Franco, speaking of those cases in which a portion of the omentum is found projecting into the hernial sac, lays great stress upon the importance of “not doing what many a surgeon has done in the past and what not a few are still doing in our time, viz., simply cutting off the imprisoned distal portion of this membrane and returning the remainder to the peritoneal cavity without first ligating the divided blood-vessels and then cauterizing the cut surface; the danger being that a failure to take these steps frequently leads to a fatal hemorrhage into the peritoneal cavity—an occurrence which actually happened to one of our most experienced surgeons in a case of enterepiplocele.”
There were certain operative procedures in which Franco took a greater interest than in others. Thus, for example, he was particularly fond of operating for the relief of cataract, and the results which he obtained were exceptionally favorable (180 cures out of a total of 200 cases subjected to operation). Von Gurlt quotes him as saying:—
If I had to choose between operations for the cure of cataract and abandoning all the rest of my surgical practice, I should prefer to adopt the latter course, so highly do I estimate the amount of good which I can do in this line of work, so very important does it appear to me, and so small is the amount of labor and worry which it entails.
Franco was also greatly interested in the cure of stone in the bladder, and it was while treating cases of this character that he invented the very important surgical procedure known in France as the “Franconian operation for stone in the bladder” (hypogastric cystotomy, suprapubic lithotomy). Here is the account which he gives of the circumstances under which he was led to devise this method of removing a stone from the bladder:—
I will mention here an experience which I had on one occasion when I tried to remove a calculus from the bladder of a boy about ten years of age. The stone was about as large as a hen’s egg and resisted all my efforts to extract it by way of the incision made in the perinaeum. Being in a quandary as to how I should proceed next, and the parents and friends being greatly demoralized by the suffering to which I was unavoidably subjecting their child,—they maintained, I should add, that they would rather have him die than be subjected to such awful suffering;—and being influenced also by the thought that I could not afford to have it charged against me that I was not able to extract the calculus, I deliberately decided that I would make an opening above the pubic bone, and would remove the stone in this manner. Accordingly I incised the skin above the pubes, a little to one side of the base of the penis, and carried the knife through the soft tissues down to the calculus, which I had simultaneously pushed upward by pressing the fingers of my left hand against the perinaeum, while at the same time my assistant made counter-pressure against the stone by firmly compressing the abdominal wall above the object. This method of extraction proved successful.
In due time the wounds healed firmly and the patient was relieved of his trouble, but only after a long and most serious illness.
Franco does not appear to have performed the suprapubic operation for the extraction of a cystic calculus more than once (the case just narrated), and he carefully refrains from recommending it to other physicians. Most surgical authors, says Edouard Nicaise, blame Franco very strongly for not having dared to recommend his suprapubic operation. “But I do not agree with this judgment; Franco should rather be praised for his prudence in not immediately announcing to the world his invention of an important surgical operation.”[90]
The subsequent history of suprapubic lithotomy shows that Franco was laboring under an exaggerated idea of the dangers attending this operation. The comments of Pascal Baseilhac—a nephew of “Brother Cosmas” (the famous French lithotomist of the early part of the eighteenth century) and himself a skilled lithotomist—are worthy of being repeated here. He says (p. 318 of his “Traité sur la lithotomie,” Paris, 1804): “Franco based his unwillingness to recommend the operation of suprapubic lithotomy on the belief which was then widely prevalent, and which still persists even in our time (middle of the eighteenth century), that the making of an incision into the main body of the urinary bladder is sure to prove fatal, a belief which experience and observation have now shown to be unwarranted.”
The Franconian operation, the great value of which was not sufficiently appreciated by its inventor nor by contemporary surgeons, was revived in 1719 by an Englishman, John Douglas, the distinguished surgeon of Westminster Hospital, London, and the brother of James Douglas—the anatomist who in 1730 described so minutely the relations of the peritonaeum to the bladder (Douglas’ cul-de-sac).
In the case the history of which has just been narrated, the circumstances attending the invention of the operation known to-day as suprapubic cystotomy[91] or “suprapubic lithotomy,” were certainly of such an unfavorable character as to call for the display of an unusual degree of courage, wisdom, patience and manual skill on the part of the surgeon in charge; and it was through a careful consideration of these facts that Edouard Nicaise was led to award such high praise to Franco for the work which he had done. Scarcely less remarkable is the talent which the latter displayed in the invention of a forceps (Fig. 22) strong enough to crush all but the hardest calculi and yet so cleverly planned that it is practicable, while the crushing end of the instrument is lying inside the bladder, to separate the blades sufficiently far apart to render possible the grasping of the stone between the jaws of the instrument without at the same moment injuriously crushing the soft parts in the narrow channel of the wound or opening.[92]