sure upon the fragments in a half sitting posture as attained by a chair which has been introduced I think by the young Dr. William Pancoast, of Philadelphia. It is an ordinary extension chair with some modifications for the case in hand, and the intention is to make this lateral pressure to allow the patient to be raised or lowered in the manner of the extension chair at will, preventing all irritation consequent upon a fixed position. At the same time a firm bandage is applied around the hips so as to make the necessary pressure on the fragments. Extension is made as desired by means of any supports that may be found necessary, attached to the back of the chair, and the extension also is made by means of a certain fastening or by any other apparatus that may be thought desirable for the purpose of preventing shortening. On motion, the discussion was closed. DR. BIGGAR: With permission of the bureau, I have this to say, two or three papers and two authors are absent; the other paper is by myself. Dr. Helmuth is here to give his experience of some recent observations he has made as to supra-pubic Lithotomy, and I trust that you will dispose of these papers by title. My paper is in regard to Psoas Abscess. There is nothing particular in the paper that is new in regard to psoas abscess, but I have given a case and the history, pathology and treatment of it; but I think it would be better if you would dispose of it in order to listen to Dr. Helmuth, for the reason that we have been here three hours already and perhaps would not care to listen or take up another hour, and so if you will dispose of my paper I will be satisfied. On motion of Dr. Helmuth, the bureau took up Dr. Biggar's paper. DR. POULSON: I have seen several cases operated upon, and in one case operated upon near the spine; there were used first water injections through the whole channel, afterwards Carbolic acid injections, once or twice a day. I used in one case Phosphoric acid. This case was that of a lady, and she got entirely well. The other case was also that of a lady, and in that case the same treatment was followed and she got well. But I would say in the two last cases that I used precisely the same mode of treatment -Phosphoric and Carbolic acids and Silicia. When the Carbolic acid injections were used the septic membrane was destroyed. The discharge became changed very soon, and there was no reason for it whatever, except it ended very badly, and unless it was necessary to expose the whole channel it should not be done. In two cases without Carbolic acid I did not use the trocar, simply operated with the bistoury in both cases, taking care to prevent the introduction of air. I did not find any reason to regret it. Prof. Helmuth wanted to know if any cases of psoas abscess were cured, so that is the reason that I mention these cases. DR. HELMUTH: What was it that you said I wanted to know? DR. POULSON: You wanted to know in your Surgery whether any person had a case on record of the cure of psoas abscess, as you considered such cases very doubtful. This case is on record; it is cured. The patient is living and well to-day. DR. HELMUTH: An author often forgets what he writes, but if my memory serves me on this point, I think I said that I would be thankful if any person would refer me to a case of psoas abscess that has not been connected with caries of the spine, that is what I said. DR. POULSON: It was connected with caries of the spine. DR. HELMUTH: I should be very thankful to hear of psoas abscess connected with caries of the spine, because I am making a collection of statistics of these kind of cases. Those two kinds of cases. I am glad to hear of this case; I will put it down. DR. MCCLELLAND: I move that the discussion now close. On motion, Dr. Helmuth made the following remarks: DR. HELMUTH: I have not prepared any paper, but I do wish to interest the surgeons on a subject which has interested me for a considerable number of years, and one which is beginning to demand the attention of surgeons all over the world, and that is epicystotomy, hypogastric lithotomy, supra-pubic lithotomy, the old fashioned high operation for stone. Before I say a word on this subject in reference to the operation itself I would not be understood as disparaging in any way, shape, manner or form litholapaxy, which as I should say is an American method of lithotripsy, which it ought to be called, for it was adopted by an American, Dr. Bigelow, of Boston, and nobody else has a right to take away the honor from us. It is now practiced with wondrous success by surgeons in all parts of the world. I therefore say that the American method of lithotripsy or litholapaxy as introduced by Dr. Bigelow should not be overlooked, but should be performed instead of the ordinary lithotomy. And when I come to speak of this method which I now offer for your consideration, it is only in those cases where the crushing operation cannot be performed with the lithotrite. With the aspirator, with any kind of instruments which are now introduced into the bladder. Stone of magnitude can be crushed and evacuated through a large tube at a single sitting with but little trouble. Still there are conditions, whether it be from an enlarged prostate, whether it be from tight strictures, 1 whether it be sensitive urethrae which would render the knife preferable to the lithotrite, then epicystotomy is the most simple and safe operation. Necessarily I am of the opinion that before long the operation which will be altogether adopted is a cutting operation—the high operation for cutting for stone in the bladder; and I will tell you why I think so, but before I enter into the description of the operation I have no doubt I shall be met at the outset with the statement that the mortality is high in the suprapubic method. It is stated to be one to three and a half or four. This is an erroneous statement, according to the statistics; as a rule, the mortality is not high by the supra-pubic method. I will tell you why it is high. It is high because those cases which will submit to it will not submit to lithotripsy. It has been taught in college and I have taught for many years, that you could not extract by the perineum, that the operation failed and if it failed you must go above the pubis and take out the calculus, so it has been recommended aud was recommended in this city when lithotripsy failed, also when the stone could not be taken out through the perineum. When the lateral operation cannot be done, when you cannot cut through the prostate, in all these cases you are to take it out above the pubis. For this reason why not adopt the supra-pubic method? For this reason the mortality is too high, because in a majority of instances the cases have been subjected to the other operations first, which have been failures. The first supra-pubic operation was performed in 1650 by Franco. Franco was unable to get out the stone through the perineum, he pushed it up, cut through the bladder above the pubis and took it out from above. Cooper, in his surgical dictionary, gives priority to Calot, in 1475. Others go further into antiquity, and state that the operation dates 1,000 years before the Christian era. This statement is denied by Velpau, who says there is no authority for making this statement. He gives the names of surgeons who cut nine successful cases. From time to time it has had many advocates. Cheselden, who cut nine consecutive cases successfully-Middleton, Thornhill, Berrier, and especially Frère Côme, who made one hundred supra-pubic operations with but nineteen deaths, being its strenuous upholders. Frère Côme was a monk. He used the supra-pubic method because it gave the patient a fair show, and that was the reason his mortality was less. In his book, published in 1782, he describes his operation. The American Journal of Medical Sciences directed attention to the supra-pubic method, and it was from the perusal of that article and the papers by Dr. Douglas that I began to think about this method. I began to see that it was simpler than any of the other methods, and that the patient had a fair show. Now why? In the first place you can see what you are doing, there is no cutting on a staff, there is no knife to slip and go into the prostate or rectum, there is no danger of lacerating the neck of the bladder, and causing impotence, there is no primary hæmorrhage to be anticipated, there is no secondary hæmorrhage to be anticipated. Above all you can see just what you are doing, which is a great thing. You can do it without feeling, you can make your incision in the median line and you will not cut a single vessel, you will go down to the bladder, you will open it, you will put in your fingers and take out the stone. Now, I say the advantage is certainly theoretically in favor of this supra-pubic method. With such reasoning I wish to bring up before this Institute this operation, in order that those surgeons who have an opportunity to operate and cut the stone instead of crushing or performing any other operation can use this method. Now, as to the operation itself, as I performed it, and performed it successfully, and as I have seen it done in the practice of another surgeon, who is now absent, a very skillful man with whom litholapaxy was a perfect failure. Now, I say that these kind of cases can be operated upon with a loss of less than four per cent., and that that is a good showing. I was called upon to see Mr. Foot. Mr. Foot was a man weighing 260 lbs. Now, it is said that the operation should not be performed on a man weighing 260 lbs. The man came to me; I had always operated by the other method, and was just beginning to turn my attention to the crushing operation and it took all the moral courage that I could bring to bear to go over them and perform the operation above the pubis. I was very glad I did, because it was successful in a very short time. Now, as to the methods of performing the operation, there have been half a dozen different methods adopted. The first method was the old fashioned one, where you had to put your fingers in the rectum, push up the stone in the bladder, incise it, open it, the bladder being full of water previous to the incision. Franco's case recovered, and he records three others afterwards. Then about the time of Frére Côme, another operation was decided upon and about that time the instrument which is called the Sonde-a-dard which goes in through the penis into the bladder. A majority of the people supposed that it was necessary that you should have free drainage. They made a double operation; they made the perineal cut and then the cut above the pubis into the bladder and removed the stone and left the wound open in order to prevent infiltration in front of the wound. Sir very Everrett Holmes was an advocate for this operation. He operated by making the perineal cut first. The operation was to put a staff in the bladder, find the stone, inject the bladder with water, make the incision in the membranous portion instead of in and through the urethra. Then carry in the Sonde-a-dard in the bladder, then make the incision in the perineum so you would have three cuts, one in the perineum for the introduction of the instrument and the ordinary operation above the pubis. The surgeons at the Hotel Dieu, Paris, discard this perineal cut. The Sonde-adard was an instrument such as I show here, which you introduce into the bladder, that is after it has been filled with water. After you have made your incision down to the bladder you push the stylet through, in order to show you the direction into that viscus. You can see how that simplified the operation, because sometimes it is difficult for you to tell when you get down to the bladder itself, and I will tell you why: in all operations of this kind you have to go through a certain portion of fat, and it bothers you to tell when you have got into the bladder and it is well to know when you do. In some instances there is what is known as bladder fat, and that will bother you. There may be one or two or three inches of fat. I know in one case upon which I operated, it took considerable time; it took me more time to cut through that fat than to do the operation. If you have got the Sonde-a-dard you push it through the fat and all which I did in the first operation. You will soon find out what structures you are going through. Then, after you have incised the abdomen and incised the bladder, which may be done from above downward or from below backward, it makes little difference which, although a great deal of stress has been laid on this point by some operators. It is surprising what an amount of war and commotion is made in the surgical circles over a little thing. The difference in the shape of the end of a bistoury, or in the shape and curve of a sound will give rise to a discussion which will estrange men for life. It is a great pity it is so, but it is so. Then as I said before, you can incise the bladder, you can cut down into the viscus and you can lift away the stone without any trouble. Now, I have detailed to you the method that has been adopted by myself with success; this is the operation with the Sonde-a-dard. Now, as to the ordinary method; in the first place you have to take a catheter and put it into the bladder and inject the bladder full of water or with carbolized water one to a hundred ; that necessitates the introduction of one instrument, then you have to take that out and put in a catheter or something of that sort into the bladder in order that you may have inside of the abdominal walls something that you can feel. You can feel in the |