1864 The Lancet  
H.M. THE QUEEN. MR. PRESIDENT AND GENTLEMEN,—Much of the interest associated with lithotomy has reference to the operation on the adult. It appears to me that the difficulties and dangers of this operation have been estimated more from the results than from the actual process. Hence, as lithotomy is known to be comparatively safe when performed on subjects at any age prior to puberty, it has been deemed equally easy in performance ; and a widespread notion prevails that in children it is so
more » ... ildren it is so readily effected that little study, thought, or care has been bestowed upon it. My own experience has led me to imagine that surgeons have treated this subject too lightly ; and, at the risk of being thought to have entered on ground already thoroughly explored, I shall venture to step freshly upon it, with the conviction that, although I may state nothing which is not already well known to experienced lithotomists, I may do much good to beginners by directing attention to certain points which have heretofore been scarcely, if at all, referred to by clinical teachers or surgical authors. It has been computed that about a third of those on whom lithotomy has been performed have been under the age of puberty, and the average mortality in such cases is about 1 in 30. Comparing this result with that of the operation on the adult, the measure of success is large indeed ; and hence, doubtless, has arisen the common impression that the mechanical process in the young is simple in all respects. I am firmly convinced, however, that a great mistake prevails on this point, and that as much care and skill are required on the part of the surgeon in operating on young subjects as on adults; I should say, even more; for in my personal experience I have often felt more doubtful during the steps of the proceeding upon children than when dealing with the full-grown man. The history of lithotomy shows clearly that when the operation is satisfactorily accomplished in children, its success is almost certain. Yet we often hear of difficulties and great mishaps in young subjects, and, in particular, we often hear of the operation being abandoned for a time, or of the cutting having been performed when a stone has in reality not been found. If these matters had been more referred to heretofore by authors, operators, and teachers, we should, I imagine, have heard more of the difficulties and fatality of lithotomy in young subjects than some people think of; at any rate, a more wholesome idea would have prevailed regarding the subject than, in my opinion, prevails at the present time. These remarks have been suggested by what I have seea, read, and heard of in the practice of others during the time I have been iu the profession, as well as by my personal experience. In my early days of study I was struck and excited by the circumstance that a surgeon of repute had cut into the bladder of a child to extract a stone where none could be felt. The case was considered an example of error in diagnosis. The patient recovered from the wound, but the symptoms of stone continued, and about three months afterwards another surgeon extracted a stone of considerable size from the bladder by the ordinary operation of lithotomy. Another case of a like kind came under my cognizance about the same time, and the impression on my mind was strong that in neither instance had the bladder been reached in the first operation. In early life I assisted an experienced operator in this proceeding on the adult. Having, as he supposed, cut into the bladder, the stone could not be touched. Here I had an opportunity of examining the wound, and, a suggestion having been made that the bladder had not been opened, the operator, with remarkable dexterity, cut further in the right direction, opened the viscus, and, with great rapidity, extracted the stone, which he had previously detected by sounding. In this instance I had no doubt whatever that the surgeon had not originally cut deep enough, but had made a space with the forefinger of his left hand, between the pubes and neck of the bladder, which he had for a time mistaken for the bladder. These and other similar instances which occasionally came to my knowledge, gave me a strong impression that in those cases where surgeons were stated to have cut for stone where one had not been present, they had probably not reached the bladder at all. In the course of time this impression has become much strengthened, and in giving, by this lecture, greater currency than heretofore to the frequent clinical observations which 1 have made on this subject, 1 feel assured that my experience and views will not be lost upon those who are earnest in the study of this most interesting operation. As a beginner, I was taught, or had imbibed the idea, that lithotomy in children was simple in execution; and when I began to operate on the living body this impression was confirmed for a time. I had seen the incisions effected with admirable dexterity by means of a common scalpel, and in my first operation 1 used a similar instrument. The proceeding seemed simple in the extreme, and I adhered to the same method on subsequent occasions with most satisfactory impressions, until unexpectedly a difficulty arose which produced an effect on my mind that time cannot efface. After many operations on the adult and on the young subject, I had in a manner forgotten my early knowledge of the position of the bladder in children, and not only was content to make the incisions with a simple scalpel, but had in a measure got careless about some matters of great importance. On the l7tlt of March, 1849, I had to operate on a boy four years of age at King's College Hospital. I used a scalpel, as I had often done before, and made the ordinary incisions for lateral lithotomy. A grooved staff with a large curve was the director into the bladder. In making the deepest part of the incision 1 purposely used the cutting instrument as lightly as possible, with a view to open only a part of the membranous portion of the urethra, and notch the prostate and neck of the bladder. These objects being effected, the point of the forefinger of my left hand was, as usual, placed on the staff, and pushed gently towards the bladder. The finger went on, but I was aware that it had not got between the urethra and the staff. With an insinuating movement (much to be appreciated by the li: botomist who, as I do, professedly makes a small incision in this locality), I endeavoured and hoped to get its point as usual into the urethra and neck of the bladder. But here I felt conscious that I had failed. I was aware that the linger was getting deeper as regarded the depth of the perineum, but that I was not materially nearer the bladder. 1 could feel a considerable space at the point of my finger, and was convinced that the upper part of the membranous portion of the urethra, as well as the sides above the wound, had given way to the pressure of the point of the finger, and that now, as the latter was getting deeper into the wound, I was only pushing the prostate gland and neck of the bladder inwards and upwards. These parts seemed to recede before the smallest imaginable force, whilst I felt that I could in a manner make any amount of space round the bare part of the staff. I had no difficulty in distinguishing between the surface of this space and that of the mucous me'hbrane of the bladder. Moreover, I knew that I had never crossed that narrow neck which is always felt as the finger passes into the bladder when a limited incision is made. An impression came over me that I was about to fail in getting into the bladder, and I had the idea that unless 1 could open the urethra just in front of the prostate more freely I should possibly never reach the stone. Any additional use of the forefinger of the left hand only endangered the further separation of the prostate and neck of the bladder from the pubes, and I was conscious that the only safety lay in cutting a little more freely on the groove of the staff. This I effected with great caution. and then I could aoc'"'ciate the passage of the finger
doi:10.1016/s0140-6736(02)68337-0 fatcat:soaetku3y5go5g76mjdlf7oiom