of inflated ileum.

    _n._ Accelerator urinæ reflected from the bulb, and discovering
    the granular lobes of Cowpers’ gland between the bulb and
    membranous urethra.

    _o._ Muscle of the membranous part of the urethra reflected;
    not forming a loop around the canal, but (as I have noticed in
    many subjects), descending from the pubes, and attached to the
    dense ligamento cellular structure which bounds the edge of the
    accelerator urinæ; it is continuous with the levator ani.

    _p._ Compressor prostatæ and levator ani partly reflected.

    _q._ Section of pyriformis.

    _r._ Vas deferens.

    _s._ Vesiculæ seminalis, partly concealed by the veins
    returning the blood from the prostate not in this subject
    injected.

    _t._ Ureter.

    _u._ Small intestines turned over the abdominal muscles on the
    right side, the latter having been left attached to the sternum
    and ribs.

    _w._ Lower part of the thorax.

    _x._ Lumbar mass of muscles.

    _y._ Anus.


PLATE II.

[Illustration: _Plate 2._

_Drawn by F.F. Giraud. 1823._ _Engraved by J. Stewart._

_London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green._]

Represents the director held in the situation for the first incision of
the operation. The left side of the bladder having been removed, the
extremity of the instrument is seen projecting some way into the base
of the viscus, which now sinks lower into the hollow of the rectum, the
latter being entirely empty. It will be observed how the slight curve
of the staff adapts it to the concavity of the bladder, and prevents
it being entangled by a fold during the depression of the handle,
preparatory to the section of the prostate. The parts being viewed
obliquely from behind, the prostate, urethra, &c. are but imperfectly
seen.


PLATE III.

[Illustration: _Plate 3._

_Drawn by F.F. Giraud. 1823._ _Engraved by J. Stewart._

_London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green._]

In this plate the section of the prostate gland is shewn; the parts being
viewed obliquely from before. The left hand of the operator holding the
staff is depressed to conduct the knife into the cavity of the bladder.
If attempt be made to depress the handle lower, the operator will feel
his hand checked by the ligament of the arch. The knife is seen piercing
the prostate in the direction which most nearly accords with Cheselden’s
section. This inclination of the knife will enable the operator to make
a very free incision, with great facility, without incurring any risk of
wounding the pudic artery, the rectum, or the veins surrounding the neck
of the bladder; unless a very large incision be required by the size of
the calculus, in which case some of the veins must necessarily be divided.

In contrasting this view with Plate I, it will be observed that the
prostate is carried somewhat upward from the rectum; this effect is
produced by the depression of the handle and the consequent elevation of
the extremity of the director. The danger of wounding the rectum is thus
still farther diminished.

One great advantage of conducting the operation on this principle arises
from the operator not being under the necessity of withdrawing the knife
from the groove of the staff, after he has once entered it, during the
subsequent steps of the operation. The extent of the incision in the
prostate and neck of the bladder may be regulated by the angle which
the knife makes in its introduction with the staff. Supposing that an
opening be required extending through the prostate from _d_ to _b_,
(which for the majority of calculi, even above the ordinary size, will be
quite sufficient, as the neck of the bladder will dilate considerably),
the point of the knife must be carried on as far as _a_ in the groove of
the staff. For it will be evident that if the same angle be maintained in
the act of carrying on the knife, the line _c b a_ will be the position
of the knife when the point has reached _a_. The edge of the knife,
although brought apparently so near to the rectum, will not injure it,
from its oblique inclination to the patient’s left side.


PLATE IV.

[Illustration: Pl. IV.

_F.F. Giraud del^t._ _J^s. Basire sculp^t._]

_Fig. 1._

Gives a view of the director used in the operation on a child under five
years of age, slightly curved towards the extremity, the more readily to
adapt itself to the concavity of the bladder when held in the position in
Plate II.

_Fig. 2._

The knife with a scalpel blade, but longer than a common scalpel, and
slightly convex on the back near the point, that it may run smoothly
along the groove of the staff. When used with a staff of this form the
whole of the cutting part of the operation may be easily performed with
it.

_Fig. 3._

The size of the calculus which was extracted in the first operation with
these instruments is here delineated, in order to shew the extent of the
opening in the cervix vesicæ and prostate gland, which in so young a
child may be made with safety, according to the method explained in Plate
III. The comparative size of the incision that can be made in the adult
may be inferred.



FOOTNOTES


[1] I allude to Mr. Martineau’s and Mr. Barlow’s papers on Lithotomy.

[2] Deschamps—page 102.

[3] Deschamps—page 104.

[4] Deschamps—page 109.

[5] Douglas’s Appendix—page 12.

[6] Deschamps—page 106.

[7] Page 107.

[8] Cheselden’s Anatomy—page 330.

[9] Bell’s Surgery—page 173.

[10] Sharp’s Surgery.

[11] The late Mr. Dease was so impressed with the hazard of passing a
cutting instrument along the curve of the staff, that he used to withdraw
the staff, after he had opened the urethra, and passing a director
through the opening into the bladder, dilated the cervix vesicæ, by
introducing the Gorget in the usual manner.

[12] Mr. Martineau’s Gorget is merely used as a director to convey the
forceps into the bladder; its edges are blunt, and therefore it does not
aid in the division of the prostate, which has been already divided by
the knife, as a reference to his operation will shew. He had the kindness
to send me a model of his Gorget, for which, and his politeness in his
communication to me on the subject, I take this opportunity of expressing
my thanks.

[13] I should not omit to mention that I did not adopt this alteration in
the instruments, without having first operated at the hospital, both with
the Cutting-Gorget, and also with the beaked knife, in conjunction with
the common staff. I was not led to lay them aside by the issue of the
cases, as they were successful; but the difficulty and hazard attending
their introduction, together with the general unsuccessful issue of
Gorget operations, compared with Cheselden’s method, induced me to use a
more simple form of instruments.

[14] See Plate 2.





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