Plate 1.Drawn by F.F. Giraud. 1823.Engraved by J. Stewart.London. Published 1824, by Messrs. Longman, Hurst, Rees, Orme, Brown & Green.
Plate 1.
Drawn by F.F. Giraud. 1823.Engraved by J. Stewart.
London. Published 1824, by Messrs. Longman, Hurst, Rees, Orme, Brown & Green.
In the usual manner of dissecting a side view of the pelvic viscera, an unnatural bearing is given to several important parts, by the following circumstances:—To assist the dissector a curved sound is previously introduced into the urethra, the consequence of which is, that the canal necessarily assumes whatever form the instrument may have. Views so taken are therefore incorrect, and give an erroneous idea of the natural course of the canal. The bladder and rectum are also excessively distended, the former being inflated to its utmost, and the latter filled with baked horse-hair. When the bladder is thus distended it rises out of the pelvis; and if in the dissection, the abdominal muscles have been turned aside, and the cellular connexions of the bladder much disturbed, its rise is so considerable as to elevate the prostate gland, and thus give a more horizontal bearing to the prostatic and membranous portions of the urethra. The distending the rectum also adds to the erroneous impression, by elevating the bladder, and thus bringing the base of the bladder, prostate gland and membranous urethra into a nearly horizontal line.
Such a view is calculated to give a correct anatomical idea of the course of the canal under retention of urine, and shews the propriety of using a catheter with the curve recommended by Sir Astley Cooper. The relative situation, however, of these parts is widely different when regarded in a lithotomic point of view.
In a person prepared for the operation the rectum is emptied by purgative medicine and an enema; and the bladder, which in a stone patient seldom contains more than eight ounces of urine, occupies the hollow of the flaccid or contracted rectum. Care has been taken not to distort these parts by the introduction of an instrument into the urethra, nor by more distention than was sufficient to preserve a general outline. To Mr. Giraud, dresser to Sir Astley Cooper, I am indebted for the drawings; the object of this plate being to represent the true bearing of the parts concerned in Lithotomy, they were drawn of the natural size, by measurement, from a young man, twenty-nine years of age, who died after six days illness; and the dissection being completed within twelve hours after his decease, the rigidity of death still remaining retained the parts in situ.
a.Section of the left os pubis.b.Articular surface of the sacrum.c.Section of the left crus penis.d.Bulb of the penis.e.Membranous portion of the urethra.f.Prostate gland; its posterior edge concealed by veins.g.Base of the bladder sinking considerably below the level of the prostate.
a.Section of the left os pubis.
b.Articular surface of the sacrum.
c.Section of the left crus penis.
d.Bulb of the penis.
e.Membranous portion of the urethra.
f.Prostate gland; its posterior edge concealed by veins.
g.Base of the bladder sinking considerably below the level of the prostate.
The relative bearing of the parts markede,f,g, may be noticed, in reference to the introduction of the instrument, as delineated inPlate II.
When the pelvis is bent upon the lumbar vertebræ, and the shoulders of the patient raised, as in the posture for Lithotomy, these parts will have a rather more perpendicular bearing than even is in this view represented.
h.The veins returning the blood from the vena magna ipsius penis injected with wax, entering the pelvis under the pubic arch, through the triangular ligament, in which the vein begins to form a plexus, and concealing the posterior edge of the prostate. In the Celsian operation, this part of the neck of the bladder was cut laterally without dividing the prostate, whence may be inferred the cause of its fatality. In the Gorget operation, if the wound in the prostate is too small for the calculus to pass, this part of the bladder is torn.i.Triangular ligament, section of. This ligament connects the membranous part of the urethra and prostate gland with the arch of the pubes, protects the dorsal nerve, artery, and veins, in their course to the dorsum penis, and serves the purpose of a barrier between the perineum and the reticular texture surrounding the bladder; it sends a process on each side of the prostate gland, to cover the vesiculæ seminales. The escape of urine after Lithotomy can only be productive of mischief, by infiltrating the cells of the scrotum, or by making its way upwards by the side of the bladder behind this ligament, when the prostate has been torn from its connexions.k.Rectus abdominis, section of.l.Peritoneum reflected over the fundus and back part of the bladder, and continued over the rectum.m.Rectum partly distended by the introduction of a portion of inflated ileum.n.Accelerator urinæ reflected from the bulb, and discovering the granular lobes of Cowpers’ gland between the bulb and membranous urethra.o.Muscle of the membranous part of the urethra reflected; not forming a loop around the canal, but (as I have noticed in many subjects), descending from the pubes, and attached to the dense ligamento cellular structure which bounds the edge of the accelerator urinæ; it is continuous with the levator ani.p.Compressor prostatæ and levator ani partly reflected.q.Section of pyriformis.r.Vas deferens.s.Vesiculæ seminalis, partly concealed by the veins returning the blood from the prostate not in this subject injected.t.Ureter.u.Small intestines turned over the abdominal muscles on the right side, the latter having been left attached to the sternum and ribs.w.Lower part of the thorax.x.Lumbar mass of muscles.y.Anus.
h.The veins returning the blood from the vena magna ipsius penis injected with wax, entering the pelvis under the pubic arch, through the triangular ligament, in which the vein begins to form a plexus, and concealing the posterior edge of the prostate. In the Celsian operation, this part of the neck of the bladder was cut laterally without dividing the prostate, whence may be inferred the cause of its fatality. In the Gorget operation, if the wound in the prostate is too small for the calculus to pass, this part of the bladder is torn.
i.Triangular ligament, section of. This ligament connects the membranous part of the urethra and prostate gland with the arch of the pubes, protects the dorsal nerve, artery, and veins, in their course to the dorsum penis, and serves the purpose of a barrier between the perineum and the reticular texture surrounding the bladder; it sends a process on each side of the prostate gland, to cover the vesiculæ seminales. The escape of urine after Lithotomy can only be productive of mischief, by infiltrating the cells of the scrotum, or by making its way upwards by the side of the bladder behind this ligament, when the prostate has been torn from its connexions.
k.Rectus abdominis, section of.
l.Peritoneum reflected over the fundus and back part of the bladder, and continued over the rectum.
m.Rectum partly distended by the introduction of a portion of inflated ileum.
n.Accelerator urinæ reflected from the bulb, and discovering the granular lobes of Cowpers’ gland between the bulb and membranous urethra.
o.Muscle of the membranous part of the urethra reflected; not forming a loop around the canal, but (as I have noticed in many subjects), descending from the pubes, and attached to the dense ligamento cellular structure which bounds the edge of the accelerator urinæ; it is continuous with the levator ani.
p.Compressor prostatæ and levator ani partly reflected.
q.Section of pyriformis.
r.Vas deferens.
s.Vesiculæ seminalis, partly concealed by the veins returning the blood from the prostate not in this subject injected.
t.Ureter.
u.Small intestines turned over the abdominal muscles on the right side, the latter having been left attached to the sternum and ribs.
w.Lower part of the thorax.
x.Lumbar mass of muscles.
y.Anus.
Plate 2.Drawn by F.F. Giraud. 1823.Engraved by J. Stewart.London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green.
Plate 2.
Drawn by F.F. Giraud. 1823.Engraved by J. Stewart.
London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green.
Represents the director held in the situation for the first incision of the operation. The left side of the bladder having been removed, the extremity of the instrument is seen projecting some way into the base of the viscus, which now sinks lower into the hollow of the rectum, the latter being entirely empty. It will be observed how the slight curve of the staff adapts it to the concavity of the bladder, and prevents it being entangled by a fold during the depression of the handle, preparatory to the section of the prostate. The parts being viewed obliquely from behind, the prostate, urethra, &c. are but imperfectly seen.
Plate 3.Drawn by F.F. Giraud. 1823.Engraved by J. Stewart.London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green.
Plate 3.
Drawn by F.F. Giraud. 1823.Engraved by J. Stewart.
London. Published 1824, by Longman, Hurst, Rees, Orme, Brown & Green.
In this plate the section of the prostate gland is shewn; the parts being viewed obliquely from before. The left hand of the operator holding the staff is depressed to conduct the knife into the cavity of the bladder. If attempt be made to depress the handle lower, the operator will feel his hand checked by the ligament of the arch. The knife is seen piercing the prostate in the direction which most nearly accords with Cheselden’s section. This inclination of the knife will enable the operator to make a very free incision, with great facility, without incurring any risk of wounding the pudic artery, the rectum, or the veins surrounding the neck of the bladder; unless a very large incision be required by the size of the calculus, in which case some of the veins must necessarily be divided.
In contrasting this view withPlate I, it will be observed that the prostate is carried somewhat upward from the rectum; this effect is produced by the depression of the handle and the consequent elevation of the extremity of the director. The danger of wounding the rectum is thus still farther diminished.
One great advantage of conducting the operation on this principle arises from the operator not being under the necessity of withdrawing the knife from the groove of the staff, after he has once entered it, during the subsequent steps of the operation. The extent of the incision in the prostate and neck of the bladder may be regulated by the angle which the knife makes in its introduction with the staff. Supposing that an opening be required extending through the prostate fromdtob, (which for the majority of calculi, even above the ordinary size, will be quite sufficient, as the neck of the bladder will dilate considerably), the point of the knife must be carried on as far asain the groove of the staff. For it will be evident that if the same angle be maintained in the act of carrying on the knife, the linec b awill be the position of the knife when the point has reacheda. The edge of the knife, although brought apparently so near to the rectum, will not injure it, from its oblique inclination to the patient’s left side.
Pl. IV.F.F. Giraud delt.Js. Basire sculpt.
Pl. IV.
F.F. Giraud delt.Js. Basire sculpt.
Gives a view of the director used in the operation on a child under five years of age, slightly curved towards the extremity, the more readily to adapt itself to the concavity of the bladder when held in the position inPlate II.
The knife with a scalpel blade, but longer than a common scalpel, and slightly convex on the back near the point, that it may run smoothly along the groove of the staff. When used with a staff of this form the whole of the cutting part of the operation may be easily performed with it.
The size of the calculus which was extracted in the first operation with these instruments is here delineated, in order to shew the extent of the opening in the cervix vesicæ and prostate gland, which in so young a child may be made with safety, according to the method explained inPlate III. The comparative size of the incision that can be made in the adult may be inferred.
FOOTNOTES[1]I allude to Mr. Martineau’s and Mr. Barlow’s papers on Lithotomy.[2]Deschamps—page 102.[3]Deschamps—page 104.[4]Deschamps—page 109.[5]Douglas’s Appendix—page 12.[6]Deschamps—page 106.[7]Page 107.[8]Cheselden’s Anatomy—page 330.[9]Bell’s Surgery—page 173.[10]Sharp’s Surgery.[11]The late Mr. Dease was so impressed with the hazard of passing a cutting instrument along the curve of the staff, that he used to withdraw the staff, after he had opened the urethra, and passing a director through the opening into the bladder, dilated the cervix vesicæ, by introducing the Gorget in the usual manner.[12]Mr. Martineau’s Gorget is merely used as a director to convey the forceps into the bladder; its edges are blunt, and therefore it does not aid in the division of the prostate, which has been already divided by the knife, as a reference to his operation will shew. He had the kindness to send me a model of his Gorget, for which, and his politeness in his communication to me on the subject, I take this opportunity of expressing my thanks.[13]I should not omit to mention that I did not adopt this alteration in the instruments, without having first operated at the hospital, both with the Cutting-Gorget, and also with the beaked knife, in conjunction with the common staff. I was not led to lay them aside by the issue of the cases, as they were successful; but the difficulty and hazard attending their introduction, together with the general unsuccessful issue of Gorget operations, compared with Cheselden’s method, induced me to use a more simple form of instruments.[14]See Plate 2.
[1]I allude to Mr. Martineau’s and Mr. Barlow’s papers on Lithotomy.
[1]I allude to Mr. Martineau’s and Mr. Barlow’s papers on Lithotomy.
[2]Deschamps—page 102.
[2]Deschamps—page 102.
[3]Deschamps—page 104.
[3]Deschamps—page 104.
[4]Deschamps—page 109.
[4]Deschamps—page 109.
[5]Douglas’s Appendix—page 12.
[5]Douglas’s Appendix—page 12.
[6]Deschamps—page 106.
[6]Deschamps—page 106.
[7]Page 107.
[7]Page 107.
[8]Cheselden’s Anatomy—page 330.
[8]Cheselden’s Anatomy—page 330.
[9]Bell’s Surgery—page 173.
[9]Bell’s Surgery—page 173.
[10]Sharp’s Surgery.
[10]Sharp’s Surgery.
[11]The late Mr. Dease was so impressed with the hazard of passing a cutting instrument along the curve of the staff, that he used to withdraw the staff, after he had opened the urethra, and passing a director through the opening into the bladder, dilated the cervix vesicæ, by introducing the Gorget in the usual manner.
[11]The late Mr. Dease was so impressed with the hazard of passing a cutting instrument along the curve of the staff, that he used to withdraw the staff, after he had opened the urethra, and passing a director through the opening into the bladder, dilated the cervix vesicæ, by introducing the Gorget in the usual manner.
[12]Mr. Martineau’s Gorget is merely used as a director to convey the forceps into the bladder; its edges are blunt, and therefore it does not aid in the division of the prostate, which has been already divided by the knife, as a reference to his operation will shew. He had the kindness to send me a model of his Gorget, for which, and his politeness in his communication to me on the subject, I take this opportunity of expressing my thanks.
[12]Mr. Martineau’s Gorget is merely used as a director to convey the forceps into the bladder; its edges are blunt, and therefore it does not aid in the division of the prostate, which has been already divided by the knife, as a reference to his operation will shew. He had the kindness to send me a model of his Gorget, for which, and his politeness in his communication to me on the subject, I take this opportunity of expressing my thanks.
[13]I should not omit to mention that I did not adopt this alteration in the instruments, without having first operated at the hospital, both with the Cutting-Gorget, and also with the beaked knife, in conjunction with the common staff. I was not led to lay them aside by the issue of the cases, as they were successful; but the difficulty and hazard attending their introduction, together with the general unsuccessful issue of Gorget operations, compared with Cheselden’s method, induced me to use a more simple form of instruments.
[13]I should not omit to mention that I did not adopt this alteration in the instruments, without having first operated at the hospital, both with the Cutting-Gorget, and also with the beaked knife, in conjunction with the common staff. I was not led to lay them aside by the issue of the cases, as they were successful; but the difficulty and hazard attending their introduction, together with the general unsuccessful issue of Gorget operations, compared with Cheselden’s method, induced me to use a more simple form of instruments.
[14]See Plate 2.
[14]See Plate 2.