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

by C. Aston Key

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.