A Contribution to the Surgery 
of the Bladder, 
BY 
WILLY MEYER, M. D., 
ATTENDING SURGEON TO THE GERMAN HOSPITAL, 
NEW YORK. 
Wclw Yorft Journal 
for February 23, 1889. 
REPRINTED FROM Reprinted from the New Yorlc Medical Journal 
for February S3, 1889. 
A CONTRIBUTION TO 
THE SURGERY OF THE BLADDER.* 
WILLY MEYER, M.D., 
ATTENDING SUEGEON TO THE GEEMAN HOSPITAL, NEWYORK. 
The great interest that has been taken in the diseases of 
the bladder by surgeons of all countries for many years 
past has not yet relaxed. The question is still under discus- 
sion, Which is the most preferable operation of opening the 
bladder for the removal of stones or tumors ? Surgeons have 
not yet agreed in regard to the best method of the after- 
treatment of epicystotomy, the operation lately so much 
more favored. The operative treatment of hypertrophy of 
the prostate is still in the early stage of its development. 
The improvement of the old cystoscope has created a per- 
fectly new branch of surgical diagnostics. 
At such a time the experience of a single man, gained 
even from a comparatively small number of cases, may be 
of interest to others, and I am of the opinion that it is the 
duty of all surgeons to publish their operative cases of dis- 
eases of the bladder, whether the result may have been good 
or bad. Only in this way can the important questions men- 
tioned above reach a definite solution. 
* Read before the New York Surgical Society, November 28, 1888. 2 
A CONTRIBUTION TO 
I do not hesitate, therefore, to put before you my ex- 
perience in regard to the diagnosis and operative treatment 
of diseases of the bladder, which I have derived from a few 
cases in this line, coming under my treatment since I have 
been a resident in this country. 
I shall not consider the question of the most preferable 
method of incising the bladder, whether above or below the 
pubes. Although I do not deny the great value of the 
median section in proper cases, I follow the views of my 
highly esteemed former chief, Professor F. Trendelenburg, 
director of the Surgical Clinic of the University of Bonn, 
and prefer suprapubic cystotomy, as not being in itself a 
dangerous operation. I adopt it, therefore, wherever I can, 
on account of its many great advantages—the easy manipu- 
lation inside of the vesical cavity, and the perfect view to be 
obtained by it of the interior of the bladder in the posture 
of the patient that has been advised by Trendelenburg.* 
The points I propose to consider to-day, in reporting my 
own six cases of epicystotoray, are: 
1. The best after-treatment of this operation; whether 
it be drainage of the bladder, f or whether we should prefer 
suture of the bladder. 
2. The great value of cystoscopy in the preliminary ex- 
amination of the patient. 
* Willy Meyer, “ Ueber die Naehbehandlung des hohen Stein- 
schnittes sowie fiber Yerwendbarkeit desselben zur Operation von Bla- 
senscheidenfisteln,” von Langenbeck’s “Archiv,” xxxvi, 3, p. 514. 
f Drainage of the bladder has been tried in different ways (Willy 
Meyer, I. c., p. 494). I consider drainage with the T-tube in latero- 
abdominal position and open-wound treatment (as proposed by Trende- 
lenburg) the simplest and safest, and therefore the best. It has been 
combined with an antiseptic dressing of iodoform gauze around the tube 
(Assendelft, von Langenbeck’s “Archiv,” xxxvi, p. U0). Although the 
real effect of an antiseptic dressing naturally is illusory in most of these 
cases, it may be handier now and then, especially in private practice. THE SURGERY OF THE BLADDER. 
Of the six suprapubic cystotomies recently performed by 
me, four were done for tumor of the bladder (one for recur- 
rent cancer), one for stone, and one for foreign bodies. I 
shall report them chronologically. 
Case I. Papilloma and Multiple Villous Groicths of the 
Bladder.*■—M. G., a native of Germany, a merchant, fifty-two 
years old, had been a healthy man up to March, 1886, when, 
without any previous warning, he suddenly passed bloody urine 
for two days. Four weeks later a more serious haemorrhage 
from the bladder set in. Since that time the patient had suffered 
from frequent haeraaturia, especially at the end of micturition, 
catarrh of the bladder, pains in the glans, and now and then 
sudden stoppages in the flow of urine. His family physician had 
treated him for chronic catarrh in the usual routine way with- 
out any material benefit. On one of the first days in October 
retention of urine occurred. The catheter was introduced and 
the bladder washed out. A chill, with consequent high fever, 
pains in both lumbar regions, and aggravation of all the symp- 
toms, resulted. The patient then consulted Dr. A. Jacobi, who 
advised an operation, and sent him to me for that purpose. 
When I saw the patient first, October 26, 1886, he was very 
weak and still feverish. He passed his water about every fifteen 
minutes with great difficulty and excruciating pains. There was 
tenderness on pressure in both lumbar regions. The beak of a 
large-eyed silver catheter was caught in a soft mass immediately 
upon entering the bladder; moving the instrument caused 
bleeding. On withdrawing the same, a large shred of tissue was 
found in the eye, evidently torn off from a larger growth. On 
macroscopical examination and under the microscope 1 found 
this to be a piece of a villous papilloma. This was, most proba- 
bly, growing at or near the trigonum, and pedunculated, as it 
sometimes closed the internal urethral orifice in urinating. The 
chemical and microscopical examination of the urine showed 
symptoms of pyelonephritis besides those of chronic catarrh of 
the bladder. 
* Cf. “ New York Medical Journal,” 1888, No. 16, p. 431. 4 
A CONTRIBUTION TO 
Having by these examinations established the diagnosis, I 
proposed to remove the growth by suprapubic cystotomy, then 
to drain the bladder, and in doing so to drain also the pelves of 
the kidneys. The operation was performed on October 28th. 
About thirteen ounces of warm water were thrown into the 
rectal colpeurynter and almost seven ounces of warm three-per- 
cent. boric lotion into the bladder. After the vesical wall had 
been incised to the extent of three inches the patient was placed 
in Trendelenburg’s posture and I found a soft pedunculated 
growth of about the size of a medium-sized apple, its pedicle 
being about as large as the thumb, inserted a little above the 
trigonum, near the orifice of the right ureter. The greatest por- 
tion of the tumor was then cut off with the curved scissors. 
The haemorrhage, in no way alarming, was controlled by small 
pieces of ice put into the cavity of the bladder. Then I pulled 
the posterior wall of the bladder forward with the help of Mu- 
zeux’s forceps, and burned off the pedicle with the Paquelin cau- 
tery, cauterizing at the same time the wall of the bladder at this 
spot down into the muscular layer. (An arterial haemorrhage from 
this spot was stopped by inserting under it a strong catgut liga- 
ture by means of a sharply curved needle.) A further careful 
examination of the bladder revealed a second tumor of the size 
of a cherry, a little to the right of and above the one just re- 
moved ; and, furthermore, the fundus of the bladder was found 
to be covered with a great many velvety villosities. They were 
all easily removed with the sharp spoon, and the haemorrhage was 
again checked by ice. (I do not know of any better styptic than 
ice in vesical haemorrhage after having opened the bladder; but 
hot water may have the same good effect.) Now Trendelen- 
burg’s T-tube was inserted and the prevesical space loosely 
packed with iodoform gauze. The abdominal and vesical 
wounds were left open for the sake of establishing in this man- 
ner a thorough drainage for the secretion of the septic pyelone- 
phritis—latero-abdominal position. The effect of this procedure 
soon became apparent. The same night there was still a slight 
fever, but on the following day the temperature was normal 
and never rose again. The septic symptoms quickly disap- 
peared and the patient made a quick recovery. The tube was THE SURGERY OF THE BLADDER. 
5 
removed on the eighth day after the operation. Twelve days 
later the first urine was passed by way of the urethra. After 
five days more it came in a strong stream, nothing escaping by 
the abdominal wound. The patient got up and soon was out- 
doors. During the next few weeks a fistula established itself 
in the lower end of the abdominal cicatrix that induced me to 
make an incision and cut away the mucous membrane of the 
bladder that was lining the canal. This was done on January 4, 
1887. 
On the 29th of March the wound was firmly closed. The pa- 
tient was able to work, and enjoyed life. He had gained con- 
siderably in weight, and passed his urine every three or four 
hours. I then lost sight of him. Six months later I saw him 
again. A ventral hernia had developed and the capacity of the 
bladder decreased. He urinated every two hours, and had slight 
tenesmus. He refused further treatment, but went around to 
consult other doctors. About a year after the operation I ex- 
amined him again. He had then incontinence but no haema- 
turia. There was about 50 per cent, of albumin in the filtered 
urine. I proposed an incision in the cicatrix, to establish a 
permanent fistula. He refused. As far as I could ascertain 
by inquiring, he died in May of this year (eighteen months after 
the operation) of dropsy and suppurative bilateral nephritis. 
Case 11. Medullary Carcinoma of the Bladder.—H. T., sixty- 
five years old, waiter, a native of Switzerland, had suffered 
from frequent attacks of painful, difficult micturition during the 
last six years. These attacks came on at intervals of about two 
weeks. In the mean time lie felt comparatively well and strong 
enough to attend to his work. About a year ago haematuria 
was first observed. Since that time the vesical symptoms have 
been permanent. Not infrequently he voided particles of the tu- 
mor, sometimes as large as a medium-sized oyster, during an act of 
painful micturition and accompanied by a serious haemorrhage. 
Vesical incontinence supervened six months ago. The patient 
was confined to his bed and became very emaciated. He lost 
forty pounds of flesh during this time. 
On admission to the German Hospital, patient is very weak 
and extremely anaemic. The pulse is small—120; afternoon 6 
A CONTRIBUTION TO 
temperature about 102° F. There is a round elastic protrusion 
above the symphysis, reaching up to the middle between it and 
the umbilicus. The spot is dull on percussion. Bimanual pal- 
pation reveals a large semi-solid mass tilling the bladder. The 
left lumbar region is painful on pressure. Examination of the 
urine shows symptoms of catarrh of the bladder and pyelo- 
nephritis. (Albumin five per cent, in urine which had been 
filtered.) The capacity of the bladder was barely three ounces, 
even in deep narcosis. Cystoscopy was practiced, but the field 
of vision remained dark, although the mignon-lamp was fully 
incandescent before introducing the instrument. I did not ex- 
pect much from cystoscopy in this case, especially as the capac- 
ity of the bladder was so extremely small. But I believe that 
a negative result of cystoscopy of this kind, provided the fluid 
in the bladder is clear and the window and prism of the cysto- 
scope are not found to be covered by a coagulum at withdrawal, 
justifies the diagnosis of a growth of large size. 
Epicystotomy was performed on April 24th, of course with 
no other intention than to relieve the patient’s deplorable con- 
dition somewhat and to establish a vesical fistula. The rectal 
colpeurynter did not hold more than about four ounces; the blad- 
der held less than three. The tumor proved to fill the entire 
bladder. It was impossible to remove it otherwise than piece- 
meal. The growth was attached a little above the mouth of the 
left ureter with a broad base. The latter was well scraped 
with the sharp spoon and then destroyed with Paquelin’s cau- 
tery in Trendelenburg’s posture. The haemorrhage, not being 
alarming, was easily controlled with ice. After thorough irri- 
gation of the wound and the bladder, and dusting with sub- 
nitrate of bismuth,* the upper part of the abdominal wound 
was closed with four silkworm-gut sutures, the prevesical 
space loosely packed with iodoform gauze that had been thor- 
oughly washed in Thiersch’s lotion to remove as much of the 
drug as possible, and the T-tube inserted. 
* I am very careful with iodoform in operations on the bladder of 
old patients, having seen poisoning even after the use of minute quan- 
tities. No patient has died, however. THE SURGERY OF THE BLADDER. 
7 
April 25th.—Patient comfortable. Rectal temperature 99-s°. 
Drainage-tube worked nicely. 
May 7th.—The T-tube is removed and a simple straight 
rubber tube of medium size introduced in its place. The blad- 
der is frequently washed. 
Upth.—Temperature normal. A small amount of urine es- 
capes by the urethra, the most part by the fistula, which lias 
been well established at this time. Measured quantity of urine 
passed in twenty-four hours, two pints. Patient has picked up 
somewhat. 
21st.—Now and then particles of tumor are thrown out of 
the bladder in washing it. The urine shows blood. 
June Ist.—Exitus lethalis. 
The autopsy disclosed a recurrence of the growth within the 
bladder to a marked degree; suppurative pyelitis in the left 
kidney and a great distension and thickening of the left ureter. 
In the abdominal cavity about three ounces of pus were found 
between the coils. No symptoms of peritonitis having been 
present during life-time, I am inclined to think that the pus 
perforated from the left kidney shortly before death. The in- 
ternal organs were free from suppuration. Hence we can not 
think of pyaemia as the cause of the abscess. No secondary 
deposit in other parts of the body. 
Case 111. Foreign Bodies in the Bladder ; Nephrolithiasis (?). 
—B. v. P., forty-one years of age, a native of Germany, artist, 
was admitted to the German Hospital as a private patient, May 
22d, this year. He had always been a healthy, stalwart man. 
Three years ago he was suddenly attacked by left renal colic and 
hsematuria. Since then the latter had been intermittent. Fre- 
quently the first drops were mixed with blood during micturi- 
tion; then the urine was clear. Now and then he passed pure 
blood. He had been examined and treated by the most eminent 
surgeons of Berlin without a diagnosis having been strictly es- 
tablished and without any remarkable benefit in regard to his 
troubles. According to the advice of one of the gentlemen, he 
had his bladder washed out with a mild solution of permanga- 
nate of potassium for a long time. Eight weeks ago a severe 
catarrh of the bladder set in. Now and then small particles of 8 
A CONTRIBUTION TO 
a semi-solid substance were pressed through the urethra. In 
passing water the flow of urine was frequently interrupted. 
The patient suffered greatly; he became emaciated and subject 
to the opium-habit. 
Although the patient exhibited more or less the symptoms of 
stone, I was unable to find any on careful examination. There 
also were no traces of a vesical new growth. The urine, muddy 
and of alkaline reaction, contained three per cent, of albumin. 
Under the microscope, red blood-corpuscles, pus, and mucus 
were found in it, but no casts. A thorough bimanual palpa- 
tion of both lumbar regions of the anesthetized patient revealed 
a tumor of about two fists’ size in the left bypochondrium, of 
the presence of which the patient bad not the slightest idea. It 
had a smooth surface, and evidently belonged to the left kidney. 
Being convinced that the latter organ was the cause of the 
whole trouble, I intended to tap it for the sake of the differen- 
tial diagnosis, to ascertain whether we had to deal with a tumor 
or with nephrolithiasis. But, as all the subjective symptoms 
pointed to vesical trouble, recourse was first had to cystoscopy. 
It had to be done under chloroform, the bladder being extremely 
irritable. Tbe examination was a great surprise to all present. 
As soon as the instrument entered the bladder and the light 
was turned on I saw a few (four or five) curiously shaped, more 
or less flat, bent bodies of black color and covered with a de- 
posit of white salts, tumbling over each other, but evidently of 
soft consistence. They frequently touched the beak, but gave 
no sound of stone. Besides these bodies, there was no stone, 
no tumor, only evidence of catarrh. 
To establish a diagnosis in regard to the nature of these 
bodies from this cystoseopic picture was entirely impossible. 
None of us had ever seen anything like them. The most proba- 
ble supposition seemed to be that of coagulated blood which 
had descended from the left kidney. But in that case the semi- 
solid condition and peculiar shape of the bodies remained un- 
explained. Nevertheless, the result of cystoscopy was highly 
satisfactory. We had seen, at least, the cause of all the vesical 
troubles, of the presence of which no searcher, no bimanual 
palpation ever had given or could give the slightest trace, It THE SURGERY OF THE BLADDER. 
9 
is worth mentioning that no vesical hasmorrhage set in during 
all these manipulations, but that a bimanual palpation of the 
tumor in the left hypogastrium caused immediate abundant 
bleeding, which lasted for nearly twenty-four hours. In view 
of this accident and of the result of cystoscopy, the plan of 
operating was: 
1. Epicystotomy for the removal of these bodies, and cathe- 
terization of both ureters, if possible, to gather the excretion 
of each kidney separately for the sake of a distinct diagnosis. 
2. Nephrotomy or nephrectomy, according to the result of 
tapping, or, if the latter gave no positive result, exploratory in- 
cision. 
On May 28th I opened the bladder above the pubes. (The 
peritonaeum reaching far down near the symphysis, its prevesi- 
cal fold was opened by mistake to the extent of about a third of 
an inch. This wound was immediately closed by a continuous 
catgut suture, and covered with a pad of iodoform gauze during 
the rest of the operation. There was no bad result whatsoever.) 
I removed about eight bodies of various sizes. They were of a 
semi solid substance, flexible, of black color, and covered with 
white salts, just as we had seen them through the cystoscope. 
Chemical analysis showed that they consisted of 60 per cent, 
organic substance (fibrin), and 40 per cent, permanganate of 
potassium. (The specimen was presented to the society.) The 
bladder proved to be healthy. The attempt at catheterizing the 
ureters was unsuccessful on account of the lack of proper small 
rubber catheters. The moutii of the ureters was well visible in 
Trendelenburg’s posture and with illumination of the bladder by 
electric light. In pressing the tumor on the left side now, we 
did not succeed in producing a haemorrhage. The wound in the 
wall of the bladder was then closed from above and below by 
several iodoform-catgut sutures up to an opening of about three 
quarters of an inch, through which the T-tube was introduced. 
The abdominal incision was also stitched up in its upper twm 
thirds. Dressing as described above. Patient made a quick 
recovery. His temperature was normal all the time, except on 
the first and fourth days after the operation, when the ther- 
mometer registered 101°. 10 
A CONTRIBUTION TO 
June 2d.—Removal of the iodoform-gauze tampon in the 
prevesical space. Patient doing very well. 
Bth.—T-tube removed. Abdominal wound healed by first 
union. 
11th.—Patient out of bed. 
21st.—Wound closed. Only slight catarrh of the bladder. 
Patient sleeps without morphine; gains in weight constantly. 
Discharged at his special request, not wanting a second opera- 
tion performed on himself right away. As far as I could ascer- 
tain lately, patient is doing very well. Whether hsematuria 
returned I am unable to say. 
16th.—Urine passed per urethram for the first time. 
Case IY. Stone in the Bladder.—B. H. D., fifty years of 
age, merchant, was admitted to the German Hospital as a private 
patient, June 18th, this year. For several years he had been 
troubled with chronic gastritis; otherwise he had been healthy. 
Returning from his summer resort in the mountains, he was 
seized with symptoms of stone, June, 1887. A thorough examina- 
tion, which was made at that time, failed to detect any stone, 
and he was advised to take proper drugs. But, his condition 
getting steadily worse, his family physician courteously sent him 
to me for cystoscopy, June 11th. The patient’s bladder being 
extremely irritable, and examination with the searcher having 
been accompanied before by great agony, I yielded to the pa- 
tient’s demand and immediately introduced Leiter’s cystoscope. 
Having turned the instrument 180°, I saw at the first glance, 
as clear as in perfect daylight, an oval-shaped, brownish body, 
covered with white spots, of the size of an almond, lying in a 
groove behind the swollen prostate gland. It threw a very 
marked shadow upon the opposite wall of the bladder. Having 
turned off the light, I touched it with the beak of the instru- 
ment, and got the sound of stone. 
June 19th.—Epicystotomy. Stone easily removed. Shape 
and appearance confirmed as diagnosticated with the cysto- 
scope. Treatment as usual. Temperature in the first seven 
days constantly somewhat above the normal; general condi- 
tion good. 
26th.—T-tube removed. THE SURGERY OF THE BLADDER. 
11 
July 2d.—Urine passed by way of the urethra for the first 
time. 
20th.—Patient discharged. Wound superficially granulat- 
ing. Since two days no urine escapes above the pubes. Patient 
leaves soon for the mountains. 
When seen again, September 21st, he relates that the rest of 
the wound was entirely closed about the middle of August. At 
this time a flat, painful swelling had formed on the right side 
of the symphysis. It suddenly disappeared when he passed a 
quantity of pus with his urine on the 27th of August. (Most 
probably a pericystitic abscess had formed and perforated into 
the bladder.) To-day patient is all right. 
Case Y. Recurring Cancer of the Bladder.—U, 8., fifty-five 
years of age, merchant, was operated on by Dr. F. Lange, of this 
city, in his private hospital, for cancer of the bladder, October 
18, 1886. Epicystotomy bad been performed, the tumor re- 
moved by an ellipsoid incision, which included a part of the 
muscular layer of the wall of the bladder, and the latter wound 
closed by stitches. The bladder then was sewed up by an 
interrupted iodoform catgut suture and drainage obtained 
through a N6laton catheter, passed by the urethra. The blad- 
der healed by first intention. Patient left the hospital on 
October 30th, cured. He had very much improved and at- 
tended to his business, when, eight months later, a new hasma- 
turia with irritability of the bladder set in. Dr. Lange, as 
well as other surgeons who were consulted, refused to per- 
form a second operation, there being no hope for a radical ex- 
tirpation of the growth. But the establishment of a perma- 
nent vesical fistula was thought of as soon as the operation 
seemed to be urgent. It was decided to defer it as long as 
possible. On July 14tb, this year, Dr. Lange being out of 
town, the patient came under my observation through the 
courtesy of Dr. J. H. Asch. I found him in a deplorable 
condition. Every ten to fifteen minutes he urinated with 
great agony, parsing each time also a small amount of thin, 
very offensively smelling fasces. Prolapsus ani and tenes- 
mus increased his sufferings. A hard, uneven tumor filled the 
space above the pubes, fully four fingers in width; it was ad- A CONTRIBUTION TO 
herent to the symphysis and pubic hones, and gave dullness on 
percussion. There was a slight ventral hernia in the cicatrix. 
Pressure in the lumbar regions, especially in the left, caused 
great pain. The urine was scarce and muddy. Its analysis 
showed catarrh of the bladder and pyelonephritis. Frequent 
chills, tongue dry, stomach rebellious, not retaining any food; 
temperature 105°, pulse 156. 
Although the patient’s condition was not very encouraging 
for operative interference, I proposed, after consulting with Dr. 
Asch, suprapubic cystotomy to the family, not concealing the 
risk that death might he expected on the operating table. 
On July 16th I performed the operation, No colpeurynter 
in the rectum. Bladder filled with three ounces of Thiersch’s 
solution. On account of the ventral hernia and in order to 
have ample room, I used the Giinther-Trendelenburg cross- 
incision.* 
Making my way down to the bones, by an incision three 
inches in length, I found the cicatrix in front of the symphysis 
well provided with blood, and saw the prevesical peritoneal 
fold about half an inch above the symphysis, entirely adherent 
to the tumor. But I failed to feel the bladder distinctly. The 
patient then was put in Trendelenburg’s posture and a small- 
bladed knife deeply thrust into the tissue just in front of the 
symphysis. Blood rushed out of the wound in large amount, 
but not a drop of the injected water escaped. It was evident 
that I had incised the tumor. The bladder had to be looked for 
somewhere else. I loosened the elastic temporary ligature 
around the penis; the water escaped. I injected again and 
was able to throw in the same amount as before—about three 
ounces. The haemorrhage from the tumor having been checked 
by ice and loose packing with iodoform gauze, I went to search 
for the bladder. Strictly following Trendelenburg’s rulesf as 
to how to get down even to the empty bladder in epicystotomy 
without the help of the rectal tampon, I peeled the tumor off 
* Eigenbrodt, “ Ueber den hohen Blasenschnitt,” “ Deutsche Zeit- 
schrift fur Ghirurgie,” xxviii, p. 66 et seq. 
f Eigenbrodt, I. c., p. VO, THE SURGERY OF THE BLADDER. 
13 
the posterior aspect of the symphysis and pubic bones with the 
second and third fingers of my left hand, turning the pulps 
toward the abdomen. I succeeded in loosening the growth, and 
there, down in the depth, below the tumor, I felt the gently dis- 
tended bladder, of the size of a pear, pressed against the rectum 
and perinaeum. I fixed it between the left second and third 
fingers, and incised it to the extent of about an inch and a half. 
Now the water poured out. After thoroughly scraping the blad- 
der the T-tube was put in, the bladder well irrigated with a 
mild boric-acid lotion, the wound sewed up on both sides of the 
tube and drained in the angles with iodoform gauze, which also 
loosely filled the wound. Latero-ahdominal position; stimu- 
lants. 
The patient stood the operation remarkably well. On the 
next day the pulse went down to 108 and the temperature to 
99 B°. The tongue was less dry. The bladder was washed out 
three times daily with a mild boric-acid solution. The septic en- 
teritis alone gave some trouble. But it was overcome, too, after a 
short time by antiseptics frequently administered by the mouth. 
The sutured portion of the wound, although being entirely 
without reaction, did not unite, however. When the stitches 
were removed the wound gaped, but the granulations showed 
a healthy appearance. On the twelfth day after the operation 
the T-tube was changed for a straight one. On the 7th of Au- 
gust (the twenty-second day after the operation) the patient was 
out of bed for the first time. Meanwhile a slight oedema of the 
left lower extremity and left side of the scrotum had developed. 
The tube in the bladder worked very well. There never was 
any leakage in the fistula, except when a piece of tumor oc- 
cluded the internal opening of the tube. Frequent flushing 
with a strong current then always removed the obstruction in 
a few days. Without any fever or new septic or uraemic symp- 
toms, patient died from marasmus, September 20th, nine weeks 
and a half after the operation. 
Post-mortem Examination (involving only the uropoietic 
system): Medullary growth (cancer) of about the size of a baby’s 
head above and in front of the bladder. Peritonaeum all around 
adherent but nowhere perforated, A portion of the tumor pro- 14 
A CONTRIBUTION TO 
jects into the bladder. The latter is very small, attached to the 
growth, its mucous membrane haemorrhagic in many spots. 
Both ureters, greatly distended and thickened, pass through the 
tumor in a curved line. They can be probed without difficulty. 
Left kidney represents a large sac filled with pus, that breaks 
at the attempt of removal. Only a small zone of its glandular 
tissue is left. The rest is in chronic inflammation, as also is 
the right kidney, which exhibits a less destructive appearance. 
The posterior wall of the growth is firmly attached to the sig- 
moid flexure. It compresses the large vessels below, especially 
the common iliac vein. Small metastatic cancerous growths 
in both kidneys only ; nowhere else. [The specimen is demon- 
strated to the society.] 
Case YI.—A. D., sixty-five years of age, a native of Russia, 
was sent to me through the courtesy of Dr. A. Jacobi for hsema- 
turia. For two years he had had frequent pains in the glans; 
three months ago haematuria set in and has not stopped up to 
the present time. In washing the bladder at my office, it was 
found that the lower portion of it was very irritable. Water 
and catheter were speedily pushed out on attempts at slowly 
throwing in a very small amount of water. But, by conducting 
the instrument gently forward and depressing the handle, I suc- 
ceeded in filling the bladder with about three ounces of water, 
the patient not being under ether. It seemed as if the bladder 
was divided into two parts, the lower being more diseased than 
the upper one. The prostate gland was very much enlarged in its 
entirety. Urine was scarce—about twelve to thirteen ounces 
in twenty-four hours. It contained a great deal of blood and 
some albumin. It was slightly sour. Microscopic examination 
showed blood and pus cells in great quantity. With Nitze’s 
cystoscope I detected a sessile growth of about the size of a 
small hazel nut in the upper part of the left side of the bladder. 
It had apparently a broad base (as it did not move on shaking 
the lower portion of the abdomen) and showed a few big pa- 
pillae. A small coagulum was adherent to its surface; the latter 
had a grayish-white color. About an inch lower down two 
more slender growths projected into the cavity of the bladder, 
floating up and down in the water. I concluded from the picture THE SURGERY OE THE BLADDER. 
15 
that all three growths probably were inserted on the same base, 
although their different appearance was strange and the mucous 
membrane between them appeared not to be materially changed. 
During the first examination the water became bloody, but I did 
not see the blood dripping down from the tumor. The mouths 
of the ureters I had no time to search for, the patient being in 
great agony to get rid of the injected water. On account of the 
result of cystoscopy, I proposed epicystotoray, not being quite 
sure that the tumor was the only trouble. Perhaps the constant 
haamaturia was partially doe to kidney disease; but, if so, I 
hoped to see bloody urine spurting out of one of the ureters dur- 
ing the coming intravesical manipulations. 
On November 16th (twelve days ago) I performed the op- 
eration at the German Hospital. Before it was begun, cystos- 
copy was once more performed, the patient being under the 
influence of chloroform. I again saw very plainly the sessile 
growth as described above, and so did all the gentlemen present. 
But those two slender tumors were found lower down on the 
right side of the trigonum. I have no doubt that they had been 
detached from their base by the water that was repeatedly thrown 
into the bladder with some force by means of a syringe to get it 
clean, and then fallen down upon the trigonum. This explana- 
tion also reveals why they could not be found afterward when 
the bladder was incised. The outpouring water evidently threw 
them out. Again the mouth of the ureters could not be de- 
tected. But I must confess that I did not take sufficient time 
to search for them, the patient being under chloroform. In re- 
gard to the operation itself 1 used again the cross-incision three 
inches long. (There were about four ounces of warm water in the 
rectal colpeurynter and five ounces of Thiersch’s solution in the 
bladder.) After dividing the insertion of the fascia, recti muscles, 
and the flat lower portion of the linea alba, the prevesical fat 
came into view. Now the patient was put into Trendelenburg’s 
posture, the peritonaeum pushed up with two fingers of the left 
hand, and between them the bladder incised about two inches 
and a half in length. The searching finger felt a small infiltrated 
spot at the location made out with the cystoscope. But, in look- 
ing at it, the bladder being held open by broad retractors, only 16 
A CONTRIBUTION TO 
the infiltrated bleeding base could be plainly detected; there 
was no projecting growth. It had evidently been of the same 
soft tissue as the other two, and my finger had unintentionally 
pushed it off. No more growths could be fouud, the bladder 
being illuminated by electric light, but on the opposite (right) 
wall of the bladder there was a flat infiltrated spot of a more 
yellowish color of about the size of a five-cent piece. The mouths 
of the ureters even now could not be seen. But the trigonum 
Lieutaudii and the anterior wall of the bladder formed a kind of 
funnel which led to the internal urethral orifice, and out of it 
ran blood, whether at intervals I can not say. I regret very 
much not having gathered some of this blood, as I am nearly 
sure, in thinking of the case now, that it was bloody urine. The 
rest of the new growth in the wall of the bladder was destroyed 
by Paquelin’s cautery, as also was the suspicious portion on the 
other side. Then I sewed up the upper third of the wound of 
the bladder with iodoform catgut, put in the T-tube, and par- 
tially closed the wound in the abdominal wall. Both angles 
were left open; they were passed by small long strips of iodo- 
form gauze which loosely filled the prevesical space. Now the 
patient was put to bed, the pulse being fair—about 84 and of good 
quality. I was unable to see the patient within the next twenty- 
four hours. Then I found him in a comatose condition, in which 
he was said to have been since early in the morning. (The night 
before he had taken water several times and answered the 
nurse’s questions in a reasonable way.) The abdomen was soft, 
tongue moist, wound without reaction. Pulse extremely weak, 
despite constant stimulation for twelve hours; pupils of medium 
size, not reacting. He had passed scarcely six ounces of urine 
slightly tinged with blood in twenty-five hours; otherwise the 
T-tube worked well. Water thrown into the bladder by means 
of a catheter introduced through the urethra escaped out of it 
perfectly clear. We continued to stimulate the patient, but he 
died the same night, at 11 p. m. 
A post-mortem examination was refused by the relatives in 
spite of my earnest demands, I feel pretty sure that the cause 
of death was uraemic coma, as we find it sometimes occurring 
after somewhat protracted manipulations inside of the bladder THE SURGERY OF THE BLADDER. 
17 
of older subjects, especially if the kidneys are diseased. It is 
not improbable that some serious trouble, perhaps a malignant 
growth, also would have been found in one of them by post- 
mortem examination, although I had not succeeded in feeling a 
tumor in one of the lumbar regions. 
Certainly the fatal result was not due to the suprapubic in- 
cision. The wound was in perfect condition. I again found 
the cross-incision very advantageous. It was very easy to see 
and avoid the peritoneal prevesical fold, that reached here 
down pretty near to the symphysis, with the help of this 
method. There was ample room to operate inside the bladder. 
1 should like to recommend the cross-incision very highly. I 
shall use it in future wherever I can. 
It did not need this experience of successful after-treat- 
ment of epicystotomy, as described in my own practice, 
to convince me of the great value of Trendelenburg’s 
method. During the time I was assistant surgeon to the 
surgical clinic of the University of Bonn I saw six pa- 
tients * attended in this manner (three of them I attended 
personally). Although two of the patients died soon after 
the operation, the fatal result was not due to the mode of 
proceeding. A few months ago Professor Trendelenburg 
had published f forty-two cases (those six included) of 
epicystotomy for various troubles of the bladder. All of 
them were drained with the T-tube in lateral position for the 
first days. The result was, as far as this mode of treatment 
is concerned, always satisfactory. (The cross-incision that 
was proposed by Gunther thirty-seven years ago and is now 
again practiced by Trendelenburg [cf. my Cases Y and Yl] 
is highly recommended in this treatise.) Others also have 
reported favorably upon it. J But, nevertheless, it is not 
* Willy Meyer, I. c. 
f Eigenbrodt, I. c. 
X Assendelfft, “ Chirurgische Erfahrungen eines Landarztes,” Dor- 
pat, 1883 ; “Archiv f. klin. Chir.,” Bd. 36, Heft. 1 ; Rodziewicz, “St. 
Petersburger med. Wochenschr.,” 1885, No. 8. 18 
A CONTRIBUTION TO 
the ideal after-treatment. This is undoubtedly the suture 
of the bladder as soon as the intravesical trouble has been 
treated. If the results gained with it have not as yet been 
always satisfactory, the cause, it seems, has to be looked 
for in a failure to select suitable cases, and furthermore, 
probably, in the insufficient accuracy and technique of the 
surgeon. It seems that the latter is the main thing. This 
is proved by the statistics of van Iterson * (ten primary 
unions out of twelve cases of epicystotomy with suture) 
and those of Dr, F. Lange, of this city, who has been kind 
enough to allow me to mention his results in this paper. 
Lange had primary union seven times out of eight cases of 
suture of the bladder, (In the one case, patient of sixty 
years, where no direct union was obtained, slight leakage 
commenced on the fourth day on account of great restless- 
ness of the patient. Otherwise the patient made a quick 
recovery.) Dr, Lange intends soon to publish the cases, f 
together with the details of the technique employed. 
Neither of the two surgeons used the funnel-shaped incision, 
as proposed by v. Antal (“Ctrlbl. f. Chir.,” No, 17, 1885). 
But, even in view of this wonderful and highly remarka- 
ble success of the two authors mentioned, I think suture 
of the bladder ought not to be practiced in all cases of epi- 
cystotomy. Undoubtedly Tredelenburg’s method of after- 
treatment is not only very simple and easily applicable, even 
without proper assistance,£ but it is safe. The free drainage 
of the bladder also drains the suppurating pelves of the 
kidneys. As long as the ureters are not obstructed, a re- 
tention of infectious material up there is utterly impossible. 
The method provides also for an easy and convenient way 
\ “ Medicinische Monatsschrift, Organ fur practische Aerzte in Nord- 
Amerika,” New York, Jan. 15, 1889. 
* “ Centralblatt fur Chirurgie,” 1886, ix, ref. 
\ Assendelfft, I. c. THE SURGERY OF THE BLADDER. 
19 
of washing out the diseased bladder thoroughly, since there 
remain two openings in it. This is of great importance. 
In regard to the time of healing, only slight differences 
have so far been recorded. According to Kraske’s advice, 
the abdominal wound is generally left open and loosely 
packed with iodoform gauze in suture of the bladder. 
If we succeeded in closing this wound in the granulating 
stage by secondary suture, as Lange proposes to do (about 
the fourth or fifth day), and leaving a drainage-tube in the 
lower angle of the wound, provided there is no leakage 
from the wound of the bladder, the time of healing would 
be materially decreased. Further experience is needed to 
decide this. Summing up, I should say on this question; 
1. If there is no catarrh of the bladder, or only a slight 
one, the wound of the bladder ought to be closed by primary 
and eventually the abdominal wound by secondary suture. 
2, If the catarrh of the bladder is serious and combined 
with septic suppurative pyelitis, the bladder ought to be 
drained. 
3. In less serious cases both methods may be combined 
with advantage—i. e., the greatest part of the wound of the 
bladder may be sewed up, and only a small spot in the 
middle left open for passing the tube. 
In regard to cases of malignant growths of the bladder, 
which could not radically be removed with resection of the 
diseased portion of the vesical wall, I should like to raise 
the question whether it might not be better for the patient 
that we should always operate with the intention of estab- 
lishing permanent fistula. V. Dittel’s apparatus would 
greatly lessen the discomfort resulting from the fistula. If 
the growth returns, a second, usually more difficult, cystoto- 
my will thus he spared. 
One more word I should like to say in regard to the 
great advantages of Trendelenburg’s posture, which, as it 20 
A CONTRIBUTION TO 
seems, has not been sufficiently tried by American sur- 
geons. 
Every surgeon who has once employed this posture for 
intravesical operation has enthusiastically acknowledged * 
Trendelenburg’s posture. (From an article by the author in von Langenbeck’s 
“ Arch. f. klin. Chir.,” xxxi, 3.) 
* Kiister, “ Sammlung klin. Yortrage,” Nos. 26*7, 268, p. 52 ; Keyes, 
“Suprapubic Cystotomy,” etc., “Jour, of Cutan. and Genito-urinary 
Bis.,” July, 188 V ; Lange, I. c.; Gerster; and others. Only Geza v. Antal 
has found “little advantage” in this posture in the removal of tumors 
of the bladder by means of the suprapubic incision. “ Spec, chirurgische 
Pathologic u. Therapie d. Harnrbhre u. Harnblase,” Stuttgart, 1888, THE SURGERY OF THE BLADDER. 
21 
its great advantages. It is by all means preferable to il- 
lumination of the inside of the bladder with an electric sur- 
gical light while the patient is flat on his back. The elec- 
tric light ought to be used rather in that posture when the 
trigonum Lieutaudii, usually the most interesting spot with- 
in the bladder, is not covered by blood and urine, but, being 
the highest point in the bladder, may be sponged and kept 
dry. To be entirely satisfied with the posture, it should 
be kept in mind that the pelvis is to be raised sufficiently 
high (figure). Many fail in that respect. Eigenbrodt em- 
phasizes the fact * that this elevation helps the surgeon to 
avoid the prevesical peritoneal fold at the time of incising 
the bladder.f 
On the great value of cystoscopy I can not add much 
to what I had the honor to say before another meeting of 
surgeons a few months ago.J Since the improved instru- 
ment has been in the market, it has been applied wherever 
surgery of the bladder is practiced. A few favorable re- 
ports have been published already ; more are to be expected. 
In regard to the instrument of Nitze and Leiter itself, I 
should like to say this after a ten-months’ experience: 
Nitze’s cystoscope has one great advantage, namely, the 
short beak, as we find it in Mercier’s prostate catheter 
(about half an inch shorter than in that of Leiter). As 
cystoscopy is and will usually be applied at the first exami- 
nation of the patient without giving ether, and as the irri- 
table bladder can sometimes only be distended to a very 
*L. c., p. '72. Of. Lange, “Med. News,” Dec. 4, 1886. 
f This posture is of great advantage also in intra-abdominal opera- 
tions where the seat of the trouble is in the true pelvis. The latter will 
thus be found very easily accessible even in its depths. (Mendes de 
Leon, “Ein neues Untersuchungsverfahren,” “ Ctrlbl. f. Gynak.,” 1888, 
No. 21; Heyder, “Ctrlbl. f. Chir.,” 1888, No. SY, p. 939; Lange, I. c.) 
\ “New York Med. Journal,” 1888, p. 426. 22 
A CONTRIBUTION TO 
small degree * (although the use of cocaine may enable us to 
inject a proper quantity—five ounces), the tip of a short 
beak will not touch the wall of the bladder so often as a 
longer one. The touch nearly always causes a burning sen- 
sation. The second disadvantage of Letter’s cystoscope— 
the short shank—has lately been removed. The newest pat- 
tern has the same length as that of Nitze. A sufficient 
length is an absolute necessity. It once happened to me in 
a patient, sixty-four years of age, with tumor of the bladder 
combined with hypertrophy of the prostate, that Letter’s 
instrument (with a short shank) did not enter the bladder at 
all, the urethra being materially lengthened. I then tried 
Nitze’s. I easily succeeded with it and saw the tumor.f 
But I saw in this case everything dark-red and somewhat 
indistinct. I thought the water was mixed with blood ; 
but when the cystoscope had been withdrawn, the water 
came out clear. On further examination, I found a very thin 
coagulum of blood on the prism. This, I think, had tinted 
th 6 rays returning from the wall of the bladder. It was as 
if 1 had looked through a red glass. I found these adherent 
coagula oftener when I first began to practice cystoscopy, 
especially in cases with hypertrophy of the prostate. I had 
the impression that the recesses of the cystoscope at the 
window (Leiter), or the lamp itself (Nitze), had something 
to do with it, glycerin having to be used as a lubricant. 
Since I have made it a rule first to inject glycerin into the 
rear portion of the urethra by means of a rubber catheter, I 
am rarely troubled in this respect. To buy a second cysto- 
scope for the fundus is unnecessary. Up to date 1 have always 
succeeded in inspecting the fundus and trigonum with the 
* In some cases I have had to satisfy myself with throwing into 
the bladder three to three ounces and a half. But even then I have usu- 
ally had a satisfactory view. 
f In practicing cystoscopy with Nitze’s instrument it has to be kept 
in mind that its telescope magnifies. THE SURGERY OF THE BLADDER. 
23 
mouths of the ureters by simply turning the instrument 
180° and depressing the handle. The inconvenience to the 
patient is slight. But both instruments do not illuminate 
the internal orifice and its immediate neighborhood. As 
is known, Nitze constructed his cystoscope, No. 3, for this 
purpose and praises its great advantages. A few days ago 
I received a communication by Dr. Nitze, notifying me that, 
after many experiments and trials, this instrument was now 
also ready for sale, but would be improved further in the near- 
est future. I shall report on its supposed advantages as soon 
as possible. Leiter’s electric battery, specially constructed 
for the purpose, has also been greatly improved. He now 
sells a smaller and very powerful one containing twelve ele- 
ments, the cells to be filled or emptied in a few seconds. 
The whole case is made of hard rubber. A small six-cell 
battery of the Galvano-Faradic Company of New York an- 
swers the same purposes.* 
How comparatively easily and yet distinctly we may 
succeed in clearing up obscure diseases of the bladder is 
plainly proved by my third and fourth cases. Even very 
experienced surgeons, who had examined the patients be- 
fore, had been unable to come to a satisfactory conclusion. 
I should like to report one more very interesting and, I 
think, quite rare case yet, where the diagnosis had been 
established by the cystoscope and proved to be right by 
treatment. 
I. P., sixty-two years of age, merchant, was sent to me by 
a well-known physician of this city for cystoscopy on account 
of a foetid catarrh of the bladder consecutive to hypertrophy of 
* F. N. Otis, “Papillomatous Tumor of the Bladder demonstrated 
by Means of Leiter’s Electro-cystoscope,” “ Med. Record,” 1888, p. 493. 
Whether this battery destroys the filament of the mignon-lamp easier 
than that of Leiter, which allows of regulating the strength of the 
current very exactly, I do not know. 24 
A CONTRIBUTION TO 
the prostate. The patient had formerly been successfully treated 
with antiseptic irrigations of the bladder and proper drugs. 
During his stay at a sea-bathing resort near by (last July) he 
caught a cold, according to his story, and soon found his catarrh 
materially worse. He followed all the orders given to him as 
punctually as ever, but the trouble grew worse. Then he con- 
sulted his family physician, who sent him to me, presuming that 
a tumor or a stone might be at the bottom of the trouble. He 
had to introduce the catheter about every half-hour in the day 
and three or four times during the night. The urine was of a 
light grayish color and had an extremely foetid, gangrenous smell. 
Lately he had lost in flesh, although his appetite had always 
been excellent. I did not expect much of cystoscopy in this 
case. I resorted to it merely on account of the patient’s and 
his doctor’s request. But I was greatly surprised when I looked 
into this bladder. Although I had washed it out for nearly 
half an hour carefully until the water returned perfectly clear, 
I saw the whole mucous membrane of a grayish-black discolora- 
tion, more on the lateral sides and anterior wall than in the 
fundus and trigonum. Many long, thin coagula of mucus ad- 
hered to the wall and became fimbriated in the fluid. I most 
decidedly had the impression of “ superficial gangrene ” of the 
mucous membrane. This explained the terrible smell of the 
urine, such as I had never met wdth before. At first I did not 
know how to interpret this picture. I never had heard or read 
of gangrene of the raucous membrane of the bladder in cases of 
hypertrophy of the prostate. I therefore ordered rest and the 
continuance of the former treatment, in which I fully concurred, 
asking the patient to report in four or five days. I did not, how- 
ever, see him again until ten days later. The catarrh was un- 
changed, rather worse; he had again lost several pounds of flesh, 
although having a fair appetite. This made me suspicious. I 
I made the sugar test and found about four per cent, of sugar. 
Upon this a strict antidiabetic regimen was ordered, together 
with the administration of opium, etc. This caused decided 
improvement in a few days. Now the patient holds his urine 
for three or four hours, he gets up during the night only once, 
has gained in weight, and attends to his business. THE SURGERY OF THE BLADDER. 
25 
I am inclined to look at this case as one of “ diabetic 
gangrene of the mucous membrane of the bladder.” The 
gangrene perhaps just affected the bladder, as it was the locus 
minoris resistentice. That the diagnosis is correct we may 
conclude ex juvantibus. 
I could add many an interesting experience yet which 
I have had in the last few months. Unfortunately, I can 
not support all that I have seen in the various bladders by 
ocular inspection at the operation. A few of the patients 
refused the operative interference which I had proposed in 
order to effect proper treatment. Nearly all of them were 
examined at my office by myself alone, no colleague being 
present to verify my cystoscopic diagnosis. But, neverthe- 
less, I may be allowed to mention in passing that I have 
seen in this time, among twenty more or less interesting 
patients (Cases 111, IV, and VI included), five tumors of 
the bladder, two stones, once foreign bodies, and the case of 
gangrene of the mucous membrane as just reported. 
There is no doubt, in my opinion, and no surgeon doubts 
it any more to-day, that cystoscopy has a great future. Of 
course we have to learn yet in many respects to recognize 
the disease in the picture, and may often be mistaken in ex- 
plaining what we see, just as that occurs to the laryngolo- 
gists, and veiy experienced ones, with diseases of the larynx. 
In many obscure cases of the uropoietic system the cysto- 
scope will render great aid in arriving at a correct diagnosis. 
But, to be successful with it, it requires a close study and a 
great deal of personal experience. REASONS WHY 
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