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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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