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

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.