Of all the great operations in surgery, lithotomy is perhaps that, in which great awkwardness, mortifying failures, and dangerous blunders, are most frequently observed. Many a surgeon, who contrives to cut off limbs, extirpate large tumors, and even tie aneurismal arteries, with éclat, cannot get through the business of taking a stone out of the bladder, in a decent, much less a masterly style. This fact is so familiarly known in the profession, and its truth so often exemplified, that I may well be excused the unpleasant task of relating, in proof of it, all the disasters, which have come to my own personal knowledge. But I must

take the liberty of remarking, that, in this branch of surgery, a great number of individuals do not profit by these instructive lessons of experience. It is true, the more they see of lithotomy, the more they are convinced of its dangers; yet, too often, instead of studying the causes of ill success, they merely derive, from the examples before them, a suspicion of the unskilfulness of the operator, or some discouraging conjectures about the difficulties of the operation.

The establishment of certain principles, to be observed in lithotomy, appears the most probable way of diminishing the frequency of the accidents and failures of this common operation. If these principles are not violated, the kind of treatment employed is but a secondary consideration, and the surgeon may do nearly the same thing with an ordinary dissecting knife, a concealed bistoury, a beaked scalpel, or a well-made gorget.

In the present paper, I propose to recite a case of lithotomy, which was attended with some particularity, and then offer a few general observations on the proper direction and size of the incision. These points are far from being settled, as must be plain to every body, who recollects, that Mr. John Bell recommends a free opening; Scarpa, a small one; that Mr. Abernethy and Scarpa prefer gorgets, which cut upwards and outwards, either at an angle of 45° or 69° from the axis of the urethra ;

and lastly, that the gorgets of Desault, Mr. Clinė, and most other surgeons, are constructed for cutting, either directly outwards, or outwards and downwards.

When I was in charge of the military hospital at Oudenbosch, in Holland, in the spring of 1814, Serjeant Ryan, of the 1st Foreign Veteran Battal lion, desired me to see his little boy, about four years old, whose complaints made me immediately suspect a stone in the bladder. As I had no sound, I introduced a small silver catheter, with which a calculus was distinctly felt. Without taking the instrument out of the urethra again, I determined to perform lithotomy with a common dissecting knife. Indeed, no other mode could be adopted, as we had neither a staff, à gorget, large forceps, nor lithotomy instruments of any kind. After making the external incision in the usual way, and dividing the membranous part of the urethra, I dissected along the side of the catheter, until the prostate gland, and a small portion of the bladder beyond it, could be plainly felt with the fore-finger of my left hand. In this step of the operation, the edge of the knife was constantly directed inwards and upwards. The catheter was then withdrawn, as its very small size, and round shape without any groove, made it impossible for me to derive any further assistance from it. The prostate gland now served as my guide in the completion of the internal part of the incision. With the edge

of the knife, therefore, directed inwards and upwards, I cut into the bladder behind the base of the prostate gland; and carrying the incision forwards, under the direction of my left fore-finger, I made the requisite division of the neck of the bladder, and upper part of the side of that gland. With a small pair of ordinary dressing forceps, a roundish stone about an inch and a quarter in diameter was readily extracted.

This operation was done at the hospital, in the presence of Dr. Shanks, of the 56th regiment, and several other medical officers. No unfortunate symptoms followed, notwithstanding the child was put into a baggage cart two days afterwards, and conveyed in this manner in the rear of the regiment, a march of two or three days. Such premature disturbance, however, and the totally neglected state of the little patient, for nearly ten days, made the wound longer in healing than usual.

The preceding case is related, not with any view of persuading future operators to adopt exactly the plan, which the want of a staff obliged me to follow; for, if this instrument had been at hand, I certainly should not have withdrawn it before the completion of the internal incision; but, having turned its convexity outwards and downwards, I would have cut inwards and upwards, into its groove. Thus, I conceive, the neck of the

bladder and side of the prostate gland, might have been divided with greater convenience and safety.

My principal design is to bring to the recollection of surgeons the several advantages of making the incision through the whole of the parts cut in lithotomy, in a straight, regular, direct manner, from the surface of the skin in the perineum, to the termination of the wound in the urethra and bladder. In an adult subject, the external wound should commence about an inch above the anus. The impropriety of beginning it higher up has been duly insisted upon by Sharp, Bertrandi *, Callisen †, and every good writer on the operation; yet, extraordinary as it may seem, this is one of the most common faults still committed modern surgeons. The incision in the integuments is to be ample, that is to say, at least between three and four inches in length; because a free opening in the skin is not only exempt from

«Il ne faut couper l'urétre que le moins qu'on peut, parcequ'on obtient par ce moyen une meilleure voie pour pénétrer dans la vessie sous l'angle du pubis. C'est avec raison que Sharp dit que l'incision de l'urétre faite au dessus de cet angle est si peu utile pour l'extraction de la pierre, qu'on n'en retireroit pas plus d'avantage en le coupant presque dans toute sa longueur." Traité des Opérations, p. 127.

"Ut eæ partes haud sectione attingantur, quæ pro calculi egressu nihil faciunt; adeoque bulbus urethræ et hujus pars corpore spongioso circumdata intacta relinquatur." Systema Chirurgie Hodiernæ; pars posterior, p. 665.