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', ,"i ij ■ / >;'■ '■ :•/ ;•; > • i ' ' V IVN 3N.3.03W JO U«IIM IVNOIIVN 3NI3I03W JO UY..I1 TVNO.IVN 3 N I 3 I 0 J W JO A B V 8 8 M IVNOIIVN 3N.3.C3W JO A 8 V 8 • IT TVNO.IVN ^ CINE NATIONAL LIBRARY OF mTdiCINE N A T I oTa I L I B R A R Y O F M E D I C I N E N A T I O N A I I I B R A R Y O F M E D I C I N E N A T I O N A L I I B R A R Y O F M E D I C I N E CINE NATIONAL LIBRARY OF MEDICINE N A T I O N A L L I B R A R Y O F M E D I C I N E N A T I O N A I I I B R A R Y O F M E D I C I N E N A T I O N A L I I B R A R Y O F M E D I C I N E E 0 IIIVN 3NI3I03W JO A8V8SI1 IVNOIIVN 3NI3IQ3W JO A8V8BI1 IVNOIIVN 3NI3IQ3W JO A8V8BI1 IVNOIIVN 3 N I 3 I 0 3 W JO A B V 1 S I 1 IVNOIIVN 9 n (rJP$$'L CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAl LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE LIBRARY OF MEDICI n/ ? \'W S ¥e>/ ? x , IIIVN 3 N I 3 I d 3W JO ABVBflll IVNOIIVN 3NI3IQ3W JO ABVBflll IVNOIIVN 3NI3IQ3W JO ABVBflll IVNOIIVN 3NI3IQ3W JO ABVBBI1 IVNOIIVN CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAl LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 5 v. 7 • ^y^f^' IIVN 3NI3IQ3W JO ABVBflll IVNOIIVN 3 N I 3 I d 3 W JO ABVBflll IVNOIIVN 3NI3IQ3W JO ABVBflll IVN ^^Wfli 3NIDI03W JO AUVdan 1YN0UVN T TDibQTSO WIN NLM051097061 SUPRAPUBIC LITHOTOMY. THE HIGH OPERATION FOR STONE-rEPICYSTOTOMY—HYPO- GASTRIC LITHOTOMY-(THE HIGH APPARATUS). BY i WM. TOD HELMUTH, M.D., * * * PROFESSOR OF SURGERY IN THE NEW YORK HOMOEOPATHIC MEDICAL COLLEGE, SURGEON TO THE HOMOEOPATHIC HOSPITAL ON WARD'S ISLAND, AND TO THE HAHNEMANN HOSPITAL, NEW YORK, ETC., ETC. ILLUSTRA TED WITH EIGHT LITHOGRAPHIC PL A TES AND NUMEROUS ENGRAVINGS ON WOOD. BOERICKE & TAFEL: NEW YORK, PHILADELPHIA, 145 Grand St. 1011 Arch St. 18 8 2. '/ss* Copyrighted, 1882, By War. Tod Helmtjth. BIBLIOGRAPHY. American Journal of the Medical Sciences. July, 1875; July, 1877; April, 1878. American Journal of the Medical Sciences. April, 1881. American Journal of the Medical Sciences. January, 1878. American Journal of the Medical Sciences. April, 1880. American Journal of the Medical Sciences. January, 1880. American Journal of the Medical Sciences. January, 1879. Medical Times. December 18th, 1880. Landmarks, Medical and Surgical. By Luther Holden, F.R.C.S. London, 1876. Gross, On the Urinary Organs. 3d Ed., Philadelphia, 1876. Handbuch der Topographischen Anatomic Hyrtl. Vol. ii. Wien, 1860. Banking's Half Yearly Abstract of the Medical Sciences. Vol. xii, 1850, pp. 130. Cooper, Samuel, Surgical Dictionary. New York, 1854. Velpeau, A.A.L.M., Operative Surgery. Vol. iii, p. 947, et seq. Belmas, Traite de la Cystotomie sus-pubienne. Paris, 1827. Heister, D. L., InstitutionesChirurgicse. Tom. ii. Amstelsedami, MDCCXXXIX. Van Buren, W. H., & Isaacs. Operative Surgery. New York, 1857. Coulson, Diseases of the Bladder. Philadelphia, 1838. Coulson, Diseases of the Bladder. Revised Edition. New York, 1881. Giinther, G. B., Operationem am Becken. Leipzig und Heidelberg, 1860. Giinther, G. B., Der hohe Steinschnitt. Leipzig, 1851. Dupuytren, G., Lithotomie, These. Paris, 1812. Concours pour la chaire de medecine operatoire. Philosophical Transactions. Vol. xii. London (1700-1722-23.) Transactions of the Provincial Medical and Surgical Association, 1850. Cheselden, W., A Treatise on the High Operation for Stone. With xvii copper-plates. London, 1723. 4 BIBLIOGRAPHY. Cheselden, W., The Anatomy of the Human Body. London, 1778. Carpue, J. C, F.R.C.S., History of the High Operation for Stone. London, 1819. Baseilhac Paschal. Eloge Historique de Frere Come, de la Taille Laterale et celle de l'hypogastrique ou Haut Appareil. Paris, 1804. Come Frere. Nouvelle methode d'extraire la pierre de la vessie par dessus la pubis qui on nomme vulgairement le Haut Appareil dans l'un et l'autre sexe, sans le secours d'aucun fluide retenu ne force dans la vessie. Paris, 1779. Humphreys, G. M., Trans, and Provincial Medical and Surgical Association. Vol. v, London, 1851. Memoires de l'Academie Royale de Medecine. Paris, 1840. Gibson, William, Institutes and Practice of Surgery. Vol. ii, Phila., 1835. London Lancet. Vol. ii, 1841. London Lancet. Vol. ii, 1858. London Lancet. Vol. ii, 1873. St. Louis Medical and Surgical Journal. 1865. Dictionnaire Encyclop. des Sciences Medicale. Paris, vol. xxv, 1880. Medical and Surgical History of the War of the Rebellion. Part ii, vol. ii. Medico-Chirurgical Review, Lithotomy and Lithotrity compared. By Thomas King, M.D., M.R.C.S. London, 1832. Medical Record. New York, January 25th, 1879. Sharp, Samuel, A Treatise on the Operations of Surgery. London, 1747. Holmes, A Treatise on Surgery, its Principles and Practice. Phila., 1876. Spence, James, F.R.C.S., Lectures on Surgery. Vol. ii, Edinburgh, 1871. Pirrie, Wm., F.R.S.E., The Principles and Practice of Surgery. London, 1873. Gross, Samuel D., A System of Surgery. Philadelphia, vol. ii, p. 894. Bryant, Thomas, F.R.C.S., The Practice of Surgery. London, 1872. Hamilton, F. H., Principles and Practice of Surgery. New York, 1872. Erichsen, John, The Science and Art of Surgery. Philadelphia, 1860. Erichsen, John E., The Science and Art of Surgery. New Edition, ii vols. Philadelphia, 1878. Latta, James, A Practical System of Surgery. In three volumes. Vol. i, London and Edinburgh, 1795. Roberts, John B., American Edition of Bryant's System of Surgery. Phila- delphia, 1881. BIBLIOGRAPHY. 5 Holmes, T., A System of Surgery. In five volumes. New York, 1871, vol. iv. London Medical and Surgical Repertory. Vol. xii-xiii. Kirby, Cases with Observations on Wry-neck, etc., Medico-Chirurgical Soc. Edinburgh, vol. ii. London Medical Gazette. Vol. i-v. Transactions Medico-Chirurgical Soc. Edinburgh, vol. ii. Bulletin de Therapeutique. Vol. xcii. Canadian Journal of Medical Sciences. Toronto, No. 2, Nov., 1881. Dictionnaire de Med. et de Chirurgie. Paris, 1831. South's Translation of Chelius's System of Surgery. Philadelphia, 1847. Bancal, A. P., Lithotomie et Lithotripsie. Bordeaux, 1839. Hildanus, Guil., Fab. Opera quae extant omnia. Frankofurte ad Msenum. 1646. Cross, John Green, A Treatise on the Formation, Constituents, and Extraction of Urinary Calculi. Prize Essay. London, 1835. Archives de Medecine. Paris, vols, xvii, xix, xx, xxi, xxvii. Anderson's Quarterly of the Medical Sciences. London, 1824-26, vol. iii. Edinburgh Journal of the Medical Sciences. 1826-27, vol. iii. Sabattier, R. B., De la Medecine Operatoire. Nouvelle Edition, par J. L. Sam- son et L. J. Begin. Four volumes. Paris, 1832. Le Courrier Medical. Paris, 1876. Poulet, A., Foreign Bodies in the Bladder. Vol. ii, New York, 1880. M£$y FRONTISPl ECE Regional Anatomy of parts concerned in Epicystotomy . g-.NUras |;H..9h'il! FRONTISPIECE. Longitudinal Section of the Abdominal Cavity. A. Bladder; portion of left wall removed. B. Prostate gland. C Vesicula seminalis (left). D. Bulb of urethra. E. Crus penis. F. Symphysis pubis. G. Anterior wall of bladder, not covered by peritoneum. H. Peritoneum reflected from fundus of bladder to abdominal wall. I. Triangular space formed by the reflection of peritoneum, marking the site of the incision; generally covered with bladder fat. K. Sacrum. L. Rectum. M. Ureter. N. Vas deferens (left). O. Anus. PREFACE. In these days, when the entire surgical world is so deeply interested in Bigelow's Litholapaxy,* or, as it should be named, " the American method of lithotrity," it would appear almost inappropriate to call attention to any form of lithotomy, especially to that one, which, in the estimation of many surgeons, is the most unreliable, and only to be performed under most peculiar circum- stances. So convinced, however, is the author of these pages that epicystotomy will, before many years have passed, receive a high place among all the cutting operations for stone in the bladder, especially in those cases in which litholapaxy is inappropriate, that this essay is offered to the profession. The author, however, in this place, desires to give to Dr. C. W. Dulles, of Phila- delphia, the credit of developing and prolonging an interest in epicystotomy, which otherwise would not have existed, and would state that it was from the perusal of his (Dr. Dulles) papersf that he was led to perform the operations which are herein detailed. In the admiration, however, which is felt for the easy performance and comparative freedom from danger of the suprapubic method, the author would net be understood as considering it preferable to the crushing operation as it is performed to-day,{ for with the present appreciation of litholapaxy and its results,§ perhaps if the second case recorded had been submitted to the lithotrite the patient might have recovered. The desire is simply to express the con- viction that if a cutting operation be desirable, hypogastric lithotomy in many cases is preferable to all others, and to direct attention to the fact that a fair * Lithotrity by a Single Operation. By Henry J. Bigelow, M.D. American Journal of the Medical Sciences. January, 1878, p. 117. f Suprapubic Lithotomy. By C. W. Dulles, M.D. American Journal of the Medical Sciences. July, 1875; July, 1877; April, 1878. I Vide "Kapid Lithotrity with Evacuation." By E. L. Keyes, A.M., M.D. American Journal of the Medical Sciences. April, 1880. \ Vide" An Article on Litholapaxy." By B,. F. Wier, M.D. American Journal of the Medical Sciences January, 1880, p. 130. 8 PREFACE. estimate of it has not been arrived at by the majority of the profession, because, as a rule, only the most aggravated cases have been to it submitted. Every candid surgeon of the present day, dispassionately considering the suprapubic method, compared with the various perineal and other operations for removing calculi from the bladder, must arrive at the conclusion that epi- cystotomy, from the anatomical construction of the parts incised, from its simplicity, and the advantage of seeing as well as feeling the varied steps of the operation, must often be the superior method. These views are gradually being entertained by the profession, as may be evinced by the newer methods of treating cystitis and enlarged prostate by an opening above the pubes after the manner of Sir Henry Thompson.* When as much time and experience have been expended upon " the high operation " as have been given to lateral and median lithotomy, and when an equal number of favorable cases have been submitted to it, the results will be better than those furnished by any other cutting methods for the extraction of stone. * Medical Times, December 18th, 1880. CONTENTS CHAPTER I. A Brief History of Suprapubic Lithotomy from the time of Franco to the present, with a Description of the Various Methods of Performing the Operation, CHAPTER II. Tables of Suprapubic Lithotomy, Chronological and Comparative, containing the Num- ber of Operations Performed, the Rates and Causes of Mortality, the Size of the Stone, and the results, ............ CHAPTER III. Opinions, Objections to, and Arguments in favor of the Operation. Experiments on the Cadaver relative to the Bladder-peritoneum. Advantages claimed for Epicys- totomy,.......... CHAPTER IV. Cases of Suprapubic Lithotomy, with a Description of the Steps of the Varjed Opera- tions Performed by the author and others,........ CHAPTER V. Method of Performing Epicystotomy. The Various Steps of the Operation and the Instruments Employed. After-treatment,........ SUPRAPUBIC LITHOTOMY. CHAPTER I. A BRIEF HISTORY OF THE HIGH OPERATION. Ix endeavoring to look into the remote history of suprapubic lithotomy, one is surprised to observe the many vicissitudes through which it has passed; sometimes standing high in the estimation of the profession, at other periods sinking entirely into oblivion. The history, however, is full of interest to those desiring to investigate the subject, for here and there throughout its lit- erature, exhaustive monographs appear, exhibiting the zeal and perseverance of those, who from time to time have been the upholders of the operation. In the whole history of hypogastric lithotomy, the most decidedly unique case in all its details is that of Jean de Dot, the smith, of Amsterdam, " who cut himself in the linea alba above the pubis, and took out of his bladder a stone as large as a hen's egg. The stone, the knife, and the portrait of the operator, may be seen to this day in the Museum at Leyden."* Being anxious while investigating this subject to learn more of this remark- able case, I addressed a communication to Mr. Holden, inquiring if more details could be furnished. I received in a courteous reply, the following ex- tract : " Jean de Dot, a smith of Amsterdam, cut a stone as big as a goose- egg out of his own bladder by the suprapubic operation; he used a pocket knife previously sharpened, and was assisted by his apprentices. " This case happened in the seventeenth century, and the history is attested by the Burgomeister and Town Council, as also by the College of Sur- geons, "t On a late visit to Holland, I took especial pains to visit the Anatomical Museum, at Leyden, and had the satisfaction of seeing the stone, the knife, which is an ordinary shoemaker's knife, not a pocket knife, as related by Hyrtl, and the certificate of the notary, " Pieter de Barry," with the date of "Maye, 1651." I observed also that the record reads Jean Doot, and not "de Dot," as is printed in several works of to-day. * Landmarks, Medical and Surgical. By Luther Holden, F.R.C.S. London, J. Churchill, p. 31; also vide Gross on the Urinary Organs, 3d ed., Philadelphia, 187G, p. 293. f Ilandbuch der Topographischen Anatomie, Hyrtl; vol. ii, p. 145; Wien, I860. 2 10 SUPRAPUBIC LITHOTOMY. It may be well here also to note the remarkable case of Josephi, in 1828, as recorded by Giinther, in which a foetus was removed by the high operation, having passed into the bladder, either from the Fallopian tube or ovary, and also another but more recent one, in which a stone was extracted at the umbili- cus through an open urachus.* The immense volume of some of the calculi which have been removed by the suprapubic method render the cases very remarkable. Thus Vitellius extracted a calculus weighing Sxxij, as related by Earle. The patient died. This case must have been among the earlier operations, as it is referred to by Hildanus, as quoted by Dulles. In Earle's paper, which was. read on March 28th, 1820, the suprapubic method is not specified. It is also mentioned that Deguise, took from a patient, aged sixty-five years, a stone weighing 5xxxj, which had been fruitlessly attempted through the peri- nseum. The patient died on the sixth day. Uytterhceven cut out a concretion weighing two pounds, as quoted by Erich- sen, Dulles, and others. In Krimer's case the stone weighed 5xxiij, the patient was fifty-eight years of age, and the perinseal operation had been unsuccessful. In the following history, the dates and items of the earlier operations, I have taken from Cheselden, Heister, Frere Come, Sharp, Baseilhrec, Carpue, Belmas, Souberbeille, Humphrey, Giinther, Dulles, Cooper, and Velpeau, with such information as I have been able to glean from other sources. The latter portion of the history, particularly that of the American operations, are given in Dr. Dulles's tables just as he has made them, not desiring in an}7 way to interfere with his labors. No apology is needed for thus employing the work of others in matters of history, for it is astonishing to find in tracing the dif- ferent writings of those interested in the subject how very minutely one author has followed another. In Belmas's book, which is the most compre- hensive, I have found many items of interest, and this work, together with that of Come, Giinther, and Carpue, have been my chief guidance. To those who desire to examine further the bibliography of suprapubic lithotomy, not only in regard to those who have operated, but also with refer- ence to those who have written upon the subject, I would recommend a pe- rusal of these works. It is the opinion of some scholars and authors that the "high apparatus" can be carried back to Philagrius, who nourished shortly after Galen; he is reputed to have operated for a calculus impacted in the urethra, for he recom- mends the incision to be made " superne ju.rta glandis magnitudinem." Samuel Cooper,f however, states that hypogastric lithotomy was first practiced * Ranking's Abstract of the Medical Sciences, vol. xii, 1850, p. 130; art. 86. f Surgical Dictionary, New York, Harper & Brother, 1854, p. 137. SUPRAPUBIC LITHOTOMY. 11 in Paris in 1475 by Colot. The patient was a criminal, and was operated upon by permission of Louis XL It is said that recovery took place in a fort- night. His claim to priority is denied by Velpeau,* who declares that Mr. Cooper had no grounds for the assertion, and that it is very uncertain what operation was performed by Colot. There is also an idea prevalent among some antiquarian searchers, among whom is found one Nevermann, that the high operation for stone in the bladder might be traced to a period as remote as 1000 years B. C.; but in speaking on this very point Giinther says that there can be no foundation for such an asser- tion, because the description of the operation in the Ayur- Veda is according " to the cut of Celsus." This, however, would scarcely be held as tenable, for Cel- sus himself may have copied from the Hindoos. Brockhaus, however, asserts that the Ayur- Veda is not older than B. C. 150. Others are of opinion that Atius, in the year 550, performed the first operation. By general consent, how- ever, priority belongs to Pierre Franco, who in 1561, according to Belmasf and YelpeauJ and 1560, according to Heister,§ resorted to suprapubic lithot- omy with success at Lausanne. The method he resorted to was the old one of " cutting on the gripe," as it was called, transferred from the perineum to the hypogastrium. He says his patient was operated upon " on the mons veneris, a little to one side and over the stone, while he raised up the last with his two fingers, which were in the fundament, and keeping it moreover under his control by means of the hands of an assistant, which made compression on the lower belly." I find also that some surgeons have stated that Franco's incision was made transversely " parallel to and a short distance above the superior border of the pubes."!! Franco, however, can scarcely be called an upholder of the method, for Heister states specifically, that he was moved more by the entreaties of the parents to rescue their child from misery than from any foregone conclusion of the superior merits of the operation. The patient was a boy, aged two years, and the stone was the size of a hen's egg, which he had been unable to extract from the perinseum.* Velpeau again corrects the latter portion of the state- ment, and avers that Franco had not previously cut the patient in the peri- neum. Carpue states that the operation was performed " en deux temps." Twenty years after, Franco's operation being in 1581, Kousset (Bossetus) described it and published a work in its favor, though he was never able to * Velpeau, Operative Surgery, vol. iii, p. 947. f Traite de la Cystotomie Suspubienne. Paris, 1827, p. 2. J Operative Surgery, vol. ii, p. 947. \ Institutiones Chirurgicae. D. Laurentii Heisteri, torn, ii, p. 927. || Bernard and Huett's Manual of Operative Surgery. Van Buren & Isaacs, New York, 1857, p. 434. If Tamesti enim primus ejusdern auctor feliciter eandern in puero bimulo, Lausannre, A.D 1560, instituerat, propterea quod calcnlnm qui ovum gallinae sequabat, in perinseo educere non poterat. D. Laurentii Heisteri Institutiones Chirurgicae, vol. ii, p. 926. 12 SUPRAPUBIC LITHOTOMY. perform it, on account of the death of Henry III, who, as Velpeau says, " had promised to assign him three or four criminals for experimentation."* This book was afterward translated into Latin under the name De Partis Gesaris. The method recommended by Bousset was to fill the bladder with water, milk, barley-water, or other fluid, to distend it sufficiently above the pubis; then to place a ligature around the penis, or to have that organ squeezed tightly by an assistant, to prevent the escape of the fluid. A razor was used to divide the integument and fascia, and a concave bistoury was then introduced just above the symphysis pubis; into this puncture a lenticular bistoury was in- serted and the incision completed from below, upwards. The calculus was then to be extracted with the fingers if possible, if not, by means of a suitable scoop. But to return. After Franco's operation a long time must have elapsed with- out much attention being given to hypogastric lithotomy, for the next record is not until the year 1635, when Mercier defended the operation in a thesis of N. Pietre. Of this Guy-Paten states that he (Pietre) performed the opera- tion several times in 1635.f Pietre died in 1649, and was the first to recommend lifting the bladder by means of a sound or catheter.! In the year 1681, we are informed by Toilet, that Bonnet (Bonnetus) prac- ticed the high operation at the Hotel Dieu, and that it was witnessed by the celebrated Petit. These records, however, were discredited by John Douglass, of whom more will be spoken ; but Belmas§ and others are of the opinion that Douglass, desiring to be considered the reviver of the operation after Franco, was therefore disposed to ignore any claims advanced by others to prioritv in its performance. In the year 1694 Proby, a surgeon of Dublin, resorted to the high opera- tion, after the method of Franco, to remove a bodkin from the bladder of a girl.|| Dupuytren^ is of opinion that this should scarcely be classed as a lithotomy, and perhaps it should m6re properly come under the head of hypo- gastric section. In 1710 John Groenvelt, a Dutch lithotomist, who after- wards, under the name of Greenfield, practiced surgery in London, informs us, in the second edition of his works, that he was obliged to resort to the hio-h. operation in a difficult case of stone in the bladder. A few years after this, viz., in 1718, James Douglass, a Scotch anatomist, read a memorial on " The High Operation for Stone," before the Boyal Society * Loc. cit,, vol. iii, p. 947. f Belmas, p. 2. The title of this Thesis was " Quaestio medico-chirurgica quam prseside Pietre tuebatur." Le Mercier. Paris, 1635. % Giinther, Operation am Becken, p. 308. I Belmas, loc. cit., p. 3; also Velpeau, vol. iii, p. 947. || Philosophical Transactions, voh xxii, as quoted by Carpue. r Lithotomie. ThSse, par G. Dupuytren. Paris, 1812, p. 35. SUPRAPUBIC LITHOTOMY. i3 of London, in which, from inference drawn from the anatomical relations of the parts, he strongly advocated the method. It was but one year after the reading of this paper (1719) that John Douglass, his brother, performed his first operation at the Westminster Hospital, and followed it by a second in the same year, and three others in 1720. It is said that Douglass, believing himself to be the reviver of the operation, called it after his own name, and published in the same year a work upon the subject.* His method was somewhat similar to that advised by Bossetus, though he discarded the razor and substituted in its place the bistoury. He moderately injected the bladder, and made the incision in the viscus with the same instrument without a previous puncture.^ He appears, in his anxiety to be considered foremost in resuscitating the method, to have discredited or ignored the labors of those who had given attention to the subject since Franco's time, and to have endeavored to introduce his method into the hospitals, as an operation of his own, bearing his own name. Accord- ing to Belmas, however, he met with decided opposition on the part of the surgeons of his time, they refusing to perform the high operation in the public charities. The only exception to this was Cheselden, who being attracted by the feasibility of the procedure proclaimed his convictions in its favor, for which service Douglass dedicated to him a panegyric in Latin. In the year 1721, Paul, of St. Thomas's Hospital, performed four successful suprapubic lithotomies. The first two of these are mentioned by Belmas and Giinther,! but the whole four are said to have been successful by Holmes.^ Humphreys, on the other hand, informs us that two died.|| Cheselden having become the champion of this method, performed his first operation in 1722, and in 1723 published a dissertation on the subject.^ Li Clieselden's Appendix** to The Anatomy of the Human Body, will be found the following : " The next season, it being my term in St. Thomas's, I resumed the high wa}', and cutting nine with success, it came again into vogue. After that every lithotomist practiced it." The method he adopted was to first inject the bladder with some bland fluid, in quantity equal to that of urine, which the patient could retain in his bladder, and" after having incised the integument in the mesial line, to cut the bladder from above downward. The success of Cheselden aroused the bitter animosity of Douglass, who accused him of appropriating to himself the honor that should belong rightly to the reviver of the operation. He wrote a diatribe against Cheselden, which contrasted * Lithotomia Douglassiana, with a Course of Operations. London, 1720. f Velpeau, loc. cit., p. 948, vol. iii. % Loc. cit., p. 5. \ System of Surgery, vol. iv, p. 1075. Also Carpue, p. 160. || Trans. Pro. Med. and Surg. Ass., 1850, p. 103. \ A Treatise on the High Operation for Stone. With seventeen copper-plates. London, 1723. ** The Anatomy of the Human Body. By W. Cheselden. Ninth Edition, with forty copper-plates, London, 1773. Chapter VI. A Short Historical Account of Cutting for the Stone, p. 327. 14 SUPRAPUBIC LITHOTOMY. singularly with his previous essay in praise of the great surgeon. It is well known that, shortly after, this distinguished surgeon abandoned the " high apparatus," and concentrated his labors upon the lateral perimeal method, with which to this day his name is inseparably connected. In giving his reasons for this he states that because " the peritoneum often being burst or cut, and the bladder itself was burst from injecting too much water, which generally proved fatal in a day or two, .... and that the urine lying continually in the wound retarded the cure," he had hoped to find a better method. It is remarkable, however, that a little further on he uses this peculiar language : " Though the operation came into universal discredit, I must declare it as my opinion, that it is much better than the old way, to which they all returned except myself, who would not have left the ' high way' but for the hope I had of a better."* In the year 1723 Heister made his first operation. It is so interesting that I may give the account of the case in his own words. He says : " Led by the same necessity as Franco and Greenfield, on April 17th, 1723, I did not hesitate to adopt this new and approved method of lithotomy, in the case of a man aged thirty years. I had ineffectually attempted to remove a part of the calculus by the ordinary method through an incision made in the perinseum, because it had fallen back into the pit, or diverticulum of the bladder, which has often been observed by others. On the following day, many students of medicine and surgery being present, without filling the bladder (which in cases of this kind cannot be done by reason of the lower wound) a cut was made over the pubes and in the body of the bladder, according to the directions of Bossetus and Douglass, by means of a curved scalpel. The wound was then extended above and below by means of a lentil-shaped instrument, and I withdrew the calculus easy enough with my fingers."f In the same year, Proebisch, a surgeon in the Prussian army, successfully performed epicystotomy on a child, twelve years of age, and reported a second recovery after an operation by Bungius, on a male patient, aged twenty-six years. According to Giinther, this operation was performed in 1727, at Ko- nigsberg. In October of the same year, MacGill performed suprapubic lith- otomy, and communicated his method with his case to Dr. Campbell, which is mentioned in Cheselclen's book. In February, Thornhill, of Bristol, operated by this method, and soon followed it by others, so that he was enabled to, pub- lish sixteen cases, of which three died. There is a little discrepancy to be found in the dates of Thornhill's operations, between Belmas and Humphrey. The former! making the date as above given, while the latter, in his tables, gives three operations in the year 1722,§ in which Giinther agrees. It is quite * Loc. cit., chapter vi, Anatomy of the Human Body. f Institutiones Chirurgicae, vol. ii, p. 929. Belmas, loc. cit., p. 5. J Loc. cit., p. 6. \ Transactions of the Provincial Medical and Surgical Association, 1850, vol. xvii, p. 103. SUPRAPUBIC LITHOTOMY. 15 remarkable that this surgeon should have seen and treated such a number of cases in so short a period of time. Carpue tells us that Middleton, of whom we shall speak directly, was present at all of Thornhill's operations. Pye, of Bristol, made his first epicystotomy in 1722, and followed it by three others, in 1724. Of the four, three died, one died of sloughing, one of cancer, and the third of kidney disease, probably pyo-nephrosis. In 1724, James Boberts, who like many others of the present day, was rather unfavorably impressed with suprapubic lithotomy, was obliged to per- form it, and the case terminating successfully, he then (and I trust his exam- ple may be followed by the surgeons of our time) altered his views and be- came a partisan of the " high apparatus." In the year 1726, Serines, a surgeon of Amsterdam, was as unfortunate as Pye, and wrote a work entirely condemning hypogastric lithotomy. It is to him that priority is due in making the supplementary incision below the pubes, which is often attributed to Come. It was for practicing this addi- tional cut, or as it was called the "button-hole" incision, that he was perse- cuted by the profession, and even condemned by the tribunal of his country.* In the year 1727, John Middleton published a short essay on the subject,f which contains also a letter from Dr. MacGill to Dr. Douglass. It is probable from this that Dr. MacGill, who is mentioned above, communicated with both Cheselden and Douglass his ideas and experience with the high apparatus. Middleton's book I have not been able to procure. In the same year Colot, who was appointed by the French Parliament to in- vestigate the high operation, made a report most adverse to it, in which he de- clared that its very contemplation inspired him with horror. He, hoAvever, states that Turbier, professor of surgery in Paris, saved, by epicystotomy, the life of a man, who was brought to the brink of the grave, by the presence of a calculus obstructing the neck of the bladder. In the year 1727, Senac re- corded twro successful operations, and in the same year, 1728, Morand, or in 1727, according to Belmas—declared himself an advocate for the hypogastric section. His first operation was unsuccessful, the patient being a paralyzed old man, but as an offset to his fatal case he introduces a successful one of Berrier, and not being discouraged, still upheld the method. It is interesting here to note a fact that Bameau, a surgeon of Montpellier, most severely criticised Morand for his adherence to hypogastric lithotomy, and that in his work may be found a careful description of the urethra, and the entrance thereto by straight instruments.! * Velpeau, loc. cit., vol. iii, p. 954. f Lithotomy by a yew Method above the Pubes, to which is added a letter from Dr. MacGill to Dr. Doug- lass. X The title of Rameau's essay is, Reflexions en forme de lettre, ou Analyse de la dissertation de M. Morand, sur la taille au haut appareil. Amsterdam, 1729. Vide Belmas, p. 10. 16 SUPRAPUBIC LITHOTOMY. Morand's operation differed but little from that of his predecessors, excepting that he directed the patient to lie with the hips elevated above the shoulders, the legs being secured to the bedposts. He also disapproved of elevating the bladder by means of injections, and reeommemfe- that' the left forefinger be hooked and inserted into the upper angle of the wound, to prevent the bladder from slipping behind the pubic bones. Morand's book was first published in 1728, and afterward in 1749, and Carpue mentions a fact which it is important to remember in regard to the statistics of the operation.* It is this, that Morand in speaking of Berrier's operating in 1727, remarked, "that he could give the history of forty opera- tions, out of which thirty-five recovered."f It is well known that Humphrey, in his tables, which have been carefully examined, omits the operations of Frere Come, and of a person he cnlls Maunde, and that Dulles states that in his classification, which formed the subject of his Thesis (but which has never been published), he also omits Maunde. Holmes also quotes from Humphrey to the same effect. To my mind, there has been an error in the reading of the manu- script, or of the proof, for "Morand " could easily be mistaken for " Maunde," and as the figures are exactly the same, it is probable that the error occurred in this manner. If Carpue makes " Bernier " read for Berrier, and Holmes makes Souberveille read for Souberbeille, and MacGill read Malgill, and Du- puytren makes Thornhill read Fornhill, why may not Maunde be meant for Morand ? In the year 1727, Senff made three suprapubics with two successes, and in 1728, Hildanus, in Switzerland, made the operation once, and in 1729, H. Hess resorted to it. It was in this year that Come entered the order of the Bernardine Monks. Quite a period then elapsed without much attention being paid to the operation. Occasionally, however, surgeons were found taking an interest in " the high apparatus," among whom are Kulmus, in 1732, and Le Cat, in 1735. The latter proposed a method somewhat different from that of those who had preceded him, and following the suggestion of Thebaut that the abdominal and bladder wound should be incised at once, he invented an instru- ment to fulfil these indications. He named it a cystome bistoury. He per- formed the operation successfully, and communicated his ideas to the Royal College of Surgeons in London. In 1755 Hempel operated with success, and in 1756 a surgeon of Copen- hagen, named Heuerman, also reports favorably of the procedure, but the appear- ance of Frere Come, with his modifications and successes, in 1758, gave a fresh impetus to " the high apparatus." In 1799, the monk,! whose name before * In Carpue's book there must have been a typographical error, for he mentions the name Bernier instead of Berrier, as referred to by Belmas, Dulles, Humphrey. f History of the High Operation for Stone. By J. C. Carpue, F.R.S. London, 1819, p. 123. X Carpue, p. 159. SUPRAPUBIC LITHOTOMY. 17 he entered the monastery was Jean Baseilhac, had performed a hundred supra- pubic lithotomies with but nineteen deaths. Some declare that this remarkable man was entirely unlettered, a fact which is untrue. This ecclesiastic was born in the year 1703 in the parish of Poyestruc, near Tarbes. His record as a medical man was good, both his grandfather and father being surgeons. In 1722 he went to Lyons and placed himself under the instruction of Baseilhac, the elder, who enjoyed a high reputation. He entered college in 1729, and was elected professor in 1740. In 1799 he published his account of the high operation for stone in the bladder, which had fallen into disrepute since the time of Morand. To those desiring to read an interesting account of his life, as also of that of Frere Jacques, a work, by his nephew, is still extant in our libraries.* The hundred operations of hypogastric lithotomy of Frere Come, with loss of only nineteen, to which allusion has just been made, are proverbial; but the fact is not generally known that in his own works, which have been carefully examined, he records but eighty-two of these cases ; the balance being- given by his nephew, Paschal Baseilhac, in the book to which reference has already been made. In confirmation of this I insert here a short translation from the work in question. "Frere Come, in his treatise on the High Operation on both sexes, gives a list of the cases in which he had operated by this method, down to the date of his publication, in 1779, from which it appears that his new method is more advantageous for females than for males ; since out of his forty-six female cases, thirty-nine were cured, and only about one-sixth died. Whereas, he reports in the same work that he had operated on thirty-six male patients, and had lost eight of them—a mortality of almost one-quarter. Since the date at which this list was published he operated, down to his death in July, 1781, on five males and thirteen females, whose names and addresses, taken from his own register, are in my possession; making altogether forty-one males, and fifty-nine females, or a grand total of one hundred operated on, of whom there died ten males and nine females, or nineteen in all, while eighty-one were cured. Frere Come would certainly not have lost so many if he could have profited by the experience, in regard to the new method, gained during the last period of his life, and if he had enjoyed better conveniences for treatment in his own infirmary, where three-fourths of his operations were performed. As he received no assistance from the government, this devoted man had to rely wholly on what his wealthy patients gave him, and on charitable contributions, which enabled him to provide proper food and attendance for scarcely thirty out of the multitude he admitted. Had he possessed the means, his wards would have been more roomy, and he would have employed trained nurses for * Eloge Historique de Frere Come, De La Taille Laterale et celle de l'hypogastric ou Haut Appareil. Par Paschal Baseilhac, p. 77. 3 18 SUPRAPUBIC LITHOTOMY. night service, instead of girls, who could scarcely keep awake after the house- hold labors of the day. We see that he was less successful in the case of males than that of females, yet out of the total number of both sexes on which he performed the high operation, rather more than four-fifths were cured, a far better result than was yielded by the grand appareil, from which usually about one-third recovered." It may also be well to remark here that although very many writers on this subject, especially his own countrymen, give the Fueillant ecclesiastic the name Come, yet others, among whom we find Dulles and Giinther, spell the name Cosme. Come is supposed by many to have introduced the sonde-a-dard, and the incision below the pubes, but, as has already been mentioned, Sermes first proposed the idea of the button-hole incision, and the introduction of sounding instruments into the perinseum to facilitate the performance of the operation. .The real inventor, however, of the " sonde," although many have proposed and effected modifications of it, was M. Pallucci,* who in 1750 brought it to the notice of the profession. However, it is not the name of the inventor, but that of the promulgator and utilizer, which generally descends to posterity. The name of Morton will always be associated with ether anaesthesia, and that of Sayre with the suspension apparatus and plaster jacket; so will the sond-a-darde be remembered as the instrument of Frere Come. His method of employing the " sonde " was rather peculiar. He first introduced a staff into the bladder; an incision about an inch in length in the perina?um, similar to that practiced in median lithotomy, was then made. A second cut was then carried into the membranous urethra. A grooved director was passed into the bladder through the last-named wound, and the staff immediately withdrawn. The sonde was, by means of the groove in the director, slid into the bladder. So soon as this was accomplished, the abdominal parietes were incised. A trocar, in which there was a concealed bistoury, was next passed into the linea alba close to the pubes, and the blade of the knife then started from its sheath toward the handle of the instrument, while its other end remained stationary ; thus the linea alba was incised from below upwards. If necessary, this incision was enlarged by means of a probe-pointed bistoury, shielded in front bv the finger, to push the peritoneum out of the way in case the knife should slip. The incision thus being made, and the bladder brought into view, the sonde was pressed up against the anterior wall of the bladder, and held there with the thumb and forefinger, while an assistant pushed up the stilette, and thus opened the viscus; a curved, sharp-pointed bistoury was then introduced into the groove in the stilette, and the bladder cut from above downward, oft-times nearly to * Giinther, Operationem am Becken, p. 308. SUPRAPUBIC LITHOTOMY. 19 its neck. The fingers were immediately introduced into the wound, and the bladder held up by them, while the sonde-a-dard was withdrawn by an assistant. As an extra precaution against the bladder falling behind the pubes, a hook was introduced into its upper extremity, and the stone readily with- drawn with forceps. An elastic catheter was then passed into the wound through the opening previously made in the peri'nseum.* The success of Come was certainly remarkable, and is admitted by the gen- erality of inquiries into the statistics of the operation. It is therefore quite unfair to omit these cases from the tables prepared by Mr. Humphreys,f simply because -the results were so favorable. That certain operations are more successful in the hands of one surgeon than another, is a peculiar and rather unpleasant fact in surgery. What might be thought of the statistics of Air. Keith in ovariotomy as compared with other skilful operators? It would be almost supposable that at a future day, as some one is looking up the history of ovariotomy, that the wonderful success of the great surgeon should be ignored because his results were so surprisingly successful. In 1784, Pascal Baseilhac performed epicystotomy on a girl, aged eigh- teen years. His work, as already mentioned, records the additional fifteen cases of his uncle and preceptor, and also analyzes and criticises other cases and the operation in general. In 1773, Le Blanc performed the opera- tion, recommending it for large calculi. In the year 1786 Lassus, as re- corded by Cooper! and Belmas,§ attempted lithotomy in the perinreum with Hawkins's gorget, but being unable to remove the calculus, he had recourse to the suprapubic method with success. About the same period Deguise was obliged to resort to the " high apparatus " to remove a stone which he had fruitlessly attempted to extract through the perinaaum. In this year also, ac- cording to Giinther, Espiaux also had recourse to the operation. In 1790 the method was resorted to by Lauvejat to remove a stone which materially ob- structed labor. Mursima, in 1797, or about that time, employed the hypo- gastric method on account of an obstinate stricture. In the year 1802 another renowned operator appears upon the field as a champion, at all events for a time, of the hypogastric method of removing calculi from the bladder, viz., Dupuytren. Belmas states specifically that he had frequently seen this distinguished operator remove large stones by this method. His thesis, presented with his application for the chair of Surgery, * Nouvelle Methode d'extraire la pierre de la vessie urinaire par dessus la pubes, quon nomme vulgairement le Haut Appareil, dans Pun et l'autre sexe, sans le secours d'aucun rluide retenu ne force, dans la vessie. Par F. Come. Paris, 1779. f Humphreys, Transactions Provincial Medical and Surgical Association, vol. v, p. 104, 18»>1. Quoted l>y Holmes, vol. iv, p. 1076, and Dulles's American Jour, of the Medical Sciences. X Surgical Dictionary, p. 137. 2 Loc. cit., page 12. 20 SUPRAPUBIC LITHOTOMY. in the Hotel Dieu, was upon lithotomy, and its varied methods.* He also in this work alludes to the fact, that the perineal incision might often be followed by disastrous consequences. In 1808 Scarpa records a successful case, and made a modification of the sonde-a-dard, which consisted in having the groove in the stilette of sufficient depth to allow the introduction of the bistoury above it, and being so arranged that the end of the instrument always must remain in the bladder, while the point of the stilette is thrust through the vesical wall. It is worthy of remark also in this place, that this distinguished surgeon re- garded the additional wound in the perinoeum as unnecessary, and that in 1812 Dupuytren also followed his example, declaring that "the sonde, or other in- strument to raise and perforate the bladder, could be introduced by way of the urethra." Between the years 1809 and 1816, Vacca Belinghieri performed the operation six times. In the year 1818, Kirby, in order to remove a probe or sound which had accidentally slipped into the bladder, opened that viscus above the pubes, and in 1820 Krouse made use of the high apparatus. In the year 1819, Carpue wrote his book, which contains a very clear description of the steps of the op- eration as it was done at that time. He first saw Souberbielle perform it, in 1817, on M. De Walville, at the Hotel cles Invalides. He writes as follows :t " First, an incision is made through the integument of the perinseum, and a small incision into the membranous part of the urethra; a director is intro- duced into the bladder, upon the staff; the staff is withdrawn ; the sonde-a- dard is introduced upon the director into the bladder; the director is now withdrawn; the sonde-a-dard is held by an assistant. An incision is made, three or four inches in length, through the integuments of the abdomen. The trocar-bistoury is passed through the linea alba, close to the posterior part of the pubis. The concealed blade is opened, by means of which the lower part of the linea alba is divided. A jn-obe-pointed bistoury is introduced, through the opening which has been made by the concealed bistoury, into the lower part of the linea alba, and the incision is continued by means of this instrument. The operator takes the sonde-a-dard from the assistant with his right hand, and pushes it forward, by which means he elevates the bladder above the pubis. The assistant now holds the sonde-a-dard, and the surgeon with his right hand pushes the stilette (which is contained in the canula of the sonde-a-dard) through the anterior part of the bladder; he takes hold of the end of the stilette with his left hand, and passes a probe-pointed bistoury along the groove (which is in the anterior part of the stilette), and makes an incision in the su- * Lithotomie, These, soutenue publiquement dans l'Amphitheatre de la Faculte de Medecine de Paris; en Presence des Juges du concours, le 29 Janvier, 1812, par G. Dupuytren, Docteur en Chirurgie, Chirurgien en chef adjoint a l'Hotel-Dieu de Paris, chef des travaux anatomiques de la Faculte, a Paris, MDCCCXII. f History of the High Operation for Stone, by J. C. Carpue, F.E.S., M.B.C.S., London, 1819. SUPRAPUBIC LITHOTOMY. 21 perior anterior part of the bladder. He passes the index finger of his left hand into the bladder, by means of which he supports it. The stilette is with- drawn from the canula of the sonde-a-dard, which is now lowered and held by an assistant; the operator introduces the suspensor of the bladder, which is held by an assistant. The stone is now to be withdrawn with the finger and thumb, which if small is done with great ease. If the bladder is large, a finger is introduced per rectum, by which the bladder is elevated, and the stone more readily found. If the stone should be in an excavation, and the bladder is not of very large size, it may be discovered with the finger, by means of which the surgeon will know whether a scooj:> or what kind of forceps is indicated. If the stone should be very large, Frere Come's forceps must be used. If the stone should adhere to the bladder, or be contained in a cyst, the means used by M. Baseilhac and Sir Everard Home should be resorted to. When the stone has been extracted, Dr. Souberbeille introduces a silver w7ire through the canula of the sonde-a-dard, and passes it through the wound made in the linea alba; this is held while the sonde-a-dard is withdrawn; a flexible gum cathe- ter is now passed into the bladder, through the wound in the membranous part of the urethra, by means of this wire. The wire is now withdrawn. The catheter is confined in this situation, by means of tapes passed around the thighs and pelvis of the patient; a bladder is tied to it to receive the urine." It is worthy of remark, in this place, that after the year 1825 Souberbeille performed the operation without the perinatal incision,* but Dulles states that the supposition is that most of his operations were made with the perinatal cut; but as the majority of the recorded cases were after 1822-1825, this must be an error. In 1835 Souberbeille made his report to the Academie Royal de Medecine of fifty cases of the operation with but four deaths ;f but these cases it must be remembered were not all suprapubic lithotomies. From a careful examination of his record it is found that of these there were thirty-nine " sus- pubienne" and eleven lateral. It may be as well also to remark here that Souberbeille begins his table with the year 1828, whereas he must have operated many times before, as I have discovered by the examination of Belmas's book, who even records cases operated upon as far back as 1796. But to retrace the history for a moment. Sir Everard Home, at St. George's Hospital, performed the operation first on the 26th of May, 1820, and fol- lowed it with two others. He called his method a new one. He made an incision in the linea alba, and detached portions of the pyramidales at their insertion ; the finger was then introduced behind the pubes and the bladder felt for. A silver catheter with an open end was passed into the bladder, and when the end was detected by the finger in the wound, a stilette was thrust * Velpeau, Operative Surgery, vol. iii, p. 9oo. f Memoires de l'Academie Royal de Medecine, Paris, 1S40. 22 SUPRAPUBIC LITHOTOMY. upward through the bladder. The opening was then enlarged, the fundus of the bladder held up with the left hand, while the stone was extracted with the right hand.* In the year 1822 Deguise performed the operation once, and about the same time Dzondi resorted to it four times. Textor in 1823 essayed the operation after lateral lithotomy. In 1824 the first American suprapubic was made by Professor Gibson, of the University of Pennsylvania. In his Surgeryf he states that he followed the method of Sir E. Home, and removed two calculi. The patient went on so well that Gibson says : " He insisted upon the catheter being withdrawn, contrary to very strict injunctions which I left with him, and in consequence soon after perished from peritoneal inflammation induced by a fusion of urine in the cavity of the pelvis.'" Between the years 1825 and 1830, the following surgeons had recourse to the method, viz.: Hutchinson, Ballingall, Amussat (7) ; Krimer, with his remarkable case of tremendous calculus ; Baudens, three operations ;t Boux, in 1827;$ Crozat, of Tours, who in performing the operation cut into the peri- toneum, but the patient (a woman) made a good recovery ;|| George Bell, on a man aged eighty,', who recovered. About the same time that Roux was opera- ting in Paris, Carpenter and McClellan performed their operations in America. For the balance of the American epicystotomies, with their dates and references, I refer the reader to Dr. Dulles's tables, which are given entire, knowing how much time and patience must have been expended upon them. The first table extends from Gibson's case in 1824 to Gidding's in 1844,** and his second comprises the operations often years, between 1867 and 1877.ff In Dr. Dulles's tables, however, I find he has overlooked an epicystotomy performed by ,# Hammer, of St. Louis.!! Gunther gives the following cases : Delpech, in 1831, two operations; Leroy d'Etiolles, 1834, one operation; Segur, 1835, three operations; Moulini, 1839, one operation; Souberbeille, to which allusion has already been made; Larrey, 1841, one operation; Smith, 1841, one operation ; Nekton, 1841, one operation; Civiale five, 1841 to 1844 ; Segalas, 1844, one; Gaillard, 1844, one; Gunther, from 1845, eight with success ; Paine, about 1848, one ; Olivarez, 1848, three; Bruns, from 1848, three ; Lang- enbeck, from 1849, five; Unger, ] 850, one; Schlobig, 1850, one; Geinetz, 1850, one; Staude, in 1854, four; Schmid, 1856, two; Stolle and Bezin, 1856, one; * Cooper's Surgical Dictionary, Article Lithotomy. f Institutes and Practice of Surgery, by William Gibson, M.D., vol. ii, p. 231. Philadelphia, 1835. X Gunther, p. 306. Sabbatier, p. 249. g \Telpeau, vol. iii, p. 951. || Velpeau, vol. iii, p. 951. ' London Lancet, vol. ii, 1858, p. 663. ** American Journal of the Medical Sciences, 1875, p. 59. ft American Journal of the Medical Sciences, 1878, p. 400. XX St. Louis Medical and Surgical Journal, 1865, p. 51. SUPRAPUBIC LITHOTOMY. 23 Morlanne, 1856, one; Solzbeck, 1858, one. It is at this date that Giinther's record closes. M. Chauvel states that D'Almiera has since 1860 performed twenty-three operations.* In 1861, Ash Wednesday, Sampson Gamgee, at the Queen's Hospital, in London, removed a good-sized calculus from a girl, aged eight years and nine months. The calculus weighed 305 grains, and measured Is inches in length, and 1 > inches in breadth.f Quite a remarkable case is recorded in 1862, by Dr. Chisholm, in which a man was shot in the crest of the ilium, and the bullet was removed by the suprapubic incision. In the same year Dr. McGue had a somewhat similar but unsuccessful case.! The following tables, showing the dates, the names of the operators, the size of the stone, etc., are offered to the profession, with the hope that they may assist in forming some idea of the history of this operation. The tables have been prepared with great care, and have taken considerable time. They are, however, very far from being perfect, for several reasons; in the first 'place, there is often a discrepancy of a year to five years between the dates assigned by different authors for the performance of the operation. Then again, the reports are very imperfect indeed, that is, in regard to the particulars of the operation, the size of the stone, and the result. Therefore, the only just method for arriving at the average mortality is to classify only those cases in which the results are given.. * Dictionnaire Encyelop. des Sciences Medicales, 1880, vol. xxv, p. 105. f London Lancet, vol. ii, 1873, p. 807. % Medical and Surgical History of the War of the Eebellion, vol. ii, p. 282. CHAPTER 11.* TABLES OF SUPRAPUBIC LITHOTOMY. It is necessary that these tables should be prefaced by a few remarks re- garding the labors, in the same direction, of others whose work has necessarily come under observation; and although in the previous chapter, most of the items of historical interest have been mentioned, yet there are a few others, bearing especially upon the statistics of the operation, which ought to be noticed in this place. One of the most important of these is the fact that M. Chauvel, in the twenty- fifth volume of the Dictionnaire Encyclopedique des Sciences JleJicales for 1880, falls into a curious error in reporting seven hundred and eighty-five operations of suprapubic lithotomy. He adds the cases collected by Belmas, Carpue, Giinther, Humphreys, Souberbeille, Gross, etc., as if the numbers mentioned by each of these surgeons represented separate and distinct cases, whereas it is very obvi- ous that Humphreys's one hundred and four includes many of those of Belmas, Carpue, Gross, and those of Souberbeille, as well as those of other surgeons, and Dulles's three hundred and sixty-four, those previously mentioned, etc. In the sixth edition of Mr. Coulson's Diseases of the Bladder, several pages are devoted to the subject, and the statistics of Dulles given as a basis of comparison with the other methods. The data of suprapubic lithotomy, how- ever, are for the most part scattered generally throughout the field of surgical literature. This will account in a great degree for the many blanks that appear in the table in reference to the particulars of age, sex, and the cause of death. Nothing doubtful or unknown has been assumed, and only such ac- cepted as authentic for which there was undoubted and trustworthy references. No ^ttempt to compile a full historical table of suprapubic lithotomy has ever before been offered to the profession, and in making the fresh effort in that direction we by no means claim to have succeeded in collectino- all the cases upon whom this method has been employed, for there are several sur- geons who are known to have recourse to this procedure, of whose cases no record has been obtained. * This chapter has been prepared with great care, by E. Guernsey Rankin, A.M., M.D., to whom the author desires to return thanks for the labor necessarily involved in the preparation of such statistics and also to Drs. Lilienthal, Freeman, Swift, and Wilcox, for their assistance in this direction. SUPRAPUBIC LITHOTOMY. 25 1 NAME. DATE. AGE. SEX. SIZE. RESULT. OBSERVATIONS. REFERENCES. Franco. 1560 '2 M. Hen's egg. Recovered. After failure of lateral Velpeau, vol. iii, p. 947. I lithotomy. Heister, vol. ii, p. 927. Franco, p. 139, et seq. Come, p. 95. Gunther, p. 305. 2 Petrie. 1635 Recovered. Belmas, p. 2. Coulson, p. 156. 3 Jean de Dot. 1651 M. Goose egg. Recovered. Operated on himself. Hyrtl, p. 293. Holden, p. 31. 4 Bonnet. 16S1 • • • Recovered. .... Belmas, p. 3. Velpeau, vol. iii, p. 947. 5 Proby. 1694 20 F. . . . Recovered. Removed a bodkin. Carpue, p. 68, et seq. Baseilhac, p. 315. Philos. Trans., vol. xxi, p. 1700. Humphrey, p. 103. i Belmas, p. 3. Sabattier, vol. iv, p. 234. Gunther, p. 33. Come, p. 9. Coulson, p. 157. Velpeau, vol. iii, p. 947. Diet. Encyclop. des Sci- ences Med., 1881, vol. xxv, p. 95. 6 Greenfield. 1710 Recovered. Carpue, p. 68. Belmas, p. 4. Sabattier, vol. xii, p. 234. Humphrey, p. 103. 7 John Douglass 1719 17 M. Small hen's egg. Recovered. Carpue, p. 77, et seq. •—• Holmes, vol. iv, p. 1075. Coulson, p. 157. 8 John Douglass. 1720 8 M. Horse-chestnut. Recovered. Baseilhac, p. 321. Gunther, p. 306. Belmas, p. 4. Philos. Trans., yrs. 1720- 9 John Douglass. 1720 3 M. Horse-chestnut. Died. Convulsions 15 hours '22, vol. iii, p. 228, et after. seq. Humphrey, p. 103. Cheselden, p. 327. Gunther (to the 9th ease 10 John Douglass. 1720 4 Horse-chestnut. Recovered. Peritoneum wounded. Intestines protruded and replaced. only), p. 340. 11 Paul. 1721 Recovered. .... Carpue, p. 160. Holmes, vol. iv, p. 1075. 12 Pmil 1721 Recovered Belmas, pp. 4 and 5. Gunther, p. 306. 13 Paul. 1721 about.) Recovered Note.—The last two 14 Paul. 1721 about.) Recovered. authors refer only to the first two cases of Mr. Paul. 15 Cheselden. 1722 7 M. Recovered. Carpue, pp. 79 and 89. Belmas, p. 5. Humphrey, p. 105. Baseilhac, p. 32. 16 Cheselden. i 1722 14 M. Recovered. .... i 4 2G SUPRAPUBIC LITHOTOMY. 17 DATE. AGE, Cheselden. 18 Cheselden. 41 42 Cheselden. Cheselden. Cheselden. Cheselden. Cheselden. Thornhill. Thornhill. Thornhill. Thornhill. Thornhill. Thornhill. Thornhill. 31 Thornhill 32 Thornhill 33 Thornhill 34 Thornhill 35 Thornhill 36 Thornhill 37 Thornhill 38 Thornhill 39 Thornhill. 40 Pye. Pye. Pve. 1722 1722 1722 1722 1722 1722 1722 1722 1722 1722 1723 1723 1723 1723 1723 1723 1724 1724 1724 1724 1724 1724 1724 1722 1724 1724 6 15 45 4 48 14 13 18 5 55 M. Peach stone. Large Nutmeg. Large. Recovered Recovered Recovered Died. Recovered Recovered, Recovered, Recovered. Recovered Recovered Recovered Recovered Recovered Died. Died. Recovered Recovered Recovered. Recovered, Recovered Recovered, Died. Recovered. Died. Recovered, Died. OBSERVATIONS. Suppuration; stone in kidney, and diar- rhoea ; death 25th day. REFERENCES. Cheselden, p. 327. Holmes, vol. iv, p. 1075. Gunther, pp. 306 and 319. Gangrene of perito neura; bladder found to be scirrhous ; peri- toneum wounded. 3d day of scirrhus of bladder. Abscess and sloughing of wound ; death on 11th da v. Ulceration and scir- rhus of bladder. Carpue. pp. 93 and 104. Humphrey, p. 103. Belmas, p. 7. Holmes, vol. iv, p. 1075. Gunther, pp. 306 and 341, refers to 13 cases only. Note.—Belmas gives the date for Thornhill's first case as 1723. Carpue, pp. S7 to 193 and 159. Belmas, p. 7. Humphrey, p. 103. Holmes, vol. iv, p. 1075. Gunther, p. 306. SUPRAPUBIC LITHOTOMY. 27 45 46 Pye. Proebisch. Heister. Heister. Heister. 48 Macgill. 49 50 51 Mac-ill. Macgill. Macgill. 52 Rungius 53 Roberts. 54 Sermes. 55 Sermes. 56 Sermes. 57 Sermes. 58 Sermes. 59 Sermes. 60 Sermes. 61 Sermes. 62 Sermes. 63 Sermes. 1724 9 ; M. 1723 12 M. 1723 30 M. Large. Large about) 1723 AJu" M. f about) 1723 I 20 M. 1703 Ret. mid 70 1723 13 1723 1723 1723 1724 1726 1726 1726 1726 35 26 M. 2 stones, each ^iv. ss. Nutmeg. Died. Recovered Died. Died. Recovered Recovered Recovered Died. Recovered, Recovered Recovered Died. Died. Died. Recovered Recovered, Recovered, Recovered, Recovered, Recovered, Recovered. observation? REFERENCES. Suppuration of kidney; Giinther, p. 306. 21st day. After failure with the lateral; abscess and dilatation of pelvis of kidney. 'th day after, gangrene, suppurative perito- nitis ; abscess of omentum. Belmas, p. 6. Gunther, pp. 306 and 341. According to the latter, this operation was per- formed 5 years later. Heister, vol. ii, p. 952. Carpue, pp. 110 and 115. Belmas, p. 5. Baseilhac, p. 325. Humphrey, p. 103. Gunther, p. 33.* Heister, vol. ii, pp. 929 and 30. Bladder was ruptured by injection. Cured, however, in 8 weeks. Stone not removed, being encysted. * Uunthcr. p. 17, Der llolie i-teinschnitt. L ipsic, 1851. Carpue, pp. 10-110. Belmas, p. 6. Giinther,pp.309 and 340. Humphrey, p. 105. Holmes, vol. iv, p. 1075. (uinther, p. 335. Giinther, p. 306. Belmas, p. 6. Gunther, p. 306. Relmas, p. 7. Giinther, p. 319. 28 SUPRAPUBIC LITHOTOMY. 64 Sermes. 65 Sermes. 66 Sermes. 67 Sermes. 63 Sermes. 69 Sermes. 70 Morand 71 72 80 81 82 83 Morand. Berrier. 73 Turbier- 74 Senac. 75 Senac. 76 Senff. 77 Senff. 78 Senff. 79 Hildanus 85 86 Hempil. Hempil. Heuermann. Unknown. Come. Come. Come. date. age. 1727 68 or '23 Belmas. 172 1727 ' 4 1727 Adult 1727 1727 1727 1727 1727 1728 1755 1755 1755 1758 1758 1758 1759 12 Adult 60 23 27 RL RI. M. RI. M. F. 3v. Nutmeg. 3111., gr. 1. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Died, Recovered. Recovered. Recovered. Recovered. Recovered. Died. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Died. observations. references. Gunther, p. 319. Died. Died. Recovered Paralytic; death on Velpeau, vol. iii, p, 947. 43d day; urethritis Belmas, p. 10. and cystitis. Carpue, p. 115. Gunther, p. 30. Giinther, p. 20, in Der Hohe-Steinschnitt. Leipsic, 1861. Belmas, p. 10. Humphrey, p. 105. Carpue, pp. 121 and 123. Giinther, pp. 306 and 335. Velpeau, vol. iii, p. 947. Belmas, p. 9. Belmas, p. 9. Gunther, in Der Hohe Steinschnitt, p. 19. Gunther, in Der Hohe Steinschnitt, p. 21. Gunther, in Der Hohe Steinschnitt, p. 22. Gunther, p. 306. 3d day, nucleus was a Poulet, vol. ii, p. 235. pin. Abscess of kidney; death 44 hours after. Come. p. 82. The following 82 cases of Frere Come are taken from his work, Nouvelle Methode pour la extraire la pierre. Paris, 1779; from pp. 79 to 173. as given for each case. C6me, p. 84. " p. 85. SUPRAPUBIC LITHOTOMY. 29 DATE. AGE. 87 Come. SS'Come. 89 Come. 90; Come. 91 [ Come. 92 Come. 93 Come. 94 Come. 95 Come. 96 Come. t 97 Come. 98 Come. 100 Come. 101 Come. 102 Come. 103 Come. 104 Come. 105 Come. 106 Come. 107 Come. 108 Come. 109 Come. 1759 1760 1760 1761 1761 1761 1761 1762 1762 7 64 25 17 5 6 or 7 26 3* 27 1762 ! U 55 1763 1764 1764 1764 1766 1766 1767 1767 1767 60 60 49 43 9 56 28 45 1767 | 59 17 1768 1768 110 C6me. 1769 4&8 mos 62 F. F. F. F. F. SIZE. RESULT. OBSERVATIONS. REFERENCES. Hen's egg. Recovered. Recovered. Frere C6m€ << , p. 85. p. 87. Walnut. Recovered. u p. 89. Walnut. Recovered. it p. 90. Large pigeon's egg- Recovered. a p. 90. Recovered.1 .... ii p. 91. Hen's egg. Recovered. . . .. . a pp. 91-92. Chestnut. Recovered. .... u p. 94. Died. 17 days after, of pleu-risy; abscess in vagina. Walnut. Recovered. .... tt p. 96. Stone broken in fragments. Recovered. .... a p. 99. Recovered. Size not mentioned; stone soft. ii pp. 99-100. . . . Recovered. .... tt pp. 100-101. Not given. Died. 7th day, extravasation of blood into sur-rounding tissue, and internal hemor-rhage; left kidney much softened. it pp. 102-103. 3 stones. Recovered. 2 flat and long; one, size of a hen's egg. a pp. 103-105. Hen's egg. Recovered. (t pp.103-105. 3*iv, gr. ii. Recovered. it p. 106. Medium, Recovered. a p. 106. Hen's egg shape. Died. << p. 105. . . . Recovered. it p. 107. Recovered. t< p. 108. Rupture of blad-der. Recovered. it p. 108. Walnut. Hen's egg. Died. Recovered. 9th day after infiltra-tion of blood into the abdomen. Bladder walls a finger thick; hemorrhagic exuda-tion in left pleura; thickened intestinal wall. a tc p. 112. p. 115. 30 SUPRAPUBIC LITHOTOMY. NAME. DATE. AGE 35 SEX. F. SIZE. RESULT. OBSERVATIONS. REFERENCES. Ill Come. 1769 Recovered . Frere Come, p. 113. 112 Come. 1769 12 F. Recovered (i p. 116. 113 Come. 1769 5 F. Died. Helminthiasis 12 days after. « p. 118. 114 Come. 1769 36 F. Died. Pyonephrosis. << p. 119. 115 Come. 1770 F. Died. Stone encysted; cys-titis, ulceration 01 bladder, pelvic cel-lulitis. « p. 120. 116 Come. -1772 72 F. Hen's egg. Recovered. it p. 123. 117 Come. 1772 Adult F. Hen's egg. Recovered. Patient had suffered tin e i years ; age not given. a p. 124. 118 Come. 1773 39 F. Recovered. it p. 124. 119 C6me. 1773 40 F. Recovered. it p. 125. 120 C6me. 1773 36 F. Recovered. it p. 125. 121 Come. 1773 27 F. Recovered. a p. 125. 122 Come. 1773 3 F. Recovered. it p. 123. 123 C6me. 1774 9} F. Recovered. it p. 126. 124 Come. 1774 40 F: Recovered. ii p. 126. 125 Come. 1775 22 F. Recovered. a p. 126. 123 Come. 1 1776 9 F. Recovered. a p. 127. 127C6me. i 1777 20 F. Recovered. a p. 127. 128 Come. 1777 34 F. Recovered. a p. 127. 129 Come. 1777 33 F. . . . Recovered. a p. 127. 130 Come. 1769 56 M. Hen's egg; 2 stones. Recovered. it p. 130. 131 Come. 1769 16 M. Cure. a p. 133. 132 Come. 1769 70 Ri. Died. Peritonitis; hemorrha-gic exudation into thoracic cavity. a p. 135. 133 Come. 1769 Adult M. Recovered. a p. 140. 134 Dome. 1769 9 RL Recovered. a p. 142. 135 i Dome. 1769 10 M. Died. 3 days after peritonitis. tt p. 142. 136 Come. 1769 74 M. giv. Recovered. a p. 144. 137 Come. 1771 24 RI. *Hen's egg. Recovered. (t p. 144. 138:Come. 1771 8 RL Recovered. a p. 144. 139 Come. 1771 15 1 yi. ... Recovered. n p. 152. SUPRAPUBIC LITHOTOMY. 31 140 NAME. DATE. AGE. SKX. M. SIZE. RESULT. OBSERVATIONS. REFERENCES. Come. 1771 13 Pigeon's egg. Died. Stone in the ureter; inflammation of kid- Frere Come, p. 152. ney. 141 Come. 1771 Adult RI. Died. 5th day after pelvic cellulitis; pleuritic exudation; pyemia. p. 155. 142 Come. 1771 47 RL Svi., gr. ss. Recovered. " . p. 157. 143:C6me. 1773 70 M. 5vii., gr. Died. Abscess of right kidnev 23d day. p. 160. 4 144 Come. 1773 33 M. Hen's egg. Recovered. .... " p. 161. 145 Come. 1773 17 M Broken pieces size of hen's egg. Recovered. 146 Come. 1775 74 M. Recovered. .... p. 162. 147iC6me. 1775 76 RI. Hen's egg. Recovered. .... p. 163. 148 Come. 1776 76 RI. 2 stones size of lien's egg. Recovered, , . . . " p. 163. 149 Come. 1776 20 "SI. Chestnut. Recovered. .... " p. 164. •150 Come. 1776 6 RI. Recovered. .... " p. 164. 151 Come. 1776 25 RL Large hen's egg- Died. Hemorrhage. p. 164. 152 Come. i 1776 7 M. Hen's egg. Recovered. p. 165. 1 153 Come. 1776 22 M. Recovered. p. 165. 154 Come. 1776 17 U. . . . Stone was fixed and extracted with for-ceps. p. 165. 155 Come. 1777 12 RI. Recovered. p. 167. 156 .Come. 1777 61 RI. Recovered. p. 168. 157iC6me. 1777 66 M. Recovered. " p. 168. 153 Come. 1777 45 ^SL " p. 169. 159 Come. 1778 RI. Hen's egg. Recovered. p. 169. 160 Come. 1778 30 U. Recovered. p. 170. 161 Come. 1778 18 RI. . Recovered. p. 170. 162 Come. 1778 69 RL Died, 9 days. Pelvis of kidney full of pus and hy-datids. " p. 170. 163 Come. 1778 11 RI. Walnut. Died. Pyemia. " p. 172. 164 Come. 1778 10 RI. Pigeon's egg. Recovered. .... " p. 172. 165 Come. 1778 42 ^1. Turkey egg. Recovered. p. 173. 166 Come. 1780 F. Recovered. Baseilhac, p. 62. ?,2 SUPRAPUBIC LITHOTOMY. 167 168 169 170 171 172 NAME. DATE. A GE. SEX. F. F. F. F. RL RI. SIZE. RESULT. OBSERVATIONS. REFERENCES. Come. Come. Come. Come. Come. Come. a •o S-< Si o •£} id Recovered. Recovered. Recovered. Died. Died. Died. From No. 167 to 183 are the cases mentioned by Pascal Baseilhac. There is no direct reference to the cases, merely a gen-eral summary of the sexes of the patients and the number of recoveries, from which these data are computed. a 173 Come. ■6 M. Recovered. ii 174 Come. o RI. Recovered. ii 175 Come. RI. Recovered. a 176 Come. "2 RI. Recovered. it 177 Come. O GO RI. Recovered. it 178 Come. i—1 RL Recovered. a 179 Come. "8 M. Recovered. tt 180 Come. a o RI. Recovered. it 181 Come. RI. Recovered. a 182 Come. 0) RI. Recovered. " 183 Come. O RI. Recovered. a 184 Le Blanc. 1773 c liild RI. Recovered. Belmas, p. 11. Gunther, p. 306. 185 Baseilhac. 1784 18 F. 3 v. Recovered. Belmas, p. 12. Humphrey, p. 105. Carpue, p. 163. 186 Lassus. 1736 6 F. Recovered. Perineal operation at-tempted. Belmas, p. 12. Cooper, p. 137. Carpue, p. 166. Humphrey, p. 105. 187 Deschamp. 1786 6 RI. Recovered. 188 Lauverjat. 1790 A dull F. Recovered. Gunther, p. 306; pp. 33-35. 189 Fourcroy. 1792 Died. 30 hours after. Gunther, p. 306; also Der Hohe Steinschnitt. 190 Fourcroy. 1792 Died. 191 Souberbeille. 1796 32 F. Si. ss. Recovered Belmas, p. 87. 192 Souberbeille. 1800 72 F. 3>i- Recovered. " p. 93. 193 Souberbeille. 1809 L6 F. gvi.ss. Recovered. " p. 86. 194 Souberbeille. 1812 >S F. r> v. Recovered. " p. 86. SUPRAPUBIC LITHOTOMY. 33 195 Souberbeille. 196! Souberbeille. 197 Souberbeille. 198 Souberbeille. 199 Souberbeille. 200 Souberbeille. 201 Souberbeille. 202 Souberbeille. 203 Souberbeille. 204 Souberbeille. DATE. ; AGE. . SEX. 1813 64 RI. 1S17 64 | RI. 1817 82 i ^. 1817 | 63 1817 75 181" i8i; RI. M. M. . M. ISIS i 58 "SI. 1818 73 i ^1. 1818 15 },1. Chestnut. Turkey's egg. Large. Several stones. Pigeon's egg. Egg. Hen's egg. Hen's egg. Died. Recovered. Died. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Died. OBSERVATIONS. Gangrene of lungs on the 46th day; lateral lithotomy 10 months prior ; two stones re- moved. Pleuritic effusion; sup- puration of right lung. REFERENCES. Belmas, p. 139. Fungoid growth of prostate filled the bladder; kidney much diseased. 205 Souberbeille. 1818 Adult RI. 7 oval calculi. Recovered. 206 Souberbeille. 1818 73 RI. 5iij- Died. Enteritis; stone in both kidneys; scrofulous patient. 207 Souberbeille. 1818 55 SI. 5 small calculi. Recovered. 208 Souberbeille. 1818 15 RI. Large. Died. Kidney disease. 209 Souberbeille. 1818 60 "SI. 15 small calculi. Died. Enlarged kidneys; py-elitis ; bladder con-tracted ; diarrhoea. 210 Souberbeille. 1X18 68 RI. 3 stones. Died. 211 Souberbeille. 1818 69 M. Large almond. Recovered. .... 212 Souberbeille. 181S 64 RI. 2 chestnuts. Recovered. Lateral, failed. 213 Souberbeille. 1818 66 RI. Large hen's egg. Died. Lateral, 6 years pre-vious ; kidney con-tained many stones. 214 Souberbeille. 1820 31 "SI. Almond. Recovered. Although in a very bad condition from den-tition and the effects of the stone. 215 Souberbeille. 1821 58 F. Walnut. Recovered. 216;Souberbeille. 1822 54 RL Hen's egg. Died. Peritonitis. 217 Souberbeille. 1823 74 RI. 3 large. Died. Pleuro-pneumonia. 218 Souberbeille. 1823 63 "SI. 2 stones. Recovered. 131. 83. 103. 98. 100. 2-15. 299. 157. 298. 136. 282. 136. 294. 109. 292. 280. 142. 288. 216. p- 'In. p- 288 p- 297 p- 160 34 SUPRAPUBIC LITHOTOMY. 219 NAME. DATE. AGE. SEX. M. SIZE. RESULT. OBSERVATIONS. REFERENCES. Souberbeille. 1823 70 3 walnuts. Died. Acute nephritis; kid-neys filled with pus. Belmas, p. 88. 220 Souberbeille. 1823 58 JSI. 1, walnut; another size of a. goose egg. Died. " p. 158. 221 Souberbeille. 1823 70 RL 3 stones. Recovered.; .... " p. 138. 222 Souberbeille. 1824 40 RI. 3vss. Recovered. " p. 134. 223 Souberbeille. 1824 71 RI. Large number of fragments equal in volume to hen's egg. Recovered. p. 135. 224 Souberbeille. 1824 66 M. 3 stones in all, equal to hen's egg- Died. 7th day. " p. 211. 225 Souberbeille. 1825 70 RI. 2 stones; one the size of small hen's egg, the other smaller. Died. .... p. 120. 226 Souberbeille. 1824 58 RI. Hen's egg. , Recovered. .... " p. 287. 227 Souberbeille. 1825 31 M. Very large; re-moved frag-ments. Died. 59 days after; cancer of bladder, left kidney enlarged, filled with pus; also enteritis. p. 152. 228 Souberbeille. 1825 48 M. Macaroon. Recovered. " p. 287. 229 Souberbeille. 1825 68 M. Large almond. Recovered. " p. 300. 230 Souberbeille. 1825 74 M. 10 stones, equal Recovered. to gi.gr. ii. j p. 150. 231 Souberbeille. 1825 74 M. 2 stones. Recovered. p. 275. 232 Souberbeille. 1825 74 M. 12 stones, size of chestnuts. Died. Apoplexy. " p. 151. 233 Souberbeille. 1825 45 M. Turkey's egg. Died. Kidneys enlarged; the pelvis of each con-tained stones; wound did not heal; patient was in a very bad state before opera-tion. " p. 106. 234 Souberbeille. 1825 83 M. Hen's egg. Died. Castro-enteritis. p. 291. 235 Souberbeille. 1826 62 M. Siv. Died. Kidneys much en-larged; ureters di-lated and filled witli purulent material; some urinary infil-tration; was in a very bad condition before the opera-tion. " p. 278. 236 Souberbeille. 1826 67 RL 4 Walnut-size; 1 smaller. Died. Pneumonia. " p. 235. SUPRAPUBIC LITHOTOMY. 35 237 Souberbeille. 238 Souberbeille. 239 240 241 Souberbeille. Souberbeille. Souberbeille. 242'Souberbeillt 243 244 Souberbeille. Souberbeille. 245 Souberbeille. 246 Souberbeille. 247|>ouberbeille. 248 (Souberbeille. 249 Souberbeille. 250|Souberbeille. 251'Souberbeille. 252 Souberbeille. 253 Souberbeille. 254 Souberbeille. 255 Souberbeille. 256.Souberbeille. I 257 Souberbeille. 258 Souberbeille. 259 Souberbeille. I 260 Souberbeille. 261 Souberbeille. 262 Souberbeille. 263 Souberbeille. 264Souberbeille. 1826 1826 1826 1826 1826 1826 1826 1828 1828 1828 1829 1829 1829 1829 1829 1829 1829 1829 1829 1829 1829 1830 1830 1830 1830 1830 1830 1830 RI. RI. 47 M. 68 | RI. 78 ! RI. 70 U. 72 RI. 71 RI. SO ^I- 66 RI. 63 ^1. 18 | RI. 52 ' ^1. 21 RL 65 ; ^i. 73 RL M. 20 small, size of hazelnuts. 4, size of almonds. 7, size of hazel- nuts. Almond. 3vss. Horse-chestnut. 300 calculi, equal in weight to 3*iii. or 3*iv. Chestnut. Chestnut. 3"ii. 3iii. §»■ §iv. 3vi. §ii. 3vi. 65 75 65 77 68 73 42 54 §iv. 311.; 2 stones. 4 stones. giiss. 3*iiss. 3 stones. 3iv' 3iv- Recovered, Died. Recovered. Recovered Recovered Recovered Recovered Died. OBSERVATIONS. Pneumonia. REFERENCES. Belmas, p. 23. " P- 234. " P. 235. p. ''37. " P. 238. " P- 240. « p. 241. Apoplexy. The stones The cases from No. 244 were lodged in the to 282 inclusive, are from folds of the bladder,'tbe Memoire de l'Acad- thus making their,emie Roy. de RIe'd., pp. extraction very tedi-1 57 to 77 ; also p. 97, year Died. Recovered Recovered Recovered, Recovered Died. Recovered Recovered Died. Died. Died. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Died. ous; there were 2 inguinal and 1 um- bilical hernia. Exhaustion. Peritonitis. Diphtheria. Rleteorism. 1840. Peritoneum wounded; kidneys diseased; bladder scirrhous,etc 36 SUPRAPUBIC LITHOTOMY 265 Souberbeille. 266 Souberbeille. 267 268 Souberbeille. Souberbeille. i 269 Souberbeille. I 270 Souberbeille. 271 Souberbeille. 272 Souberbeille. 273 Souberbeille. 274 Souberbeille. 275 Souberbeille. 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 Souberbeille. Souberbeille. Souberbeille. Souberbeille. Souberbeille. Souberbeille. Souberbeille. Mursinna. Dupuytren. Scarpa. Vacca Berlin- ghieri. Berlinghieri. Berlinghieri. Berlinghieri. Berlinghieri. Berlinghieri. 1830 1830 1830 1831 1831 1831 1832 1832 1832 1833 1833 1833 65 RI. 68 • RL 59 | M. 76 ^1. 72 ' M. 70 RI. 70 j M. 67 i M. 78 [ M. 63 "SI. 1833 69 1833 80 1833 74 1833 55 1834 70 1834 54 1797 30 1802 62 1808 1808 72 1809 2 25 62 M. 64 RI. M. M. M. M. M. M. RL SI. 3~iii. §iii. 3 stones. Egg. 12 stones. §iss. 3*ii. !"■ .?»• 3»- gii. 3ss. 2 stones. 5 stones. ^viii. 3iiss. 4 stones. 2 stones. gviii. Died. Died. Recovered Recovered, Died. Recovered. Recovered, Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Died. Recovered. Recovered. Recovered. Died. Recovered, OBSERVATIONS. REl'KRKN' ]■>. Recovered. Recovered. Recovered. Died. Hemorrhage, source of RIemoire de I'Academie blood not clear. | Roy. de RIed., 1840. Exhaustion. Typhoid fevei Urethro-rectal abscess. Phthisis; no sound Gunther, p. 306. could be passed ; ob- stinate stricture of urethra, and on 5th day, asthenia. ■ • • • Belmas, p. 12. Hemphrey, p. 105. Lon. RIed. Gaz., vol. i, p. 367. Archiv. fur Klin. Chir., 1881, p. 54. .... Belmas, p. 13. * Gunther, p. 306. Died. Died. Died. Peritonitis and urinary Giinther, pp. 306 and 308. infiltration. Urinary infiltration. '< Abscess and several calculi. SUPRAPUBIC LITHOTOMY. DATE. AGE. . SEX. 292 Unknown. 293; Kirby. 294 Home. 1811 28 F. 1818 40 295 25)6 Home. Home. 1820 16 RI 1820 Child. RI 1820 Adult U. 297Delpech. 1820 298: A German stir- 1S20 geon. RL 299 Dzondi. 300! Dzondi. 30llDzondi. 302 Dzondi. 303 Deguise. 304 Hutchinson. 307E\vbank. Krimer. 308 309 Roux. 310 Amussat. 1822 30 RI. 1S22 30 M. 1823 53 1823 30 1822 30 1824 73 RI. SI. SI. M. 305 Hutchinson. 1825 20 306 ■Ballingall. 3xxxi. HISKRYA'IIONS. Died. Removed an "etui," 21st day. Recovered. Removed an elastic catheter. Recovered. Recovered. Recovered. REFERENCES. Died. Recovered. Died. Recovered. - Recovered. Recovered. Died. Died. 48th dav. Poulet, vol. ii, p. 235. Giinther, pp. 306 and 334. Kirby's cases, p. 92. Belmas, p. 13. Cooper, vol. iii, p. 139. Humphrey, p. 103. Giinther, pp. 44 and 45, in Der Hohe Steinschnitt, refers to all three cases but the following ref- erences : Archiv der RIed., vol. i, p. 142. Belmas, p. 13. Humphrey, p. 105. Carpue, p. 167. Cooper, p. 207, refers to the 1st case only. Gunther, p. 335. Belmas, p. 13. Gunther, p. 335. M. 1826 1827 . . (about.) 1827 j 23 1827 Very old. 1827 65 2 inches in di- Recovered, ameter, and H broad. Died. This operation was for,Gunther, p. 46, in Der the removal of a large Hohe Steinschikitt. clot of blood follow- Lond. Med. Gaz., New ing hemorrhage, and Series, vol. xxii, p. 12. from a fungoid tu-'Anderson, Quart. RIed. mor of the prostate. Science, 1824-6, p. 134, vol. iii. Edin. RIed. & Surg. Jour- nal, vol. xxvii, p. 188. Lond. RIed. Repos., New Series, vol. i, p. 559. Gunther, p. 306. Cooper, vol. ii, p. 267. Operation not finished. Died. Recovered. Humphrey, p. 105. Gunther, p. 306. Humphrey, p. 100. Velpeau, vol. iii, p. 960. Cooper, vol. ii, p. 209. RI. RI. Died. Recovered. 115th day, urinary infil- Giinther, p. 306. tration and abscess. [Humphrey, p. 105. |Velpeau, vol. iii, p. 960. Cooper, p. 137. 38 SUPRAPUBIC LITHOTOMY. 311 Arnussat. 312 Amussat. 313 Amussat. 314 315 Amussat. Amussat. 316 Amussat. 317,Crozat. 318 319 Baudens. Baudens. 320 Baudens. 321 Lisfranc. 322 Lisfranc. 323> Lisfranc. 324 Bell. i 325 Catereau. 326 Rognette. 327 Voisson. 328 Voisson. 329 Leroy d'Etiolles. 330 Seger. 33l|Seger. 332 Seger. 333 Cazeneuve. 334 Wz. 1827 1827 1827 1827 1834 1834 1828 1829 23 1829 6 AGE. SEX. 69 | RI. 76 | RI. 2* ^1. OBSERVATIONS Recovered. Recovered. Recovered. Recovered. Recovered. Died. Gunther, in Der Hohe Steinschnitt, pp. 49-52. 1829 5} RI. 1829 1829 1829 80 1832 57 F. Infiltration of urine. Le Courrier RIed., July 15, 1876. Recovered. Peritoneum was laid Velpeau, vol. iii, p. 966. open to a consider-! able extent. Report Hop. du Rlidi, 1830, p. 290-2. Sabattier, vol. iv,«p. 249. Giinther, p. 306. Recovered. Recovered. I Recovered. Recovered. Died. Infiltration of urine. Lond. RIed. Gaz., 1829, vol. v, p. 123. Died. Infiltration of urine. Lond. RIed. Gaz., 1829, ! vol. v, p. 123. Very large. 183:', 44 , RI. Small walnut. 1834 I 56 1839 1834 1836 1836 35 70 5 27 8 9 49 RI. RI. Ri. SI. RI. M. M. RI. Recovered. Recovered. Recovered. London Lancet, 1833, p. 668. Gaz. RIed., 1832, p. 777. Gaz. RIed., 1836, p. 373. Velpeau, vol. iii, p. 960. Died. Gang/ene 3d day; stone not wholly removed; a portion remaining ! strangulated behind the prostate. Recovered. Died. i8th day, stone encysted ; Gunther, pp. 306 and 335. not removed; pelvic cellulitis. Recovered.( .... Giinther. Der Hohe Steinschnitt, p. 306. Recovered. Recovered. i Died. 47 hours after perito-jRIemoire Acad Roy 1837 nitis- J p. 407. Recovered. . . Gaz. RIed., 1839, p. 509. SUPRAPUBIC LITHOTOMY. 39 DATE. AfiE. SEX. 335 Bancal. 336 Tonnelle\ 337 Leonadon. 338 RIoulinie". 339 C iviale. 340 Civiale. 341 Civiale. 342 Civiale. 343 Civiale. 344 Larrey. 345 Smith. 346 Nelaton. 347 Segalas. 34S Giinther. 349 Gunther. 350 Gunther. 351 Gunther. 352 Gunther. 353 Gunther. 354 Giinther. 355 Gunther. 356f Olivarez. 357 Olivarez, 358 Olivarez. 359 Humphrey. 360 Briins. 3611 Briins. 362 Briins. 363 Landouzy. 364 Langenbeck. 1838 58 1839 . . . 1839 . . 1839 Child. RI. RI. 1S41 33 1841 , 30 1841 , 73 1844 37 F. M. M. M. SI. 1845 29 1845 child. 1847 13 i RI 1851 9 - M 1851 1851 1851 About. 1860 1848 1848 . . ; . . 1848 | . . 1848 14 SI. 1848 26 M. 1848 17 I RI. 1848 3 M. 1S48 Uduit! M. 1849 I 3£ Died. 1 Died. Recovered Died. Died. Recovered. Recovered. Recovered. Recovered. Recovered. 5i.5ii.gr. viii. Died. 15, each size of Died. apricot-stone. Recovered . ■ . | Recovered . . . Recovered Recovered . . . j Recovered. . . . ! Recovered. i . . . | Recovered. . . . | Recovered. . . . i Recovered . . . Recovered . . . i Recovered . . . 1 Recovered, Recovered, Recovered. Recovered. Recovered. Recovered. Recovered. OBSERVATION-- Hemorrhage. REFERENCES. Bancal, p. 119. Velpeau, vol. iii, p. 964. Velpeau, vol. iii, p. 960. Gaz. Med., 1839, p. 795. Obstinate stricture of Gunther, p. 306. urethra; bilateral! first tried ; stone was' not removed. j Gunther, p. 306. Phthisis; exhaustion. Gunther, p. 306; Lancet, I April, 1841, p. 118. '9th day, exhaustion. JGunther, p. 306. f • • • • Gaz. RIed., 1844, p. 630. Gunther, p. 335. 3i- 3iv. Giinther, pp. 59 and 60, Der Hohe Steinschnitt. Humphrey, p. 105. Gunther, p. 306. a it Gaz. RIed., 1849, p. 239. 40 SUPRAPUBIC LITHOTOMY. DATE. AGE. 365 Langenbeck. 366 Langenbeck. 367 j Langenbeck. 368; Langenbeck. 369|Schlobig. 370,Unger. 371 Geinitz. 372 Huguier. 373|Staude. 374 Staude. 375 Staude. 37 61 Staude. j 377 p'Almeida. This surgeon I operated on 22 leases; 7 died and the remainder 'were all success- ful...... The particu- lars of these |cases have not i been found. 400 Vitellius. 1850 15 1852 j 34 1854 I . . 1860 401 402 403 Uytterhoeven. Von Graefe. Halm. 404 Stilling. 405 Gamgee. 30 SI. 1850 i 2| i RI. 1851 ! 27 ' U. RI. SI. . RI. . . 46 1861 58 § xxii. 3-xlii. 3*xxiss. OBSERVATIONS. REFERENCES. Recovered, Recovered Recovered Died. Died. Died. Died. Died. Recovered. Recovered. Recovered. Recovered. Recovered. 7 died, 16 recovered. Recovered. 3d day. Pleuro-pneumonia; ul- ceration above pubes gangrene. Gunther, p. 306. Deutsch. Klin., 1850. Gunther, p. 306. Gunther, p. 306. 4 days, uraemia; left Gunther, p. 306. kidney atrophied; right,hypertrophied. Bulletin de la Soc. de Chir., 1852, p. 306. Gunther, p. 335. Diet. Encyc. des Science RIed., vol. xxv, part 1st, p. 103. Died. Recovered Died. 9th dav. Hair-pin was the nu- cleus of the stone; had been in the bladder for 30 years. Up to the 14th day after the operation she had no fever, when she suddenly died of urae- mia ; she had hydro- nephrosis ; one ureter was entirely obliter ated, the other partly Recovered, Recovered, Archiv fiir Klin. Chir., 1881, p. 48. Archiv fiir Klin. Chir., 1881, p. 48. Erichsen, vol. ii, p. 772. Coulson, p. 476. Archiv fiir Klin. Chir., 1881, p. 53. Archiv fiir Klin. Chir. 1881, p. 53. Lancet,vol. ii, 1873, p. 807 SUPRAPUBIC LITHOTOMY. 41 400 Chisholra. 407 RIcGill. 4< »8 Hammer. 409L)ever. 4l0Dever. 411 Simon. 412 RIerciei. 413 Adams. 414 Amussat tils. 415 Amussat tils. 410 Trendelenberg. 417 Fowler. 418 Keyes. 419 Keyes. 4'JO Keyes. 421:Helmuth. 422Helmuth. 423 Helmuth. 424;Helmuth. 425J Rachel. 426JJ. Hutchin-oii. 427 Lesehick. 428JDoughty. 4291 Billroth. 430 Groves. 431: Groves. 1S62 1W2 1865 1867 1869 1867 About. 1867 1868 1876 1876 1877 1877 1877 1877 1877 1878 1878 1879 1882 1878 1878 1878 AGE. SEX, Adult RI. Adult SI. H • • 9h M. 9 M. 6 M. 54 ^1. Adult M. 2 SI. 16 SI. 2 M. 16 SI 75 RI. 73 SI. 65 RI. 53 M. 70 ^1. 65 SI. 70 RI. 5 SI. 26 SI. 5 SI. iBSERVATIONS REFERENCES. 3"j- dps. 3iij. grs. x. 3 calculi. 3iss. grs. xii. ar. xliv. 3viss. RecoveredJShot above the pelvis;!Med. and Surg. History bullet lodged in the of the Rebellion, part bladder by the ope- ii, vol. ii, p. 282. ration. Died. Shot above the pubis ; Same as above. lodged in bladder. Died. 18 hours after, of con-jSt. Louis RIed. and Sur<-. vulsions, following a! Journ., p. 51. bath. ■ • • • Bulletin de Therapeu- tique, vol. 92, p. 13. Recovered Recovered. Died. Erysipelas. Recovered. .... Recovered. Failure after lateral Recovered. .... Recovered. Recovered. . . Deutsch. Klin., 1867, p. 23. Mercier. p. 456. Med. Times and Gazette, Oct. 16, 1878. Le Courrier Med., July, 1876, p. 219. • • ■ . Lond. Med. Rec, Feb. 15, 1877. Berlin Klin. Woch, Mar. 2, 1877. Recovered. After failure of lithot-Monthly Abs. Med. Sci- rity and lateral lith-- ence, Dec, 1878. otomy. In very low condition Rledical Record, 1877, p. before operation; the 234. others were in the! same desperate state. Died. Died. Died. Recovered Died. Died. Shock. Vide page 65. " " 69. a a ~2_ 1880 39 M. 1880 30 yi. 1880 30 M. 1880 6 M. 4 inches long, 9 inches circum- ference. 6 cab, 5 an inch in diameter, 6th smaller. Gangrene of bladder; in very bad condition at time of operation. Recovered. Failure of litholapaxy. " " 73. Recovered. .... Am. Journ. RIed. Sci- ences, 1879, p. 117. Died. Pyamiia 5 weeks after. RIed. Times and Gazette Oct. 19, 1878. Recovered. 18 days- in healing ;'Berlin Klin. Woch, 4th patient was made to Mars, 1872. lie on the stomach for the first five days. Recovered.(Failure of litholapaxy. Died. Recovered. Recovered. Phthisical patient; ex- haustion. Canadian Journ. RIed. Sc, Nov. 1881, p. 354. 6 4-2 SUPRAPUBIC LITHOTOMY. TABLE A .* Dr. Dulles's Table of Suprapubic Lithotomies performed by American Surgeons only. Gibson 2 Carpenter. McClellan. McClellan. McClellan. McClellan. McClellan. Gardner. 9 W". L. Atlee. 10 iDe Valetti. 11 Delery. 12 I Pope. I 13 ;W. J. Johnson. Parker. Parker. Parker. Parker. Parker. Pitcher. Eve. Eve. Weber. Noeggerath. Hewitt. Krackowizer. Krackowizer. Krackowizer. Krackowizer. Krackowizer. Krackowizer. Wood. Eel ton. Mackenzie. Westmoreland. Robertson. Guido Bell. Guido Bell. 1824 Old. M 1844 42 1848 Man. 184!)' " 1850 12 1850J 22 1853| 53 1853 1854 1855, 1854 1855 1858 1856 1857 1859 1859 1860 I860 1862 1863 1865 1867 1872 Bock. 11873 Bock. il874 H. Lenox Hodge 1874 F.dw. Geddings.1866 Bailey. [1874 Eli Geddings. 1871 3 Boy. zy2 6 3 52 8 40 2 calculi. ........... I R. ::::::::::: j I Sixss. R. F. M. iy2 m. 3 i M. Circumfer- ence 4". SHJ. 3VSS., and as much more. Svj. 2" X W. M. i ............ M. ............ M. ............ M. ! ............ M. I ............ M. Pigeon's egg1 M. ............ Snj. Sj- 3ij 3iv. 5ij. 3ij. Sj. Svj. grs. xvj. 5jss. 3j- Sijss. 2XA long. 54 grs. a c^ D. Reference. Gibson's Surgery, 1835. Am. Med. Rec, Ne. 39, 1827, p. 199; Eclectic Med. Journ. of Medicine, vol. ii, Mav, 1838, p 288. Gross, Diseases of I'rinarvj Organs, p. 632. Remarks. Was doing very well, but withdrew his catheter, and peritonitis set in. Gross, Kentucky Surgery, p. 105 ; Letter of Gardner, Feb. 16, 1875. Eve, Remarkable Cases in Sur- gery. New Orleans Med. and Surg. Journ., Sept. 1849, p. 176. L'Union Medicale de Louisi- ana, No. 3, March, 1852, p. 46. St. Louis Med. and Surgical Journal, Sept. and Oct., 1864. Southern Med. Journ., Dec, 1851, p. 727. N. Y. Med. Journ., Mar., 1855, p. 252. Letter of Dr. Parker, Sept. 21, '74. Letter of Dr. Parker, Sept. 21, 1874, and also Am. Med. Times, July 7, 1860. Letter of Dr. S. H. Douglas, Oct. 5, 1874. Trans. Am. Med. Association, '71, vol. xxii} p. 273. N. Y. Med. Journ.. July. 1*56, p. 45. N. Y. Med. Journ., Jan., 1858. p. 9. N. Y. Med. Journ.. Mar., 1859, p. 217. Am. Med. Times, July 7, I860 Letter of Dr. K., Sept. 23, 1874. Am. Med. Times. July 7, 1860. Nashville Journ. of Med. and Surg., Jan., 1867, p. 502. Letter from Dr. M. Aug l)9 1874. Letter from Dr. C. H. Mastin, Jan. 1, 1875. Pacific Med. and Surg. Journ., April, 1868, p. 499. Memorabilien Heilbroun, Mar. 28, 1874, p. 552. Letter of Dr. B., Sept. 10,1874, Letter of Dr. B., Dec. 8, 1874 C. W. D. Letter of Dr. G., May 1.5, 1875. Letter of Dr. B., Mav 28, 1875. Letter from Dr. G., May 13, '75. Constitution very much shat- tered by previous disease. Immediately after failure of perineal operation. Lateral operation had failed six months before. Calculus 18 years. Applied sulph. of iron and camphor to prevent urin- ary infiltration. Did perineal operation also, and tunnelled through and through the calculus. Perineal operation had failed, and also a great many inef- fectual attempts to crush. Died of emesis from inflam- mation of stomach. Died of emesis from chloro- form. Died of pneumonia. Peritoneum cut in two places. To remove a shrapnel shot. Placed iu a semi-sitting pos- ture for 48 hours after ope- ration. Bladder sewed up; catheter pulled out same evening. Peritoneum cut, but no harm resulted. Immediately after failure of perineal operation. * American Journal of the Medical Sciences, January, 1875. SUPRAPUBIC LITHOTOMY. 43 TABLE B.* Suprapubic Lithotomies, from 1867 to 1877.—(Dr. Dulles.) NO. SURGEON. RIercier. DATE. 1867 A'iE. 30 DESCRIPTION OF CALCULI. 3iij. ^iiiss. RESULT. R. TIME AFTER OPERATION OF RECOVERI OR DEATH. REFERENCES. 1 46 C ays. Gazette Hebdom., 1869, p. 583. 2 Bell. 1867 it grs. xvi. R. 26 u Western Journ. of RIed., Nov., 1867. 3 Bell. 1S72 3 grs. xcvi. R, 21 a RIemorabilien Heilbronn, RIarch 28 1874. 4 Bell. 1875 •> 3 ij • R. 30 a Indiana Journ. of Med., Aug., 1875. 5 Bell. 1875 ■'■J" Large bean size. R. 62 a Am. Practitioner, RIarch, 1876. 6 Brodie. 1868 35 Walnut size. R. Letter from Dr. Brodie, May 5, 1876. 7 Brady. 1868 42 5iss. R, 21 a Detroit Rec. of Med. Pharm., Sept., 1869. s Betz. 1869 6 Acorn size. R. 42 ii RIemorabilien Heilbronn, Feb. 28, 1874. 9 Betz. 1870 8 Cherry size. R. 42 ii Memorabilien Heilbronn, Feb. 28, 1874. 10 Deering. 1870 40 o •" .31V- gr.s.xx. "(gv.grs.xiv. R. 14 (i RIed. and Surg. Rep., April 29, 1876. 11 Watson. 1871 56 5viiiss. R. 42 '« Letter from Dr. Watson, Oct, 6, 1874. 12 Bock. 1873 il o'y R. 21 a Letter from Dr. Bock, Sept. 10, 1S74. 13 Bock. 1874 3 grs. xxv. R. 12 tt Letter from Dr. Bock, Dec. 8, 1874. 14 Bock. 1874 4 grs. lvijss. R. 11 a Letter from Dr. Bock, Jan. 30, 1878. 15 Bailey. W4 2J grs. liv. R. 21 it Letter from Dr. Bailey, Rlay 28, 1875. 16 Billroth. 1874 12 Tumor apple size. R. 33 a Letter from Dr. Karl Schwa ighofer, Nov. 3,1874. 17 Langenbeck. 1875 If Date-seed size. R. 35 " Arch. f. Klin. Chir.-Bd., xxi, Sup. Heft., S. 210. is Rachel. 1875 4 3>j- D. i a This article. 19 Starr. 1876 35 3i- 3i- R. 16 n Am. Journ. RIed. Sciences, July, 1877. 20 Fletcher. 1876 2i grs. lxiijss. D. 2 " Letter from Dr. Fletcher, Jan. 30, 1878. R ^covered, 18 Average time of recovery, 29 days. t) ied, 2 Death ratio 1 in 10. Total, 20 * Tables A and B are taken from Dulles's articles; with these exceptions, all the other references have been carefullv examined. American Journal of the Medical Sciences, April, 1878. SUPRAPUBIC LITHOTOMY. Reference. Giinther, page 306. TABLE C* Operations in which the Result is Unknown. Date. A surgeon of Strasburg, . . . 1727. Hess,.........1729. Kulmus,........1732. Le Cat, 3 cases,......1735. Anthelme,........1828. Josephi,........1828. Paully, 3 cases,......1843. Gaillard,........1844. Paine,.........1848. Frenzel,........1848. Pech,..........1848. Fleury,.........1852. Stolle,.........1856. Berger,.........1856. Schmidt,........1856. Morlanne,........1856. Returners,........... Lotzbeck,........185*. Breslau,........... Maudt, ) -r,- , .... ,,,,«, ' K Velpeau, vol. m, pp. U48-064. Lagouest, Archiv fiir Klin. Chir., 18S0, vol. xxv. Vollemeier, Gaz. Med., p. 240. Billroth, 2 cases. Petersen, 4 cases. Am. Journ. Med. Science, April, 1881, p. 573. TABLE D. A General Summary of the Operations since 1561. Author. Recovered. Rankin,.......312 Dulles's 1st Table, .... 28 2d " .... 18 Died. 119 Unknown Result. 33 Total 464 14 1 43 2 20 Total, 358 135 34 * These cases are omitted from all the tables which follow. 527 SUPRAPUBIC LITHOTOMY. 45 TABLE E. Operations performed since 187s. No. Name. Helmuth. Date. 1878 Age. 53 Sex. M. Size. 3iij. Biss. Result. Recovered. Remarks.. 1 2 Helmuth. 1878 70 M. 3iij. grs. x. Died. Shock. 3 Helmuth. 1879 6o M. 3 calculi. 3iss. grs. xij. Died. Gangrene of bladder. 4 5 Helmuth. Rachel. 1882 1878 70 5 M. M. %}■ 3ij- 9j-grs. xlv. Recovered. Recovered. Much debility ; failure of litholapaxy. Am. Journ. Med. Sci.. 1879, p. 117. 6 7 8 Hutchinsou. Leschick. Billroth. 1878 1S78 1880 26 5 30 M. M. M. ls\. ss. Died of Pytemia. Recovered. Died. Med. Times and Gazette, Oct. 19, 1878. Berlin Klin. Woch., March 4, 1878. 9 Doughty. 1880 39 M. 3iij.3ij-gi's.xxx. Recovered. Bigelow's litholapaxy failed. 10 Groves. 1881 67 M. 6 calculi; 5 about 1 inch diameter. Recovered. Canada Journal of Med-ical Sciences, Nov., 1881. 11 Groves. 1881 63 M. Recovered. In statistical comparisons between different operations, the causes of death are, perhaps, the most important topic, and the discussion of this subject is the greatest benefit to be deduced from such a computation. The subject has been divided into two sections. The first including those causes which are due to the operation itself; the second into those which arose from sources independent of the operation. A large number of cases (forty-two) have necessarily been omitted as being defective in this particular. In the other tables which followr, similar omis- sions have been made, thus giving a variety of figures, for in some instances there is no record of the sex, in others none of the age, and in others the date is deficient. SUPRAPUBIC LITHOTOMY. TABLE F. Causes of Death arising from the Operation. Abscess and sloughing of wound,.......... 1 Peritonitis,.................11 Peritonitis and urinary infiltration,.........1 Pelvic cellulitis,................2 Hemorrhage,................. 5 Cystitis,.................. 1 Blood poisoning,...............^ 1 Asthenia,............. 2 Wound of peritoneum,.............2 Urinary infiltration,.............. 5 Erysipelas,............... ] Meteorism,.......... 1 Gangrene of bladder, ) of wound, j ' ' *..........3 Shock,.........._ \ Pyemia,.................. 3 40 TABLE G. Causes of death not due to the Operation. Suppuration of kidney with stone,.........1 Convulsions,........... o Carcinoma of bladder,............. 4 Pyelitis,.................. 3 Abscess of kidney,........... 9 Inflammation of kidney, with stone in the ureter, .... 1 Hydatids in pelvis of kidney,...........i Pleurisy,.......... 9 Helminthiasis,........... , i Gangrene of lung,.......... j Asthenia from old age,........ 2 Disease of kidneys and stone,...........5 Diarrhoea,........... 2 Pleuro-pneumonia,........ 9 Pneumonia,........... o Apoplexy,............ 2 Enteritis,............ Gastro-euteritis,.......... Emesis from chloroform,........ / Gastritis,........... Phthisis and phthisical exhaustion,........ 3 Urethro-rectal abscess,....... j Uroemia,......... .; Unfinished operation ; non-removal of stone, ... 3 Debility from previous disease, ...... 4 Diphtheria,.......... ' 1 Acute nephritis,......... I Typhoid fever,......... -1 53 Causes not mentioned,........ .9 " from operation,.......... ^() SUPRAPUBIC LITHOTOMY. 47 Thus it appears that 53 out of the 13.3 deaths cannot, with any fairness, be set down to the operation, and if these should be omitted from the general sum, together with those in whom the cause of death is not stated, we would have a remainder of 388 cases, with 40 deaths due to the method, giving a ratio of mortality as 1 in 9.7. It is a curious coincidence that we obtain the same results in regard to the fatal cases as Dr. Dulles, whereas we differ materially in particulars. Dulles assigns only 2/> accidents and complications as causes of death. He places pyaemia, phlebitis, and cystitis as not arising from the procedure, while " pe- rineal operation complicating'' "terrible operation," cannot be set down as very definite causes. These in this table have been set down as not stated. The average size of the stones extracted by the suprapubic operation is exceptionally large. Among the largest are—Deguise's case, of 5xxxi; Kri- mer's 5xxiij ; Yitellius's, Sxxij ; and Uytterhoeven's, oxlij. In those cases which have been adduced, the average weight of the calculus is about Sivss, whereas the average in the lateral method, according to the tables of Mr. (Vosse, is between .§i and 3i*s. TABLE H.* Showing the Results at Different Periods of Life as compared with the Lateral Method. LATERAL. Ages. NO- OF Cases. Recovered. 688 Fatal. 46 Proportion of Fatal. 1 in 15.73 1-10 734 Average age, 24. 10-20 298 266 32 lin 9.31 20-30 213 191 22 1 in 9.0* 30-40 164 134 30 1 in 5.46 40-50 149 120 29 lin 5.13 50-60 182 143 39 lin 4.66 60-70 140 104 36' 1 in 3.88 70-80 28 18 1664 10 lin 2.80 1908 244 lin 7.81jjf * These cases are collected from the statistics of Cheselden, from the Williams table of the Norfolk and Norwich Hospital, and from those of the Saharunpore Dispensary. 48 SUPRAPUBIC LITHOTOMY. No. OF Cases. 84 SUPRAPUBIC* Ages. Recovered. Fatal. 16 Proportion of Fatal. 1 in 5.25 1-10 68 Average age, 32.83 years. 10-20 45 34 11 lin 4.09 2O-30 29 23 lj lin 4.83 30-40 27 1* 9 lin 3.00 40-50 23 19 4 lin 5.75 50-60 32 21 8 lin 4.00 60-70 52 34 18 lin 2.8* 70-80 50 32 252 18 90 1 in lin 2.77 SAO 342 In the lateral operations, assuming that all the cases under ten years average five, all between ten and twenty years, fifteen, all between twenty and thirty, twenty-five, all between thirty and forty, thirty-five, and so on, we obtain an average of 24.22 years. There are lo2 cases of suprapubic operation in which the age is not stated, leaving 342, the actual age of which is known, making an average of 32.82 fatal. Thus it seems that the average age in the suprapubic operations is over 8 years more than that of the lateral. In 1908 cases of the latter, only 28 were over 70 years of age, whereas in 343 of the former, where the age is known, 50 had reached and passed that age. Again, 102 cases, or nearly one-third in the suprapubic operations, were over 60 years ; in the lateral, only 168, or about one-eleventh. In glancing over the tables, the reader will see that Frere Come and M. Souberbeille occupy a very prominent place; in fact, contributing together over one-third of the cases. It would only be natural, therefore, to ask for the results of these individually. Frere C6me, as has been stated, lost 19 in 100; but Souberbeille lost 31 out of 90, or a frac- tion over one-third. The cause of this great mortality, Avhich at first glance seems to speak strongly against the operation, can in a great measure be ex- plained as due, first, to the extreme age of his patients, several of whom were over 80 years of age; secondly, to the effects of previous disease. The aver- age age of these cases is 61.92, or nearly (52 -years. This extremely high average shows that the majority of these patients must have suffered from stone and numerous complications for years before submitting to the opera- *This table includes 49 cases from Dr. Dulles's tables. Tlie ayes of the remainder of his cases are not stated. SUPRAPUBIC LITHOTOMY. 49 tion. That this is the case is well demonstrated by the fact that 22 out of the 31 deaths were due to causes, not from the operation. If these 22, to- gether with 2 others in which the cause, of death is not stated, should be omitted, M. Souberbeille's statistics would read, 66 operations with 7 deaths. Thus, instead of the statistics arguing against this method, they show that the character of a large portion of cases has been of the most desperate and hopeless nature: and when these unfavorable conditions are set aside, and the operation put upon a fair basis and viewed from the same standpoint as the other methods, we find that the ratio of mortality compares favorably. (,See table.) TABLE I. Table showing the Mortality in each Sex, compared with the Lateral Operation. LATERAL.* bUPRAPUB.C. ^KX- Total. Recovered. Fatal. Prop. Fatal, Males, 669 578 91 1 in 7.35 Sex. Total. Recovered. Fatal. Prop. Fatal. Males, 285 191 93 1 in 3.05 Females, 35 33 2 1 in 17.50 Females, 87 75 12 1 in 7.25 Not stated, 122 92 30 In the cases where the sex is not recorded it is very probable that the ma- jority, if not all with a few exceptions, were " male." Assuming them as such, the figures would read: Total, 406; recovered, 283; died, 123; pro- portion fatal, 1 in 3.29. TABLE K. Showing the. Mortality at Different Ages. Ages. Total. Under 5,.......41 5 to 10, . .......43 10 to 15,.......21 15 to 20,.......24 20 to 25,.......13 25 to 30,.......16 30 to 35,.......17 35 to 40,.......10 .40 to 45,.. ...>... 11 45 to 50,.......12 50 to oo,.......12 '^ to 60,.......20 60 to 65,.......25 65 to 70,.......28 70 to 75........33 75 to 80,.......13 80 and over,.....4 Recovered. Fatal. Prop. Fatal. 34 7 1 in 5.85 :!4 9 1 iu 4.77 16 5 1 iu 4.20 18 ii 1 in 4.00 11 2 1 in 6.50 12 4 1 iu 4.00 10 7 1 in 2.42 s 9 1 in 5.00 11 0 1 in 0.00 s 4 1 in 3.00 10 9 1 in 6.00 14 6 1 in 3.33, 20 5 1 in 5.00 15 13 1 in 2.15 18 15 1 in 2.20 12 1 1 in 13.00 o 2 1 in 2.00 543 253 90 * From J. G. Crosse's "Treatise on Stone." 50 SUPRAPUBIC LITHOTOMY. TABLE L. Showing the General Results of Different Methods of Lithotomy. Total. Recovered. Fatal. Prop. Fatal. Lateral . . . 10,150 9036 1114 1 in 9.11 Bilatera. ,. . , 536 495 41 1 in 13.07 Median, . . . 350 318 32 1 in 10.93 Recto-vesical, . 83 67 16 1 in 5.18 Suprapubic, . . 493 or 388 358 or 348 135 or 40 1 in 3.65 or 1 in 9.70 * From Gross's " Diseases of the Bladder.'' p. 338. CHAPTER III. OPINIONS, OBJECTIONS, AND EXPERIMENTS RELATIVE TO SUPRAPUBIC lithotomy; THE ADVANTAGES OF THE OPERATION. It is quite curious, in reviewing the literature of this subject, to observe upon what various grounds this operation has been considered unworthy of regard, thus, an editor of the Medico-Chirurgical Review, in commenting upon Dr. King's work,* gives the author's and his own opinion of the procedure in a very few decisive words. He says, when speaking of the high operation : " As Dr. King very justly observes, this operation is not only more liable than the lateral operation to be succeeded by infiltration of urine into the cellular tissue, but also by peritonitis, the two chief dangers of the latter. When we add that the operation is one of e.vtreme difficulty, we pronounce its condemnation in the most emphatic terms. A very large stone has been supposed to be its only justification, yet we venture to say, that if a calculus is too large to admit of extraction by any operation but that above the pubes, it were better not extracted at all; the patient must almost surely die." Mr. Holmes Coot lias stated the entire impossibility of the operation in many cases, and Lizars in his Surgery, as also quoted by Dulles, says, "Sir Astley Cooper gives so horrible a picture of an operator, in Paris, wounding the peritonceum, and, the intestines protruding, as to dissuade anyone from adopting this operation." It is just such unfortunate expressions, written without any experience or any study of the subject, which have, no doubt, deterred very many from attempting the operation. The ideas promulgated in such texts are wrong. The operation is not difficult, and is, as it has proved itself, particularly applicable to those cases wherein the other methods have been unsuccessful, and with care there is but little danger of wounding the peritonaeum. And yet the majority of the teaching in our medical colleges tends to disparage Hypogastric Lithotomy.f Why this is so, I cannot understand, but the fact remains. The answer may be that the rate of mortality is very much against the operation. This may be, for reasons already given, but in Dulles's last table he makes the ratio one in ten, and from the previous chapter we make it about equal to the lateral. The fact is, as the operation stands before the profession, the rate of mortality ought to be far greater than by other methods, for the simple reason that the * Lithotomy and Lithotrity Compared, etc., by Thomas King, M.D., M.R.C.S., Surgeon to his Excellency the French ambassador, etc., London, 1*32, p. 330; Medico-Chirurgical Review, 1832, p. 42. f As an exception, we refer the reader to the last edition of Bryant's Practice of Surgery, wherein the American editor distinctly states that lie always instructs his classes in the method of performing the hypo- gastric section. 52 SUPRAPUBIC LITHOTOMY. very worst cases are those which have often been assigned to it. W hen peri- neal section has failed, or when lithotrity has been unavailing, then as a la*t resort the hypogastric method is brought into requisition. This indeed is the teaching of the colleges and the textbooks, and the figures allowed to stand in the tables as fair representatives of the value of the operation. A short time since Dr. Keyes (perhaps in answer to a reviewer of Dr. L. A. Stimson's work on Operative Surgery, who asks, " How often Dr. Keyes has made suprapubic lithotomy?"),* in a report to the New York Pathological Society,t detailed three cases of death following the suprapubic operation, stating that up to that period he had operated by lithotomy and lithotrity thirty-eight times and lost four cases ; three being the result of the suprapubic method. The latter cases I give somewhat in detail, and as a sample of the kind that are generally referred to the hypogastric section. In the first case, the patient was seventy-five years old. In 1877, stone caught and measured 11 to II inches. " The nervous, irri- table temperament of the patient and the size of the stone rendered lithotrity un- desirable, and lithotomy was proposed but declined by the patient.''^ Two months and a half later, the patient's symptoms became more distressing, "and the suprapubic operation was performed."....." The whole operation occupied less than half an hour." The patient died on the third day. In the second case, a man, aged seventy-three, had been cut sixteen years pre- viously in the perinreum and six phosphatic calculi removed. " He had atony of the bladder." . . . "The urine contained albumen and casts, and there was much cystitis." He was sounded and the instrument " gently introduced," and yet the patient " was laid up for two weeks, as the result of this explora- tion, and no operation was advised." His sufferings, however, continued to tor- ment him until he demanded relief. A lithotrite was therefore passed, one stone was caught, crushed once, and nothing more attempted. This oper- ation aggravated the cystitis, and then the suprapubic operation was per- formed. The patient died on the seventh day, the autopsv showing granular kidney and pyelitis. In the third case, the patient was sixty-five vears old, had been operated upon two years before in Bellevue Hospital by lithotrity, and a stone of one and a half inches in diameter, composed of urates and uric acid, caught and crushed several times. The size and hard sharp edges of the frag- ments caused some cystitis, and after a rest of a couple of weeks Dr. Keves decided to give ether, and crush as much as possible at a single sitting, usino- a new lithotrite of Ileliquet's. " After a few fragments had been crushed, it became evident that the blades were clogged. Xo efforts succeeded in o-ettino- rid of the fragments, which filled the female blade. The instrument Wctstherefore - American Journal of the Medical Sciences, January, 1879, p. -_>10. t New York Medical Record, January 2.3th, 1S7D. p. -_>3J. X The italics are the author's. * SUPRAPUBIC LITHOTOMY. 53 withdrawn, and enough force had to be used during its extraction to divulse (slightly) the urethra at its point of natural constriction, about two inches from the meatus. The patient had a chill and did badly." This cystitis increased and suprapubic lithotomy was performed, drainage being managed by a con- volvulus catheter passed through the bas-fond and out at the anus. The pa- tient did not rally ; death occurred on the second day, and surgical kidney was found on both sides at the autopsy. I leave any unprejudiced mind to decide whether such cases as these ought to be admitted into the tables, and whether they offer a fair estimate of the value of the operation. In the first case, the patient was an old man (seventy-five years), with such an irritable temperament and such a large stone that lithotrity was undesirable, and lithotomy denied. Two months and a half afterwards, when his condi- tion had become much worse, the suprapubic method was resorted to. In the second case, the patient was nearly as old, had atony of the bladder, aggravated cystitis, albumen and granular casts in the urine, a urethra and bladder so sensitive that the gentle introduction of a lithotrite laid him up two weeks. Litholapaxy was afterward attempted and failed, and then hypogastric lithotomy performed. Of course he died; so he would after any other operation. In the third case, the man was aged sixty-five; litholapaxy was attempted and failed; the urethra was divulsed in withdrawing the instrument; severe cystitis set in and he " did badly ; " and then again the high operation was re- sorted to. I say again, of course the patient died. The question is, ought the records of cases of this character dissuade the surgeon from attempting the operation in favorable cases? Advocates for epicvstotomv have stated especially the character of cases that ought to be sub- jected to it, and I am quite sure, as I have already written in the preface, that there are a large number of cases of calculus in the bladder which should only be treated by crushing; when, however, the stone is large and hard, as in Dr. Doughty's case; when the patient is too young to allow large-sized instruments to pass the urethra, especially in those cases where there is such a sensitive canal that ther mere introduction of a sound, or of the searcher, may be followed by a chill, urethral fever and death ; where the stone, as in my fourth case, was sacculated behind the prostate; where there has been intense and prolonged cystitis, and in many cases of stone in females, hypogastric lithotomy is the operation which, in my judgment, ought to be attempted. At the present writing, I am quite aware that the voice of the majority is rather against me, and when I come to examine into the reasons for this an- tagonism I really cannot find them tenable. The objections are mainly two, viz., peritonitis and urinary infiltration. Of course, at this era we leave out the'accidents of bursting the bladder with injections, or tearing the peritoneum 54 SUPRAPUBIC LITHOTOMY. accidentally from the struggling of the patient; although, in reality, these are by no means fatal. To show the opinion of those of the profession who have considered the subject with regard to the dangers of the operation, a few ancient and modern authorities are here inserted. Thus, Heister says, after alluding to the rather accidental and compulsory operation of Franco, that surgeons have been for the most part dissuaded from performing the suprapubic operation, " because a wound made in the superior or membranous portion of the bladder seemed to the ancients, since the time of Hippocrates, certainly fatal."* Samuel Sharp,t who was a pupil of Cheselden, to whom this method of oper- ation owes so much, condemns it for many reasons, but especially in cases "of indurated bladder, in which there is always more or less difficulty and danger; but it would he frightful in this, not only by reason of the necessity of wound- ing the peritonaeum, but of the difficulty of coming at the stone." Holmes also says: % "The main danger is that of wounding the peritonaeum;" and, again, Spence speaks of the great risk of such an occurrence and of the intes- tines escaping.§ Pirrie|| says, one of the immediate dangers of the operation is wounding the peritonaeum, and one of the greatest objections is the danger of infiltration of urine into the cellular tissue around the anus. Cross writes,* "The r^rocedure is liable to be followed by the injury of the peritonaeum and urinary infiltration." Bryant agrees with the above: '* The causes of death appear to have been peritonitis and urinary infiltration."** Hamilton uses the following expressive words: " There are two principal sources of danger in the high operation, namely, urinary infiltration and open- ing into the cavity of the peritonaeum. The precautionary measures which are to be adopted to prevent the first will presently be described ; with reference to the second, it must be admitted that it is in certain cases with difficulty avoided. We have seen it happen in the hands of an experienced and skilful surgeon, and that, too, when he had just assured us that there was no danger of this accident when proper care was em ployed, "ft Latta,Q thus writes : "In * Id ipsum quidem magis ideo, quia vulnus in superiori,sive membranacea vesica; parte faetum-veteribus, a tempore jam Hippocrates lithiferum utique videbater. Heister De Lithotomia, quia Lit. Alto ut Vocant, etc., Book I, p. 296. t A Treatise on the Operations of Surgery. By Samuel Sharp, Surgeon to Guv's Hospital London 1747 p. 92. % A Treatise on Surgery. Philadelphia, 1876, p. 816. 'i Lectures on Surgery. By James Spence, F.R.C.S E. Edinburgh, 1871, vol. ii, p. 1241. | Principles and Practice of Surgery. By William Pirrie. London, 1873, p. 770. 'j A.System of Surgery. By Samuel D. Gross, M.D. Vol. ii, p. 894. ** The Practice of Surgery. London, 1872, p. 559 ft The Principles and Practice of Surgery. New York, 1872, p. 857. XX A Practical System of Surgery. By Jame> Latta, Surgeon in Edinburgh. In three volumes Fdinbunrh and London, 1795, vol. i, p. 432. ' " * SUPRAPUBIC LITHOTOMY. 55 the high operation, it has been remarked that the wound, both in the bladder and in the external integument, is much more difficult to be healed than in any other way of operating." Erichsen* also adds his testimony in the following words : " After the opera- tion there will always be the risk of urinary infiltration into the cellular tissue, around the margins of the wound. Another cause of danger is the wounding of the peritonaeum." On the other hand, a few surgeons, as Parker, Gunther, Noeggerath, Souber- beille, and especially Dulles, Rachel,Podoska,Trendelenberg,and Petersen, have upheld the performance of epicystotomy. Dr. Noeggerath says,f after detail- ing his method of operation : " We conclude, therefore, that the high operation for stone, in a general point of view, may be executed just as easily and safely as the lateral or perineal section, while it presents some striking advantages over these methods in performing it upon women and children," etc. Parker considers the method the very best for removing stones from the female bladder. Petersen thus formulates the conditions which are favorable: 1st. For large hard stones. 2d. Encapsuled stones, or stones lodged in saccules behind the prostate. 3d. Hypertrophied prostate. 4th. " Haemorrhoids." oth. " Very fat people." 6th. "Tumors of the bladder." 7th. "Impermeable stricture where it is desirable to pass a fine catheter."J Dr. Rachel writes : " Suprapubic lithotomy is no dernier ressort; it is a first- class operation, and ought to be recognized as such."§ Malgaigne,|| in his celebrated thesis, presented to the Academy of Medicine at Paris, 1850, and which gained for him the Chair of Operative Surgery, in drawing a comparison between the different operations for the removal of stone, expresses the opinion, in which I heartily concur, that the high operation is by far the easiest, and is especially adapted for the removal of large stones, even after lateral lithotomy has failed. And that the ease and rapidity with which calculi are discovered and removed, the freedom from haemorrhage, the little danger of making false passages, or laceration of the soft parts, all should render the operation worthy of the highest consideration. In the last American edition of Bryant's Surgery, the editor, after referring to the statistics of the operation as given by Dr. Dulles in his last table, says: " I am convinced the operation is a good one and should be frequently performed. I always teach it to my students in operative surgery."^ It is useless, however, to multiply * The Science and Art of Surgery. Philadelphia, p. 928. t Epicystotomy, with Report of a Successful Case. liy E. Noeggerath. New York Medical Journal, Jan- uary, 1858. X American Journal of the Medical Sciences, April, 18S1, p. 573. \ American Journal of the Medical Sciences, January, 1879, p. 153. || British and Foreign Medico-Chirurgical Review, vol. vi, 1850, pp. 34, 3s. 1, Brvant's Practice of Surgery, edited by John B. Roberts. A.M., M.D., Philadelphia, 1881 5G SUPRAPUBIC LITHOTOMY. quotations on this point; all surgeons appear to be agreed that the chief sources of danger are but two, these being peritoneal inflammation and urinary infil- tration. To satisfy my mind on these points, and to ascertain the height to which the bladder will rise above the pubes at various ages, and how much of the apex of the viscus is generally covered with peritonaeum, as well as to observe the character of the connective tissue behind the bones, I had the fol- lowing experiments made on the cadaver. These dissections were made for me by Dr. McDowell, at the hospital on AVard's Island, the whole I think making a valuable table for the anatomist as well as for the surgeon who desires to attempt suprapubic lithotomy. I am, however, very well aware that these experiments are to be taken with a degree of caution, and must only be regarded as comparative, because in many cases of stone, in which the patients have suf- fered for a considerable time, the bladder is able to retain much less urine than during health. Yet it is interesting and instructive to the surgeon about to perform suprapubic lithotomy to know that in ordinary cases there will be suf- ficient space to allow him to remove a large stone without touching the peri- tonaeum, even after most aggravated symptoms have continued for years. It may be well to note in this place, that Petersen, always an advocate for suprapubic lithotomy, proposes not only to distend the bladder but the rectum also, after the manner of Braune, and thus still further push up the'serous coating of the intestines. Experiment I. Female, age 31; the bladder was injected until it reached 5 inches above the pubes, and was within 2 inches of the umbilicus. In this position the re- flection of the peritonaeum was 2* inches above the superior border of the pubes, and the intervening space was filled by connective and cellular tissue only. Experiment II. Male, age 37 ; the bladder was injected (24 oz.) until distended; it reached 4 inches above the pubes and within 2 inches of the umbilicus. Here the duplication of the peritonaeum from the anterior wall of the bladder on to the inner surface of the abdominal walls did not reach within 2? inches of the upper border of the pubes. Experiment III. Male, age 50; 32 ounces water injected into bladder, it then reached 5 inches above the pubes, and within i inch of the umbilicus. In this position the duplication of the peritonaeum was 2i inches above the superior border of the pubes. Experiment IX. Male, age 20; injected 28 ounces of water into the bladder with moderate force. The bladder mounted 4 inches above the pubes. Transverse diameter PLATE I. Vide kxperimevil Xl.page 58 >ocpenyiievil- IV. pai$e56. SUPRAPUBIC LITHOTOMY. 57 of the bladder, 4 inches. The lower margin of the peritonaeum was 21 inches above the pubes; it described a gentle curve, going below the internal abdominal ring on each side. Injected from 54 to 60 ounces of water with considerable force, when the bladder gave way between the pubes and the fold of peritonaeum. Experiment V. Male, age 27 ; injected 30 ounces of water into the bladder. The bladder mounted 5 inches above the pubes, its transverse diameter being 3§ inches. Space between the pubes and peritonaeum, 2J inches. Experiment VI. Male, age 30; injected 25 ounces of water into the bladder. The summit of the bladder was 3? inches above the pubes. Transverse diameter, 31 inches. Distance between the pubes and peritonaeum, II inches. On the left of the median line the peritonaeum made a rapid descent toward the pubes, while on the right it maintained its height for 11 inches, and then de- scended abruptly. Injected from 60 to 63 ounces, when the bladder gave way at a point above the lower line of the peritonaeum. Experiment VII. Male, age 30; injected 26 ounces of water into the bladder. Summit of the bladder rose 4 inches above the pubes. Transverse diameter of the bladder, 31 inches. Peritonaeum to pubes, If inches. The lower margin of the peritonaeum was irregular, being lower on the left side than the right, forming an angle a little to the left of the median line. There were no signs of previous inflammation. Experiment VIII. Male, age 39; injected 27 ounces of water into bladder. Bladder rose 4i inches above pubes. Transverse diameter of bladder, 31 inches. Space between the pubes and peritonaeum, 2i inches. Margin of peritonaeum in a short curve, meeting the pelvis if inches from the symphysis on either side. Injected from oo to 60 ounces of water, when the walls of the bladder gave way at two points, side by side, on the superior surface. Experiment IX. Male, age 40; injected 22 ounces of water. Bladder rose 4 inches above pubes. Transverse diameter, 3i inches. From pubes to peritonaeum, If inches. The fold of peritonaeum was almost a straight line at right angles with the median line. 58 SUPRAPUBIC LITHOTOMY. Experiment X. Male, age 45; injected 19 ounces of water; bladder above pubes, 3 inches; transverse diameter, 3£ inches; pubes to peritonaeum, li inches; again injected 24 ounces; bladder above pubes, 3? inches; transverse diameter, 31 inches; pubes to peritonaeum, li inches. Experiment XL Male, age 47; injected 32 ounces of water into the bladder. Bladder mounted 3 inches above the pubes. Transverse diameter of bladder, 41 inches. The bladder did not project anteriorly as in other cases. Usually when being injected, the anterior surface of the bladder rotates from below upwards, the portion of the bladder walls behind the pubes rising upwards, but in this case the portion behind the pubes remained stationary, so that the bladder appeared to rotate in the opposite direction. AATien injected, the peritonaeum did not rise at all from the pubes. There were no adhesions of the bladder, peritonaeum, or pubes; they separated on slight traction. No thickening or discoloration of parts, and no known history of inflammatory disease. Experiment XII. Male, age 49; injected into bladder, 26 ounces; bladder rose 4i inches above the pubes; space between the pubes and fold of peritonaeum, 2 inches. Experiment XIII. Male, age 50; injected water, 24 ounces; bladder above pubes, 4? inches; transverse diameter, 4 inches; pubes to peritonaeum, 21 inches. Experiment XIV. Male, age 57; injected 22 ounces; bladder above pubes, 3± inches; transverse diameter, 3f inches; pubes to peritonaeum, I inch; again in- jected, 32 ounces; bladder above pubes, 4i inches; pubes to peritonaeum, If inches. Experiment XV. Male, age 65; injected 27 ounces of water. Bladder rose Si inches above the pubes; it was somewhat conical in shape, the apex projecting anteriorly and being li inches above the level of the pubes (body horizontal). Trans- verse diameter of bladder was 4 J inches. The lower margin of the peritonaeum was irregular, being higher at one point than at another. (See diagram.) At the highest point -it was If inches above the pubes, and at the lowest It inches. Between the lower point and the pubes, the connective tissue was tense; it was not thickened, and gave way on slight traction; the peritonaeum appeared PLATE II. .44>**t? ' ^.;J;.;y;;.:V.:;.-;v-: y' '..'.-'.■Vi V ^ >xpe,rimeviF 15 naqt, 58. SUPRAPUBIC LITHOTOMY. 59 normal. Again injected 40 ounces water; the bladder rose 41 inches above the pubes; transverse diameter of bladder, 41 inches; lower margin of peri- tonaeum nearly regular and 2i inches above the pubes; injected from >~)0 to 60 ounces, when the bladder gave way between the pubes and peritonaeum. Experiment XVI. Male, age 72; injected 28 ounces of water into the bladder; bladder rose 4i inches above pubes; space between pubes and peritonaeum 21 inches. Experiment XVII. Female, age 30; injected 30 ounces water; bladder rose 3f inches above the pubes; space between pubes and the peritonaeum, li inches. Experiment XVIII. Female, age 30; injected 24 ounces of water; summit of the bladder was 4 inches above the pubes; transverse diameter 4i inches; from pubes to peri- tonaeum 3 inches. The uterus was enlarged, and there was some thickening of the peritonaeum between the uterus and bladder. No evidences of cystitis or general peritonitis. Cause of death, carcinoma uteri. Experiment XIX. Female, age 34; injected 28 ounces; bladder above pubes, 3f inches; transverse diameter, 3i inches; pubes to peritonaeum, 1J inches; injected, 35 ounces; bladder above pubes, 4 inches; pubes to peritonaeum, II inches. Lower margin of the peritonaeum curved as usual. Experiment XX. Female, age 40; injected 28 ounces; bladder above pubes, 4£ inches; transverse diameter, 4 inches; pubes to peritonaeum, 2 inches. The folds of the peritonaeum extended across almost in a straight line. Experiment XXI. Female, age 43; injected 28 ounces; bladder above pubes, 4 inches; pubes to peritonaeum, li inches. Lower margin of peritonaeum curved. Experiment XXII. Female, age 24; injected 20 ounces water; bladder mounted 'M inches above the pubes; space between pubes and the peritonaeum, 21 inches ; again injected 40 ounces, when the peritonaeum was 3i inches above the pubes. 60 SUPRAPUBIC LITHOTOMY Experiment XXIII. Female, age 47; injected 26 ounces; bladder above pubes, 31 inches; transverse diameter, 4 inches; pubes to peritonaeum, If inches. The lower margin of the peritonaeum met the pelvic brim about two inches from the sym- physis on the right side; on the left it described a shorter curve, coming one inch from the symphysis. Experiment XXIV. Female, age 50; injected 25 ounces; bladder above pubes, 41 inches; transverse diameter, 4 inches. The peritonaeum extended to the pubes. It was very much thickened, of a yellow color, very dull in appearance; the bladder walls were not appreciably thickened. Water withdrawn, and bladder again injected; when 35 ounces had been injected, the adhesions between the peri- tonaeum and pubes were torn apart by hand, it requiring considerable force to do so. After this, continuing to inject, the peritonaeum rose from the pubes as in other subjects. When from 60 to 6o ounces had been injected, the bladder ruptured a little below the middle of the anterior surface. Experiment XXV. Female, age 76; injected 27 ounces; bladder above pubes, 3f inches; transverse diameter, 4i inches; pubes to peritonaeum, 2 inches; again injected 35 ounces; bladder above pubes, 4f inches; transverse diameter, 5 inches; pubes to peritonaeum, 21 inches. Quantity of Water Injected till Bladder Ruptured. Number of ounces. Case 4, " 6, " 8, " lo, " 24, Average, 54 to 60 60 to 63 oo to 60 55 to 60 60 to Qo 591 ounces. Quantity of Urine Retained in the Bladder till there was Urgent Desire to Urinate. Case 1, age 19, .... . 16 ounces " 2, 25, .... . 12 u - i 26, .... . 10 it " 4, 28, .... . 13 It " 5, 39, .... . 8 it " 6, 40, .... . 10 (( " 7, 45, .... . 8 ii " 8, 56, .... . 8 (( SUPRAPUBIC LITHOTOMY. 61 By carefully reading over the table annexed, it will be seen that oppor- tunity thus far has not allowed the dissection of any subjects younger than twenty-six years of age, but I am in hopes ere long to present some further experiments in this direction. However, in this patient, tabulated as Case 4, the bladder rose above the pubes 4 inches, 21 inches being uncovered by peritonaeum. In the oldest patient (case 25, aged seventy-six years), the blad- der rose 4i inches above the pubes, there being but two inches uncovered by the serous sac. In the former twenty-eight ounces of fluid were employed, in the latter twentv-seven. >ox. A i;o. No. fl. oz. Height of Transverse Pubes to 34 injected. bladder. diameter. peritonaeum. Case 1, Male, 5 2.5 a o " 50 32 5 2! " 3, " 37 24 4 4 ' 2i " 4, •' 2li 28 4 4 n " 5, " 27 30 5 3q 2k " 6, 30 25 te 3| l! " 7, 30 26 4 3f If " 8, 39 •>- 44 3J 21 " 9, " 40 22 4 3i If " 10, " 45 24 3i 3| li " 11, 47 32 3" 4 j 0 " 12, " 4!) •26 4* 0 " 13, 50 24 41 4 ' n " 14, " 57 32 4i 4} if " 15, " 65 27 3i 4i if " 16, " -•> 28 41 OL — 1 " 17, Female, 30 30 3| n " 18* " 30 24 4 4 V 3 '■' 19, " 34 28 3| 3i li " 20, 40 28 4i 4 2" " 21, 43 28 4 li " 22 " 45 20 3J -1 " 23, " 47 26 3| 4 ' 1:1 a 94 * « 50 25 4J 4 0 " 2o' " 76 27 3a o4 4i 2 Average, . . 43M 26H 4-V 0 43 °T4 4 2-3~ In case Xo. 2 (a man aged forty-seven years), the anatomical conforma- tion was very remarkable. The bladder rotated from behind forward, so that the anterior wall was completely covered by peritoneal investment, the con- trarv of which is found in the majority of cases, and this occurred, as Dr. McDowell remarks, without thickening or discoloration of parts or of any known history of inflammatory disease. In case No. 24 (a woman aged fifty years), there was also no portion of the bladder which became uncovered with the membrane; on the contrary it ex- tended to the pubes. By referring to this case, it will be seen that all the ap- pearances of old pelveo-peritonitis were apparent. * Peritonitis. 62 SUPRAPUBIC LITHOTOMY. In case No. 17 (a woman aged thirty), with the injection of thirty ounces of fluid, the bladder rose three and three-quarters inches above the pubes, but left one and a half inches between the pubic symphysis and the duplicature of the peritonaeum. In the fifteen male cases recorded, there were six in which the bladder when injected did not rise uncovered to two inches, eight in which the space.between the pubes and the anterior fold of the peritonaeum was between two and three inches, and one in which the bladder was entirely covered anteriorly by the membrane. Leaving out, then, the latter, as an anatomical anomaly the average space which is free from the peritonaeum above the pubes in the injected bladder is within a small fraction of two inches. It will also be remarked that there will be a space of about four inches of bladder-wall above the pubes, if the size of the stone necessitates an extension of the incision above the line of peritoneal reflection. Advantages. The advantages claimed for the suprapubic method are, first, the absence of danger from haemorrhage. From this, however, it must not be inferred that there is no bleeding whatsoever, because very frequently there is quite a pro- fuse discharge of blood from the incised bladder-wall, especially if the mucous membrane is sensitive and congested. A needle-puncture sometimes gives rise to a considerable flow of blood, as I have observed in some cases of vesico- vaginal fistula,* and therefore, if it be possible, when the incision into the bladder is being brought together, the needle should be carried through the thickness of the bladder, but brought out at the verge of the mucous lining. These bleedings, however, cannot be of much moment, for there are no vessels of any magnitude divided either in the incision in the linea alba, or the divi- sion of the bladder-wall, unless there be an anomalous course of the arteries and veins, and I am disposed to think this must have been the condition where such haemorrhage has occurred, these cases being very few. The next great advantage in the performance of hypogastric lithotomy is that of being able to see the different steps of the operation. No matter to what degree of perfection the tactus eruditus may have been cultivated, it is much more satisfactory to have " your eye upon " all the manipulations of knife and forceps. In the lateral operation, after the bulb of the bistourv or gorget has entered the groove in the staff, which indeed must be found by feeling, the operator can actually see nothing more of the procedure. The blade enters the bladder unseen, the finger enlarges the opening throuoh the * M. Cazenave was compelled to perform the hypogastric section to remove clots of blood whicl 1 \ formed from a simple puncture. Bulletin Med. de Bordeaux, 1833. p. 82. Quoted hv Velpeau SUPRAPUBIC LITHOTOMY. 63 prostate, the forceps are passed in and withdrawn with " touch " alone to guide them, while in the hypogastric section every step of the performance is assisted by the sense of sight, and an immense assistance it is. Another point of superiority in epicystotomy, is that it admits of the removal of stones of greater magnitude than by any other method, as is conclusively proven by many cases in which it has been successfully performed when the perineal methods and litholapaxy have failed. Again, the accidents of wounding the rectum, of incontinence of urine, of impotence, of urinary fistulae, are not to be feared as resulting from the method of Franco, while some or all of them may follow the other and more popular methods of removing calculi from the bladder through the perinaeum. The main objections, as have already been fully considered in the first portion of this chapter, are urinary infiltration and peritonitis, which latter, as statistics prove, is rather rare, and it appears to me, need scarcely happen, unless there is an abnormal direction given to the peritonaeum as the bladder rises above the pubes, as in one of the experiments made upon the cadaver. CHAPTER IV. CASES OF SUPRAPUBIC LITHOTOMY. Uxtil about two years ago, whenever a case manifesting the symptoms of vesical calculus, of sufficient definiteness to suggest the thought of lithotomy, was presented to my notice, the idea of the operation was at once associated with one or other of the methods performed through the perinaeum. In fact, having been taught, and read almost universally, that suprapubic lithotomy was obsolete and only to be undertaken under most peculiar circumstances, and having accepted the tradition without inquiry and without much thought, lithotomy, to my mind, meant perineal section, either lateral, bilateral, or me- dian, for the removal of stone in the bladder. The proper estimation of the suprapubic method forced itself upon my mind, from the perusal of cases in which, from enlargement of the prostate or the magnitude of the calculus, the perineal operation, which had been actually commenced, had to be abandoned for the suprapubic, which was performed with success ; and because in most of the modern works upon surgery, the high operation is only recommended for such extreme cases. Thus in a case of impacted calculus weighing eight and one-half ounces, it was impossible to remove the stone through the perinaeum, and the high oper- ation was resorted to with success.* Samuel Cooper also thus writes: "Des- champs mentions an instance, in which M. Lassus, after using Hawkins's gor- get, could not draw out the calculus, and he therefore immediately did the high operation, and the patient recovered."f Still more interesting is the fact that Franco, the author of the operation, was first led to perform it, for similar reasons, in the year 1560, as reported by Heister, as already noted in the chap- ter upon the history of this operation. VelpeauJ disbelieves the latter state- ment, although he gives us no authority for his assertion. Liston§ also re- cords a similar case, as does also Eve,|| and the case of Krimer, in which a stone of twenty-three ounces was removed by the suprapubic method, after the failure of the perineal section the day before, is well known.^j I have also witnessed lately a similar case in the hands of Dr. Doughty, in which Bigelow's litholapaxy failed, and an enormous stone was removed by the * Vide Dulles, Suprapubic Lithotomy, American Journal of the Medical Sciences, April, 1878, p. 4ol. f Cooper's Surgical Dictionary, Article Lithotomy. + Operative Surgery, vol. iii, p. 952. \ Practical Surgery, p. 409. |j Remarkable Ca>es in Snrcerv, p. 624. \ American Journal of the Medical Sciences (Dulles), 1S75, p. 41. SUPRAPUBIC LITHOTOMY. 65 high operation with success.* Erichsen also refers to two cases, and one has occurred to myself. Vide Case IV, page 73. The inferences from such cases as these might certainly be that if supra- pubic lithotomy were successful in such extremities, why would it not be ap- propriate in those cases where no such obstacles existed? And if the statistics of these operations, as presented in most of the modern surgical works, are drawn from such records, do they represent fairly the value of the method? Shortly after this, the following cases came under my observation : Case I.—I. I. S., aged fifty-three years, weight two hundred and forty pounds, florid complexion, and nervous temperament, consulted Dr. Henry Minton, of Brooklyn, for a trouble of the urinary bladder of several years' du- ration. Some years since, the patient had suffered from internal haemorrhoids, with occasional haemorrhages from the rectum, complicated with a fistula in ano, which was operated upon with the knife and healed rapidly. Five years after, a second fistula appeared, which was cured by the internal administration of medicine. AYhen I visited the patient, I found him in apparently good health, with a moderate appetite, and no inconvenience, save the frequent and per- sistent desire to urinate, which, gradually increasing for the past three years, had become almost unbearable. From time to time the urine passed had con- tained blood, for which he had also received treatment. He presented all the ordinary symptoms of stone, such as aching pain in the small of the back, drawing in the groin, pains in the perinaeum, and uneasiness at the end of penis. When urinating, he would relieve the vesical tenesmus, which was very great, by bending the body forward and pressing his fingers upon the peri- naeum with great force. He had a pricking sensation at the neck of the blad- der and elongation of the prepuce. In fact his physician had diagnosed the presence of a calculus, and called the consultation in regard to the propriety of its removal. Upon introducing the sound, there was such severe vesical spasm, that although the offending substance was detected, it was thought best, as my time was then limited, to make a more thorough examination, with the patient fully etherized, on the day but one following. A portion of his urine however, gave the following analysis: Sp. gr. 1018; reaction, acid; no sugar ; a trace of albumen; sediment bulky and heavy, with a large amount of isolated and aggregated pus-corpuscles; one crystal of the triple phosphates. This, as will be seen, was rather negative in its results, so far as the pres- ence of the calculus was concerned. At the appointed time, the patient was thoroughly anaesthetized, the bladder was injected with a few ounces of water, at body temperature, and a calculus, an inch and three quarters in length, was found, resting on the left side of the bottom of the bladder. After due con- * The reader is referred to Case V in this chapter. 'J 6Q SUPRAPUBIC LITHOTOMY. sulfation, I concluded to perform lateral lithotomy, not only because my expe- rience was larger with that method than with any other, but because I had not lost a patient therefrom. The time was then appointed for the operation, but in the interval I again referred to the literature of epicystotomy, and after a good deal of thought, and I must own with some misgivings, determined to alter my mind, and to extract the stone above the pubes. The operation certainly ap- peared theoretically the simplest and the least dangerous, the objections to it, as laid down by all writers, being more apparent than real. In these days of ovariotomy, laparotomy, and excision of the rectum, a wound of the peritonaeum .« is by no means fatal, and urinary infiltration, although an untoward accident, may be prevented, and is quite as likely to happen after the perineal section. Still, the very facts, that the opinions of the majority of the profession were opposed to the suprapubic method; that I had performed lateral and median lithotomy successfully; and above all, in case of an unfavorable result, the censure which would probably be cast upon the operator, not only by the friends and relatives of the patient, but by his own conscience for having de- parted from the beaten track and sacrificed a life to his temerity, were sufficient to cause considerable anxiety regarding the termination of the case. However, fortified by late statistics,* on the 13th of May, 1878, at 3.15 o'clock p.m., assisted by Drs. Burdick, Richardson and Minton, and in the pres- ence of several medical students, the operation was performed as follows : All the instruments, bed-clothing, vessels and sponges being "listered," and the atmosphere of the room charged with thymol spray, 1 to 100, the patient was placed on the table on his back, and ether administered. When the anaes- thesia was complete, he was as usual, sounded, all the gentlemen present hear- ing the click and feeling the stone. The sound, No. 14 English scale, was then withdrawn, and a catheter of the same calibre, to the end of which a stopcock was attached, was introduced into the bladder, which was then thoroughly washed out and injected with carbolized water, 1 to 100, at a temperature of 0SJ°. The bladder was filled by means of a good-sized syringe, holding about four ounces, and about twelve ounces were injected into the viscus. The stopcock was then turned, the catheter was held at a right angle with the pubis, and retained in this position by an assistant encircling the penis with the forefinger and thumb to prevent the escape of fluid by the side of the catheter. An incision was then made, about four inches in length, in the linea alba, to the root of the penis. It was necessary to enlarge this integumental cut during the operation, on account of the immense amount of adipose tissue beneath the skin. As soon as the abdominal cavity was opened, a mass of fat presented at the wound, which, as in Dr. Rachel's case, prolonged the operation somewhat; * The tables of Suprapubic Lithotomy show a mortality of but 1. in 9.7. Vide page 47. SUPRAPUBIC LITHOTOMY. <>7 the delay being occasioned by the anxiety to avoid the peritonaeum or the omen- tum, to which these masses of fat might have been attached. Cutting carefully through this layer brought the bladder to view. The handle of the catheter was then depressed between the legs of the patient, and its point made to press upon the anterior wall of the bladder. The point of the finger was then in- serted into the wound, which was at least three inches in depth, and by moving the catheter the correct relation of the parts was distinctly made out. The lips of the wound were then carefully held aside with retractors, and a good- sized curved needle, threaded with a double carbolized catgut ligature, was passed through the upper portion of the bladder, drawn through and tied in a loop; the needle was cut off, and the loop hooked upon the finger of a trusty assistant. At this stage of the operation, the patient, very plethoric, became almost asphyxiated; the face was perfectly purple, respiration ceased, and the pulse was feeble and intermittent. Within five minutes, by drawing the tongue forward with a tenaculum, and performing artificial respiration (Sylvester's method), the symptoms subsided, and the operation was continued. By turning the stopcock fixed at the end of the catheter, about one-third the quantity of water was allowed to escape from the bladder in order to prevent too much of a gush of fluid when the viscus was incised; and, to render the recti tense, the legs of the patient were allowed to fall over the edge of the table, thus bringing the muscular walls of the abdomen down upon the bladder, with a view of also preventing the water from flowing into the abdominal cavity. Although, from experience in ovariotomy, such an occurrence would not have probably occasioned inconvenience, still these precautions at that time were deemed necessary. A curved bistoury was then introduced in front of the loop of catgut; and the bladder incised toward the pubes. A small quantity of the carbolized water gushed out, and being caught with sponges did not pass into the abdomen. I did not, as has been recommended, follow the course of the bistoury with my finger, nor was the stone whirled up to the opening made in the bladder. When the parts were all dry, I inserted my finger into the bladder, distinctly felt the stone lying on the right side of the prostate, and with a pair of lith- otomy forceps extracted it without any difficulty. The catheter was withdrawn from the bladder as soon as the incision had* been made in the viscus. The loop of catgut was then drawn well up, to bring the lips of the bladder wound well into view, which was closed with fine carbolized catgut sutures, the ends of the threads being cut off close to the knots. The loop of catgut was then slackened, and the bladder allowed to drop into position; sufficient traction, however, being made to prevent a complete approximation of the vesical walls. The loop was then secured at the upper angle of the wound, and the abdominal incision closed with silver-wire sutures passing through the entire abdominal (iS s U PR A P U HI C LITH ()rrO M Y. walls, integument, fat, and muscular tissue. An inch, however, at the lower end of the cut was allowed to remain open for drainage, and a good-sized car- bolized tent inserted into the opening. As the anaesthesia was passing off symptoms of vesical tenesmus of a violent character presented, for which, at 4.45 p.m., tine, hyos., gtt. xv, were given. At 5 p.m., and after the patient had been placed in bed, the pulse was 68, and the temperature was 97°. At 5.15, the vesical tenesmus appeared to threaten again, when the dose of hyoscyamus was repeated. Shortly after the second dose this symptom entirely disappeared. At 8 o'clock p.m., there was a sudden desire to urinate, and a small quantity of urine was passed through the urethra, In an hour the catheter was intro- duced and six ounces of urine drawn. At midnight two ounces of water were drawn with the catheter; the pulse was 84, and the temperature 99§°. Had slept quietly for two hours. May 14th, second day, 5 o'clock a.m.: Temperature 99i°; pulse 92; water drawn. At 7 o'clock a.m., night-dress and bedclothes changed without trouble. The patient was bright and cheerful, having nothing of which to complain. During the night there was occasionally a discharge of urine from the wound. At 5 o'clock p.m. : Temperature lOOf ° ; pulse 95. Urine drawn every two hours. May 15th, third day, 10 o'clock a.m. : Temperature 99|°; pulse 88. At 5 o'clock p.m. : Pulse 104, temperature 100|°. Discharge from wound somewhat offensive. On the morning of the 16th I received the following word from Dr. C. W. Cornell, who had the patient entirely in charge during my absence: " Mr. S. passed a better night than last, sleeping most of the time. Was not nearly so restless. Feels very comfortable this morning. The odor from the lower angle of the wound is still offensive. The discharge is, however, less. I removed the dressing this morning under the spray (thymol), not, however, removing the straps, but cleansing the parts between them. I change the seton quite often, thoroughly cleansing the parts at the same time. Urine has been drawn regularly, and is about the same in every respect." On the 17th, fifth day, I cut out the catgut suture holding up the bladder. On the 18th, sixth clay, the report was: " The patient slept very well. The discharge is about the same in quantity and character. The urine still escapes from the wound, causing considerable discomfort, The probe can be passed down between the lips of the wound about 3* inches. This morning, according to directions, I coated the line of incision with collodion, and should judge from appearances that the wound has united along its entire upper portion. PLATE m CaseI.J.S. Travelling agent, age 03'years, Weight Uo % . (page 69; May 13**- Hbty 15th 17 th 1878 P. M. AM. P.M AM. F.M AM P.M. 5 12 5 .5 10 5 /0-5 /oz° L._ --- -- --- --- --- /oo /o/° — -ft— -- -- ;\ i \ > \ 35 700° 1 ■ i -- A T/Ti /\ y V I V / i------- \ --- w 90 99° v. t A i i-------- __ 1 j ff \ * 1 •s~ / \ 1 i 1 \ i \ ,' i 8J 98° I \; i I * i \ j i 4 ' 1 1 i \ 1 80 97" \ ZL 1 ZL --- zt zu 7J 96" r — I \ ----- 70 9J° m......i i i i j_ i 1 i 65 i 4 1 i The doiied hne> represents the pnlst SUPRAPUBIC LITHOTOMY. 69 Temperature and pulse remain the same, the former being 99|°, the latter 88. No untoward symptoms have developed. Catheter is passed every three hours." On the 19th, the seventh day, I removed the wires, and, as a matter of ex- periment, and to ascertain if I could reach the bladder above the pubes and thus make drainage, I ordered a catheter placed in the wound instead of the tent, and to have it retained there by means of lint packed around it, On May 21st, I received the following from Dr. Cornell: " Patient passed a most com- fortable night, and is in as good, if not better, condition than when you saw him. I have placed a catheter in the wound, and packed the lint around it. I first placed dry lint in the lower portion of the wound, and above this, lint saturated with oil, to prevent the absorption of urine. The packing was secured by strips of adhesive plaster. Since then there has been but a slight discharge. Very little, if any, of the urine, however, escaped through the catheter in the wound, most of it being drawn with the catheter. This morning I carefully examined the wound and find it thoroughly closed." On the 12th day I removed all the packing and catheter, and allowed the patient to sit up. Occasionally—sometimes once a day, sometimes twice a day, sometimes once in three days—a little urine would escape from the wound ; but this soon passed away, and he was going about his room in four weeks, and soon attended to his regular business, and is to-day cured. The Plate will show the pulse and heat line of the patient, The calculus was a mixed one and weighed 5iij ;")jss. I have been, perhaps, somewhat too minute in the details of this case, but I have given it in full, because often the treatment was experimental, on account of the great diversity of opinions that exist regarding these very details; some surgeons preferring that no sutures be used, the wound being allowed to take care of itself; others, that drainage should be made through the rectum, while others advise the permanent retention of the catheter. This case must be regarded as rather a typical one, on account of the cor- pulence of the patient, which condition is said by some to contraindicate the operation. Case II.—Not very long after this time, and when I had made myself some- what more familiar with the history of these operations, and had made an espe- cial studv regarding the duplications of the peritonaeum over the bladder, a second case was sent to me, by Dr. John Butler, of this city (New York). This patient came from the country to Dr. Butler, to be treated for senile hy- pertrophy of the prostate. The doctor discovered, immediately upon introdu- cing the catheter, the presence of a calculus, and asked me to take charge of the case. The patient was in his seventieth year, had always had good health, excepting of late, when he had trouble in passing his urine, with great urinary tenesmus, and sometimes complete retention. He had also suffered from stric- 70 SUPRAPUBIC LITHOTOMY. ture of the urethra, and had a false passage leading from the urethra to the right of the penis. He was of spare habit of body, but possessed apparently much vitality. Although the age of this patient was rather against the success of the opera- tion, yet his prostate was so enormously enlarged that I was well convinced I should have great trouble in completing any variety of perineal lithotomy, and therefore determined to resort to the high operation. According to the table of M. Belmas,::: the proportion of deaths at this age, after suprapubic lithotomy, is 1 to If; and according to Rankin 1 in 3.80. Vide page 48. On the 24th of December, at the Hahnemann Hospital, I performed the operation, assisted by Dr. John Butler and several medical students. The same process as that I have already recorded was adopted. The bladder was injected with the carbolic water, 1 to 100, at a temperature of 98°, through the catheter fitted with a stopcock. I noticed upon attempting to distend the bladder, after 4 to 6 ounces of water were injected, that there appeared to be an obstacle to the further entrance of the fluid into the viscus, which I found afterwards was occasioned by the thickness of the walls of the bladder, and to the space occupied by the hypertrophied prostate. The incision was commenced and carried in the same direction as before, and the usual amount of fat found upon the apex of the bladder. Upon in- cising the viscus, the stone, weighing about 190 grains, was readily extracted. Search was made for other calculi, but none were found. It was during this manipulation that 1 was able to ascertain the approximate size of the prostate, which appeared about that of a large orange, and felt like a fleshy tumor inside the bladder. The vesical wound was carefully stitched with fine carbolized catgut ligatures, and the external cut brought together with silver-wire, excepting the lower angle, into which a tent saturated with carbolized vaseline was inserted. At 5.30 o'clock p.m., the pulse was 68, temperature 98°. At 7 o'clock p.m., pulse was 100, temperature 99i°. At 12 o'clock, midnight, the pulse was 112, temperature 99i°. On the 25th (Christmas day), at 9 o'clock a.m., pulse 122, temperature, 100°. At 12 o'clock a.m., pulse 125, temperature 1013°. When I made my visit the pulse was weak ; the patient had vomited. There was a thick coating upon his tongue, much thirst, a blueness around the eyes, a hectic flush upon his cheeks, and altogether the symptoms were not favorable. He was, however, rational, and answered questions well and promptly. His urine had been drawn regularly every two hours; none had escaped from the wound. I ordered the catheter (a soft Nekton, with countersunk eye) to be retained in the bladder, and gave him, or rather ordered, aconite to be continued. At 3 o'clock p.m., pulse 132, temperature 101 i°. * Traite de la Cystotomy Sus-pubienne, Paris, 1827, p. 91. , SUPRAPUBIC LITHOTOMY. 71 At 5.30 o'clock p.m., pulse 128, temperature 101°. At 11 o'clock p.m., pulse 120, temperature 100T\°. At 12 o'clock p.m., pulse 120, temperature 99s0. On December 26th, at 5 o'clock a.m., pulse 130, temperature 102°. At 7 o'clock a.m., pulse 135, temperature 99r8n°. At 8 o'clock a.m., pulse 104, temperature 99^°. When I saw him this morning his appearance was about the same as when I had made my visit the night before. But his general aspect was not very favorable. R. Arsen. 3d, every hour. The urine had escaped freely from the catheter. He had taken some milk, which he relished, but still had thirst and was very restless. Had, however, a good deal of sleep, but awakened unrefreshed. Wound was carefully dressed, all soiled linen, bandages and straps removed. Medicine continued. At 4 o'clock, pulse and temperature about the same. Gave stimulants (brandy) frequently. At 6 o'clock p.m., pulse 110, temperature 98°. At 10 o'clock he appeared more quiet. From 10.45 o'clock to 11.30 p.m. he slept. From 11.30 o'clock to 12.30 p.m. was awake; took some milk. The sheet being a little soiled was changed, the tent taken out and cleaned, and a powder of Arsen. 3d trit. given, which was to be repeated every hour, and stimulants pro re na'ta. From 1 to 2 o'clock a.m., slept, took some milk and cracked ice with brandy. Vomited slightly. Pulse 104, temperature 97°. Catheter cleaned and a new carbolized tent introduced. No urine had escaped from the wound. From 3 to 4 o'clock a.m. was restless, but slept a little. Pulse weak. On 27th, 9 o'clock a.m., patient appeared to be sinking. His pulse was very weak, but not very rapid, beating at about 104, with a temperature of about '.»7C. There was some slight tympanitis, but no sensitiveness of the ab- domen, in fact excepting the usual soreness attendant upon the wound, the sen- sitiveness of the parts had gradually diminished. Carbo veg. 6th was given every hour, and stimulants pushed as far as he could bear them. I may here state that from the first day he had been troubled with hiccough, which was temporarily arrested by Hyos. 3d in water. This symptom had now returned with renewed violence. At 12 o'clock he appeared about the same with a slight fall in the tempera- ture. At 6 p.m., he was very restless and more sunken, with a pulse of 135, and a temperature of 96°. At 12 o'clock, pulse 140, temperature 96i°. Very rest- less and some muttering, cold extremities and cold sweat upon the forehead. On the 2Sth, at 12.05 o'clock, midnight, the pulse was 13(5, temperature 96°. No urine escaping from the catheter for the last two hours. 72 SUPRAPUBIC LITHOTOMY. At 3.30 a.m., pulse 135, temperature 96°. At 6 o'clock a.m., pulse 136, temperature 90°. 28th December, 7.30 a.m., pulse 124 and very faint, temperature 95°. Un- conscious. (The Plate shows the lines of pulse and temperature.) He died about 3 o'clock in the afternoon. The post-mortem examination was made that evening, by myself, Drs. But- ler and Dennison. Rapid decomposition was taking place, and there was some air in the intes- tines. The incision in the abdominal walls had healed almost entirely, and there was a large amount of plastic material around and beneath the wound. The bladder wound had also closed for the most part. The lower portion of the incision, however, was open; in it a catgut ligature, somewhat softened, was found. The ligatures at the upper angle of the wound had almost entirely disappeared. The bladder was small, contracted, and very much thickened, and as before stated, the prostate, enormously enlarged, occupied the greater portion of the viscus. The peritonaeum just above the wound was congested for the space of about half an inch, and then appeared perfectly healthy, as did all the other viscera examined. Although this was an unfortunate ending to this case, it does not, to my mind, present any evidences against suprapubic lithotomy, and I felt the better satisfied that I had selected this method, after I had ascertained the size of the prostate. I scarcely think that I should have been able to extract the stone through such an enlarged and hardened mass. The patient died of exhaustion, as he would in all probability had the lateral or the median perineal section been performed. We must remember that at the age of this patient, the mortality by the ordinary methods is about 1 in 31.* Cask III.—U. P. W., was born in New York city, on March 10th, 1817, and lived his entire life in the vicinity. At the time of his demise, his age was sixty-two years, nine months, and six days. His health was always mod- erate, having been never confined to his bed up to one year prior to his death. His first indisposition occurred about 1858, he suffering at that time from dyspepsia, which continued for four or five years. In 18(53, he was affected with haemorrhoids, which troubled him for many years, and for which he un- derwent a great variety of treatment, with varied results, but without any per- manent amelioration. In 187(5, he was attacked with nephritic colic, and began passing uric acid calculi. In July, 1879, all the symptoms of stone manifested themselves in a most aggravated form, and for a relief of these symptoms he was sent to me. He was emaciated, passing putrid urine loaded with pus and blood-corpuscles, hyaline and granular casts, and epithelia from pelvis of kidney and ureter. The most aggravated suffering, however, was the * Holmes's System of Surgery, vol. iv, p. 10*51. PLATE IV. fag* 7ZJ UuEfatient aged }(■* YearsJaririer by occupation .suffered from shie/ure and false passages. Dee emMer 788, i ?~+t1u Z5^ OglyK- Z7*^ zs*^ F. M. A.M. P. M. A.M. P.M A M P. M. A. M. Hours - ■J 7 /£ & /& .3 5 // It 5 7 8 6 2, 9 6 « mh 3h. 6 1% m•' HO ~1 ---' 108" 135 A -- — ----- \' N _i_ \ 'V- i— - / | -W ! - 4-a»— i 1 ^-^x*r 101" 130 ■ ■ - 14- .j___j____ _. _.; \ ! -- -- YV 1 ! \ T rTZ T " • \ ~£ i _.. i_.._i] - i \ 1 ' ins i \~- W 1 1 -?■ .--. -A- —: _.__ \ V \- -* / T I i A- - \ i 1 \ _| J ... ^_ i I \ 103° no / —+ \ i \ ' ' ■ i J \ / i f \ \ i A. V "< i 115 1 i f i i io*0 i 103<" 710 i i i A i l \ t j__\ i l \ | 105 --- - i 1 \ I i \ ~* I0& 1 j i Co 1 _: 1 \' j i I \. 101" 700 / X L I \ — — --- —i / TT \ ; i TT V f~T tx \ i M 1 100 « 95 r ______i —\ "ff-iq i , \ r r - i t^ i \ 99° 90 i \r X 1 ] i \ ~> t i - \ . \T \ i i/ \ '/'ftripej ature 1 \ i n 98° 85 — — - 4 , t 97° 80 — i A 1 - — , 1 ! | ■ | 1 [ 96° — 1 75 i 95° JO" ! 1 1 ^>-A^ j 1 ..(. . ,.. fuJse 1 --- , _!,„ ■ ■ ...I. i - ■ .... t------------k- 65" \ , 1 \ i _, The clotted hne Teprtsents ike, pulse . SUPRAPUBIC LITHOTOMY. 73 terrible urinary tenesmus, strangury, and priapism, with bloody urine, which nothing but the largest doses of Morphia could relieve, and then he never was entirely free from suffering. On December 13th, 1879, as a dernier restart, he being in very bad condi- tion for any operation whatsoever, and having a urethra so extremely sensitive that the passage of a soft flexible bougie wTould throw him into a chill, imme- diately followed by the most intense suffering, I concluded, at his request, to perform hypogastric lithotomy. The operation was readily accomplished after the manner laid down in the succeeding chapter, and three uric acid calculi extracted with the fingers, weighing oss, grains xij. But the condition of the mucous lining of the bladder was remarkable for its pulpy, dark-brown hue; the walls were immensely thickened, and the prostate much enlarged. The operation was completed at 3.30 p.m., having begun shortly after 2 o'clock, and there being several delays occasioned by the extreme prostration of the patient. From time to time, it was necessary to give him hypodermic injections of whiskey to restore the pulse, which on several occasions failed entirely. At 5 p.m., his pulse was 98, temperature 95i°. Coldness over surface and somewhat wandering in mind. R. Aconite and Veratrum every two hours. 12, midnight, pulse 110, temperature 99°. Patient restless but more con- scious, violent urinary tenesmus, and great pain in the wound, fy. Hyos., gtt. xx, eveiy three hours, in alternation with arsenic. December 14th, i) a.m., pulse 135, temperature i05.4c; almost unconscious; no urine from either catheter or wound. Vide Plate. December 15th, died. This was a rapid demise. The post-mortem appearances showed surgical kidney, trabeculated bladder, with immensely hypertrophied walls, which were covered on the outside with dark purple spots; the whole mucous membrane was pulpy and purple, and in a state of decomposition. Case IV.—The history of this case previous to the operation, is well described by the gentleman himself, who, in the following expressive letter, details the circumstances surrounding and the pain attending upon his case. New York, January 3d, 1X82. Dr. Wrr.LiAM Tod Helmuth. Dear Sir: Having suffered for several years, various pains connected with the bladder, scrotum, and glans penis, and being often compelled to micturate from ten to twelve times a day, the annoyance led me to consult with various laymen, as well as physicians, and also to refer to such medical works as would enlighten me upon the subject. Aconite, Rhus, Bryonia, Buchu, Ignatia, Mercurius, Colocyuth, Phosphorus, Belladonna, Podophyllin, Lycopodium, Capsicum, and Nux vomica, were all taken, sometimes combined, and sometimes alternated. A physician of celebrity in this city stated that I had not a calculus, as my face did not indi- cate the preseuce of stone. I am nearly seventy years of age, never smoke or use tobacco or spirits, and have always lived a temperate life, my general health being excellent. About 10 74 SUPRAPUBIC LITHOTOMY. eighteen months since I was seized with a severe pain in my left side, followed by ^no^r attack about ten mouths after. In both these the suffering was most intense. In May, 1< - , I visited New Haven, Connecticut (74 miles), and returned the same day. My business re- quired that I should ride two or three hours about the city, and then having occasion to mic- turate, I observed that the urine was flecked with blood, which was the first evidence that there was anything seriously wrong with my bladder. A month or two later, after walking down Broadway to my store, about two miles from my house, I again passed blood from my bladder. From that period, my urine became a matter of study with me, and purchasing a dozen six-ounce large-mouthed white bottles, I micturated in them when at home, and allowed them to stand from one to two days or more, and watched the result. There was always some pain iu the penis, and difficult micturition. I take at random from my note-book (March 8th, 1881), the periods at which I was obliged to urinate, passing from 1 to 3 or 4 ounces : "a.m., 3.30, 6, s.10, 10.45 ; p.m., 12.50, 2.45, 4.50, 6.20, 7.45, 10, 11.05; thermometer 36°." There was always pain along the urethra and in the glans penis, and constant desire to urinate. I went with my family to Poland Springs, Maine, where the water is said to be pure and alkaline, and remained there two months. I found a large number of people afflicted with kidney or urinary troubles there, but of whose troubles one would know nothing unless drawn out in private conversation. Most of the visitors supposed they were benefited by the waters, and I found the rest and change favorable, but when body and mind were redirected to their accustomed employment, the recurrence of pain evinced the relief was temporary. At first, after much activity, the albumen in my urine was very marked, and taking it to my physician, he tested it with Nitric acid, and informed me that it was one-third albumen. It was examined by him several times, and when I was not actively employed, it was only slightly charged with mucus, but generally heavily loaded with albumen. Being anxious con- cerning my condition, I submitted my urine to a professional microscopist, who informed me that there were many casts found in it, and that I certainly was suffering from Bright's dis- ease. Subsequently, however, the urine was examined by one of the most celebrated surgeons, who could not detect any casts, but found a large excess of uric acid. It was again examined in Boston, by a professed microscopist, who informed me there were no casts in my urine, but much uric acid. I suffered great agony from the jar of riding iu a carriage, the urine being bloody, and I therefore concluded there was a calculus in my bladder; the idea had been sug- gested before, and I had been advised to be sounded. Having an aversion to this, supposing it to be more .objectionable than it proved, and being worried by pain in the urethra and glans penis, and having to micturate frequently, at the solicitations of my friends, I called on Dr. T. F. Allen, who suggested immediate sounding, which being done, a calculus was found, which appeared to be encysted and not easy of access, and which my experience told me must be re- moved in time, or in time it would remove me. Respectfully yours, etc. Dr. Allen referred the patient to me; and, after carefully sounding him, I could detect with ease, a calculus, lying on the left of the prostate, which appeared immovable, and which from the peculiar nature of the " feel" given to the searcher indicated that a portion of it was covered by membrane. At this period, as the urine was very ammoniacal, I therefore had the bladder washed out twice a day, with a saturated solution of the biborate of soda; and an analysis made which showed: color, amber; reaction, slightly acid ; specific gravity, 1.020 ; albumen, i of 1 per cent.; pus-corpuscles very abundant; con- SUPRAPUBIC LITHOTOMY. 75 nective tissue in scanty shreds; epithelia, prostatic, vesical (middle and deep layers), pelvic, and renal. The absence of acid constituents in this specimen was probably owing to the alkaline washings. On December 21st, 1881,1 attempted litholapaxy, using Key's lithotrite. Do what I could, it was impossible to dislodge the calculus sufliciently to get it firmly within the jaws of the instrument; and though I could fasten the lithotrite upon the projecting portion of the stone, the blades would slip off, only taking off a small portion of the offending substance. In several instances I had firm hold of the stone, but from the " feel " imparted to my hand, I knew I had either the bladder-wall, or that portion of it covering the greater portion of the calculus within my grasp, and dared not risk turning the screw. The patient was turned on both sides, placed in the recumbent and semi-recumbent positions, but without avail; and, after an hour and a half's hard work, I was obliged, very much to my chagrin, to relinquish the operation. Upon this, I determined to resort to the high operation, which was performed on the 18th of January, 1882. There was a large accumulation of fat over the bladder, and the superficial adipose tissue on the abdominal wall was very deep. the incision measuring in depth about five inches. Upon opening the bladder there was very profuse haemorrhage, which being arrested, I introduced my fingers into the wround, and found the calculus lying deeply in the left side of the bas-fond, and almost completely encysted ; after some difficulty I was enabled to turn it out with my fingers, and then easily withdrew it with the forceps. In this instance, instead of holding up the viscus with the curved needle, I employed forceps with catches at the handles, and with wide fenestrated blades. This method saved the puncture made in the wall of the vesica by the needle. The calculus (composed of uric acid and ammonium urate), was horse-chest- nut-shaped and was 5 s inches in circumference, and 1 inch in diameter; weight, 620 grains. The bladder was closed with carbolized catgut, and the incision with silver wire. An india-rubber drainage-tube was introduced at the lower extremity of the wound, which was dressed with borated cotton and old linen, and washed with a weak solution of carbolic acid. The deeper portions of the cut were dressed with glycerine and carbolic acid. The incision was then properly strapped with adhesive plaster, the application of which was continued after sutures were taken out, and the straps covered with collodion, as was also the surface in the region of the incision; this was done to prevent excoriation from urine. The sutures were removed January 24th. The wound was dressed three times a day for the first week, and subsequently twice daily, except when copious discharges from the incision required additional attention. On January 31st, the drainage-tube was discontinued, and iodoform bougies, 5 grains each, were introduced regularly twice each day, in the entire depth of the cut, Patient sat up for the first time on January 30th, for about fifteen minutes, and 7(i SUPRAPUBIC LITHOTOMY. on January 31st, for three hours (from 11 a.m.-2 p.m.), also from 4.30-7.30 p.m., making sjx hours in all. February 12th, patient sat up for eleven hours, and walked at times during the day, thirty to forty-five minutes. February 14th, remained oftt of bed for six hours, and walked for about half an hour about the room and in the hall. The catheter was introduced at time of the operation (January 18th), and was removed and cleansed at each dressing for the first week, and subsequently every three hours. On first sitting up in a chair (January 31st) the catheter was removed, but it was reintroduced again on lying dowm, and its use was steadily continued. On February 7th, india-rubber tubing was attached to the instrument, which acted as a siphon, and proved a great convenience. On February 8th, the use of the catheter was discontinued on account of the irritation of the urethra, the urine passing naturally. Flow of Urine.—From January 18th to 21st, copious discharge of urine came from the wound, tinged with blood. On January 21st, the first clear urine passed from the catheter, making during the day (twenty-four hours) Is pints. Other discharges as follows: January 23d, 1 pint, 15 ounces; January 24th, 2 pints ; January 25th, 2 pints ; January 26th, 2 pints ; January 27th, 2 pints ; January 28th, 1 pint, and much discharge from the incision ; January 29th, 2 pints ; January 30th, 2 pints; January 31st, 1 pint. Catheter out, and more discharged from the wound. When less urine was passed, it was because a portion of it passed through the incision and could not be collected or measured. February 8th, catheter was removed, and 4 ounces of urine passed naturally by the urethra. Feb- ruary 10th, 23 ounces were voided naturally, the remainder coming through the cut. On February 12th, the water was passed naturally once in two hours, to prevent its escape through the wound. Diet.—January 18th to 23d, barley-water every four hours,subsequently, with slight variations, as follows: 2 o'clock a.m., 7 ounces of barley-water; 6 o'clock a.m., 7 ounces of mutton and barley broth ; 10 o'clock a.m., 2 lean mutton-chops, with Irish potatoes, Graham bread with butter, and black tea. A 2 o'clock p.m. (dinner), mutton, or fowl, and potatoes, baked apples, bread (always Graham), butter, and tea; 6 p.m., 7 ounces of mutton and barley broth, with some of the pieces of the mutton in it; 10 p.m., 7 ounces of mutton and barley broth, or barley alone if the mutton is too heavy. February 13th, exchanged the black tea for 7 ounces of milk. State of Health.—First day, much nausea on recovering from effects of the ether. Second day, vomited 3* pints of black bile. Third day, vomited 2i pints more. Fourth day, 1 pint more. Afterwards he was fed with and re- PLATE V. Showing (lie Case-of J.WX Aye SOT February 8" 1881. Omduion Married. Occupation, dealer in Iron-, Merali ic. Disenvc - Calatlm or Stone inMaddtr. Operation Supra Pubu. Resuir, Cure. Operation performril Janutiry IS'* 1S8?.. JPM. HhMu of Patient,, Temperate,, using no Liquor, Tobacco, &y. rtiene Table si m- /our obscrvau wm /vr rfiew . eodt, PuJm aiul Tejiiperature.. 188? Ja nzuu-u/81*- /».«*- 20* 2/*' '.> 1 nd :::)'.■' '.'■If SS'.1- Z6lk 271^ ?8!*- £<)t^ A X P .V a\m P M A u r M A — - A \m l'\M .I\M P'.il A hr f'h A w p H A Jf P M A H P H A v r, i ' A » i— K.i UUL 1 J 1— s p 8 -i s ■*-* 8 Z7 '. 8 H **- « ; 8 - " ■■ I X ■■ j * * - 8 A _l_ 8 5 8 — 8 /? 8 a 8 « « ^ ! 8 —1— 8 Z 8 1---1 . 80 7.: too' as- -= i "K r^V y. r^ f -x- A, Y V -V— / -V A N r ^ - T i V p A - f -- V 1 £ v ^ A w A —V-—f— 4-—i—I — pc_ A 4] --- ><- -f" - — ^-K -^-f- 4- / y— -*' A / , "*- 6.! ST T u— A r"*^ =<- A— V ^^ \ f y- \ —. . * ^^ — .►. +. --- Z 1 "S "*—— ~~*zzz. - __ I QO Mt>' 11 I zz. --1 . - ! V - - ^~ | ss ■?•>' « i'eJ>ruari/ f" o„d iri 4 th JV 6th- 7tA- 8th- 3th- 1Q,K lltK 12<*- B? ,4o. AJM P f ^ jf ■/* |jf m M P M A M p ;V yi M p K A W p Jf A if P IK A if P H A H e x A M p >f A if 1 P. w A X P\M Jteu Z jj* 2 i I * Z s z 8 ; * z * 2 «? « 8 Z * I 8 «■ « £' 8 a 3 2 * 2 « Z 8 2 8 1 8 , 8 z 8 2 « i 8 ^ * Z. « I z « Z 8 Z\8 .._ S3 | j -__- - , tt j: " — A ----4----1 —A A 4- --•—, - V- ~^-_ .24- "V4-- r—h- *C~ »^H— -V- ^_ -X^_ .^•"S 4^ E K^ -V A L/ A ^ 'c sr i ~K -r- T — -----1 ir T — A - - 1--1 \ V £- \ V +- \ ** §= r \ 1— 1 ii J!£- -4 — —t--*- O- ■-i- 1-- >^- A.. 1 ■ -L- — a.- -^- ._. _w. -rf- ■*— te • -*r ^ -^ -/- -A'. — i \— — s— -*— ~T -r- A- -*i *— — — I sI.T P ]| a P FBI C L I T H OTO M Y. / < tamed barley-water till January 24th. No chill or indication of fever occurred. The sleep was first irregular, from four to eight hours, but as a rule the patient suffered no inconvenience from want of sleep. February 11th, was awakened by nurse every two hours, that the urine might pass per urethram, and thus prevent any flow through the wound. After the operation the pain was acute for about twelve hours. Action of Bowels.— First, on January 26th (eight days after operation), a full passage, using 12 ounces of tepid water. Second, four days later, using 10 ounces of water. Third, natural action, without any enema, and subsequently regular daily evacuations, using small enemata. The patient steadily improved, and is now cured. 1 called upon him to-day, June 4th, and found him at his Sunday-school. The following chart shows the pulse and temperature during his confinement within doors. After this work had been completely prepared for the press, I opened the blad- der (above the pubes) of a boy, aged five years, who I supposed was dying of rup- ture of the bladder, and who was almost pulseless when I placed him on the table. The case had been sent to my clinic, at the college, presenting all the symptoms of stone; the child rolling on the floor with agony when endeavoring to micturate, and then passing only small quantities of urine. He had also occasional haemor- rhage from his bladder, and was feverish and restless, with a pained expression of countenance. Withal he had an exceedingly elongated prepuce, the orifice being about the size of a needle. I sounded him at once, and could detect no calculus, but distinctly felt on the convex surface of the curve of the sound, just at the neck of the bladder, a rough and uneven surface,—just such a sensation as belongs to a trabeculated bladder from atony and long cystitis, and which I had often recognized before. There was no sharp, metallic click, which immediately points to the presence of stone. I circumcised him at once, and for several days all his symptoms appeared to improve. In a fortnight he was brought back to the college in a most pitiable condition. I sent him to the hospital, and that afternoon (Saturday), in the presence of several medical gentlemen, easily detected the soft grating, or what I might call " mucoid sensation," with the sound. I then endeavored to draw off his urine with a fine flexible catheter, but only succeeded (he being under ether) in removing an ounce of water. On the next morning early, I was informed by the house surgeon that the boy had passed an agonizing night, that no water could be drawn from the bladder, and that he was rapidly sinking. I then endeavored to catheterize him, but found no urine. The bladder reached to the umbilicus and its anterior wall, hard, and apparently distended, could be felt beneath the integument. I introduced an aspirating needle at two points, but without effect, and as a last resort determined to make a suprapubic cut 7.S SUPRAPUBIC LITHOTOMY. into the abdomen. I could not, nor could those with me, understand why the bladder should be so high above the pelvis, and yet contain no urine. _ I ex- plained to the mother (an Italian) the very desperate condition of her son, and, although he was sinking, determined to do what I could to relieve him. A very small quantity of ether sufficed to completely anaesthetize him, and I rapidly incised the bladder, which was empty, very much thickened, and very small. Upon introducing my finger into it, I found the roughened surface to cover up something extremely hard, and upon separating the tissue with my nail came upon a calculus situated in the prostate gland, occupying its entire area, and effectually closing the mouth of the urethra. It was with a great deal of difficulty that this stone could be dislodged, and it was only when one of my assistants introduced his finger into the rectum and forced up the stone that I could turn it out. The boy died in about an hour after the operation, and a post-mortem examination revealed an empty bladder, abscesses in both kidneys, a large quantity of pus in the pelvis of the right one, and an immense abscess, containing nearly a quart of matter, extending from the lower margin of the right kidney to the fundus of the bladder. The adhesions to the sur- rounding intestines and to the upper portion of the bladder were very numerous and dense, and thus raised that viscus out of the pelvis. I have not had this case inserted in the tables, for several reasons. First, because the operation was not undertaken as a suprapubic lithotomy, but to relieve a supposed ex- travasation, or as an entirely explorative one; second, because all the tables constituting the second chapter were then completed by Dr. Rankin, and ready for the printers; and, third, because of the bad condition of the boy for any operation whatsoever. The lesson, however, that it has taught me in the field of hypogastric section for stone, is this: that in children it is the most readily performed of any other operations of lithotomy. The time consumed in the performance of the operation was about four and a half minutes, the instru- ments, a small sound, a pair of forceps, and a curved bistoury. Case V.—The following very interesting case occurred in the practice of my friend Dr. Doughty. I was present and assisted at both the operations. M. O. D., a gentleman thirty-nine years old, had been troubled from early childhood with difficult and painful micturition. When about twelve years of age he had an attack of kidney colic, which was followed by cystitis, from which he suffered for the following four months, passing large quantities of pus, but no blood. The cystitis and general debility were so severe that his life was despaired of. Fie, however, rallied and regained good health, but the painful micturition continued to annoy him. With this exception, his health was good up to about twelve years ago, when he began to have frequently recurring at- tacks of chills, followed by fever and sweats, which were called malaria, The difficulty in micturition and the so-called malarial chills becoming more S U P R APUB1 C LI T H O T O M Y. 79 severe, he was examined on Mac 30th, 1879, by his physician for stone and stricture, but neither was found. For the next four months he had ure- thral fever, intense pain on making water, and general debility. A considera- ble portion of this time he was confined to his bed. In the early part of July, 1S79, Dr. F. E. Doughty was called to take charge of the case. Although there were many of the symptoms of stone in the bladder, it did not seem advisable to make an examination at that time, on ac- count of the fever, cystitis, and great debility of the patient, which condition was the result of the examination made May 30th." A change to a neighbor- ing seaside resort, however, was recommended, where the patient remained one month, returning much improved in his general health, but the local symptoms remained about the same. Dr. Doughty now determined to examine the bladder, and accordingly did so with the result of plainly detecting the presence of a large calculus. Lith- otomy was accordingly proposed as the only means of relief, but the patient and his family would not consent to any cutting operation being performed. Dr. Doughty therefore decided to attempt litholapaxy, the patient insisting on having that operation performed. The urethra was prepared by dilatation, and sounds passed up to No. 16 English, the meatus having been cut. On November 20th, 187*.>, ether having been administered, the crushing operation was attempted. There was no difficulty in clasping the stone, but on account of its immense size it was impossible to obtain sufficient purchase upon it to break it. Some small pieces were broken off, but the main portion remained intact. After two hours' fruitless endeavor, the operation was aban- doned. The patient was put in bed and made as comfortable as possible. This was about 4 p.m., the operation having been commenced at about 2 o'clock. There was a great deal of nausea and vomiting from the ether. At 11.30 p.m., about 4 ounces of dark but not decidedly bloody urine were passed. There was only slight fever. Every three hours during the night he would pass 3 or 4 ounces of dark urine. On the morning after (November 21st), the tem- perature was 99§°. UTp to this time he had been unable to retain any nour- ishment ; the vomiting now, however, ceased. He continued during the day, at intervals of about three hours, to pass his water, with intense pain, and with it a considerable number of broken bits of calculus were discharged. At 2.30 p.m., the temperature was 101° ; in the evening. 1011°, and the pulse 112. During the following night he continued to pass, with great pain, urine con- taining small bits of calculus. On November 22d, the second day after the operation, there was more calcareous debris discharged every time the bladder was emptied, and the pain on micturition was more severe than before. The temperature during the day was normal and the pulse 88. The general con- 80 SUPRAPUBIC LITHOTOMY. dition was about the same. There was some tenderness over the hypogastric region. For the next three days the symptoms remained unchanged; every i'ew hours he would urinate, with great suffering, passing dark-colored and now oc- casionally, bloody urine, with broken bits of calculus. On November 25th, it was decided to perform suprapubic lithotomy, the pa- tient now having consented to any measure likely to give him relief. Up to this time the most nutritious and easily digested food had been given, and at different intervals, arsenic and brandy, with an occasional hypodermic injection of Magendie (12 in all). The operation was performed after the following manner: The patient, after being thoroughly anaesthetized, was placed on the table and the bladder injected with about 12 ounces of water carbolized. The incision was made in the linea alba, and the bladder easily reached. It was then secured by means of a loop of catgut, and held in position. The bladder was then punctured, from within outward, by means of the "sonde-a-dard" just above the pubes, and with the knife an incision was made upward and downward to the desired extent. The finger was now passed into the bladder, and immediately came in contact with a large calculus. Forceps were then introduced, and after considerable difficulty, including an extension of the incision to the utmost limits admissible, a calculus of uric acid, weighing three (3) ounces and one hundred and fifty (150) grains, was extracted. The diameters of the stone were 21 inches X 2 inches X If inches. Several good-sized pieces, the result of the previous operation, were also removed ; which with the debris washed out at first sitting, plus that obtained by filtering the urine voided between the operations, gave 96 grains additional, making in all a'calculus weighing three ounces and two hundred and forty-eight grains. The bladder was now washed, and the edges brought together by means of interrupted sutures of catgut. The external wound was closed by silver su- tures. A drainage-tube was introduced at the bottom of the wound, and a soft rubber catheter tied into the bladder, via the urethra. There was no nausea or vomiting after this second operation, whereas these symptoms had been very troublesome in the first. At 7 p.m., there were two ounces of not very bloody urine in the bottle, and about three ounces on a towel. By midnight half a gill more had collected, quite clear. He was feverish and complained of much pain R. Aconitefl, followed by a hyp- odermic injection of fifteen minims of Magendie. 5.45 a.m., November 26th, temperature 100?° ; gave eight minims of Magen- die. 8 a..m., six ounces of clear urine in the bottle. 10 a.m., has considerable pain and is much distended with wind, which he SUPRAPUBIC LITHOTOMY. 81 is unable to expel. Temperature 100?°, pulse 128. Clear urine continues to collect, (lave eight minims more of Magendie solution. 3 p.m., is suffering severely again from wind. Gave Magendie again, same dose as before. 5.30 p.m., temperature (3Si°, pulse 12, at a temperature of 100°, allowed to run into the wound; this should be continued until a quart of the solution has been so used. Then the dresser, taking his probe, wraps the end of it with borated cotton, introduces it to the depth of the incision, and wipes out the wound; he then removes the cotton, reapplies another piece, uses it in like manner, and so on continues until the whole cavity is dry. This may take half an hour or even more. The catheter also is removed from the bladder, washed and carbolized, and is ready for readjustment. The surface of the abdomen must then be covered with a large wad of borated absorbent cotton, and a muslin binder applied over it, and securely fastened with safety-pins. The catheter for the first few days must be perma- nently retained in the bladder, which is best accomplished as follows: Take six or eight hooks, such as are used in fastening ladies' dresses (hooks and eyes), secure three of them just below the glans penis, by wrapping around the organ a strap of india-rubber salicylated adhesive plaster, apply a corresponding number to the flexible catheter at a point about an inch from the meatus, after the catheter is inserted, and by slipping over both corresponding hooks a small india-rubber band, which from its elasticity will allow sufficient expansion of the penis, which sometimes has a tendency to erect, or at least enlarge, the instrument will be comfortably kept in position. After the first week, the per- manent use of the catheter should be dispensed with, and the urine drawn every two or three hours. Notk.__In concluding this monograph, the Author would state, that the greater portion of it (comprising most of the first, third and fourth chapters), was prepared in 1S7S-79, and constituted his Thesis for admission to the Medico-Chirurgical Society of New Y'ork. Dr. Rankins table, forming the second chapter, was constructed later, and also was accepted as his Thesis for membership to the same organization. / ^269? *&'/ 5" ^'M^ ~3£ IBRARY OF MEDICINE NATIO c I / I vf1 310 JNI3IQ3W JO A.VBSI1 IVNOIIVN 3 N I 3 I 0 3 W J O A . V a 8 IT T V N O I 1 V N 3 N I 3 I 0 3 W J O A » V » 8 II T V N O 11 V N 3 N I 3 I 0 3 W J O A . 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