In skillful and experienced hands the results of Bigelow's method all are that could be asked in cases suited to that operation. On the contrary, when performed by the general surgeon of limited experience in that operation, more damage is apt to be done than by lithotomy in the same hands. Both methods, however, have come to stay, and no surgeon should pin his faith to either method so exclusively as to cause him to overlook the advantages of the other. That method should be selected which is best suited to the conditions of each individual case. Taking the ground, therefore, that a certain class of stone cases, those not adapted to litholopaxy, fall within the legitimate domain of the lithotomist, let us discuss the merits of the several cutting operations for the removal of vesical calculi. These operations are classified into the supra-pubic and the perineal operations.

The supra-pubic, or the high operation, was first practiced about the middle of the sixteenth century. Few surgical procedures have undergone as many vicissitudes as the supra-pubic. In its early history it had only a few adherents and soon fell into disuse. Revived by Mercier, and for a while extensively practiced, it again fell into disrepute. In the recent past, under the advocacy of Peterson, Guyon, Dulles and others, it has again become a recognized operation especially well adapted to certain cases of stone. The supra-pubic method should be reserved for all cases of stone too large to be removed by the perineal operations.

Of the perineal operations, lateral lithotomy was first practiced by Pierre Franco in the middle of the sixteenth century, brought into prominence by Frere Jacques in the latter part of the seventeenth century, and perfected by Cheselden in the early part of the eighteenth century, is the operation at the present time most frequently resorted to all over the world. It is claimed for the lateral operation that while it does not fully satisfy anatomical requirements, it offers the best route for the extraction of large stones.

The objections that may be urged against lateral lithotomy are that it affords an indirect route to the bladder, that it involves the necessary division of important anatomical structures, that hemorrhage is sometimes excessive, and that the capsule of

the prostate gland is endangered in cases of large calculi. The various central operations were designed to meet these objections, the median raphe being selected as the site of incision, as that line represents the intersection of the muscular structures of the perineum, and is devoid of blood-vessels of troublesome size. The median operation originated in the old Marian operation, practiced in the sixteenth century and long afterwards, but for a long time extinct on account of its great fatality as compared with its rival, the lateral method. The high mortality of this ancient method was due to the small incision necessitating a fatal degree of laceration of the neck of the bladder and the deep portions of the urethra in the extraction of large stones. Allarton, in 1854, revived the median operation, and with an improved technicque established it on a firm footing. The improved median operation is peculiarly well suited to cases of small stones, for the removal of which it is an ideal operation. Buchanan modified the median operation by employing a rectangular staff.

Dupuytren's bilateral method of lithotomy represents another effort to establish a procedure free from the disadvantages of the lateral operation. This operation was first performed by Dupuytren in 1824, and has since been extensively practiced in Europe and in this country, notably in this city by the late Professor Paul F. Eve, whose success as a lithotomist was preeminent, and by the late Professor W. T. Briggs, whose earlier operations for stone were all practiced after this method. The recto-vesical is another plan proposed in which the median incision is continued into the rectum. This operation has very few adherents, and has little to recommend it. Quite a number of modifications of the procedures already mentioned have been suggested and occasionally practiced, but have never been established as standard surgical

measures.

In 1829 Civiale devised and practiced the medio-bilateral method of lithotomy. In this operation the advantages of the median and the bilateral are combined without the disadvantages of either. The incision to the staff in the urethra is made in the perineal raphe, while the deeper parts are divided to an equal extent on both sides of the median line. "Nature seems

to have purposed the median line for such an operation, for it is merely a fibrous septum formed by the tendinous union of the muscles of the perineum, serving to separate the important structures of the two sides, and permitting the surgeon's knife to reach and open the bladder without wounding any part of great importance." Medio-bilateral lithotomy does not seem to have acquired the favor of surgeons to which it is properly entitled by its merits. Civiale employed the method a great many times with marked success. Sir Henry Thompson operated by the medio-bilateral method in most of the cases he submitted to the knife, and speaks very highly of it. In this country the late Professor W. T. Briggs adopted this method exclusively in the latter part of his life, and reported a series of 174 cases operated on by this method, the series including patients of all ages, with only four deaths. Truly a remarkable record. I have operated by this method on thirty patients, with only one death. In this State and the south quite a number of cases operated on by the medio-bilateral method by graduates of the Medical Department of the University of Nashville have been from time to time reported. Recent textbooks referring to lithotomy barely mention this method, and in numerous instances do not mention it at all. Surely an operation originated by one of the most illustrious surgeons of the nineteenth century, endorsed by Sir Henry Thompson, and practiced in this State to the number of nearly three hundred cases with an unequaled success, deserves a higher place among surgical procedures than it now occupies. In my opinion, medio-bilateral lithotomy is superior to all methods for the removal of calculi through the pelvic outlet.

In every case of stone the surgeon should exercise the most careful discrimination in his choice of method. Litholopaxy in selected cases should be done. The supra-pubic operation is especially demanded in cases where the stone is too large to permit of safe extraction through a perineal incision, or when complicated by an hypertrophied prostate gland; but in all cases suitable to perineal cutting operations, the medio-bilateral operation presents the most advantages, because it satisfies all anatomical requirements, it is the safest, and it affords the most direct route to the bladder. The median operation is

unsuitable for large stones, as the passage afforded by it is inadequate, and on that account involves dangerous laceration of important parts. The supplemental bilateral section of the deeper parts in Civiale's method removes this objection. This bilateral section of the parts surrounding the neck of the bladder permits of a more extended incision, and therefore furnishes much more room, with a minimum of danger of exceeding the limits of the capsule of the prostate gland than in the single deep cut made in lateral lithotomy. After incision in the medio-bilateral method the tissues are readily dilatable so that the necessity for a long incision for the extraction of large stones is not so great as is generally imagined.

The principal objection urged against the medio-bilateral operation is that it is not adapted for the removal of large stones. I maintain that as large stones can be removed through the somewhat limited incision of that method as through the rather fallacious incision made in the lateral operation. It will be admitted that the difference in the length of incisions in the two methods is principally in that involving the skin and superficial fascia. The section of the deeper parts can be more extensive in the medio-bilateral than in the lateral, on account of the fact that in the former the cut is made on both sides of the median line, while in the latter it is confined to one side. The superficial parts of the perineum are composed of highly dilatable tissue, the tension of which is maintained by the raphe. If this is divided, the dilatability of the parts becomes very great.

The late Professor W. T. Briggs, in a paper read at a meeting of the Southern Surgical Association at New Orleans in 1893, used the following words: "The relative dilatability of the parts can be well illustrated by a sheet of india-rubber, through which passes a moulded seam, itself inelastic and exerting tension upon the sheet of rubber. If an incision is made in the length of the seam, the dilatability of the section will be as much greater than a transverse or oblique section, as the circumfrence of a circle is greater than its diameter. It was upon the principle of dilatability of the perineal tissues that Allarton originated the modern median operation, and were the deeper parts as dilatable as the superficial, median

lithotomy, would be of all methods the most desirable, but the deeper parts are capable of only a moderate degree of dilatation. Efforts at forced dilatation in the extraction of large stones inevitably cause laceration. When, however, these parts are incised bilaterally, as in the medio-bilateral method, they yield to dilatation as readily as the more superficial parts. In the matter of dilatation the medio-bilateral possesses a decided advantage over that afforded by the lateral method in that the incision in the former being in the median line of the perineum, dilatation is the same in all directions, while in the latter it is limited on the left by the ramus and tuberosity of the ischium. If the extraction of large stones depended on the length of the cutaneous incision the superiority of the lateral operation would be undisputed, for an incision carried obliquely down from a point a quarter of an inch to the left of the raphe, and an inch or an inch and a half above the anus may be made to a point between the anus and the tuberosity of the ischium to the extent of three and a half inches or more, while in the median operations the incision must necessarily be limited below by the anus and above by the bulb of the urethra, so that between these points an incision not much exceeding an inch and a half can only be made. Fortunately, the flexibility of the skin and the dilatability of the superficial parts of the perineum render a long skin incision unnecessary. Some of the largest calculi in our collection were removed through an inch and a half skin incision.

The rectum is compressible to the greatest extent, as shown in the passage of the child's head in parturition. This canal, therefore, cannot be in the way of extraction of large stones. Its position renders it somewhat liable to be wounded in the medio-bilateral operation, it is true, but a little care on the part of the surgeon will prevent such an accident.

A considerable advantage of the medio-bilateral method is the small amount of hemorrhage. The incision is made through the least vascular portion of the perineum, and the operation may be finished in many instances with the loss of not more than a tablespoonful of blood. If the incision be carried too high, so as to wound the bulb, hemorrhage may be greater, but in every case it can be easily controlled.