REPORT 
OF 
SEVEN OPERATIONS FOR STONE 
IN 
P a i? s . 
BY 
PAUL E. EVE, M.D. 
Head before the State Medical Society, 10th April, 1867, and ordered to be Printed. 
i&JTrisljmllc, $tnn.: 
UNIVERSITY MEDICAL PRESS—W. II. F. LIGON. PRINTER. 
1867. OPERATIONS FOR STONE. 
Report of Seven Operations for Stone in thirty-three days. 
By Paul F. Eve, M.D. 
In the April number of the American Journal of Medical 
Sciences for 1866, was published a paper which was read before 
the Nashville Medical Society, sent with the title of “Report 
of Eight cases of Lithotomy during the War.” As published 
in that periodical, this was altered so as to read “ during the 
past four years” Although the inaccuracy of this unwarranta- 
ble change was pointed out, in the fact that while the war did 
last over four years, yet these eight operations were performed 
in less than half that period of time, no correction has been 
made ; and in the list of contributors of Original Articles to the 
American Journal, extensively published for 1866, in both it and 
Ranking’s Half-Yearly Abstract, and its advertising sheets, my 
name is omitted altogether. 
In my letter to Dr. Isaac Hays, Editor of said Journal, it was 4 
..stated that the chief object of my article was to ascertain, if 
possible, the number of cases of stone which the late war ex- 
posed, many of which never would have been made known, but 
for it. Hostilities commenced, as will be remembered, by the 
attempt of the Star of the West, to throw supplies into Fort 
Sumpter in Charleston harbor, January 9th, 18G1 ; hut in the 
first paragraph I stated that during my connection writh the 
Southern Army these eight cases were operated on for urinary 
calculi in the States of Mississippi, Alabama, Georgia, and South 
Carolina. In looking over my day-book, I find five cases of 
Lithotomy recorded for 1861, performed that year in Tennessee. 
So these might justly have been added to the other eight, making 
thirteen, if my object was alone, to boast of the number of ope- 
rations for stone, within a given period. I left Nashville, Feb- 
ruary, 1862, and gave the date of my first Lithotomy case while 
absent May 26th, of that year, and the last October 21st, 1864, 
being an interval less than two years. 
The value of the inquiry into the prevalence of urinary cal- 
culi in our country, will he appreciated when it is made known 
that in the U. S. Army, for the year ending the 30th of June, 
1863, no less than 867 cases of gravel and stone were reported ; 
and this too without including the Southern States, then en- 
gaged in a struggle for their independence. 
I acknowledge that I now take pleasure in being permitted 
to report seven cases of stone successfully operated upon, within 
the short period of two or three days over a month, six of them 
in nineteen days, and all having a speedy recovery, six by the 
bi-lateral operation, and one by lithotrity. If I lost three of 
the eight cases already referred to, during my service in the 
army, I can now report a successful result in my last nine cases, 
although fortunately five of them were adults, of which number 
one was aged. In the last twenty-two cases, of three deaths, one 
alone can, I think, be attributed to the operation ; for in the 
other two, one an old man died from erysipelas in a hospital, but 
not of the wound, and the other from imprudence, fainting and 
falling on the hearth from getting out of bed too soon. The 
ease too, which died, and I am pretty certain from the operation, as I have candidly confessed, was not the bi-lateral, but the only 
one in which I ever used the gorget. 
Case I.—Bi-lateral Operation in a boy four years old—tivo 
small Calculi extracted. 
The father of James K. Dunlap brought his little son to me 
the first of last November, stating he had gravel. They came 
from near Humboldt, Western District of this State. The pa- 
tient had been troubled three years of his short life with dis- 
turbed micturition. He was recently sounded, and the calculus 
felt. He is still in pretty fair health, though small for his age, 
four years. 
On Monday, the 4th of this month, the usual bi-lateral opera- 
tion was performed in the presence of the Medical Class, and 
two small calculi extracted. The first resembles closely in shape 
a coffee bean, though larger, having a well defined groove or de- 
pression on one of its surfaces ; the other is of a flat ovoid shape, 
size of a hazle-nut. They have a dark brown color external and 
yellowish white within. The two together weighed one drachm 
and one scruple. Their composition is phosphate of lime 
and magnesia with uric acid in layers. The uric acid externally 
and the phosphate within, which is just the reverse of the usual 
order of structure in cystic calculi. 
The patient returned home on the fourth day after the opera- 
tion, and recovered without an unpleasant symptom. He was 
only a week in Nashville altogether ; his father insisting on car- 
rying him home on his lap by railway. 
March 1st, 1867, he wrote to me that his little boy is relieved 
of all his pain. 
Case II.—Lithotrity in an adidt—Relieved at one sitting, or by 
one operation. 
Mr. W., of Mississippi, aged 34 years, weighs 220 pounds, is 
6 feet 4 inches high, having a chest like a barrel, and is alto- 
gether a splendid specimen of the genus homo, consulted me in 
September last for stone in the bladder. With a silver catheter, 
I pushed what was taken to be a smallj calculus from its neck. 6 
The patient had been using very freely the waters at the Epper- 
son Springs, in Macon county, of this State, and as he thought 
with decided advantage. As the diagnosis of the foreign body, 
small in size, was so favorable, he decided to return, and give 
this treatment a further trial. At the end of about six weeks 
he called again, and after due preparation, on the 13th of No- 
vember, a small stone was caught in the lithotritor, by the first 
attempt, and easily crushed. Having subsequently explored the 
bladder several times without finding any foreign substance, and 
the patient repeatedly assuring me he suffered now no uneasiness 
whatever in his urinary apparatus, he returned home to Missis- 
sippi. Entertaining some doubts as to the permanency of this 
relief, I addressed two notes to Mr. W., one the 8th of March, 
but have received no reply. 
The following are the brief notes in the history of this case, 
of course, furnished by the patient himself: he attributes the 
formation of gravel to the abuse of diuretics. During the sum- 
mer of 1861, he experienced his first attack of renal gravel 
passing to the bladder, attended with the usual distressing 
symptoms of deep-seated pain in the right lumbar region, re- 
traction of the testicle, vomiting, &c.; which were relieved by 
opiates, and hot hip-baths. In a week he had a similar parox- 
ysm, but then in the left side ; and for months they continued to 
recur at irregular intervals. During 1862, one of these nephritic 
attacks lasted eight hours, and for which he found a strong tea 
made of horse-raddish root to relieve him sooner, and better than 
any internal agent that he tried while suffering acutely from fits 
of the gravel. In December, the same year, he passed one, size 
of a coffee grain, per urethram. In 1863, another lodged in the 
bladder, creating great irritation, and producing occasionally 
bloody urine. His renal symptoms now disappeared, and his 
distress was exclusively confined to the bladder. Dr. Nott, of 
Mobile, first sounded him. In February, 1864, Dr. Marable 
detected the calculus in the cystic cavity ; then in April, same 
year, Drs. Whitefield, Buffington, Kyle, and Grilmore, all con- 
firmed the existence of stone. In 1865, lastly Dr. Jackson, of 
Columbus, Mississippi, verified the same thing. 7 
July, 1866, our patient visited the Springs already named, in 
this State, which have quite a reputation for dissolving urinary 
calculi. He estimates the quantity of gravel passed from his blad- 
der, by these waters, at five table-spoonfuls, some of which he 
brought and placed at my disposal. Knowing well the import- 
ance involved in the question of the possibility of dissolving 
stone in the bladder, by the waters of certain springs, I imme- 
diately put into the hands of my friend and colleague, Dr. Jo- 
seph Jones, this supposed specimen of gravel, kept carefully in a 
well corked vial, and also the particles or fragments which were 
collected after the lithor trip tic operation just performed within 
his bladder. No. 1, the analysis of the contents of the vial, 
is as follows : Mixture of Triple Phosphates, and Uric Acid, 
and Urates of Ammonia and Soda : Uric Acid in the form of 
high-colored lozenge-shaped crystals. Phosphates chiefly in 
prismatic crystals. Evidently deposited in successive layers upon 
side of chamber, from the urine after standing a length of time. 
Just such as is deposited at the close of a paroxysm of inter- 
mittent fever. This patient lives in the malarial region of the 
Mississippi bottom. No. 2 is that of the vesical calculus, which 
is chiefly Uric Acid, some cells and portions of tubuli uriniferi, 
and a small proportion of the phosphates. The differences in 
these two substances warrant the assertion that they could not 
have been derived from the same source. In their physical ap- 
pearances they are quite distinct. The powder in the vial is no 
gravel at all; it is very light, porous, of a whitish-yellow color, 
presents brilliant dazzling scales, and crystals, but leaves no grit 
or sand when rubbed between the fingers. It floats on water, 
when mixed dissolves in it, and there is no deposit of gravel. 
' There can be but little doubt that these deposits collected from the 
chamber-pots at watering places are due to spontaneous changes in 
the urine, promoted by long retention in the urinary vessels and 
by the summer heat; for during the winter months the manufac- 
ture of them ceases, the proprietors declare because the waters 
have become too weak, though not a drop of rain may have 
fallen. The benefit to health of these fashionable resorts is not 8 
denied, nor the diluent, soothing influence hy freely partaking of 
the waters, which may wash out many hurtful agents from the 
system, but cannot, we contend dissolve stone in the bladder. 
There are calculi, which disintegrate alone by the action of the 
air upon them, just as is being done daily by it on the rocks of 
which our State Capitol is built; and there are cases in which 
the diuretic effect of cold springs will promote the discharge of 
even sand or gravel, but their action then is more mechanical 
than chemical. Of the many instances in which mineral waters 
have been tried to dissolve the stone, I have yet to learn the first 
successful case. This too, was the experience of the late Prof. 
A. II. Buchanan, whose patients like mine have been compelled 
regularly to make an annual visit during the summer to the 
springs in Macon county, many of whom found relief during the 
sojourn there, but have never been cured. Dr. Jones has done 
good service by exposing the manner, not to say trick, by which 
people are constantly deceived on the subject of so-called mine- 
ral waters dissolving stones in the bladder. 
Case III.—Bi-lateral Operation in an aged and fleshy gentle- 
man,) with enlarged Prostate—excellent Recovery. 
Mr. C , is one of our most respectable citizens, and a dis- 
tinguished artist. He is now 64 years of age, and had for years 
weighed 250 pounds. Until the war commenced he enjoyed ex- 
cellent health, lived in a beautiful place near the city, exercised 
freely, and enjoyed life almost to perfect contentment. 
The first symptom of urinary distress occurred during the 
winter of 1861-2. He then commenced passing gravel in the 
form of tine sand ; had his urine anylized by Prof. Erni, now of 
Washington City, who announced to him that it contained too 
much free uric and oxalic acids. Tincture of Buchu was pre- 
scribed, but after using two bottles, he became quite sick, and 
was so for two or three weeks. No more gravel now passed, but 
symptoms of stone were experienced, gradually increasing in 
annoyance ; and then, too, an inguinal hernia formed, for which. 9 
he wore a truss. This patient first consulted me during the 
summer of 1866, when a foreign substance was readily detected 
in the bladder. His weight now was reduced to 220 pounds. 
He was placed on treatment preparatory to having the stone 
crushed. Owing to the enlargement of the prostate gland, the 
ltihotritor, Mercier’s duck bill, a modification of Civiale, had to 
be introduced very far, deeply over the middle or third lobe of 
the prostate. A calculus measuring fifteen lines was taken up, 
and the full power of the hand applied, without avail, to break 
it. In the course of two weeks, another similar attempt wa3 
made, with no better success. At these manipulations I was 
kindly aided by Drs. Martin and I)u Pre. A consultation with 
Drs. Thomas Maddin and Jennings was next held, when after 
deliberation it was decided that the bi-lateral operation should be 
performed. I was rather inclined to the high operation. Dur- 
ing this meeting a stone was seized measuring only nine lines, 
when I declared this must be a second one, which was at once 
verified, by striking another calculus, while one was retained in 
the beak of the instrument. An attempt was also made to 
crush this smaller one, but it likewise failed. It was deemed 
imprudent in this case to use the power of the screw. 
On the 15th of November, assisted by Drs. Maddin, Du Pr6, 
Martin, Jones, and Mr. Dow, Medical Student, the bilateral 
section was made. The finger never was able to explore tho 
bladder, its tip apparently entered just through the division 
made in the prostate gland. The largest stone was grasped by 
forceps, but all efforts at extracting it were unavailing, until by 
the force applied, it was broken into large fragments, when these, 
and a second smaller calculus were removed with forceps and 
scoop. The bladder was now well syringed, and the patient re- 
lieved from the position for lithotomy. 
I am happy to state that Mr. C., after a week or two, when he 
required a few doses of medicine, has been fully restored to- 
health. He says he feels as well as he ever did, takes his former 
exercise, and pursues his profession with remarkable vigor for one of his years. He has never felt the least uneasiness about 
the bladder since the wound healed at the end of t wenty days. 
These are almost pure uric acid calculi, are of brick or iron 
rust color, and are nearly homogenous throughout. They re- 
semble the west of Europe calculus, the large majority of which 
consist of uric acid. 
Case IY.—Bi-lateral operation in a necjro boy—Calculus 
weighing two drachms. 
This was the case of Cud-Joe, a negro hoy aged 12, constitu- 
tion good, and health excellent. He had had symptoms of stone 
for five years, and its presence revealed by sounding. His father, 
a worthy man, came with him, and after his return home, did 
not forget to renumerate the doctor, as those of a fairer skin too 
often do. The patient is from Williamson county, Tennessee. 
The operation was performed on the 21st of November, and a 
calculus weighing, about two drachms removed ; it was quite 
friable, and broke into several pieces during its extraction. The 
nucleus of it was unfortunately lost while passing it around the 
class. The fragments remaining in my possession are composed 
of the phosphates and oxalate, resembling the mulberry, having 
externally a nodulated structure. 
This boy had a rapid recovery, returning home a week after 
the operation. 
Case 5th.-—Bi-lateral Operation—a rough calculus weighing 
three drachms. 
Wm. Howland, eight years old, was cut the next day, (the 
22nd) for stone, with symptoms of which he had labored 
severely for a long period of his short life. He was now a poor, 
feeble, anmmic lad, having a quick irritable pulse ; smooth 
polished tongue ; irregular appetite ; dry skin ; and making 
frequent efforts to pass water, which was loaded with ropy 
mucus. The family physician, the venerable Dr. Robinson, 
pf Rutherford county, kindly accompanied him. This was 11 
another instance of the friable calculus, and was crushed in the 
forceps during its removal. It weighed three drachms, is 
quite rough and irregular on its surface. Its composition is 
uric acid and the phosphates. 
The day after this, the patient had a slight chill, followed on 
the fourth by a severe paroxysm of internetting fever. He was 
placed on quinine, to which, sulphate of iron was added in a day 
or two, and so far recovered that he left for home within two 
weeks. Dr. E. wrote to me on the 10th of December : “ I never 
saw a smoother or handsomer cicatrix in my life. He has been 
kept confined since he came home, and has required scarcely any 
medicine. He is as pert as a cricket, as lively as a lark, and as 
talkative as a blue-jay.” 
Case YI.—Bi-latercd Operation in a little boy—a large calcu- 
lus extracted, having attached to it a strip of membrane. 
On the 24th of this month, Wm, Dickson, from Hardin 
county, near the Tennessee river, was operated on. He is five 
years old, but in appearance, resembles a child of half this age. 
His mother says, that while an infant, she detected two gravels 
on his diapers. The specimen removed is a curious one. It 
weighed about two and half drachms, and is evidently constituted 
of a more recent addition to an older calculus. The first is of 
a dark mahogany color, and solid ; the more recent structure 
looks very like fish-row eggs, aggregated upon it. It is composed 
of uric acid originally with the phosphates deposited upon it. 
Another peculiarity in this operation is a strip of membrane, 
a portion of the lining of the bladder, adheres to one end of the 
stone. The patient had some fever developed within twenty- 
four hours after being operated on, but by the use of calomel 
and compound syrup of pink-root, he passed four large worms, 
(lumbracoides,) when he began to improve, and left for home in 
ten days. The dry piece of mucous membrane is still united to 
this calculus, and is another fact to prove the adherence of these 
foreign bodies occasionally to the bladder. Nor did its severance 12 
from this organ retard the cure of the case in the least. His 
father wrote me in December that he had entirely recovered. 
Case VII.—Bi-lateral Operation—large calculus from an 
adult—rapid recovery. 
The calculus from this patient, is one of the handsomest in my 
collection of two hundred and forty-nine removed in eighty-nine 
operations. It weighs over two and a half ounces and meas- 
ures six by four and seven-eighths of an inch in its circumference; 
is of a kidney shape ; very hard; whitish in color ; spangles and 
has a smooth glistening crystallized surface. 11 is the phosphate 
of lime, and remarkably compact. 
The patient was twenty-five years old, a little under medium 
height, and came from Fayette county,[forty miles this side [of 
Memphis The formation of this soj gradual 
and imperceptible, that he cannot tell the exact time of its com- 
mencement, but from his earliest recollection, he thinks there 
has been some trouble in urinating. 
Mr. Gober suffered so little, that in ISGlIheyrolunteered in a 
Tennessee Regiment, and served in the field nearly three years, 
when a stone in the bladder having been detected, at Marietta 
Georgia, he was detailed for light duty. Since the war, by 
severe exercise, his urine became bloody, and deposited mucus. 
He is now generally compelled to urinate three or four times 
every night. 
The operation was performed the 8th of December, before the 
class. The section made was as near median as possible, just 
so large as to introduce the fore finger, then by dilatation, and 
gently, but gradually increasing, and varying the direction of, 
the traction, the large stone was removed through it. 
This patient made an excellent recovery. Within two weeks 
he was, of his own accord, out on the streets, and greeted his friends 
and relations at his home on Christmas day. 
Within a few days, I read in the March No. of the Cincinnati 
Journal of Medicine, that Dr. B. J. Raphael of New York City, 13 
is expected to make a report to the American Medical Asso- 
ciation on the Comparative Merits of the Different Opera- 
tions for Extraction of Vesical Culculi. I have fortunately 
preserved the statistics in full of seventy-seven cases of 
the bi-lateral operation for stone. I have the date, age, sex, 
race, method of operation, number of calculi, and result. I have 
also performed the lateral, high, urethal, or vaginal seotion, 
lithotrity, and employed dilatation. In every instance where the 
result was fatal, I have not hesitated to publish the full particu- 
lars, and these are now before the profession. 
While the mortality in the supra-pubic operation has been one 
in two cases, and in the lateral one in three, by the bi-lateral, it has 
been less than one in eighteen. This includes every death, whether 
the case was favorable, or unfavorable. I have never declined to 
operate whenever there was a reasonable hope of benefitting the 
patient; but I do consider it perfectly right and fair, that in 
arriving at safe and proper conclusions, in the statistics of any 
operation, deduction should be made for desperate cases or unusual 
complications developed during its performance. I now know that 
in two or three of my cases no active procedure should have 
been attempted. The whole number of deaths is here given by 
each method, but if the above rule is correct, then the mortality 
in my high operation would be nothing, for they amounted to 
only two cases, and in the fatal one, the size, and shape of the 
stone, and condition of the patient, rendered success almost im- 
possible ; and in the lateral, but one of the three was due, I still 
believe, without a doubt, to the operation. It was performed 
during the war when I was deprived of instruments, and used 
the gorget. 
By omitting the unfavorable cases in those cut bi-laterally, 
the mortality will amount to two or three in the seventy-seven 
cases, or about one in thirty. Sixty-nine of this number had a 
speedy recovery. This is not now claimed, but the minute 
history of these cases may shortly be published when the pro- 
fession can judge for itself.