BIRMINGHAM MEDICAL REVIEW.

SON MEDICA

JULY, 1888.

APR 5 1889

ORIGINAL COMMUNICATIONS.

ON SUPRAPUBIC LITHOTOMY,

WITH NOTES OF SIX CONSECUTIVE SUCCESSFUL CASES.
BY JORDAN LLOYD, M.S., F.R.C.S. (ENG),

SURGEON TO QUEEN'S HOSPITAL, BIRMINGHAM,

*

Unfor

DR. BIGELOW has taught the profession that litholopaxy is the procedure for the removal of stones from the bladder, and that none other should be thought of in any case until the surgeon is confronted by some contra-indicating circumstance. tunately the obstacles to litholopaxy are many; a large number of vesical calculi therefore will still have to be dealt with by other means. My remarks will be confined to stone as it occurs in the male, and it will be well at the outset to enumerate the circumstances under which Bigelow's operation is inapplicable. Firstly, those negativing conditions of the stone itself, as large size, excessive hardness, multiple number (when they amount in the aggregate to a considerable mass), and, lastly, encysted stones. Secondly, anatomical conditions, such as stricture and enlarged prostate. Thirdly, advanced kidney disease, where the prolonged administration of ether is likely to be dangerous; and, lastly-the largest class of all-calculi in boys. With regard to the latter, the recently published results of the work of Surgeon-Majors Keegan and Fryer in India, make

* Paper read before the Midland Medical Society, Feb. 29, 1888.

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it probable that many stones in boys will, in the future, have to be dealt with by litholopaxy; setting aside these, however, there still remain a large number for the cure of which the profession is not yet unanimous in its opinion as to the best procedure. There are three claimants in the field at least : lateral, median, and suprapubic lithotomy. My own experience suggests that to each might legitimately be allotted a share of the residuum. To the lateral operation I would assign stones of moderate size, which are very hard or multiple; and those cases complicated by advanced kidney disorder, or by stricture. To median lithotomy, small stones in small children only, and the remainder, large stones, encysted stones, and stones associated with enlarged prostates to suprapubic lithotomy.

The six cases detailed at the end of this paper have occurred during the past 18 months: they do not include all my lithotomies for this period, and although I might not now elect to deal with the whole of them by the suprapubic incision, there were circumstances in each, at the time of operation, which led me to adopt it in preference to perineal lithotomy.

Suprapubic lithotomy was probably the first operation practised for the removal of a stone from the bladder. It has been revived, and has fallen into disuse again and again, and not until quite recent times has it ever taken a tight hold of the operating surgeon's fancy; probably because its frequentlyoccurring wound of the peritoneum and injury to the pelvic connective tissue gave the operation a higher death-rate than attended incisions through the perineum. It was not until Peterssen, of Kiel, systematised a plan by which danger could be reduced to a minimum, if not altogether avoided, that the operaion came seriously into competition with Cheselden's lateral lithotomy. Our countryman, Garson, demonstrated by experiment, several years ago, how the peritoneal reflection was lifted up from the pubes during combined rectal and vesical distension; but no particular notice seems to have been taken of his observations. Whether Peterssen worked out the matter for himself or took advantage of Garson's publications there is no need to discuss,

it is quite certain that if he had not devised the procedure which carries his name, the present revival of suprapubic lithotomy would not have been seen. Sir Henry Thompson appreciated at once the value of Peterssen's work, and was the first to call attention to it in this country.

The anatomy of the suprapubic region offers a few points of importance, and from the fact that it is a locality to which the students' particular attention is not directed, these points are apt to be overlooked. The fat in this region is of considerable thickness, and often gives great depth to a wound before the muscular structures of the belly wall are reached. The pyramidalis muscles, springing from each side of the front of the pubes are seen as fleshy fibres, passing upwards and inwards, to be inserted into the linea alba between the symphysis and the umbilicus. They are not to be mistaken for the recti muscles; they lie superficial to the proper abdominal muscles. The linea alba forms a single layer in front of the recti muscles only, and must be divided before those muscles are seen. The recti here are tendinous in their lowest parts, and immediately behind them the fascia transversalis is found, and must be cut through before the subperitoneal fat is reached. The transversalis fascia, according to Harrison, divides opposite the top of the pubes into two layers, one of which is attached to the pubic rim, and the other passes backwards onto the posterior wall of the bladder. Large veins are found on the upper part of the front of the viscus, running more or less transversely towards the vesical plexuses at the sides of the organ. Between the bladder and the pubes is a loose layer of connective tissue, which is easily disturbed by fingering. The most important anatomical feature of all is the reflected fold of the peritoneum, passing from the abdominal parietes on to the posterior wall of the bladder. The level of this fold varies with age and with the condition of the bladder and rectum. In children, under all conditions of the viscera, it rarely descends into the pelvis, but in adults it sinks as far as one and a half inches below the top of the pubes when both the rectum and bladder are empty, and rises,

on the other hand, to a point from one and a half to three and a half inches above the bone when they are fully distended.

For suprapubic operation the patient is placed flat on his back, with the knees slightly bent over a pillow. The lower parts of abdomen, pubes, and genitals are thoroughly washed and shaved and the bladder emptied by catheter. A globular or sausage shaped india rubber bag, varying in capacity from 4 to 12 ounces according to age of patient, and furnished with a 12-inch long tube and stop cock, is emptied of air, lubricated thoroughly and introduced into the rectum. It facilitates this introduction if the skin around the anus is well oiled beforehand. The bag is now distended with fluid, according to its size. I consider this rectal bag an essential part of the operation. I am aware that some surgeons object to it because they regard it as dangerous to the rectal wall, but I have seen no harm attend its use. A sponge has been oftened employed instead of the bag, and two of my own operations were done without either.

A gum elastic catheter is next passed into the bladder and warm boracic acid lotion injected until a slight resistance is felt by the syringing hand. The catheter is now withdrawn and a tape tied lightly round the penis. The quantity of fluid thrown into the bladder varies from 4 to 20 ounces. The distended organ may now be felt as a globular tumour above the pubes. It naturally follows that the more fluid we can introduce into the viscus, without in any way using force, the more will the organ rise in the belly, and the farther will the peritoneum be carried out of harm's way. An incision is made from the pubic level upwards in the middle line for 2 to 3 inches. A variable thickness of fat is cut through, and the deep layer of the superficial fascia covering the pyramidalis muscles is seen. The interval between these muscles is found, and deepened until a dense layer of fascia, the linea alba proper is arrived at. When this is divided the space between the recti muscles is opened--the muscles themselves often not being exposed. The parts being held asunder by retractors, the fascia transversalis is discovered on the floor of the wound. This is incised and the sub-peritoneal fat at once