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 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.