C. Aston Key

“ 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. ”

“ 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 [25] 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.
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. ”

“ 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. ”

“ 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 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. ”

“ 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? ”

“ 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. ”

“ 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 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. ”

“ In the majority of cases it will merely be necessary to pass the knife along the director, and, having cut the [27] 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. ”

“ 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. ”