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Show ( . 2-10 rmsr memos FOR LITHOTOMY. But this does not correspond with my idea of the proper incision. In the first place, I do not approve of the staff be« ing held so far to the left Side of the perineum, nor of its being made to bulge out so much. I let it remain in its unconstrained position ; then making it be held firm, cut down to it, making an incision towards the fore part of the prostate gland, not as if searching for the statl". This cutting for the staff, and having no other object than to prepare for the beak of the gorget entering the groove of the staff, is the conception of the mcrest tyro. Our object, in the first instance, is to lay the perineum open, in sufficient extent for the extraction of the stone, and to unbridle and cut across the muscles which support the perineum. The sharp point of the knife ought to be made to pierce di« rectly in towards the lower part of the arch of the pubes ; and it should enter by the side of the spongy body of the urethra (or, in other words, by the side of the staff), and betwixt that eurrrsc 'rnn enemas. " 447 the edge of the knife slits the urethra, and fits the gorget in the groove, and then it carries it forward to the bladder, the instrument passes over a very strong faciculus of muscular fibres, which afterward<, in extraction of the stone, strongly binds up the instrument, and forcing it against the arch of the pubis, throws the stone oil" the grasp of the forceps. There are few lithotomists who have not experienced this : they call it the slipping of the stone. They seize the stone again and again, with increasing violence and desperation. This muscle, the deep transversalis we may call it, so little attended to, I have thought it necessary to represent in an ad« joining sketch; as I have attributed many untoward accidents during the operation to the neglect of it. In cutting through this muscle, the operator must carry the finger of the left hand into the lower part of the wound, and press down the rectum, else it may be. woundeda‘e. He must body and the crus of the penis. From this with a deep, steady incision, it is carried down directly betwixt the anus continue his incision until he feels the prostate gland, andthat there is no stricture on the wound below, from the crossing of the flesh. and tuberosity of the ischium, and ending opposite the lowest part of the margin of the anus. C U TTING THE URETHRA. c Now, we are told that a small incision of the skin impedes and embarrasses the surgeon in the extraction of the stone. But this first cut cannot do effectually what is required in the first incision, as it is termed. The accuracy of this outward cut is of importance only as it naturally leads to the full separation of the muscles, which are truly the cause of any embar~ rassment, the skin always yielding sufficiently. IF the staff has been kept hitherto nearly in the middle, it must be now inclined with the handle to the right groin : so that the convexity of the instrument may appear bulging in the wound of the perineum. And now the surgeon merely turns up the edge of the knife, and cuts freely and decidedly into the groove of the staff. Here he can do no mischieff. One or two successive strokes of the knife deepen the wound, and the surgeon must be careful that he carries the knife from the side of the staff down by the side of the rectum, and that he cut through the transversalis perinei muscle. But even this is not sufficient ; and by experience, as well as by observing the difficulties of surgeons, in circumstances where I * \Vhen the rectum is cut, it generally heals ; but sometimes the wound rlegenerates into a fistula. Though it is easily cured, it is truly a fistula in ano. 'f I am satisfied, that of ten operators whom I have seen operate, nine have cut into the bulb of the urethra. There is no great harm in this ; only, that when not aware of it, they make too small a cut into the urethra. ; they But when the surgeon find the beak of the gorget does not enter upon the staff; they cut a second time and again, and then the young surgeon, perhaps thinking too much of what others are thinking of him, becomes ashamed of his awkwardness, and cuts through the transversalis perinei muscle, and turning UP Rakes at last adespemte plunge. with the garnet, imperfectly fixcdin the could not interfere, I well know the forceps are checked when this is thought a sufficient incision. ‘ mom M09917" ! |