text-books, but as my paper is not a book quotation but the relation of every-day experiences, it must stand for what it is worth. I do materially take issue with certain writers of note who claim that the crushing operation is nearly devoid of danger and applicable to the majority of cases.

The only death I have had in vesical operations was from cystitis following the use of the lithotrite. Patient was a man of 65 years, had been a hard drinker in his early days, had an hypertrophied prostate, and had for years been obliged to urinate every hour or oftener day and night. From his great corpulency (weighing over two hundred pounds) I deemed the cutting operation too hazardous, but from further experience I am induced to believe he would have stood that operation best.

I now believe that the supra-pubic operation for stone is the best "all round" operation. It is possible to so closely suture the walls of the bladder by the Lembert suture that there will practically be no leakage; once remove the possibility of infiltrating urine and you remove all danger of the operation.

DISCUSSION.

DR. OBETZ: I think it is a very clear and concise statement of what should be done in those cases. I think the method of operation at the different stages is well chosen.

DR. WALTON: I would like to call attention to one procedure in regard to the supra-pubic operation, which has not been mentioned by Dr. Wilcox. He left the impression on my mind that he invariably sutured the bladder after the extraction of stone, and he spoke of it as an easy thing to do-to put in the Lembert suture. I have found it a very difficult matter to suture a bladder, so I do not do it. I leave it an open wound. It simplifies the whole process. I put nothing into the rectum to distend it with, such as water, as the text-books tell us to do, but you cut through, make your wound and extract your stone, and that is ail there is of it.

in

What will you do with the urine? Have two large sponges carbolized water and change them under the patient. One sponge will hold all the water that escapes for two hours; then change the sponges and that simplifies the whole operation. One way of performing the supra-pubic operation is by the introduction of a steel catheter through the urethra. Tip it up and cut down on to the end of the sound. That is better than subjecting the patient to the risk of rupture of the rectum, etc.

J. E. JAMES, M.D.: I have but little to add to so good a paper Dr. Wilcox's. My habit has been to thoroughly wash out the bladder,

then inject a small quantity of boric solution, two to four ounces; make the usual incision, hook up the bladder with a tenaculum, incise it and remove the stone. It shortens the operation, reduces the amount of manipulation and thus lessens the shock.

C. G. HIGBEE, M.D.: The doctor spoke of a case where there. was a stricture of the urethra and he could not pass the sound. I think he ought to have cured the stricture before he operated for the He could have done it all at the same time, but he did not

stone. do it.

DR. PRATT: I agree with the paper in the preference for the supra-pubic operation. It is impossible to examine the entire surface of the bladder by the perineal operation. It is possible to have uræmic poisoning from the urine dribbling down over the integument. I have seen it so many times when simple cleanliness would clear up a foggy brain and relieve the case.

Dr. Walton's suggestion of the sponges is a good one. The contact of the urine with the margin of the wound is sometimes dangerSome way must be found to prevent the contact of the urine with the tissues.

ous.

A. BOOTHBY, M.D.: There is one matter I think is important in this connection. If it is possible, the bladder should be made aseptic before the operation is commenced. If you make the suprapubic operation for stone in the bladder with the urine in the condition it is usually found without any previous preparation, you will certainly get into trouble. If you carry out the idea Dr. Walton has suggested, I believe you will do better. I do it before I make the operation. I pass a silkworm-gut suture through the integument down into the bladder on each side of the incision, and hold the bladder up to the external wall in order to prevent extravasation and aid in completing the operation. One is very liable to dissect the bladder away from the pubic bone if he is not careful.

WM. D. FOSTER, M.D.: In regard to the matter of extravasation of urine following the high operation, I have been in the habit some years myself, after having made the incision through the integument down to the viscus, of packing the wound with bichloride gauze, and leaving it there for 24 or 36 hours, as circumstances may seem to require, in order that the walls of the wound may become seared over. Then after the expiration of 24 or 36 hours, I have opened the bladder and extracted the stone in some of the ways mentioned. There appears to be no surgical objection to this device, and if it should contribute to the recovery of the patient, it is certainly commendable.

S. B. PARSONS, M.D.: Why not just as well go down and unite the walls of the bladder to the cutaneous surface, and then we have a surface over which the urine may flow, and you will have no extensive raw surface. We have more exposed surface in the

perineal incision than in the supra-pubic. Of course, we have a more natural drainage in the perineal region-an up-hill course in one case and a down-hill drainage in the other; but my observation is that healthy urine does not seriously affect the tissues except the peritoneum or if it is allowed to pocket. If you cannot pass the catheter backwards, you can pass it forwards through a supra-pubic opening, and may leave it in for a few hours, and then substitute a larger one for it, I am not afraid to have urine flow over healthy, freshly-cut tissue.

WM. D. FOSTER, M.D.: It has been suggested that uræmic infection following operations for stone is not so apt to occur as a result of the urine flowing over the surgical wound as it is from pathological defects of the kidneys in eliminating the anaesthetic from the blood.

DR. PRATT: I know what I am talking about when I say that normal fresh urine is not harmful to the tissues; but I know that it does not take very long for urine to become stale. It is very bad practice to allow urine to run upon the cloth and become putrid and old. It is dangerous and bad to allow the urine to dribble. The best way to rinse the bladder is through the urethra. I learned a trick from Whitehead, of Manchester, England. He washes all the urine out from above downward, and you must keep the cloth dry, or you cannot keep the patient in a safe condition.

S. B. PARSONS, M.D.: I admit that decomposed urine is a bad substance on a fresh wound, but we do not always have decomposed urine after an operation for stone. Is there a man here who dares operate on a bladder full or partially full of decomposed urine? There is no one here who would not take every due precaution in regard to the condition of the patient and also as to the condition of the bladder and its contents. It is as necessary to analyze the urine as it is to analyze the general condition of the body, for where there is a calculous condition existing for a long time, we are very liable to have renal changes and they are worse to contend with than any condition of the urine that we can meet, and we will have retained in the body effete matter that should have been eliminated. It is when the urine is retained in the bladder day after day that it becomes dangerous. It is not so when it is there only a few hours. It is the ammoniacal condition with catarrhal discharges that make the poisonous condition in bladder trouble. It is an easy matter to coltrol the urine above if you have a free opening through the urethra. In the supra-pubic operation you can have complete flow and good evacuation, and if you have trouble, it is because of your lack of

care.

E. V. VAN NORMAN, M.D.: I would like to ask Dr. Walton if he uses sponge drainage alone in cases where there is ulceration and great friability of tissue, sufficient to produce troublesome purulent discharges from time of operation?

DR. WALTON: I never had such a case, but if I had, I should certainly wash and treat it on surgical principles. If I had a patient who could not treat himself or would not allow himself to be kept clean and dry, I would hire a nurse and see to it that he was kept properly clean. A sponge laid under him and covered with oiled silk protects the bed and the patient. The urine is not going to change character so rapidly as to make serious trouble.

E. V. VAN NORMAN, M.D.: I had a case about two months since of the characters spoken of. I operated for stone in the bladder-the supra pubic operation-and after going through the tissue, I found the anterior wall of the bladder so adherent to the stone, that when the peritoneum was removed, it lay bare, and the contents of the bladder escaped into the wound. I am aware how easy it is to operate where there are no complications-in such cases, sponges answer the purpose admirably-but, with a stone of four ounces, and a bladder so ulcerated and friable, as in this case, I fear sponge drainage alone would be insufficient. In ordinary cases, I like sponge drainage, but in this instance we found, on washing the bladder for several days, a large quantity of fine calcareous matter that obstructed and retarded the healing of the wound; therefore, we considered circuitous drainage demanded through the urethra, and drainage-tube placed within the bladder, and lower angle of the wound, and with the most careful washing twice a day-even with this drainage, we found great difficulty in ridding the bladder of the calcareous matter accumulating in that cavity, upon and within the tubes-requiring but a few hours to form a crust like that of an egg-shell. I can but feel that sponge drainage alone, would have been fatal to my patient.

DR. GORDON: I have just a word to say in regard to the case spoken of. I would suggest that the excessive washing was probably the cause of the trouble. I find that the excessive use of

water in wounds of any kind is detrimental.

THE APPENDIX CLUB; OR, A NEW EVOLUTION.

BY CHAS. E. WALTON, M.D., CINCINNATI, O.

IT is the year 3000, and records found in the closet of a doctor who flourished in the latter part of the nineteenth century throw an illumination upon a subject hitherto very obscure. They contain a history of the Appendix Club, which flourished in that early day, the object of which was to illustrate the inutility of the appendix vermiformis except for operative purposes. Physiological science had failed to develop any functional activity in this part of the anatomy which was essential to the human autonomy, and had relinquished any further claim to exclusive proprietorship. It fell to the lot of the operative surgeons to develop its uses. For many years patients had been dying by the direct interposition of Providence, and undertakers and expectant heirs even learned to know a sure thing when they saw it. This Providential interposition was manifest by certain symptoms as undeniable as those attending a tubercular meningitis. If the patients died, the diagnosis was unquestioned; if they got well, something else was the matter with them. About this time surgical activity had nearly exhausted the ovarian harvest, and new fields for operative work must be sought. The hitherto neglected vermiformis sprang into a prominence which had never been attained since the day of the exuberant prepuce. Cases of abdominal pain in the right inguinal region, accompanied by vomiting, constipation, tenderness over a point midway between the umbilicus and the anterior superior spinous process of the ilium, which had been baptized with the name McBurny, became objects of surgical suspicion, especially if there was at the same time tumefaction and little fever and a depressed pulse. Under this array of symptoms the reluctant surgeon was enticed into a vivisection which many times demonstrated, to his complete satisfaction, the uselessness of the inoffensive appendix, which seemed quite content to curl up snugly in its old quarters and keep warm by the adjacent inflam