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:—