STONE IN THE BLADDER; 
ABSCESS OF THE LIVER. 
I 
Clinical Lecture Delivered at the German Hospital. 
BY 
JOHN B. DEAVER, M.D., 
Professor of Surgery, Philadelphia Polyclinic, and Assistant Professor of 'Applied Anatomy, University 
of Pennsylvania. 
Reprinted from the International Medical Magazine for April, 1892. STONE IN THE BLADDER; ABSCESS OF 
THE LIVER, 
STONE IN THE BLADDER. 
Ladies and Gentlemen,-The first patient upon whom I will 
operate to-day is a boy nineteen years of age, with a stone in the bladder. 
What are the symptoms of stone in the bladder? They are subjective and 
objective. The subjective are those elicited from the patient, namely, pain- 
ful and frequent micturition, the pain being more pronounced at the end of 
the act, owing to the contraction of the sensitive mucous membrane at the 
neck of the bladder upon the stone; the pain also is referred to the end of 
the penis about one inch within the meatus; another striking example of 
referred pain is in hip-disease, where it is referred to the inner side of the 
knee. The objective evidences of stone in the bladder are its detection by 
means of the sound or the cystoscope, and the presence of blood and pus 
in the urine. In the case of young children it is not uncommon for them 
to grasp and pull at the prepuce, owing to the irritation occasioned by the 
stone being communicated to this part of the organ; at the same time we 
may have associated with this symptom more or less prolapse of the rectum. 
When a child is brought to me with prolapse of the rectum, I never fail to 
explore the bladder for stone. In children the stone is most commonly of 
renal origin, while in the adult it more commonly originates within the 
bladder. 
Of the different operations for stone in the bladder I will mention but 
four,-lateral, median perineal, and suprapubic lithotomy, and litholapaxy. 
Each of these operations, I believe, has still a place in surgery, notwith- 
standing the fact that the suprapubic is so well thought of, and recom- 
mended by many surgeons as fulfilling all the indications for the extraction 
of a stone from the bladder. I practise all of these operations, and there- 
fore teach their indications. The ideal operation for stone in the bladder, 
to my mind, is litholapaxy, which consists in crushing the stone and washing 
the fragments out at one sitting. I contend that it requires as good judgment 
to select the proper operation in any given case of stone in the bladder as it 
does to decide upon the propriety of an operation in certain questionable 
cases of gangrene, therefore each case must be analyzed and judged upon 2 
JOHN B. DEAVER, M.D., ON 
its own merits. I will speak briefly for a few minutes upon what I regard 
as indications for each of the four operations. 
Median Perineal Lithotomy.-Adults; very small stone ; irritable and 
contracted bladder; marked cystitis; moderate-sized prostate. 
Lateral Perineal Lithotomy.-Children under five years of age, medium- 
sized stone; adults where there is present a very bad cystitis, contracted 
and irritable bladder, medium-sized stone. Under these circumstances the 
lateral is preferable to the median operation. Owing to the wound being 
larger, the bladder can be better drained and the stone more easily 
extracted. 
Suprapubic Lithotomy. - Adults and children; very large and hard 
stone; stone, the nucleus of which is a foreign body; marked enlarge- 
ment of the prostate. Where the latter is present this operation gives the 
surgeon, after having removed the calculus, the opportunity of doing a 
partial prostatectomy, which operation enables the patient to live without 
the use of the catheter, or at least renders the passage of the instrument 
less difficult. 
Litholapaxy.-Absence of Bright's disease; absence of cystitis to any 
degree; a non-contracted and retentive bladder, one which, if in an adult, 
will contain and retain six to ten ounces of boracic acid solution, or the 
equivalent amount of urine, and, if a child, from four to six ounces; a 
non-irritable urethra. This is determined by passing a steel bougie, the 
size of the urethra, for two or three days before the operation. 
Should the urethra be the seat of a stricture or strictures, there being 
no other contra-indication to crushing, they should be either cut or dilated, 
depending upon their location; a prostate not too large to embarrass the 
ready passage of a large lithotrite and the evacuating catheter; a urethra 
allowing the ready passage of the lithotrite and evacuating tube; a stone 
neither too large nor too hard. 
Experience has taught us that litholapaxy is a more fatal operation in 
cases of Bright's disease than lithotomy. The greater fatality of litholapaxy 
over lithotomy in this condition is, I believe, due to the concussion of the 
bladder walls which occurs during the washing out of the fragments of stone. 
The greater the amount of water in the bladder short of distending it, 
the greater will be the force of the wave displaced when forcing water into 
it with the evacuator. Therefore, it is the practice of operators not to have 
more than six to eight ounces of fluid in the bladder of an adult when 
ready to evacuate. By having too much fluid in the bladder, and using too 
great force in washing out the fragments of stone, this organ has been 
ruptured. In the cases where rupture has occurred the walls of the bladder 
were probably undergoing fatty degeneration. 
I have said that litholapaxy is the ideal operation, and for the following 
reasons, namely, that, ordinarily, the patient is not confined to his bed, after 
this operation, longer than one week, when he is able to resume his previous 
mode of life. STONE IN THE BLADDER; ABSCESS OF THE LIVER. 
3 
The amount of pain is less than that after lithotomy, granting, of course, 
that the operation has been properly and skilfully done. Litholapaxy is 
never followed by a fistulous communication with the bladder through 
which urine constantly passes, to the great annoyance of the patient, which 
is a risk every patient on whom lithotomy is done assumes. 
To determine whether or not litholapaxy was indicated or contra-indicated 
in the patient who is being etherized in your presence, his urine has been 
examined with negative result; the calibre of his urethra measured and 
found to be twenty-nine; it also showed the absence of any obstruction. 
A No. 29 steel bougie has been passed three or four times without occasion- 
ing any unpleasant symptoms, showing the absence of irritability of the 
urethra. 
The prostate was examined per rectum, we not detecting, of course, in 
so young a man any enlargement. 
The retentive power of the bladder, as well as its capacity, has been 
tested; the size of the stone determined with a small lithotrite, and found 
to be an inch and a quarter in diameter. 
The chemical and microscopical examination of the urine and the 
examination with the sound lead me to believe that the stone is probably 
phosphatic in character. Although a day or two ago I detected the stone 
with the sound, I will again make the examination and see whether or not, 
with the aid of a sounding-board, I can make the click occasioned by the con- 
tact of the sound with the stone audible to you all. This I do very readily. 
Had I failed, before refusing to go on with the operation, as is the rule 
with surgeons under such circumstances, I would have made a cystoscopic 
examination, when, if still unsuccessful, I should have postponed the oper- 
ation. 
The patient being now fully under the influence of the anaesthetic (and 
I emphasize the word fully because in this class of operations particularly it 
is important that full anaesthesia be induced), I introduce into the bladder 
a soft catheter, and through it inject eight ounces of a saturated solution 
of boracic acid. 
I next withdraw the catheter and introduce a medium-sized Thompson 
crusher, with which, when it is well-engaged, I feel for the stone. 
Having come in contact with it, I open the blades of the instrument, 
and with slight manipulation you see that I have grasped the stone. 
I next fix the blades, so as not to lose hold of the stone when I depress 
the handle of the crusher, and bring the beak of the instrument well into 
the centre of the bladder, where, on revolving it, I find it moves readily, 
thus demonstrating that the mucous lining of the bladder has not been 
grasped with the stone. By turning the screw at the base of the handle I 
reduce this stone to fragments. 
The fragments, as was the stone, are grasped by the lithotrite and reduced. 
You will note that I have continued this manipulation until I am no 
longer able to grasp a fragment of any size. 4 
JOHN B. DEAVER, M.D., ON 
I therefore withdraw the crusher, and, strange to say, it is arrested at a 
point in the urethra, about two inches behind the meatus. The cause of 
this I do not understand, as the blades are certainly in apposition, as in- 
dicated at the base of the handle of the instrument. I will make fairly 
strong traction on the instrument, at the same time endeavoring not to tear 
the urethra, to see whether or not I can withdraw it. This I am able to do, 
and within the grasp of the blades you perceive what evidently is a piece 
of leather shoestring about four inches in length. This was undoubtedly 
introduced from without and formed the nucleus of the stone. This makes 
the fourth case of stone in the bladder, upon which I have operated, where 
a foreign body formed the nucleus of the stone. Of the other three cases, 
all of which were females, the foreign body in one was a hair-pin, and in 
the remaining two a silk ligature. The ligatures had ulcerated their way 
into the bladder from the stump of the pedicle of an ovarian tumor. I next 
introduce this evacuating tube or catheter, the calibre of which is twenty- 
seven millimetres, two millimetres less than the size of the urethra, which, 
you will recollect, measured twenty-nine millimetres. This tube is fashioned 
after the pattern of Otis, differing from Bigelow's in that it is straight and 
has a larger fenestrum at the bladder end. 
To this, the free end of the catheter, I attach the Otis evacuator and 
proceed to wash out the debris, which, you will note, is done by making 
gentle pressure upon this rubber bulb, thus throwing the boracic acid 
solution, with which the evacuator is filled, into the bladder, while the 
debris is washed out and deposited in the reservoir of the instrument. 
You will also note that the liquid pumped out of the bladder is but 
little if any discolored, showing that the mucous lining has been left intact. 
A considerable amount of debris now occupying the reservoir, I detach 
the evacuator and empty the reservoir, when I find together with the 
fragments of stone two pieces of shoestring, each about half an inch in 
length. 
The evacuator is again filled with boracic acid solution, attached to the 
catheter, and the bladder rewashed, when, as you will see, some fragments 
again appear in the reservoir. I again detach it, and in it I find two more 
pieces of shoestring, each about half an inch in length, these with the 
other pieces having evidently been bitten off by the crusher. 
I again fill the evacuator and wash out for the third time, when failing to 
remove any further fragments I detach it, remove the catheter, and introduce 
a sound, with which I explore the bladder, but am unable to find any frag- 
ments ; therefore it simply remains for me to withdraw the sound, introduce 
a rubber catheter, and evacuate the bladder. I now wash it out with boracic 
acid solution, which you see escapes perfectly clear, withdraw the catheter, 
and introduce into the rectum a suppository composed of one quarter of a 
grain of morphine and ten grains of quinine. 
The patient will now be returned to bed, and warm bottles applied to 
the body. STONE IN THE BLADDER; ABSCESS OF THE LIVER. 
5 
The after-treatment will consist simply in the administration of morphine 
in small doses if there'is pain, two grains of quinine by the mouth four 
times daily, Buffalo lithia water given ad libitum, and the patient confined 
to a liquid diet for two or three days. 
For the first forty-eight hours I will have the urine drawn with a soft 
catheter and the bladder washed out twice daily with boracic acid solution. 
After this the patient will be allowed to pass his water voluntarily. 
I neglected stating that the preparatory treatment consisted in giving 
three grains and a half of salol with five grains of boracic acid four times 
daily for the past five days, and in clearing out the bowels immediately be- 
fore the operation. The object of this treatment is to asepticize the urine, 
therefore rendering complications less liable to occur. 
ABSCESS OF THE LIVER. 
The second patient I will bring before you is a man, aged forty-two, 
transferred to me by my colleague, Dr. Wolff. 
Seeing the patient now for the first time, and not familiar with either 
his history or his condition, I will ask Dr. Wolff, who is present, to kindly 
say a few words to you, explaining why the case has been placed under 
my care. 
From what Dr. Wolff has said, I have no hesitancy in concurring with 
him in the opinion that this man is the subject of an hepatic abscess, and, 
if such is the case, there is no question about the advisability of imme- 
diately evacuating the same. 
The operation of opening a liver abscess is technically known by the 
name of hepatotomy. 
When the urgency of the case does not demand immediate evacuation, 
this operation can be done in two steps, the first consisting in exposing the 
liver at the site where the incision into it is to be made when the serous 
covering of the organ is stitched to the parietal peritoneum around the 
margins of the wound, the object of this being to have the peritoneal cavity 
shut off by inflammatory adhesion, so that when the abscess is opened, two 
or three days later, there will not be any danger of the pus finding its way 
into the peritoneal cavity. This part of the operation is known as hepator- 
rhaphy. 
When the case is very urgent it may not be justifiable to resort to this, 
fearing that the abscess will rupture into the peritoneal cavity ; therefore, 
it is necessary to open it at once, and in order to prevent the escape of pus 
into the cavity of the peritoneum, we introduce sponges at the site of the 
incision into the liver, between the serous covering of the liver and the 
parietal peritoneum around. 
Under the latter circumstances there is much more likelihood of the 
peritoneum becoming infected, therefore it is attended by more risk. 
As the most prominent portion of the swelling in this case is to the 
right of the linea alba, I will make the incision over the summit of the 6 
STONE IN THE BLADDER ' ABSCESS OF THE LIVER. 
prominence in a vertical direction, which brings me directly down upon 
the rectus muscle. I cut through the muscle, when I expose the posterior 
layer of its sheath; this I will take up and divide the full length of the 
incision, in this way exposing the transversal is fascia, which I find is infil- 
trated, suggesting that nature has shut off the general peritoneal cavity by 
inflammatory adhesions. 
This upon further dissection I find to be so, therefore I will at once open 
the abscess, from which you see escaping a large quantity of purulent matter. 
I next wash out this cavity with boracic acid solution, introduce to the 
bottom of the cavity a glass drainage-tube, around which I pack the cavity 
with iodoform gauze. I will also pack the wound with the gauze, apply 
an iodoform-gauze dressing, and return the patient to bed. 
[Both of the above cases were shown to the class the following week. 
The stone case walked into the amphitheatre well, while the man with ab- 
scess of the liver was brought in on his bed and dressed. The latter is 
improving rapidly, as is shown both by his appearance and the chart, which 
contains a record of his pulse, temperature, and respirations. 
The subsequent history df the stone case having proved quite unique, 
I will include it with the above lecture. The boy continued to complain, 
just as he had done previous to the operation, of pain when passing water, 
more marked at the end of the act, and an examination with the Leiter 
electric light cystoscope revealed a foreign body at the base of the blad- 
der. I therefore cut him through the perineum and removed sixteen 
inches of shoestring, making, with the pieces removed at the crushing, 
twenty-two inches in all. The reason I did not attempt to remove it with 
the lithotrite was owing to the presence of a cystitis, and the fact that the 
pieces of the string previously removed were so brittle.]