probably the most perfect. I know that it has been particularly successful in Mr Skey's hands, and in Mr Pollock's; but, with all deference, I am still disposed, from all I know of the subject, to prefer a free incision above the soft palate, whereby the levator palati may be divided to a certainty. In addition, I look upon this wound as of great service in this respect-the lymph effused upon it acts as a splint, whereby the palate is kept fixed as a board until union in the mesial line is complete.

As to attitudes in this operation, the patient may sit or lie, as may best suit convenience. Latterly, I have made most use of the recumbent. I find that the head can be kept best on the same line in this position; and as regards my own views on the anatomy and physiology of the parts concerned, I deem the subject of some importance. For instance, if the patient sits with the head slightly thrown backwards, the palato-pharyngei, when irritated, pull the soft palate downwards towards the epiglottis, so as to leave a space between the palate and the base of the cranium; but if the head be thrown far backwards the axis of action is altered, and these muscles draw the soft parts upwards, or, in other words, bring the soft palate towards the base of the cranium, and thus add to the difficulties of the surgeon by limiting the space above the soft palate where he has to work with the needles in introducing sutures. Here, as in hare-lip, the surgeon has generally stood before his patient, but I invariably select his right side in preference to all other places.

The grand practical object of this operation is to improve the voice and articulation. Defective deglutition from this malformation is what attracts the mother's or nurse's attention in early life. The cries of infancy are in nowise peculiar in tone; but when definite articulation commences, or rather should commence, the value of an entire palate is then appreciated. The air and sound, in passing outwards from the larynx, escape in part through the nostrils by the split in the palate. A nasal twang is the result, and articulation as in the normal state of the parts is impossible.

Immediately after the operation, the modification on the voice can be at once detected. It is customary to keep those operated on from speaking for eight to ten days. It is, however, a needless restriction as regards my operation. In reality, few care, under the circumstances, to speak at all; yet I do not think that it would do harm. In the course of eight or ten days, when the fever or distress following the operation has gone, the tone of the voice is at once perceived to be changed for the better. Improved articulation, however, comes more slowly. Years, many years, are required for distinct articulation when the whole organs are to all appearance in perfection; and after the most successful operation for cleft palate, months and years are required to alter defective sounds. Voice and speech have to be modified anew. With some the changes come slowly and sluggishly; but with others they are so rapid and perfect that in a few years the original defect cannot be detected except by a practised ear.

LECTURE IV.

ON LITHOTOMY IN CHILDREN AND ON LITHOTRITY."

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 readily effected that comparatively 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 for beginners by directing attention to certain points which have here

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tofore 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 seen, read, and heard of in the practice of others during the time I have been in 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