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.