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.
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.
