Practical observations on the lateral operation of lithotomy / by William Keith.

  • Keith, William, 1802 or 1803-1871.
Date:
[1844]
Catalogue details

Licence: Public Domain Mark

Credit: Practical observations on the lateral operation of lithotomy / by William Keith. Source: Wellcome Collection.

    16/36 (page 26)
    28 and bladder, that the operator may find a sure director into the latter when his dissection has brought him to the face of the pros¬ tate ; let it, therefore, remain fixed in the mesial line, pressed against the symphysis pubis during the whole operation, and then he knows where to find it, just where by nature the urethra runs. The ad¬ vice given by some writers, to make the assistant meet the knife by pressing the convexity of the staff against the left side of the peri¬ neum, is, to say the least of it, injudicious; it occasions a risk of the point of the staff escaping from the bladder; it alters the na¬ tural position of parts, and limits the space into which the operator has to cut, pushing his incision towards the ramus of the ischium, under the edge of which the pudic artery runs, the nearer to which that the lesser arteries are cut the more energetically will they bleed : and, lastly, the parts are thereby so pressed down upon the rectum as to endanger it at the very first cut. Then, again, the blunt gorget is supplied, not as a substitute for anatomical knowledge, but as an instrument capable of opening the neck of the bladder just as far as safety admits, (that is, as far as the prostate gland extends,) and quite as far as sound principle requires, seeing that the elasticity of the coats of the bladder is sufficient to allow of the easy escape of any fair average sized stone, after that gland and the spincter of the bladder have been di¬ vided. Surely much need not be said to satisfy any surgeon that one is quite safe to draw upon the elasticity of the coats of the living bladder to allow of the escape of a large stone through a comparatively small opening; the prostate might be injured and shattered by great dilatation ; no elastic quality resides in it; but it is essential to the very function of the bladder that it shall di¬ late and contract—at one time reduced to the size of an egg, and in six hours expanded to the size of a human head—and again, in half a minute, by the power of the will, down to two and a-half inches in diameter. What difficulty can there be in obtaining for a minute or two the expansion of a small wound in such a membrane, freed of the girding effect of an uncut prostate, to al¬ low of the escape of even a large foreign body, forcibly withdrawn in the grasp of a forceps, whose blades, smooth on the back, come out possessed of all the powers of the wedge ; and why, then, in¬ cur the fatal risk by extending the incision beyond the base of the prostate, of laying open the pelvis to the ingress of urine, by wounding the ileo-vesical fascia, when you not only have this elas-