LITHOTOMY. 



neum, and raife the fcrotum with his left hand, in order to 

 cxpofc the peiineiim completely to the furgeon's view. 



The next confideration is the manner of making the ex- 

 ternal iiicifion, A moll common error is that of beginninjr 

 the cut too high up. Nearly all the old furgeons commit 

 this fault, by commencing the incifion over the bulb of the 

 urethra, 'i'his pradice is above all things difadvantageous, 

 efpecially when the operator makes the outward wound 

 rather too fmall. Suppofe, for inllaiice, that the furgeon 

 begins the incifion as high as the bii b of the urethra, and 

 does not carry it fufRciently far downwards ; and that he 

 next divides the prollate gland and neck of the biaddpr wi'h 

 the gorget. Now, on attempting ro take out the flonc, the 

 external part of the wound is too high, in regard to the in- 

 ternal portion ; and the paffage, through which the (lone is 

 to be extracted, .not being ftraight and direct, as much im- 

 pediment to the cxtraftion is thereby occafioncd as from *he 

 circumftance of the wound being too fmall. We are de- 

 cidedly of opinion, that " a free and direCl opening for the 

 palTage of the ilone ought always to be made in the opera- 

 tion of lithotomy ;" and ;hat tlie fatal termiisation of nume- 

 rous cafes is entirely owing to the wound not being fuffi- 

 cieiitly ample and diredl: The laceration of the parts, 

 ■which mud happen under fuch circum.llances, is too fre- 

 quently produdlive of peritoneal inflammation, the mod 

 alarming confeq\ience of the operation. Nothing has a 

 greater tendency to render the wound indirect, than making 

 the incifion through the fl<in too high up ; or, in other 

 words, fo high as to inte-cfl; the bulb of the urethra. 



On the contrary, the wound (hould commence over the 

 membranous part of the urethra, at the place where the 

 operator means to make his firft cut into the groove of the 

 flafF; and the incifion is to extend about three inches ob- 

 licjuely downwards, to the left of the raphe of the perineum. 

 The point to which it ought to be direfted, is the centre 

 of a line drawn from the anus to the tuberofity of the 

 ifchium. 



Mr. Serjeant Hawkins has made his name exceedingly 

 famous, by his having been the inventor of cutting gorgets. 

 We have already related how the ancient furgeons fomctime* 

 employed blunt gorgets for dilating the parts, in the per- 

 formance of the apparatus major. A reference to the fiir- 

 gii:al plates of this work will more readily convey an idea of 

 what a gorget is, than any verbal defcription. There we 

 have given reprefentations of the blunt gorget, as well as of 

 (harp gorgets, devifed by Hawkins, Cline, and Abernethy. 

 The gorget of Mr. Cline appears to us the moft eligible, as 

 it will make the freeft opening into the bladder, and cut in 

 the nioft dcfirable direction. lis edge, being quite flraight, 

 may be readily g'-ound very (harp, and is bell fuited for 

 making an even clean in -ifion. By cutting laterally, inllead 

 of more or lefs obliquely upwards, a larger incifion may be 

 fafeiy made with it than with molt other gorgets, which, 

 having their edges turned upwards, cut in a direction where 

 the rami of the ofia ifchium converge, and leave lEfufficient 

 room for the eafy paflage of a lar^^e (lone ; and where alfo 

 the trunk of the pudendal artery is liable to be injured, in 

 making a wound even of moderate extent. We are firmly 

 perfuaded of the truth of Ponteau's opinion, that the (lone 

 ought alwavs to be extracted where the arch of the pubcs is 

 widell Cline's gorget, befides having the material advan- 

 tages of making the freed opening, and cutting in the mod 

 defirable direction, a'fo pofTeffes the excellence of being di- 

 verted of that very ufelefs and objectionable part, the blunt 

 prominence on the left hand of the beak, fometinies termed 

 the fhoulder of the gorget. This (hould always be filed 

 away, as it can only ferve to render the introdudtiou of the 

 infirument more difficult. 



We (hould like Mr. Abernethy's gorget very well, if its 

 edge were foniewhat more extenfive, and had a more hori- 

 zontal direction. But the fird improvement would be im- 

 proper without^ the lall ; fmce a freer cut fo much upwards 

 mud endanger the pudendal arter^'. 



Every furgeon, before undertaking lithotomy, (hould be 



The requifite divilion of the integuments being made, the careful that the beak of the gorget and the groove of the 



next object is to divide the tranfverfalrs perinaei mufclcs, daff fit each other v.'ith precilion. The embarralTment and 



and to make an opening into the membranous part of the rid^ of doing mifchief, into which the operator would fall, 



urethra, fo as to be able to feel didincily with the finger the could he not make the beak Aide along tlie groove, mud be 



groove and edges of the (b.fF. plain to every underdanding. 



The operator has now to accomplifh a very important Having divided the urethra a confiderable way towards 



objedl, and one that is for the mod part fadly neglecftcd 

 we allude to cutting the left fide of the urethra with the 

 knife, as far as poffible along the groove of the daft" to- 

 wards the bladder. In doing this, the point of the fcalpel 

 (hou'd be pla ed in the groove of the daff, and the edge be 

 turned to the left, v-hile t!ie operator's left fore-finger, ap- 

 phed to the back of the blade, ferves to guide its courfe 

 with greater deadinefs and fecurity. When this part of the 

 operation is carefully done, very little remains to be effected 

 by the gcrget. 



Were the furgeon, with too much boldnefs, to lay open 

 the lower part of the urethra onward to the bladder, he 

 ■would inevitably wound the rectum ; " becaufe,'' as an 

 excellent writer has obferved, " the incision being carried 



the neck of the bladder, m the manner explained above, the 

 operator is to place the beak of the gorget in the groove of 

 the dafF; and, being Aire that this is accompliflied, he is to 

 rife from his chair, and take hold if the handle of the dalT 

 with his left hand, while with his right he hods the gorget 

 with its beak carefully mainiained in the groove of the llafF, 

 along, which it is to glide ino the bladder. But,' before 

 piifhing the gorget onward, a moll important thing is to be 

 obierved: this is " to bring forward the handle of the ftnfF, 

 fo as to elevate the extremity of the indrument in the blad- 

 der ; by uhich meats, the gorget can be introduced along 

 the groove of the ilaff, in the direction of the axis of the 

 above vifcus. In fa6t, the gorget (hould always be intro- 

 dueed nea-ly in a direction corrcfponding to a line drawn 



on from the urethra, it will necelFarily lead to that part of rrom the os coccygis to ihe umbilicus." Bv following this 



the neck of the bladder that lies upon, and is contiguous to, plan, the gorget can hardly ever v.ound the reCtum, or in- 



the redtum." (Jiharp in Critical Inquiry, &c. p. 212. (innate itfclf into the cell'.' ar fubdance between this intedine 



edit. 4 ) But when the urethra is divided in the manner and the bladder. It is evic" 'nt, ho^tever, that there can be 



above recommended, with the ed^e of the fcalpel turned no fafety, if the beak of liie gorget rtiould happen to (lip 



fidoways, no ri(k of cutting the intedine is encountered. out of the groove, which isdeiigued to guide it. 



The next important dep is to f'.ivide the prodate gland Immediately the gorget has been introduced, the ftafF is 



and neck of the bladder; for wlic purpole, the gorget, to be \\ithdrawn, and a fuitable pair of forceps is to be 



that difgracef'J indrument, which we Ihould like to lee ex- paffed, along the upper fuiface of he gorget," into the 



pelled from furgery, is deiigned. bladder, for the purpofe of feizing and extrafting the done. 



Wliilc 



