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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..1069f56 --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #60489 (https://www.gutenberg.org/ebooks/60489) diff --git a/old/60489-0.txt b/old/60489-0.txt deleted file mode 100644 index a2b8ca2..0000000 --- a/old/60489-0.txt +++ /dev/null @@ -1,1375 +0,0 @@ -The Project Gutenberg EBook of A Short Treatise on the Section of the -Prostate Gland in Lithotomy, by Charles Aston Key - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: A Short Treatise on the Section of the Prostate Gland in Lithotomy - -Author: Charles Aston Key - -Release Date: October 13, 2019 [EBook #60489] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK SHORT TREATISE--SECTION OF PROSTATE GLAND *** - - - - -Produced by deaurider and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - - - - - - - - - - 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. - - - - - -End of the Project Gutenberg EBook of A Short Treatise on the Section of the -Prostate Gland in Lithotomy, by Charles Aston Key - -*** END OF THIS PROJECT GUTENBERG EBOOK SHORT TREATISE--SECTION OF PROSTATE GLAND *** - -***** This file should be named 60489-0.txt or 60489-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/0/4/8/60489/ - -Produced by deaurider and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: A Short Treatise on the Section of the Prostate Gland in Lithotomy - -Author: Charles Aston Key - -Release Date: October 13, 2019 [EBook #60489] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK SHORT TREATISE--SECTION OF PROSTATE GLAND *** - - - - -Produced by deaurider and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - - - - - -</pre> - - -<p class="center mt3 larger"><span class="smaller">A</span><br /> -SHORT TREATISE<br /> -<span class="smaller">ON THE</span><br /> -SECTION OF THE PROSTATE GLAND,<br /> -<span class="smaller">IN</span><br /> -<span class="larger">LITHOTOMY.</span></p> - -<p class="center mt3 smaller">F. WARR, <span class="smcap">Printer</span>,<br /> -RED LION PASSAGE, RED LION SQUARE.</p> - -<hr /> - -<p><span class="pagenum"><a name="Page_i" id="Page_i">[i]</a></span></p> - -<div class="tp"> - -<p class="center mt3 larger"><span class="smaller">A</span><br /> -SHORT TREATISE<br /> -<span class="smaller">ON THE</span><br /> -SECTION OF THE PROSTATE GLAND<br /> -<span class="smaller">IN</span><br /> -<span class="larger">LITHOTOMY;</span></p> - -<p class="center">WITH AN EXPLANATION OF A SAFE AND EASY METHOD OF CONDUCTING -THE OPERATION ON THE PRINCIPLES OF<br /> -<b>CHESELDEN.</b></p> - -<p class="center mt3"><i>ILLUSTRATED BY ENGRAVINGS.</i></p> - -<p class="center mt3"><span class="smcap">By C. ASTON KEY</span>,<br /> -<span class="smaller">SURGEON TO GUY’S HOSPITAL, AND TO THE MAGDALEN.</span></p> - -<p class="mt3 smaller">“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.”</p> - -<p class="smaller smcap right">Deschamps.</p> - -<p class="center mt3">LONDON:<br /> -<span class="smaller">LONGMAN, HURST, REES, ORME, BROWN, AND GREEN, PATERNOSTER ROW:<br /> -S. HIGHLEY, 74, FLEET STREET; T. & G. UNDERWOOD, 32, FLEET STREET;<br /> -AND E. COX & SON, ST. THOMAS’S STREET, SOUTHWARK.</span><br /> -MDCCCXXIV.</p> - -</div> - -<p><span class="pagenum"><a name="Page_ii" id="Page_ii">[ii]</a></span></p> - -<hr /> - -<p><span class="pagenum"><a name="Page_iii" id="Page_iii">[iii]</a></span></p> - -<h2>TO<br /> -SIR ASTLEY COOPER, BART., F.R.S.,<br /> -<span class="smaller"><span class="smaller">SURGEON TO THE KING, AND TO GUY’S HOSPITAL,</span><br /> -THE FOLLOWING PAGES ARE INSCRIBED BY HIS SINCERE FRIEND -AND GRATEFUL PUPIL.</span></h2> - -<p>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.</p> - -<p>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.</p> - -<p class="right">C. ASTON KEY.</p> - -<p><i>18, St. Helen’s Place, April, 1824.</i></p> - -<p><span class="pagenum"><a name="Page_iv" id="Page_iv">[iv]</a></span></p> - -<hr /> - -<p><span class="pagenum"><a name="Page_v" id="Page_v">[v]</a></span></p> - -<h2>PREFACE.</h2> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_vi" id="Page_vi">[vi]</a></span> -disease, I need offer no apology for reviewing what appears -to me to be the true principle of the operation.</p> - -<p>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.</p> - -<hr /> - -<p><span class="pagenum"><a name="Page_1" id="Page_1">[1]</a></span></p> - -<h1><span class="smaller"><span class="smaller">A</span><br /> -SHORT TREATISE<br /> -<span class="smaller">ON</span></span><br /> -LITHOTOMY.</h1> - -<p>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.</p> - -<p>After the records recently laid before the public by two -able and successful Lithotomists,<a name="FNanchor_1" id="FNanchor_1"></a><a href="#Footnote_1" class="fnanchor">[1]</a> it may appear superfluous,<span class="pagenum"><a name="Page_2" id="Page_2">[2]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_3" id="Page_3">[3]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_4" id="Page_4">[4]</a></span> -gland, has since been denominated the Lateral Operation. -This, his second operation, is thus described by Douglas in -his appendix.</p> - -<p>“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.”</p> - -<p>Morand, to whom Cheselden communicated the particulars -of his operation, describes it as follows:—</p> - -<p>“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.”<a name="FNanchor_2" id="FNanchor_2"></a><a href="#Footnote_2" class="fnanchor">[2]</a></p> - -<p>Deschamps gives the following account:—“L’incision des -tégumens faite, il continue de couper de haut en bas entre les<span class="pagenum"><a name="Page_5" id="Page_5">[5]</a></span> -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.”<a name="FNanchor_3" id="FNanchor_3"></a><a href="#Footnote_3" class="fnanchor">[3]</a></p> - -<p>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,”<span class="pagenum"><a name="Page_6" id="Page_6">[6]</a></span> -&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.”<a name="FNanchor_4" id="FNanchor_4"></a><a href="#Footnote_4" class="fnanchor">[4]</a></p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_7" id="Page_7">[7]</a></span> -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.</p> - -<p>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.”</p> - -<p>“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<span class="pagenum"><a name="Page_8" id="Page_8">[8]</a></span> -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.”<a name="FNanchor_5" id="FNanchor_5"></a><a href="#Footnote_5" class="fnanchor">[5]</a></p> - -<p>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.”<a name="FNanchor_6" id="FNanchor_6"></a><a href="#Footnote_6" class="fnanchor">[6]</a> 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.”<a name="FNanchor_7" id="FNanchor_7"></a><a href="#Footnote_7" class="fnanchor">[7]</a></p> - -<p>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<span class="pagenum"><a name="Page_9" id="Page_9">[9]</a></span> -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, <em>cutting from -below upwards to avoid the gut</em>.”<a name="FNanchor_8" id="FNanchor_8"></a><a href="#Footnote_8" class="fnanchor">[8]</a></p> - -<p>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.<a name="FNanchor_9" id="FNanchor_9"></a><a href="#Footnote_9" class="fnanchor">[9]</a></p> - -<p>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.”<a name="FNanchor_10" id="FNanchor_10"></a><a href="#Footnote_10" class="fnanchor">[10]</a> When speaking of the knife<span class="pagenum"><a name="Page_10" id="Page_10">[10]</a></span> -he remarks, “That the back of the knife being blunt is a -security against wounding the rectum <em>when we cut the neck -of the bladder from below upwards</em>.”</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_11" id="Page_11">[11]</a></span></p> - -<p>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.</p> - -<p>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.<a name="FNanchor_11" id="FNanchor_11"></a><a href="#Footnote_11" class="fnanchor">[11]</a> 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<span class="pagenum"><a name="Page_12" id="Page_12">[12]</a></span> -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.”</p> - -<p>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,<span class="pagenum"><a name="Page_13" id="Page_13">[13]</a></span> -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.</p> - -<p>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,<span class="pagenum"><a name="Page_14" id="Page_14">[14]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_15" id="Page_15">[15]</a></span> -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.”<a name="FNanchor_12" id="FNanchor_12"></a><a href="#Footnote_12" class="fnanchor">[12]</a></p> - -<p><span class="pagenum"><a name="Page_16" id="Page_16">[16]</a></span></p> - -<p>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.</p> - -<p>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?</p> - -<p>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<span class="pagenum"><a name="Page_17" id="Page_17">[17]</a></span> -to make the several sections too high; giving rise to the -following unavoidable evils:—</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_18" id="Page_18">[18]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_19" id="Page_19">[19]</a></span> -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<span class="pagenum"><a name="Page_20" id="Page_20">[20]</a></span> -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<span class="pagenum"><a name="Page_21" id="Page_21">[21]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_22" id="Page_22">[22]</a></span> -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.</p> - -<p>A reference to the <a href="#plate1">plate</a> of the side view of the pelvis, -will illustrate the several defective points in the Gorget -operation to which I have adverted.</p> - -<p><span class="pagenum"><a name="Page_23" id="Page_23">[23]</a></span></p> - -<p>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.<a name="FNanchor_13" id="FNanchor_13"></a><a href="#Footnote_13" class="fnanchor">[13]</a></p> - -<p>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.</p> - -<p>The introduction of this instrument (<a href="#plate4"><i>see plate</i></a>), is not -attended with any difficulty; it enters the bladder of the adult,<span class="pagenum"><a name="Page_24" id="Page_24">[24]</a></span> -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 <a href="#plate2">plate 2</a>; and in every subject on -which I tried it, I found the extremity projecting some way -into the base of the bladder. In <a href="#plate2">plate 2</a> 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<span class="pagenum"><a name="Page_25" id="Page_25">[25]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_26" id="Page_26">[26]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_27" id="Page_27">[27]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_28" id="Page_28">[28]</a></span> -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.</p> - -<p>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.</p> - -<p>The mode of conducting the operation is as follows:—</p> - -<p>An assistant holding the director, with the handle somewhat -inclined towards the operator,<a name="FNanchor_14" id="FNanchor_14"></a><a href="#Footnote_14" class="fnanchor">[14]</a> 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<span class="pagenum"><a name="Page_29" id="Page_29">[29]</a></span> -director, and lowers it till he brings the handle to the -elevation described in <a href="#plate3">plate 3</a>, 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.</p> - -<p>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<span class="pagenum"><a name="Page_30" id="Page_30">[30]</a></span> -always to dilate with the knife, rather than expose the patient -to the inevitable danger consequent upon laceration.</p> - -<p>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.</p> - -<p>The operation was performed in the presence of Mr. -Travers, Mr. Green, and Mr. Tyrrell, Surgeons to St. Thomas’s -Hospital.</p> - -<p class="center mt3">FINIS.</p> - -<hr /> - -<p>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.</p> - -<hr /> - -<h2>PLATES AND EXPLANATIONS.</h2> - -<div class="transnote"> -Transcriber’s Note: Click plate for a larger image. -</div> - -<h3>PLATE I.</h3> - -<div class="figcenter" style="width: 500px;" id="plate1"> -<a href="images/plate1.jpg"><img src="images/plate1-small.jpg" width="320" height="200" alt="" /></a> -<p class="caption"><i>Plate 1.</i></p> -<p class="caption"><i>Drawn by F.F. Giraud. 1823.</i> <i>Engraved by J. Stewart.</i></p> -<p class="caption"><i>London. Published 1824, by Messrs. Longman, Hurst, Rees, Orme, Brown & Green.</i></p> -</div> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="hanging"> - -<p><i>a.</i> Section of the left os pubis.</p> - -<p><i>b.</i> Articular surface of the sacrum.</p> - -<p><i>c.</i> Section of the left crus penis.</p> - -<p><i>d.</i> Bulb of the penis.</p> - -<p><i>e.</i> Membranous portion of the urethra.</p> - -<p><i>f.</i> Prostate gland; its posterior edge concealed by veins.</p> - -<p><i>g.</i> Base of the bladder sinking considerably below the level -of the prostate.</p> - -</div> - -<p>The relative bearing of the parts marked <i>e</i>, <i>f</i>, <i>g</i>, may be -noticed, in reference to the introduction of the instrument, as -delineated in <a href="#plate2">Plate II</a>.</p> - -<p>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.</p> - -<div class="hanging"> - -<p><i>h.</i> 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.</p> - -<p><i>i.</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.</p> - -<p><i>k.</i> Rectus abdominis, section of.</p> - -<p><i>l.</i> Peritoneum reflected over the fundus and back part of the -bladder, and continued over the rectum.</p> - -<p><i>m.</i> Rectum partly distended by the introduction of a portion of -inflated ileum.</p> - -<p><i>n.</i> Accelerator urinæ reflected from the bulb, and discovering -the granular lobes of Cowpers’ gland between the bulb -and membranous urethra.</p> - -<p><i>o.</i> 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> - -<p><i>p.</i> Compressor prostatæ and levator ani partly reflected.</p> - -<p><i>q.</i> Section of pyriformis.</p> - -<p><i>r.</i> Vas deferens.</p> - -<p><i>s.</i> Vesiculæ seminalis, partly concealed by the veins returning -the blood from the prostate not in this subject injected.</p> - -<p><i>t.</i> Ureter.</p> - -<p><i>u.</i> Small intestines turned over the abdominal muscles on the -right side, the latter having been left attached to the -sternum and ribs.</p> - -<p><i>w.</i> Lower part of the thorax.</p> - -<p><i>x.</i> Lumbar mass of muscles.</p> - -<p><i>y.</i> Anus.</p> - -</div> - -<h3>PLATE II.</h3> - -<div class="figcenter" style="width: 500px;" id="plate2"> -<a href="images/plate2.jpg"><img src="images/plate2-small.jpg" width="320" height="200" alt="" /></a> -<p class="caption"><i>Plate 2.</i></p> -<p class="caption"><i>Drawn by F.F. Giraud. 1823.</i> <i>Engraved by J. Stewart.</i></p> -<p class="caption"><i>London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green.</i></p> -</div> - -<p>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.</p> - -<h3>PLATE III.</h3> - -<div class="figcenter" style="width: 500px;" id="plate3"> -<a href="images/plate3.jpg"><img src="images/plate3-small.jpg" width="320" height="200" alt="" /></a> -<p class="caption"><i>Plate 3.</i></p> -<p class="caption"><i>Drawn by F.F. Giraud. 1823.</i> <i>Engraved by J. Stewart.</i></p> -<p class="caption"><i>London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green.</i></p> -</div> - -<p>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.</p> - -<p>In contrasting this view with <a href="#plate1">Plate I</a>, 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.</p> - -<p>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 <i>d</i> to <i>b</i>, -(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 <i>a</i> 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 <i>c b a</i> will be the position of the knife when -the point has reached <i>a</i>. 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.</p> - -<h3>PLATE IV.</h3> - -<div class="figcenter" style="width: 500px;" id="plate4"> -<a href="images/plate4.jpg"><img src="images/plate4-small.jpg" width="220" height="300" alt="" /></a> -<p class="caption">Pl. IV.</p> -<p class="caption"><i>F.F. Giraud del<sup>t</sup>.</i> <i>J<sup>s</sup>. Basire sculp<sup>t</sup>.</i></p> -</div> - -<h4><i>Fig. 1.</i></h4> - -<p>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 <a href="#plate2">Plate II</a>.</p> - -<h4><i>Fig. 2.</i></h4> - -<p>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.</p> - -<h4><i>Fig. 3.</i></h4> - -<p>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 <a href="#plate3">Plate III</a>. The comparative -size of the incision that can be made in the adult may be -inferred.</p> - -<hr /> - -<div class="footnotes"> - -<h2>FOOTNOTES</h2> - -<div class="footnote"> - -<p><a name="Footnote_1" id="Footnote_1"></a><a href="#FNanchor_1"><span class="label">[1]</span></a> I allude to Mr. Martineau’s and Mr. Barlow’s papers on Lithotomy.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_2" id="Footnote_2"></a><a href="#FNanchor_2"><span class="label">[2]</span></a> Deschamps—page 102.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_3" id="Footnote_3"></a><a href="#FNanchor_3"><span class="label">[3]</span></a> Deschamps—page 104.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_4" id="Footnote_4"></a><a href="#FNanchor_4"><span class="label">[4]</span></a> Deschamps—page 109.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_5" id="Footnote_5"></a><a href="#FNanchor_5"><span class="label">[5]</span></a> Douglas’s Appendix—page 12.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_6" id="Footnote_6"></a><a href="#FNanchor_6"><span class="label">[6]</span></a> Deschamps—page 106.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_7" id="Footnote_7"></a><a href="#FNanchor_7"><span class="label">[7]</span></a> Page 107.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_8" id="Footnote_8"></a><a href="#FNanchor_8"><span class="label">[8]</span></a> Cheselden’s Anatomy—page 330.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_9" id="Footnote_9"></a><a href="#FNanchor_9"><span class="label">[9]</span></a> Bell’s Surgery—page 173.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_10" id="Footnote_10"></a><a href="#FNanchor_10"><span class="label">[10]</span></a> Sharp’s Surgery.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_11" id="Footnote_11"></a><a href="#FNanchor_11"><span class="label">[11]</span></a> 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.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_12" id="Footnote_12"></a><a href="#FNanchor_12"><span class="label">[12]</span></a> 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.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_13" id="Footnote_13"></a><a href="#FNanchor_13"><span class="label">[13]</span></a> 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.</p> - -</div> - -<div class="footnote"> - -<p><a name="Footnote_14" id="Footnote_14"></a><a href="#FNanchor_14"><span class="label">[14]</span></a> <a href="#plate2">See Plate 2.</a></p> - -</div> - -</div> - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of A Short Treatise on the Section of the -Prostate Gland in Lithotomy, by Charles Aston Key - -*** END OF THIS PROJECT GUTENBERG EBOOK SHORT TREATISE--SECTION OF PROSTATE GLAND *** - -***** This file should be named 60489-h.htm or 60489-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/0/4/8/60489/ - -Produced by deaurider and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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