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The
George E. Wantz
(UM Medicine 1946)
Collection
1031010MIRIJOSDINANSIER1114 APELINTIINTINDERE
ShrumMeis 18h
AN ACCOUNT
OF
THE MODE OF PERFORMING
TUE
LATERAL OPERATION OF LITHOTOMY.
WITHI
ILLUSTRATIONS.
BY EDWARD STANLEY,
ASSISTANT SURGEON, AND LECTURER ON ANATOMY AND PHYSIOLOGY, AT
SAINT BARTHOLOMEW'S HOSPITAL.
1
LONDON:
PRINTED FOR LONGMAN, REES, ORME, BROWN, AND GREEN,
-
..
,
PATERNOSTER-ROW.
1829.
i
"Taviran. Ear2
Beve
s!
AN ACCOUNT OF THE MODE
OF PERFORMING THE
LATERAL OPERATION OF LITHOTOMY.
WITH ILLUSTRATIONS.
.
-
LONDON:
Printed by A. & R. Spottiswoode,
New-Street-Square.
PREFACE.
66
RESPECTING the operation of Lithotomy, Mr. Cheselden ob-
serves, 66 If I have any reputation in this way, I have earned it
dearly; for no one ever endured more anxiety and sickness
“s before an operation ; yet, from the time I began to operate,
all uneasiness ceased; and if I have had better success than
some others, I do not impute it to more knowledge, but to
" the happiness of a mind that was never ruffled or discon-
is certed, and a hand that never trembled during any operation.”
If these were the feelings of Mr. Cheselden, with his
knowledge and experience, at each repetition of the operation
for the stone, we are not to be surprised at the anxiety which
most individuals endure the first time they perform it. In en-
deavouring to be serviceable on such an occasion, I have experi-
enced the want of a simple, yet sufficiently detailed account of
the mode of performing the operation, unencumbered by critical
or historical matter. Such an account it has been my object to
supply, and with the hope of having increased its utility, I have
added some illustrations of the parts concerned in the operation,
in their healthy and diseased states.
)
TO
THOMAS BLIZARD, ESQ. F.R.S. L. & E.
LATE SURGEON TO THE LONDON HOSPITAL,
THE FOLLOWING PAGES
ARE DEDICATED,
WITH EVERY FEELING OF RESPECT AND AFFECTION,
5
BY HIS NEPHEW,
EDWARD STANLEY.
Lincoln's Inn Fields,
September, 1829.
ACCOUNT
OF
THE LATERAL OPERATION.
SECTION I.
ON THE MODE OF PERFORMING THE OPERATION.
the oper-
accomplish-
The design of the operation is to form a direct passage from Design of
the perineum, through the left side of the prostate gland, to the ation.
bladder.
The operation is accomplished by a free incision of the How to be
skin and subjacent fat ; by dividing the transversalis muscle, and ed.
a part of the triangular ligament; by opening the urethra at its
membranous portion, and continuing the incision through the
left side of the prostate.
About three hours before the operation, warm water should Points of at.
be freely injected into the rectum. In an instance where this mediately
had been negligently done, the gut was wounded, and much
fæcal matter escaped through the outward incision. That the
tention im.
before the
operation.
B
2
ON THE MODE OF
bladder should, at the time of the operation, contain some
urine, is advantageous on several accounts: it lessens the risk
of wounding any other part of the bladder than its neck ; it
gives to the operator an assurance that his knife or gorget
has entered the bladder, by the flow of urine then taking place
through the wound; and it may favourably influence the seizure
of the stone by the forceps. But on this point, Cheselden
has recorded the following observations : “ Here I must
take notice, it is very convenient to have the bladder empty of
urine before the operation ; for if there is any quantity to flow
out of the bladder at the passing of the gorget, the bladder
does not contract, but collapses into folds, which makes it
difficult to lay hold of the stone without hurting the bladder:
but if the bladder is contracted, it is so easy to lay hold of it
that I have never been delayed one moment, unless the stone
was very small.”*
That the stone should not be lodged in a sort of recess,
between folds of the bladder,—that it should be perfectly
free in the cavity of the bladder, is obviously desirable ; but
whether this will be more likely to happen from the bladder
being, at the time of the operation, full or empty, is a point
upon which the best authorities may not agree.
When
* A short historical account of cutting for the stone, appended to the Anatomy of the Human
Body, 1768.
PERFORMING THE OPERATION.
3
the irritability of the bladder will not permit it to retain any
urine, its opposite sides will be, in some situations, in contact ;
and in others, applied upon the stone: under these circum-
stances, and especially if the stone be small, there may be
some risk of extending the incision of the bladder beyond its
proper limits.
of the ban-
I have not thought it necessary to describe the application of Application
the bandages, but it may be well to notice the importance of dages.
this being properly done. An operator, without the advantage of
experienced assistants, must himself ascertain that the bandages
are applied in a manner to prevent the possibility of their yield-
ing. It is better that the bandages should be applied before
the staff is introduced, that there may be no risk of changing
the situation of the point of the staff, after it has touched the
stone.
The straight part of the staff should be held perpendicu- Adjustment
larly : its curved part should not be pressed in one or other
direction against the sides of the urethra. The assistant
receiving the staff thus adjusted, must hold it firmly, and with-
out changing its position in the slightest degree.
The pressure of the curved part of the staff upwards is
objectionable, as it may lead to the incisions being made into
the narrower part of the space beneath the arch of the pubes.
To the pressure of the staff downwards, the objections are,
B 2
1
1
4
ON THE MODE OF
ON
that it may have the effect of withdrawing the point of the
instrument from the bladder, and of approximating the bladder
and urethra to the rectum. In an instance where the assistant
pressed the staff downwards, the rectum was wounded by the
scalpel in the first stage of the operation ; and, in the young
subject, the risk of such an occurrence will be greater, on ac.
count of the small size and soft texture of the prostate gland.
The assistant holding the staff is usually on the right side of the
patient ; but an advantage may result from his being on the
opposite side : it gives him the command of the staff with his
right hand. That the staff should be held steadily, in the po-
sition in which it is received from the operator, is indispensable.
The least movement of the staff to either side, by altering the
direction of its groove, must embarrass the operator; as he
will then cut, first on one side of it, then on the other, and in
this way repeat the incisions of the urethra in many places
before the groove is fairly penetrated.
Besides the assistant holding the staff, two other assistants,
at the sides of the patient, by firmly grasping his knees and feet,
must resist the efforts he will make to raise and approximate his
knees, much to the embarrassment of the operator. Another
assistant should be placed at the patients shoulders. The pelvis,
being brought to the edge of the table, is to be so adjusted that
the anterior superior spines of the ilia will be in a horizontal
Position of
the patient.
년
​.
PERFORMING THE OPERATION.
5
anatomy.
sion.
line, and it is to be kept in this position until the operation is
completed.
Before the incisions are commenced, the operator may Attention to
direct his attention to the situation of the tuberosity and ramus
of the left ischium ; then, by recollecting that the corpus spon-
giosum is directly behind the raphé of the perineum, he can
mark with precision the triangular space between the corpus
spongiosum and the crus penis, through which the incisions are
to be directed to the membranous portion of the urethra.
The first incision is to be commenced an inch and a quarter First inci-
above the anus, and a little more than a quarter of an inch to
the left of the raphé, and is to be continued obliquely, outwards
and downwards, to the extent of about three inches, towards the
tuberosity of the ischium. The thumb and fore-finger placed
against the perineum will mark the points where the incision
should begin and terminate. *
The first incision should be through the skin, subjacent fat,
and tendinous fibres. Its length should never be much less
than three inches ; and, in the case of an unusually large stone,
it must be extended towards the tuber ischii even to four inches.
Its exact line should be one third from the tuberosity and ramus
of the ischium, and two thirds from the anus.
Any deviation
* It is necessary to observe, that this, with the other directions for the operation, is designed
for the adult.
6
ON THE MODE OF
Subsequent
incisions.
from this had better be by an approximation of the incision to
the tuberosity, than to the anus.
In a thin person, a scalpel may be plunged through the
integuments directly into the membranous portion of the ure-
thra ; but, with a considerable depth of fat in the perineum,
this is difficult, and in attempting it the bulb will be almost
certainly divided, its artery wounded, and the urethra pene-
trated anterior to its membranous portion.
With the left fore-finger in the wound, the incisions are to
be continued to the membranous portion of the urethra. These
incisions, being made in the triangular space between the cor-
pus spongiosum and the crus penis, will divide the transversalis
perinei muscle, branches of the perineal artery, a small part of
the triangular ligament, and the front edge of the levator ani
muscle.
The left fore-finger and the scalpel moving together to-
wards the membranous portion of the urethra, and the staff
being felt, with the edge of the scalpel turned upwards,
in the urethra is then to be made, to the extent of half an inch
at least. *
The nail of the fore-finger passing by the side of
the scalpel into the groove of the staff, is to remain there as a
Opening the
urethra.
a slit
* It is here presumed, that a single-edged scalpel has been used for the first and subsequent
incisions. Then, to secure a free incision of the urethra, the edge of the scalpel must be turned
upwards; but with a double-edged scalpel this movement would be unnecessary.
PERFORMING THE OPERATION.
7
guide to the beak of the knife or gorget, whichever instru-
ment may be used to complete the operation.
That there may be a certainty of opening the urethra in
its membranous portion, let it be recollected, that the scalpel
must enter the staff directly under the symphysis pubis : of
the importance of this rule there can be no doubt. Mr. Blizard,
—the dexterity of whose numerous operations at the London
Hospital has been acknowledged in the strongest terms by all
who witnessed them,-attributes his success to the rule of invari-
ably penetrating the urethra in its membranous portion. Mr.
Martineau, who has recorded the result of his great experience,
states: “I introduce the point of the knife into it (the groove)
)
as low down as I and cut the membranous part of the
urethra. The nearer to the prostate gland the urethra is
opened the better, as it lessens
as it lessens the risk of wounding the
bulb or its artery.
As soon as the urethra is opened, urine may flow through
the wound : this must be recollected; otherwise it might be
supposed the bladder had been opened when the incisions have
not reached the prostate.
can, and
The knife being conducted along the left fore-finger to completion
the staff, its beak is to be moved a little within the
groove, to
of the oper-
ation by a
knife narrow-
bladed and
beaked.
* Med. Chir. Trans. vol. xi.
8
ON THE MODE OF
ascertain that the two instruments are in contact. The staff,
then taken in the left hand, is to be held firmly and without
any change of its position, whilst, with the right, the knife is
urged slowly onwards to the bladder. Its entrance into the
bladder will be indicated by the sudden removal of resistance
to its progress, and, probably, by a gush of urine. The incision
of the prostate is yet to be adequately enlarged in withdrawing
the knife from the bladder, and at the same time directing its
blade outwards and downwards. This incision through the
left side of the prostate will correspond with the incision of
the outward parts, and it should be of sufficient extent to per-
mit the easy passage of the finger into the bladder. .
The knife should be held lightly as it is withdrawn from
the bladder, that the operator, sensible of the resistance it
meets, may judge accurately of its progress through the pros-
In withdrawing the knife, attention should be given to
the position of its handle, which may be inclined towards the
left ischium, but not towards the right, as the blade would
then be directed towards the pudendal artery.
The gorget is to be conducted to the bladder in the same
manner as the knife. The management of the staff is the same
with the gorget as with the knife. Since the gorget, by the
width of its blade, has adequately divided the prostate in its
tate.
Completion
of the oper-
ation by a
gorget.
ܪ
1
PERFORMING THE OPERATION.
9
of the oper-
sition of the
staff during
of the pros-
tate.
progress to the bladder, it is then to be simply withdrawn pre-
paratory to the introduction of the forceps.
The scalpel, with which the first and the subsequent inci- Completion
sions have been made, is used by some operators for the incision stilpehy a
of the prostate. Thus will the operation be simplified; but it
may be doubted whether a common scalpel, even by an expe-
rienced hand, will be conducted along the groove of the staff
with the same precision as an instrument to the end of which a
beak is appended.
The foregoing directions imply that, whether a knife or a on the po-
gorget be used for the incision of the prostate, the operator, the incision
taking the staff in his left hand, is not to change its position
until he withdraws it from the bladder. But there are other
methods. The handle of the staff may be depressed, in order
that, by the elevation of its other extremity, any risk of injuring
the lower part of the bladder may be avoided ; and for this
position of the staff, a corresponding depression of the handle
of the knife or gorget will be required to secure the continued
adaptation of the two instruments. Or, the staff may be left in
the hand of the assistant until the incision of the prostate is com-
pleted. The operator can then pass his left fore-finger along
the side of the knife, whilst he is dividing the prostate, for the
purpose of ascertaining when the incision of the gland is suffi-
cient to permit the easy passage of the finger into the bladder.
C
10
ON THE MODE OF
Introduction
of the for-
ceps.
For the reason that the depression of the staff and the adapt-
ation of the beak of the knife or gorget to its groove require
a consent of action between the two hands of the operator,
which experience only can give him, it may seem preferable to
leave the staff in the hand of the assistant; but as a general
rule, it is better that the operator should depend entirely upon
himself for holding the staff with the requisite steadiness.
The knife or the gorget having been withdrawn, the staff
is to be taken in the right hand, and the left fore-finger passed
along it into the bladder. The staff is then to be withdrawn,
and it is to be ascertained by the finger to what part of the
bladder the forceps should be directed, that they may imme-
diately touch the stone. On withdrawing the finger, the forceps,
with their blades closed, are to be passed slowly through the
wound, and inclined upwards as they approach the bladder,
carefully observing when they enter its cavity.
Upon the foregoing plan, the staff will be the conductor
of the finger into the bladder, and the finger the conductor of
the forceps. The introduction of the finger is useful to ascer-
tain the situation of the stone, and, by separating the sides of
the incision in the prostate, to facilitate the passage of the for-
ceps. By allowing the staff to remain in the bladder until the
finger has entered its cavity, the beaked or probe-pointed knife
can be readily conducted to the bladder, for the purpose of
PERFORMING THE OPERATION.
11
of the stone.
enlarging the incision of the prostate, should this have been
inadequately made : and if, from an unusual firmness of the
prostate, the sides of the incision through it do not readily
yield, much difficulty may be experienced in discovering the
passage to the bladder, when the staff has been withdrawn, and
its aid, as a conductor of the finger, is thereby lost. So many
sources of difficulty are avoided by a strict adherence to the
rule of not withdrawing the staff untill the finger has fairly
entered the bladder, that it cannot be pressed too strongly upon
the attention of the operator.
When the blades of the forceps happen to be passed to Extraction
the upper or to the under surface of the stone, it may be seized
directly they are opened. But when the forceps touch the
stone only on its anterior surface, it is necessary, in opening
the blades, to advance them a little, otherwise, in separating,
they will recede from the stone.
When the first attempt to seize the stone has failed, the
forceps should be directly withdrawn, and the finger introduced
into the bladder, to change the situation and position of the
But the finger may not reach the stone : a scoop or
other instrument must then be introduced, to dislodge the stone
from its unfavourable situation ; and it is scarcely necessary to
mention the importance of introducing into the bladder but few
instruments, and these as gently as possible. A stone lodged
stone.
C2
12
ON THE MODE OF .
in the lower part of the bladder has in some instances been
raised, and its position changed, by the finger introduced into
the rectum.
But, to meet the various difficulties which may occur in
extracting the stone, rules will avail but little, so much must
depend on the discretion and the dexterity of the operator, in
selecting the method which may be suited to the circumstances
of the individual case. In
many instances, the seizure of the
stone is resisted by the forcible contraction of the bladder upon
it. It has happened that a stone which, from the sensation
communicated through the sound, was believed to be loose in
the bladder, has been found partly lodged within a distinct cyst
or within the orifice of the ureter. Under either of these cir-
cumstances, its extraction may be difficult. There may be an
adhesion of the stone to the bladder", or a sort of hour-glass
contraction of the bladder, separating its cavity into two com-
partments. In most of these cases, the peculiarity in the
situation of the stone is discovered in the progress of the oper-
ation. Perhaps, the entrance of the gorget into the bladder
may be impeded by the stone being fixed near to, or within,
* In admitting the possibility of the adhesion of a stone to the bladder, I must state, that I have
never seen more than an irregular deposition, or a thin layer of calculous matter, which was
adherent, either to the mucous membrane in a diseased state, or to a soft fungous excrescence which
had arisen from it.
+ Specimens of this state of the bladder are to be seen in the Hunterian Collection.
4 A
PERFORMING THE OPERATION.
13
the prostate, or, on attempting to seize the stone, it may then be
discovered to be partly within a cyst, or partly within the ureter.
Some peculiarity, however, in the situation of the stone might
be suspected from the occurrence of any unusual circumstance
in sounding the patient. Some years since, I operated upon a
boy, in whom the stone could not be always discovered, and it
was doubtful whether the sound touched the stone before or
after its entrance into the bladder. The membranous portion
of the urethra was opened. A beaked knife was then passed
slowly along the groove of the staff to the stone, which was
lodged in the prostate gland.
Whether the operation has been completed by a knife or
by a gorget, some resistance to the progress of the stone
through the wound may be expected. This resistance may be
in the prostate or in the external parts ; but in either case, it
will yield to the skilful use of the forceps, provided that the
incisions have been properly made, that the stone is not un-
usually large, and that the prostate has undergone no change
in its structure.
The skilful management of the forceps consists in press-
ing their blades gently against the sides of the wound, first in
one direction, then in another, but especially downwards *, and
in drawing them outwards slowly, that time may be allowed
* This will be towards the wider part of the space between the rami of the ischia.
14
ON THE MODE OF
for the yielding of the surrounding parts. Laceration, or
severe contusion, of the sides of the wound will probably be
followed by suppuration, which, by spreading extensively
through the surrounding cellular tissue, may be destructive of
life. With these circumstances in his mind, the operator must
judge to what extent the effort to extract the stone may be
safely persevered in, and when he ought to desist, for the pur-
pose of enlarging the wound with the knife in the situation
where there is the most resistance.
When the resistance to the progress of the stone is in the
prostate, although the left side of the gland has been divided
to the usual extent, it will be better to cut into its right side
than to extend the incision of the left at the risk of wounding
the pudendal artery, or of cutting the coats of the bladder
beyond its neck.*
When the resistance to the progress of the stone is in the
external parts, the incision of these must be enlarged towards
the tuberosity of the left ischium.
The extraction of the stone must be directly followed by
the introduction of the finger into the bladder, for the purpose
of examining every part of its internal surface; and this must
* The thin coats of the bladder can scarcely resist the extraction of the stone, and from the
incision of the bladder beyond its neck, there will be the danger of infiltration of urine into the pelvis,
and of injury to the ureter, so close to the neck of the bladder is its ternination in some subjects.
7
PERFORMING THE OPERATION.
15
be carefully done, as there may be a second stone not readily
discoverable in consequence of its being lodged in a recess of
the bladder at its fundus or elsewhere.
And it is necessary to examine the surface of the stone.
A particle of it may have been chipped off, and retained either
in the tract of the wound or in the bladder. Unless it can
be discovered in the wound, and thence dislodged by the end
of the finger, a stream of warm water must be directed with a
good syringe through the wound to the cavity of the bladder,
to detach the particle of stone which may be sticking to its
mucous membrane.
::
16
SECTION II.
ON THE DIRECTION AND THE EXTENT OF THE INCISION OF THE
PROSTATE GLAND.
E
{
܀
any other
A
DIFFERENCE of opinion can scarcely arise respecting the
proper direction of the incision of the prostate. By dividing
its left lobe obliquely outwards and downwards, there will be a
correspondence between the incisions of the outward and inward
parts, which must be favourable for the extraction of the stone,
and for the free discharge of the urine : and it may be added,
that an incision of the prostate cannot be made in
direction with so little risk of injury to the pudendal artery or
to the rectum.
In the preceding pages it has been stated that the incision
of the prostate should permit the easy passage of the finger into
the bladder. Such an extent of incision is usually sufficient.
There would be no practical good in specifying the largest size
of a stone, which has been successfully drawn through an
incision of the prostate confined to its left lobe, because the
1
.
DIRECTION OF THE INCISION.
17
stance.
facility of extracting the stone, must depend on the readiness
with which the prostate and neck of the bladder may yield, and
this will vary in different instances, and at different periods of
life. In the young subject, the prostate will yield more readily
than in the adult, and the induration of the prostate, frequently
present in advanced age, is obviously an unfavourable circum-
An appeal might be made to the successful experience
of some of our best operators who use a gorget, cutting only
one side of the prostate, were it necessary to prove that this
extent of incision is usually sufficient: and in instances wherein
I have examined the parts concerned in the operation, which
had been performed a short time before death, the gorget used
in one case, and the knife in another, had not in either, com-
pletely divided the left side of the prostate, yet the incision had
been sufficient for the extraction of a large stone.
İn
a case of an unusually large stone, it is better to deter-
mine upon the incision of both sides of the prostate, whereby an
increase of space will be obtained, which is to be measured, not
merely by the increased extent of the incision, but by the
greater facility with which the neck of the bladder will then
yield to the pressure of the forceps, than when one side of the
prostate only has been divided. But the stone may be so large
that even with the incision of both sides of the prostate, its ex-
D
18
DIRECTION OF THE
$
E
traction cannot be safely attempted; the desirable object will
then be to break it, which might possibly be effected by a pair
of strong forceps with much projecting teeth, but it would be
necessary in such a case to be provided with the instrument
which has been contrived by Mr. Earle for this purpose, a
description of which will be found in his paper entitled
“ Remarks on the Danger of extracting Large Calculi,” in
the eleventh volume of the Medico-Chirurgical Transactions.
An exclusive preference is not to be given to the gorget or
to the knife for the incision of the prostate. With either instru-
ment, skilfully used, the operation may be well done. With a
gorget, properly constructed, there is no risk of wounding the
pudendal artery or the rectum, because the limits of the incision
are determined by the dimension and form of the instrument.
With a knife, in an inexperienced hand, there is not so much
certainty of confining the incision within its proper limits.
A comparison of the gorget with the knife, so far instituted,
is favourable to the former ; but to the narrow-bladed and
beaked knife, first used by Mr. Blizard, an advantage belongs,
which a gorget, from the width of its blade, cannot possess.
The knife enters the bladder, as Mr. Blizard was accustomed
to remark, as easily as a probe. The gorget, on the other
hand, must ineet resistance in passing through the prostate.
Very much less, however, will this resistance be than it has
Y
}
INCISION OF THE PROSTATE GLAND.
19
been usually represented when the gorget has been properly
made, and it is guided with skill.
For the young subject, or for a thin adult, the knife is
especially suited. It is also to be preferred for any case in
which the bladder is closely contracted upon the stone.
But
for a very fat, or for an old subject, in whom, by the enlarge-
ment of the prostate, or the dilatation of the rectum, the blad-
der is raised much above its natural situation, the gorget is
better adapted, on account of the great distance from the peri-
neum at which the prostate and neck of the bladder are, in such
instances, situated.
Other methods of dividing the prostate, and other instru-
ments for doing it, have been recommended : doubtless, some of
these are good; but, for the mention of them here, consistently
with my present object, it would be necessary for them to be
better than those which have been described, and I have not
been able to satisfy myself that they are so.
1 2
20
SECTION III.
ON THE CONSTRUCTION OF INSTRUMENTS FOR THE OPERATION.
Of the Sound.— To meet the various circumstances of diffi-
culty in discovering a stone in the bladder, sounds must be
provided varying in length, thickness, and in the degree of
their curve.
For a contracted bladder, a sound, the curve of
which is short, and forms part of a small circle is best suited ;
its point can be moved freely so as to touch every part of the
internal surface of the bladder, and being turned downwards,
it
may touch a stone which may be situated below and behind
the prostate when other instruments have failed. A sound
should lie loosely in the urethra, that its point may move freely
within the bladder; but the urethra contracting upon the
instrument may impede the movement of its point, which
may be to a certain extent obviated by the use of a sound of
less than the usual thickness.
Of the Staff.- Formerly the curvature of the staff was
directed not so much to the facility of its introduction as to
the projection of its most convex part in the perineum, but as
it is not intended to open the spongy portion of the urethra,
*
INSTRUMENTS FOR THE OPERATION.
21
*
the projection of the staff is not wanted as a guide for the first
incision. In plate 1. is the representation of a staff which
may be passed to the bladder with facility; and, provided that
the urethra has been opened in the right situation, the small
portion of the groove of this staff, along which the beak of
the knife or gorget will be conducted, is so little curved, that
the difference between it and a straight staff can scarcely
influence the precision with which the operation may be
completed."
The further directions respecting the staff are, that it
should be as thick as the size of the urethra will permit, that its
groove may be wide and deep; and at its extremity, the groove
should be closed. It is true that the beak of the knife or
gorget usually slips out of the groove as soon as it enters the
bladder ; but should this not happen, with a staff having a closed
groove, there will be no risk of wounding the part of the bladder
with which the end of the instrument may be in contact.
Of the Gorget. — The handle of the gorget has been
usually turned downwards to facilitate the passage of the forceps
over it; but this is unnecessary. A straight gorget is prefer-
able, because it can be guided with more convenience and preci-
sion. A gorget, the blade of which is horizontal, may be so
* I owe to the politeness of Mr. Key an opportunity of witnessing his dexterous use of the
straight staff in a boy upon whom he operated in Guy's Hospital.
22
CONSTRUCTION OF INSTRUMENTS
held, in passing it through the prostate, that the incision of the
gland will be obliquely outwards and downwards, but it is better
to adapt the form of the blade to the direction of the incision
it is designed to make. The gorget should be double-edged,
that it may cut both sides of the prostate, as the neck of the
bladder will then yield far more readily than when an incision of
the same extent has been confined to one side of the gland.
A double-edged gorget is also preferable from the greater
facility with which it will pass through a firm prostate.
Both edges of the gorget should be turned obliquely down-
wards to the extent that each edge will form, with the beak,
an angle of forty-five degrees. The beak of the gorget
should be so placed that two-thirds of the incision of the
prostate will be through its left side, in order that the larger
share of the incision of the gland may correspond with the
incision of the outward parts. With a gorget thus constructed,
the blade of which is an inch wide, the left side of the pros-
tate will be divided nearly in its whole length and breadth,
and the right side, to half this extent. A straight and double-
edged gorget, properly set, in respect to the facility with which
it will pass through the prostate is justly represented as a
double edged scalpel.*
* The gorget here described resembles in some points that which was used by the late Mr. Trye
of Gloucester.
FOR THE OPERATION.
23
Of the Beaked Knife.--It is only necessary to allude to
the necessity of having the beak of the knife exactly adapted
to the groove of the staff. The length of the beak should
correspond with the depth of the groove, in order that the
edge of the knife, in any position of it, may be close to, but
not in contact with, the edge of the staff.
It
may
be well to notice, that in cases where there is an
unusual depth of fat in the perineum, or an enlargement of
the prostate gland, all the instruments should be longer than
usual. In an instance of enlarged prostate, the urethra mea-
sured eleven inches between its external orifice and the bladder.
Here, therefore, a staff fourteen inches in length would be
required, and the other instruments in proportion to it.
The
prostate, with its enlargement in advanced life, usually acquires
a firmness of texture equal to that of the hardest gizzard,
which will make the incision of the gland difficult; and from the
indisposition of its sides to yield, the separation of the blades of
the forceps to the requisite extent will be greatly resisted.
For a case of this kind, the blades of the forceps should be
longer than usual, and the handles should be constructed upon
the plan recommended by Assalini, which it is unecessary to
describe, as the instrument-makers are generally provided
with them.
*
EXPLANATION OF THE PLATES,
E

PLATE 1
7
d
a
Eigh
h
I
2
Drawon by 9.9. Baynon
on Stone by Vam Fariana
London Puisiza by Bongman X 6o Požernoster Pow. Och 1, 1829
Prmted by Engemann Graf Condet. V. Co.
PLATE I.
Fig. 1.
A FRONT VIEW OF THE MUSCLES IN THE PERINEUM.
d, The sphincter ani.
b, Fibres of the sphincter terminating in the subcutaneous cellular tissue.
Other fibres of the sphincter are continued to the junction of the
accelerator and transversus muscles.
C, The accelerator urinæ.
d, The transversus.
e, The erector penis.
ff, The levator ani.
g,
The
coccygeus.
h, The edge of the glutæus maximus.
i, The perineal artery.
A dotted line represents the first incision in the lateral operation. The
upper part of this line is in front of the bulb; but in making the subsequent
incisions, the bulb will be pressed to the right side, away from the scalpel,
by the left fore-finger.
Fig. 2.
А representation of the curve of the staff, for the adult. It has been a
little shortened in the handle.
E 2

PLATE 2
a
o
Drawn by W. J. Bayntin
On Stone by Tho Farrland
London Published by Longman &6. Paternoster Row, Oct. 1, 1829
Printed by Engelmamm, Graf, Coindet & Co.
PLATE II.
A LATERAL VIEW OF THE MUSCLES IN THE PERINEUM.
a, The levator ani.
b, The accelerator urinæ.
C, The transversus, detached from its origin.
It will be observed, that a part of the front edge of the levator ani is in
contact with the fibres of the accelerator urinæ, and that the membranous
portion of the urethra, concealed from view by the levator ani, cannot be
opened without dividing some fibres of this muscle.
d, The portion of the triangular ligament which has been detached
from the left os pubis. It is elevated by a hook.
The triangular
ligament being situated immediately behind the bulb, will be in
part divided by the scalpel in its progress to the membranous por-
tion of the urethra.
e, The left crus penis.
f, The dense cellular tissue by which the sphincter ani is attached to
the coccyx.
,
The
coccygeus muscle detached from the spine of the ischium.
60

PLATE 3
е é
b
д a
mu
7
d
On Stone by Tho. Fazrland
Drawn by W. 7 Bayntin
London Published by Longman & Co. Paternoster Row, Oct. 1, 1829.
Printed by Engelmann, Graf, Cavideo #Co.
PLATE III.
A FRONT VIEW OF THE VISCERA OF THE PELVIS, AND OF THE MUSCLES IN THE
PERINEUM.
This view was obtained by passing a scalpel immediately behind the
ossa pubis, directly downwards through the membranous portion of the
urethra and the rectum, and then removing all the parts anterior to this
section.
a a, The acetabula.
b, The ramus of the left ischium.
c c, The posterior sacro-ischiatic ligaments.
d, The coccyx.
e, The bladder.
.
f, The urethra emerging from the apex of the prostate.
g, The right ureter.
h, The right vesicula seminalis.
i, The cut edge of the rectum.
jj, The coccygei muscles.
k, A part of the left levator ani.
1, The pudendal artery, in its progress across the obturator internus
muscle, to the ramus of the ischium.
m, Cellular tissue between the vesicula seminalis and the rectum.
1
In this view of the parts concerned in the lateral operation, the follow-
ing points may be especially noticed.
The pudendal artery, its distance from, and its relation to, the side of the
prostate. To
pass a ligature around the artery, should it have been wounded
EXPLANATION OF THE PLATES.
in the lateral operation, the incision may require to be continued backwards
to the ischiatic ligament.
The termination of the ureter in the bladder, its relation to the side of
the prostate.
The vesicula seminalis, its relation to the side of the prostate.
The levator ani, its application upon the side of the prostate. Besides
the levator ani, a layer of fat, of varying thickness, and the fascia covering the
obturator internus muscle, intervene between the side of the prostate and
the pudendal artery.

PLATE 4
1
TU
k
h
J
q
p.
On Stone by tomu airlane
Drawn by W. J. Bayniin
London: Published by Longman & Co. Paternoster Row, Ocz?!, 1829
Printed by Engelmann, Graf, Conndet & Co.
PLATE IV
A REPRESENTATION OF THE COURSE OF THE PUDENDAL ARTERY AND ITS BRANCHES.
a, The internal iliac artery.
b, The glutæal artery.
c, The ischiatic artery.
d, The pudendal artery.
e, The anterior sacro-ischiatic ligament.
f, The posterior sacro-ischiatic ligament.
8, The pyriformis muscle.
h, The obturator internus muscle.
i, The tuber ischii.
j, The corpus spongiosum.
k, The left crus penis.
l, The right os pubis.
m, The psoas muscle.
n, The right external iliac artery.
0, The obturator artery, which in this instance arose from the external
iliac.
p, The perineal artery.
9. The artery of the bulb.
r, The artery of the corpus cavernosum.
s, The superficial artery of the penis.
F

PLATE 5.
Fig. 1.
c.
Fig. 3.
Fig. 2.
G
Fig. 4
Fig. 5
Dokle
a
b
UN
a
Drarun by M M Winnie
On Stone by Wm Fairland
London Reblished by Longman & Co. Paternoster Row. Oct. 1, 1829
Printed by Engelmann, Graf Coundet Co
PLATE V.
Fig. 1.
A REPRESENTATION OF THE ARTERY OF THE BULB DEVIATING FROM ITS USUAL ORIGIN
AND COURSE.
a, The left levator ani.
b, The left half of the triangular ligament. The pelvic surface of the
ligament is here viewed, in consequence of the bulb having been
drawn upwards and to the left side.
c, The inferior edge of the triangular ligament drawn upwards with the
bulb.
d, The artery of the perineum.
e, The artery of the bulb.
f, The artery of the penis ascending upon the ramus of the ischium.
The artery of the bulb, in this instance arising from the pudendal at a
greater distance from the bulb than usual, proceeds along the pelvic
surface of the triangular ligament, and just above its inferior edge. Here,
therefore, the artery of the bulb would have been divided in the
lateral operation
FIG. 2.
A representation of the size of the prostate gland at the age of
four years.
FIG. 3.
A representation of the prostate gland at the age of twelve years,
showing the small size it retains to the period of puberty.
F 2
ܪ
EXPLANATION OF THE PLATES.
In performing the lateral operation upon the young subject, it is
necessary to recollect the small size which the prostate retains to the
period of puberty, that there may be no risk of extending the incision of the
gland beyond its proper limits. It may seem that an incision which is
confined to the left lobe of the prostate in the young subject, cannot be
sufficient for the extraction of even a small stone; but it is to be recollected
that the small extent of the incision in the young subject is compensated
by the facility with which the parts will yield to the gentlest pressure.
FIG 4.
:
A front view of the triangular ligament, showing its extent, and its
attachment to the under part of the symphysis, and to the rami of the ossa
pubis, also the form of its inferior edge, and the aperture in its centre from
which the urethra has been removed.
Fig. 5.
A lateral view of the bladder and rectum from a boy aged six years,
upon whom the lateral operation had been performed a fortnight before
death.
The wound is only in part healed. A bristle has been passed through
it into the bladder.
It will be observed, that by the operation, a direct channel is formed
between the perineum and the bladder ; that the urethra has been opened
in its membranous portion, and at a little distance from the bulb; and that
the outward incision has been made between the bulb and the crus penis.
The incision of the prostate was made by a single-edged gorget, and it ex-
tends through two thirds of the left side of the gland.
a, The left crus penis.
b, The bulb.
c, The opening in the urethra, commencing a little behind the bulb.
-d, The left vesicula seminalis.
e, The left ureter.
,-
&
C

PLATE 6.
a
32
9
Drawn by W. H. Clit
On Stone by Tho Fazzland.
London: Published by Longman & Co. Paternoster Row. Oct. 1, 1829
Printed by Engelmann, Graf, Coindet 80 CM.
1
:
.
1
PLATE VI.
.
A LATERAL VIEW OF THE BLADDER AND RECTUM, FROM AN OLD SUBJECT.
:
a, The prostate gland larger than naturally.
6, An incision of the prostate made by a gorget.
C, A portion of the prostate projecting into the bladder immediately
behind the orifice of the urethra.
d, A probe passed from the bladder into the urethra.
e, The left ureter.
f, The left vesicula seminalis and vas deferens.
g, The lower part of the rectum considerably dilated.
1.
In trying differently-formed gorgets upon the dead subject, I happened
to perform the operation upon the subject from whom the parts here repre-
sented were taken. Having withdrawn the gorget, I passed my finger through
the prostate, but could not reach the bladder. Then, dissecting the organs,
I found the lower part of the rectum much dilated, the prostate enlarged,
and the bladder raised much above its natural situation.
If, in this individual, the lateral operation had been performed, the
rectum, from its dilated condition, would have been exposed to injury; and
although, with a knife or gorget of a sufficient length, the incision of the
prostate might have been adequately made, yet, from the finger not reaching
the bladder, the extraction of calculi would have been difficult, and
espe-
cially so, if, as usually happens with the enlargement of the prostate, there
had been many small calculi in the bladder. Here, then, was a combination
of circumstances unfavourable for the lateral operation, indeed for
mode of opening the bladder than above the pubes.
any other
-
1
EXPLANATION OF THE PLATES.
In subjects of an advanced age, a deep perineum, as it is termed, is fre-
quently met with. This
This may be occasioned either by an unusual quantity
of fat in the perineum, or by an enlarged prostate, or by the dilatation of
that part of the rectum which is contiguous to the prostate and bladder
Under either of these circumstances, the prostate and bladder become situ-
ated higher in the pelvis than naturally, and, consequently, at a greater
distance from the perineum. In an instance of this kind, the lateral oper-
ation was performed by an experienced surgeon, who was not prepared to
find the prostate and bladder so deeply situated, and he was in consequence
compelled to continue the incisions more deeply, after he had supposed that
they reached the bladder.
.
.
ܫ
1

PLATE 7
2
3
BUR
Drawn by W. H. Cleft.
On Stone by Tho. Fazrland,
London Published by Longman & Co. Paternoster Row, Oct. 1, 1829.
Prints i by Engelmann, Graf Coindet & Co.
1
PLATE VII.
A LATERAL VIEW OF THE BLADDER AND OF THE RECTUM, FROM AN OLD SUBJECT.
The prostate is greatly enlarged, and the coats of the bladder are ex-
ceedingly thick. The enlargement of the prostate has occasioned the ele-
vation of the bladder to the extent that it is almost completely above the ossa
pubis. The section of the prostate displays the increased length, and the
altered direction of the urethra within the gland. The measure of the
urethra between the orifice of the glans and the orifice of the bladder was
eleven inches. It will be well to remark the sudden turn which the urethra
makes on entering the prostate, and its further progress directly upwards to
the cavity of the bladder, with a view to the sort of curve a silver catheter
would have required in this case. Above thirty small calculi were found
in the bladder.
6,
a a, The circumference of the prostate.
The lower and posterior part of the prostate pressing against the
rectum.
C,
The left ureter.
d,
The urethra traversing the prostate.