and should cease about a quarter of an inch from the extremity, in order to prevent the knife from passing too far into the bladder. The staff is intrusted to

an assistant, who is directed to hold it firmly with the handle in the vertical direction, and the plane of the instrument in the middle line. Many surgeons advise

us to direct the handle gently to the right side, so as to make the convexity project slightly on the left side of the perinæum, and act as a guide during the first incisions. Deschamps also gives the same advice, because the inclination of the staff removes the urethra from the rectum. My own experience, however, inclines me to affirm that there is no necessity either of pressing the convexity of the staff down on the middle line of the perinæum, or of directing it towards the left ischium.

The direction of the instrument should, on the contrary, correspond as closely as possible to the natural curve of the urethra; and the staff should be held in such a manner, during the course of the operation, as not to alter a single natural relation of parts. Dr. A. Buchanan, of Glasgow, has substituted a staff, with a rectangular bend in it, instead of the ordinary curved staff. The angle is situate about three inches from the extremity of the staff, and makes a very prominent projection in the perinæum, on which the operator cuts down with facility. The straight extremity of the staff also conducts the knife or bistoury readily into the bladder.

Having thus fixed the staff, and intrusted it to a proper assistant, the surgeon places the fingers of the left hand on the right buttock, and with the thumb makes the skin of the perinæum tense. In doing so he

must be careful not to draw the skin up too much, because if this were done the superior angle of the wound would fall too low after the completion of the operation, and thus give rise to much inconvenience. With a common scalpel the first incision is now made into the integuments. This should commence three or four lines on the left side of the raphé, about one inch above the anus, and be carried obliquely downwards and outwards, a little below the level of the tuber ischii, and a little nearer to that point than the anus. The length of the incision will depend on the size of the perinæum,

Fig. 86-Position of a patient. Dark line shows the first incision; dotted lines show the bony structures

and, generally speaking, extends in the adult from three to three and a half inches. In children, the first incision should commence according to their age, at five or seven lines above the anus. Deschamps was in the habit of terminating the incision at about an inch from the left border of the anus, and did not often exceed an inch and a half or two inches in length,

except when the calculus was supposed to be large. He inclined the incision eight lines from the anus, and four from the ischium. Other writers advise that the external incision should terminate midway on a line drawn from the tuber ischii to the anus; but I think it may be slightly lateralized without danger and with advantage, -that is to say, carried a few lines rather towards the ischium than the middle point alluded to.

In making the first incision, care must be taken neither to commence too high, under the arch of the pubes, nor too low, near the rectum; and not to carry it too obliquely on the ramus of the ischium. There are several objections against commencing the incision too high; a high incision brings us on the bulb, which may be wounded or its artery divided ; it also makes the operator commence his internal incisions too far forwards; hence a greater length of the canal than necessary is divided, and, what is worse still, during extraction, the calculus is brought in an unfavourable position; that is to say, towards the apex of the triangle instead of towards the base. If the incision be commenced too low, the rectum runs great risk of being injured; and by carrying the oblique incision too much towards the left side, especially at the lower part, we encounter the risk of dividing the internal pudic artery as it ascends along the ramus of the ischium, an accident of the most troublesome, if not dangerous, nature, for it is very difficult to secure the vessel in this position.

Some operators, formerly rather than now, were in the habit of cutting on the groove of the staff with a single incision; but, unless the perinæum be extremely shallow, I would not recommend such a

proceeding. On the other hand, we must not grope about or lose valuable time, but, with a few rapid touches of the scalpel, continue the incision on to the staff. In thin persons or children this is very soon found; in others, the finger soon distinguishes the bulb of the urethra, and near to it the convex surface of the staff, as it enters the membranous portion of the urethra. The left index-finger is now passed to the bottom of the wound, the nail soon falls on the groove, and serves to guide the point of the knife on the staff. The first incision divides successively the integuments, the fatty cellular tissue about the anus, the transverse muscle of the perinæum, the fatty cellular

Fig. 87.-View of parts cut in this stage of the operation. a, a, tuberosities of ischii; b, b, sacro-sciatic ligaments; the trunk of the internal pudic artery is seen emerging just beyond this line; c, erector penis; to the left along the middle line is the superficial artery of the perinæum ; just below the origin of this artery is seen the external incision; and the dark line in the centre of this shows the line of incision through the prostate.

layer between the left erector penis and accelerator urinæ muscles, and some fibres of the levator ani muscle. The superficial artery of the perinæum is likewise generally divided. Having distinctly felt with his nail the groove of the staff, and directed the point of the knife along the finger, the surgeon's next care is to open the urethra. Formerly lithotomists were in the habit of making this opening much too far forwards; but since Cheselden's time all are agreed that the bulbous portion should not be divided. The best point to open, perhaps, is as close to the anterior part of the prostate as possible. This was the late Mr. Liston's opinion. Mr. Allen says we should enter the membranous portion of the urethra about half an inch in front of the prostate. Deschamps made his opening in such a manner as to divide eight or ten lines of the membranous portion of the canal. When the point of the knife has once entered the groove, the surgeon should ascertain, by a slight motion of the point from side to side, that it remains in contact with the staff; and directing the edge upwards and inwards, he makes a small incision through the membranous portion of the urethra. The object of this incision is to make an opening for the instrument, which will presently be mentioned. Some operators, following the original example of Cheselden, cut onwards, along the groove of the staff into the bladder with the same knife which served to make the first incision. Mr. Liston used commonly to operate in this way, and it is at once elegant, simple, and expeditious; but it is not always easy to keep the point of the knife perfectly in contact with the groove of the curved staff. Hence the practice often adopted in this

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