Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson.

  • Thompson, Henry, Sir, 1820-1904.
Date:
1882
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Licence: Public Domain Mark

Credit: Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson. Source: Wellcome Collection.

    110/192 (page 98)
    At this point the operation continned for some years until the end of the century, and then ' the gorget' came into fashion. A few years ago a patient was rarely cut without it; now, I suppose, few of you know what it is. Originally one of the directors used in the ' apparatus major,' its edges were sharpened for the pur- pose of making the deep incision through the ])rostate. This was the idea of Sir Caesar Hawkins, whose name was affixed to it; but subsequently almost every surgeon had his own gorget, making it wider or narrower, or altering it in some fashion or another. A great deal of mystery has been made of this instrument, but it is simpl}^ a wide knife with a beak or probe-point at the end, which is care- fully maintained in the groove of the staff. In employing the ordinary knife, if you require a deep incision, the blade must perhaps leave the staff a little. The object of the gorget is to make an incision sufficiently deep without leaving the staff. Here is one which formerly belonged to Scarpa, the celebrated anatomist, and here are others which, having been used by many celebrated operators, have fallen into my hands, and they are leading types of the instrument. In F]-ance at this time the lithotome cache of Frere Come was much used, and with the same object in view, viz., of attaining certainty and precision in the extent of the incision through the prostate. The practical difference between it and the gorget is, that in the latter the division of tissues is made by pu-^hing inwards a while G were females ; dcductin;^ these latter, there remain 78 male cat-cs, of which not less than 34 were under 15 years of age, leaving onlj' 44 adults. Of these 44 adults, no mora than 11 were upwards of t)0 years of age ; only 24 were 50 years old and upward^, giving for the latter a mean age of 02^ year-;; the 2 deaths occurred among them. No error is more common than that of compar- ing lists of cases without noting this most impor- tant element of age. Death after lithoto-ny in children is notoriously infrequent ; indeed, it is a result scarcely to be expected, unl^s under circum- stances of some rarity. Daring middle life, also, lithotomy is a very successful operation ; but at the }i<xe of sixty and upwards it is one of considerable ri-k. Hence, unless an exact statement respecting the patient's age is aftbrded, no inference can be drawn from an)^ number of cases of which the results are reported. A mere statement of the number of patients operated on, with the proportion of recoveries and deaths, is absolutely valueless, and is often misleading. For comparison between these results and tliose of modern lithotrity see previous Lecture, p. 93, where in 112 cases of male adults (children being entirely ex(4uded), with a mean age of G2i years, there -were only 3 fatal cases, or a mortality'oi* 2'^ per cent. sharp blade of known width through them: and that in the former a sharp blade is opened to a known extent at the* farthest limit of the parts to be cut, and is drawn outwards to the operator, dividing them. In 181G, Dupuytren, of Paris, not being content with the lateral, introduced his bilateral operation. His object was to make the deep incision by a cut on each side of the prostate, instead of a large one on the left side only. And he, with the same view of limiting accurately the extent of the wound, designed a special in- strument for the purpose. This, the ' two- bladed lithotome,' is also a member of the ancient surgical armamentarium, made more elegant and manageable by modern skill. Here again, instead of making the internal incision by pushing a cutting blade inwards, as with the knife or gorget, you carry this instrument [showing it] into the bladder along the staff, there open its two concealed blades, and draw- ing it towards you, these cut their way outwards. The blades can be arranged so as to have the incision as wide or as narrow as you please. In 1825 or 1830, the 'median opera- tion,' often loosely spoken of as a revived Marian operation, came into some note in this country, while in Italy it had been long previously employed with much suc- cess. In the meantime Civiale, in Paris, combined the median and bilateral opera- tions in one proceeding, which he called the medio-bilateral; and you have seen me frequently perform both of them here ; they shall be briefly described hereafter. Subsequently, Nelaton devised an opera- tion to which he gave the name of ' pre- rectal.' This may be fairly described as a bilateral operation, conducted by means of a carefully made dissection for the purpose of obtaining more space between the rectum and the bulb of the urethra, and especially to avoid wounding the latter. More recently still, the late M. Dolbeau, of Paris, adopted a method, by no rn^ans before untried, of making a median perineal opening into the prostatic urethra, which he dilated by expanding metallic dilators, crushing the stone through it, and removing all the debris at one operation. It has generally proved to be a tedious pro- ceeding, requiring much instrumental contact with the bladder after all the urine has escaped; and it is there-