Cases of Suprapubic 
Cystotomy. 
BT 
L. BOLTON BANGS, M. D., 
S0K6HON TO ST. LUKE’S AND CHARITY HOSPITALS, AND 
PROFESSOR OF GENITO-URINARY DISEASES IN THE 
NEW YORK POST-GRADUATE MEDICAL SCHOOL. 
BEPBINTED FHOM 
)Z Hfeto Yorfe Journal 
for June 22, 1889. Reprinted from the Mew York Medical Journal 
for June 22, 1889. 
CASES OF SUPRAPUBIC CYSTOTOMY.* 
By L. BOLTON BANGS, M. D., 
SURGEON TO ST. LUKE’S AND CHARITY HOSPITALS, AND PROFESSOR OF 
GENITO-URINARY DISEASES IN THE NEW YORK POST-GRADUATE 
MEDICAL SCHOOL. 
My object in presenting; the following cases for your 
consideration is simply to place them upon record, with the 
hope that, perhaps, something in their management may 
add to the experience of others. 
My own experience has been limited to six cases—two 
for the removal of tumors from the wall of the bladder, 
three for vesicular calculi, and one for the removal of a 
calculus, together with the excision of three small tumors 
(probably prostatic) from the internal urethral orifice. 
Case I. Calculi.—Patient aged seventy-three, native of the 
United States, mechanic. This old man gave no renal, pulmo- 
nary or specific history. He has had some pain over the heart, 
“spots before his eyes,” and attacks of dizziness. His arteries 
are notably atheromatous. For some years he has had frequent 
urination, but no pain till about a year before this history was 
taken, when he experienced a burning sensation in his urethra 
and pain at the end of the penis. At that time he was searched, 
but no stone was found. Since then he has been gradually get- 
ting worse. He has had attacks of baematuria, especially after 
* Read before the American Association of Genito-urinary Surgeons 
at its third annual meeting. 2 
CASES OF SUPRAPUBIC CYSTOTOMY. 
walking or any muscular effort, and he is compelled to urinate 
about every two hours. On searching him with a lithotrite, 
one stone was grasped aud another could be felt in the bladder. 
Suprapubic cystotomy being decided upon, the operation was 
done with the aid of Petersen’s rectal bag. 
The bladder was reached easily, and, on being opened, con- 
siderable hypertrophy of the prostate was found. Behind the 
prostate was a deep pouch in which were four stones, one large 
one and three smaller. The latter accurately fitted each other 
by facets, forming a tesselated stony floor to the pouch, upon 
which the large stone rested. 
Inasmuch as the patient had considerable cystitis, the blad- 
der was not sutured. Two rubber drainage tubes were intro- 
duced to the base of the bladder, the wound was packed with 
iodoform gauze, and over this the usual antiseptic and absorbent 
dressings, consisting of layers of iodoform and bichloride-of- 
mercury gauze and absorbent cotton, were applied. The wound 
was irrigated frequently with a solution of mercuric bichloride 
(1 to 5,000), but the bladder was irrigated with a boro-salicylic 
solution. One of the tubes was removed on the fourth, and the 
remaining tube on the seventh day. From that time the cathe- 
ter was passed twice daily, and the bladder irrigated with the 
customary boro-salicylic solution. The wound granulated rap- 
idly. On the eleventh day the patient was out of bed, passing the 
greater portion of his urine by the natural channel, but still 
continued to wear over the sinus leading to the bladder a pad 
of absorbent cotton, which, when properly attended to—i. e., 
when changed frequently enough—kept his clothing dry. 
Two weeks after, it is noted that he still had a sinus, through 
which a little urine escaped, but most of it passed per urethram. 
Ten days later the wound was entirely closed, and, in spite of 
the enlargement of the prostate, he was able to evacuate his 
bladder spontaneously. During the whole course of the healing 
process this patient had no pain. On the day of the operation 
he was comfortable, and on the second day after -was lying on 
his side reading the newspaper. The drainage may be consid- 
ered to have been efficient so far as the bladder was concerned, 
but his bed and clothing were always somewhat wet until he CASES OF SUPRAPUBIC CYSTOTOMY. 
3 
was permitted out of bed, and even then his clothing would be 
wet unless the absorbent cotton was frequently changed. 
Case II. Papilloma of the Bladder.—This patient was 
kindly referred to me for operation in St. Luke’s Hospital by 
Dr. Otis, and has already been reported by him * in illustration of 
the advantage of the cystoscope. I mention it briefly only to 
give some details of the operation and of the after-treatment. 
Petersen’s method was attempted, but, for some reason or other 
which was not discovered till after the operation, the rectal bag 
did not lift the bladder. The patient’s abdomen being very fat, 
and its muscles rigid from imperfect etherization (he did not 
take ether well), a sound was passed into the bladder through 
the urethra, and the incision guided by this. The recti muscles 
contracted so firmly that at first I experienced difficulty in ex- 
amining the interior of the bladder, but by deepening the ether 
narcosis and using vaginal specula as retractors, the tumor was 
fully exposed and easily removed by scissors, the curette, and 
Paquelin’s cautery. One large drainage-tube was inserted to 
the bottom of the bladder, and the incision in the latter was 
brought together by a continuous catgut suture, as likewire 
were the different layers of the abdominal wall, leaving only an 
opening for the tube. The abdomen was dusted with iodoform, 
and over all a thick antiseptic dressing of bichloride gauze and 
absorbent cotton was placed. The free end of the drainage- 
tube was placed in the dressings. After the operation the pa- 
tient had violent vesical tenesmus for three days, controlled only 
by hypodermatic injections of morphine. 
For the first week, besides the urine, there was a discharge of 
pus and mucus stained with blood, and the bladder was washed 
out through the abdominal wound three times daily with a 
boro salicylic solution. This discharge gradually disappeared, 
and on the eighth day the tube was removed. The wound had 
united by first intention, but in the first week about two thirds 
of it broke down and slowly healed by granulation. Even by 
frequent changing of the dressing it was impossible to keep the 
patient dry. lie could not endure the use of the catheter, and 
was excessively liypersesthetic and “nervous,” but he steadily 
* See “Medical Record,” May 5, 1888. 4 
CASES OF SUPRAPUBIC CYSTOTOMY. 
regained the power of evacuating his bladder by the natural 
channel, and by the twenty-fifth day did so entirely. It was 
not till the thirty-fifth day that the wound in the abdominal 
parietes was entirely healed. 
Case III. Papilloma of the Bladder.—This patient was also 
referred to my service in St. Luke’s Hospital by Dr. Otis. Two 
years before coming under observation he noticed, while pass- 
ing water, that a large amount of blood came with it. He had 
no further trouble until several months later, when he had a 
second haemorrhage. For some months past he has had at dif- 
ferent times haemorrhages while urinating, none of which were 
very large, but he had them repeated to an extent sufficient to 
cause anaemia and great deterioration of his health. By means 
of the cystoscope, Dr. Otis diagnosticated a tumor, probably pa- 
pillomatous, on the right side of the bladder. His haemorrhages 
had now become so frequent and so abundant that his urine 
always contained a large amount of blood, and his condition 
was such that operative interference was imperative. At the 
time of the operation I repeated the examination with the 
cystoscope and located the tumor, hut it was covered with clots 
of blood and I could not definitely describe it. The rectal hag 
was inserted and distended with twelve ounces of water. Nine 
ounces of a warm and weak boro-salicylic solution injected 
into the bladder before the latter was made prominent above 
the pubes. The abdomen was very thick and contained a large 
amount of fat. After dividing the transversalis fascia and the 
layer of fascia covering the supravesicular fat, the latter was 
easily and rapidly stripped up, carrying with it the peritonaeum. 
Silk sutures, one on either side of the median line, were then 
passed through the bladder, which wras thus held up into the 
wound and incised with a pair of scissors. As the fluid escaped 
from the bladder, a suspicious-looking fat (which proved to be 
omentum) appeared in the upper part of the wound. A careful 
examination being made, it was found that one of the sutures 
had caught the peritonaaum where it was lower on one side of 
the surface of the bladder and was thus drawn into the line of 
the incision. The wound in the peritonfeum was sutuied im- 
mediately by catgut and the bladder opened freely toward the CASES OF SUPRAPUBIC CYSTOTOMY. 
5 
pubes. The bladder was held open by a vaginal speculum, and 
the tumor seen on the right side of the bladder was removed 
by scissors. A good-sized artery supplied the center of the 
tumor and free haemorrhage occurred, but it was controlled 
with a silk ligature, the ends of which were brought out of the 
wound. There was also considerable parenchymatous haemor- 
rhage from the base of the tumor, which persisted in spite of the 
use of the actual cautery. Against this a strip of iodoform 
gauze was carefully packed, and the two drainage-tubes, placed 
in the bladder, made sufficient pressure against the gauze to 
stop all bleeding. A small drainage-tube was inserted in front 
of the bladder in the lower angle of the wound ; the upper part 
of the abdominal wound was brought together by continuous 
catgut sutures and an antiseptic absorbent dressing applied. 
The patient had very little pain immediately after the opera- 
tion, but for nearly ten days thereafter had paroxysms of pain, 
especially at night; but these gradually decreased in severity 
and finally ceased. The bladder was irrigated twice daily by a 
boro-salicylic solution. On the fourth day the iodoform gauze 
in the bladder and one tube were removed. The wound granu- 
lated well. From the second day after the operation the 
catheter was passed daily and the bladder irrigated also by 
means of this, but on the seventh day after the operation, the 
patient had some urethritis, and the use of the catheter was 
omitted. On the thirteenth day the patient was out of bed, 
passing some urine through the urethra. On the eighteenth 
day the wound was closed, so that when the patient was in a 
standing position and pressure made over the pubes, he could 
urinate normally. On the twenty-fourth day he went to his 
business, but there was a fine sinus leading down ward and back- 
ward, through which a probe could be passed, and from which 
a few drops of urine escaped. I passed through the urethra as 
large a sound as the meatus would admit, and four days later 
he reported to me that some urine had escaped from the sinus 
the night of the operation (i. e., the introduction of the sound), 
but none since. This patient had no temperature above 99° F. 
during the whole process of healing. 
Case IY. Calculus.—This patient was a well-preserved man 6 
OASES OF SUPRAPUBIC CYSTOTOMY. 
of forty-nine. For several years lie had had symptoms of vesi- 
cal irritability. Of late he had had haematnria, painful and 
frequent urination, and continued pain in the bladder with par- 
oxysmal exacerbations, the pain especially increased by loco- 
motion. The first searching revealed a stone of comparatively 
large size, but subsequent searchings failed to detect it. Being 
certain as to the first exploration, and finding that the bladder 
wras very irritable, I decided upon suprapubic cystotomy, which 
was performed a few days later. This patient’s abdomen was 
very fat and the muscular wall of the bladder was not easily ex- 
posed, but by two silk sutures inserted, one on either side of 
the median line, it was lifted and opened. A large, flat stone 
was found resting behind the pubes, which may account for its 
eluding the searcher, the latter being resisted and compressed 
by the irritable bladder. One small, straight rubber drainage- 
tube (about seven centimetres in diameter) was placed in the 
bladder, and the wound in the latter sutured with catgut, ex- 
cepting the small part occupied by the tube. A fine drainage- 
tube was placed in front of the bladder in the lower angle of the 
wound, and the abdominal tissues were then sutured with cat- 
gut. The whole was covered by an antiseptic dressing, con- 
sisting first of layers of iodoform gauze, then of several thick- 
nesses of bichloride gauze, and over all a thick layer of absorb- 
ent cotton. The end of the drainage-tube was carried through 
a layer of absorbent cotton packed in the mouth of a glass urinal 
(known in hospital parlance as a “duck”), which was placed 
on the bed beside the patient. 
At first this promised well, and served to accumulate a large 
proportion of urine, but the patient soon began to suffer from 
vesical tenesmus. The paroxysmal contractions of the bladder 
forced a certain amount of urine by the side of the drainage- 
tube, sufficient to saturate the immediate dressings, and thence 
by imbibition to the bed-clothing. 
For forty-eight hours it was necessary to relieve his pain by 
hypodermatic injections of morphine. After that he had no pain. 
On the evening of the operation his temperature was 101° F. 
For five days it was about 100°, and after that normal. On the 
tenth day he passed some urine normally, and from that time CASES OF SUPRAPUBIC CYSTOTOMY. 
7 
on the quantity passed by the urethra gradually increased. On 
the sixteenth day he was out of bed, wearing a pad of absorbent 
cotton, which took up a small amount of urine escaping from 
time to time from a suprapubic sinus. On the twenty-first 
day he returned to his business, but he still had a narrow sinus, 
which I probed and measured and found to be three inches long, 
curving downward and backward behind the pubes. From this 
a drachm or so of urine escaped, especially at night. As there 
was no prostatic obstruction in this case, I thought, as in the 
preceding case, that perhaps the urethra had lost tone from dis- 
use, and therefore passed through the urethra, well into the 
bladder, a sound as large as the meatus would admit. 
On the second day after this simple manoeuvre there was 
no discharge whatever from the sinus, and on the fourth day it 
had entirely healed to the level of the skin. 
Case Y. Calculus; Three Small Tumors.—This patient was 
a professional man of fifty nine—a man of temperate and regu- 
lar habits, a total abstainer as regards alcohol and tobacco, and 
without any venereal history of any kind. About thirty-four 
years ago he had a retention of urine for several hours, without 
any known cause excepting “ catching cold.” This was relieved 
by the catheter, and he had no further trouble. For several 
years he had frequent urination, but never any pain or anything 
that called particular attention to himself until about two years 
ago. At that time he began to have cause to urinate every 
two hours, the amount of urine each time being scanty. The 
stream would stop suddenly and then come on again. lie was 
examined by an electrician, and was told that he had one or 
two strictures. These were said to have been “ cured ” by elec- 
tricity ; but he was under treatment for eighteen months, and 
during the course of this treatment it was discovered that he 
had “ enlarged prostate,” and he was recommended to use the 
catheter. He had some relief from his sufferings both as to 
frequency and pain in the act of urination ; but he soon (in the 
course of three months) began to have intense pain, and the 
calls to urinate increased again to once in two hours and oftener. 
Then the electrician made four applications of the galvano- 
cautery to the so-called “ enlarged prostate.” After that he 8 
CASES OF SUPRAPUBIC CYSTOTOMY. 
was confined to his room ; his urine became “ foul ” and bloody, 
and he was said to have had “fever” every night. For eighty- 
six days before I examined him he had been utterly unable to 
pass any urine except by the catheter. His sufferings were 
extreme—continuous pain in the bladder and penis, wiih parox- 
ysmal exacerbations of extreme intensity. When I first ex- 
amined him there was by the rectum no appreciative enlarge- 
ment of the prostate. The ordinary Thompson searcher passed 
readily and easily into the bladder, without deflection or depres- 
sion of its handle, and its beak immediately produced the char- 
acteristic click of a calculus. TIis urine was loaded with pus 
and mucus, and was horribly offensive in spite of an occasional 
washing of the bladder, which he resorted to unwillingly, as it 
seemed to aggravate his sufferings. This was his condition in 
spite of the daily use of electricity and of the homoeopathic 
remedies which he was taking with religious fidelity every two 
hours, night and day. A few days after this examination the 
operation of suprapubic cystotomy was done in the usual man- 
ner. The bladder was easily reached, incised, and a very large 
spherical calculus, weighing 390 grains, easily removed. The 
bladder seemed to have contracted around the stone in such a 
way as to form a shallow pocket (not like a diverticulum or sac 
with a narrow mouth), in which the stone moved or rolled, but 
which could be distinctly made out by the exploring finger. 
The small portion of the bladder between the anterior wall of 
this pocket and the month of the urethra seemed to be normal. 
By means of the vaginal specula, aided from time to time by 
the electric light, the interior of the bladder was easily inspected. 
The mucous membrane was greatly hypertrophied, bluish-red in 
color, bleeding easily, and near the base posteriorly were seen 
a few drops of clear pus oozing into the bladder. At first I 
thought it to be escapiug from one of the ureters, but close ex- 
amination revealed a little abscess in the bladder wall, probably 
near the site of the calculus. During the subsequent manipula- 
tions this was thoroughly evacuated and irrigated. Around the 
internal orifice of the urethra were three small sessile tumors, 
soft in consistence, and apparently of hypertrophied mucous 
membrane. They were of unequal size, but were about the di- CASES OF SUPRAPUBIC CYSTOTOMY. 
9 
mensions of half a cherry. Their globular surfaces projected in- 
ward and toward each other in such a way that, when they folded 
together, they completely occluded the urethra. They were 
easily separated by the finger from within, or by an instrument 
(sound) passed through the urethra from without ; but they 
immediately approximated themselves, and evidently acted dur- 
ing a contraction of the bladder as an obstructing valve to the 
exit of fluids. An attempt wras made to excise these with a 
wire dcraseur, but failed because they were too soft to be drawn 
into the loop of the wire. I then seized each one in turn by 
forceps, and removed it with scissors and a sharp spoon. They 
were so friable that the portion in the grasp of the forceps 
would tear off immediately, and it was by a process of nicking 
and scratching that they were finally removed, so that, both to 
the sense of sight and touch, there was no obstruction to the 
urethra. The bleeding surfaces were treated by Paquelin’s cau- 
tery ; but an artery of considerable size, supplying one of the 
tumors, was, after some difficulty, secured by a catgut ligature. 
The bladder was thoroughly irrigated; a drainage-tube, of about 
five centimetres in diameter, placed in the bladder, was held in 
situ by a silk ligature carried through the abdominal wmll and 
through the tube. I deemed it unadvisable to suture the blad- 
der or the layers of abdominal tissue, but packed the wound 
with iodoform gauze, and over this placed the usual antiseptic 
and absorbent dressings. 
The free end of the drainage-tube was placed in a larger 
one, three or four feet long, the other end of this second tube 
being weighted and led beneath the level of a solution of (1 to 40) 
carbolic acid in a glass jar. The latter was placed on the floor 
near the bed, and a perfect siphon process established. The 
patient for the first night had repeated attacks of vesical tenes- 
mus relieved by the use of morphine. After that he had no 
pain. For three days the drainage-tube worked perfectly, and 
the patient’s dressings were kept dry. After that it ceased to be 
efficient, and, although it siphoned over the greater amount of 
urine, some escaped by the side of the tube upon the dressings. 
The tube was removed on the fifth day, and after this, in order 
to keep the patient’s dressings dry, it was necessary to remove 10 
CASES OF SUPRAPUBIC CYSTOTOMY. 
the pads of absorbent cotton every few hours. The patient’s 
nocturnal temperature bad been 102° F. before the operation, 
but after this it daily decreased, and on the fourth day was nor- 
mal. In every respect his improvement was rapid. The offen- 
sive odor disappeared immediately, but the bladder was irri- 
gated every time that the dressings were changed till the ninth 
day, when the mucus and pus had decreased so greatly that 
after that the bladder was irrigated but once a day. On the 
eleventh day the patient passed some urine by the urethra, and 
on the thirteenth day he was out of bed for a few hours only. 
The wound granulated freely, and on the ninth day it is re- 
corded that only the narrow point of the irrigating tube could 
he insinuated into the bladder. This patient is still under ob- 
servation. He has not yet regained normal urination, but passes 
a few drachms spontaneously. 
Case VI. Calculus.—The patient, aged sixty-nine, native of 
the United States, was a temperate man of good general history. 
For a number of years he has had paroxysms of dyspnoea last- 
ing a few moments and occurring especially at night. No 
gastric or other symptoms. For a month or six weeks he 
has had some swelling of the right foot and leg, with an ulcer 
on the leg and pain in the heel. For some months he has had 
frequent micturition, more marked at night, some hesitation 
and straining at commencement of the act, and occasional 
stoppage of the flow of urine. The stream is small, the last 
few drops passing always without control, and the quantity 
passed at a time is small. Sometimes his urination is precipi- 
tate, and at times he has pain at the end of the penis on uri- 
nating. Driving or jolting increases his micturition. He has 
had one attack of haematuria. About two months ago he un- 
derwent an operation for haemorrhoids, which were supposed 
to he the source of his troubles. He makes from twenty-seven 
to thirty-seven ounces of urine in the twenty-four hours, which 
contains a large amount of leucocytes and about one per cent, 
of albumin. There is felt per rectum considerable hyper- 
trophy of the prostate. With great difficulty and after some 
persistency the searcher is introduced into the bladder and a 
calculus detected. The operation was done in the usual way. CASES OF SUPRAPUBIC CYSTOTOMY. 
11 
Seven ounces of warm boro-salicylic solution were injected into 
the bladder, and into the rectal bag nine ounces. Although the 
patient was very obese, the bladder was brought prominently in 
view, and was reached without difficulty. The layer of fascia, 
containing a mass of fat, was easily rolled up, carrying with it 
the peritonaeum. The bladder was opened, and two stones of 
very unusual shape were removed. One consisted of a spheri- 
cal central portion, with seven secondary crystalline deposits 
radiating from it like the spokes of a wheel. The radii were 
about half an inch in length, were bifid at their extremity, 
and the whole stone had the appearance of an ordinary iron 
“jack-stone” used by the children. The second stone was 
cone-shaped, the apex of the cone being very sharp. A single 
drainage-tube was placed in the bladder, secured by a silk liga- 
ture to the abdominal wall and to the lower end of the wound. 
The wound in the bladder was carefully brought together by 
continuous catgut suture down to the drainage-tube, and the 
wound in the abdomen treated in the same way. 
The usual antiseptic dressings were applied, and the siphon 
drainage as described in the preceding case was established. 
The siphonage was perfect for three days. Then urine began 
to escape by the side of the tube and also per urethram. From 
twelve to fifteen ounces were passed each day in the natural 
way. The patient had no pain frqm the time of the operation. 
His temperature did not rise above 100, and then only for a 
day. After that it was normal. The tube was removed on the 
third day and the proportion of urine which escaped through 
the abdominal wound was received by the usual absorbent cot- 
ton, and by frequent changing the patient was kept comfortable 
and comparatively dry. On the sixteenth day he was out of 
bed, urinating entirely by the urethra, and with the wound in 
the bladder and abdomen closed. 
Permit me a few remarks upon the technique of these 
operations and upon their after-management. In making 
the incisions through the abdomen, I have observed that 
the line between the pyramidales muscles may be readily 
found by first ascertaining the notch made by the junction 12 
CASES OF SUPRAPUBIC CYSTOTOMY. 
of the two pubic bones. The pigmented line of the rhaphe 
curves laterally in some individuals at the lower part of the 
abdomen, and is not always a good guide to the separation 
between these two muscles, but by deep pressure above the 
mons Veneris this notch can always be felt, and the lower 
end of the incision should be directed to this point without 
regard to the course of the rhaphe. The consecutive incis- 
ions following the line of the first one easily and rapidly 
proceed to the transversalis fascia, which, being divided 
(sometimes also another thin film of fascia), the supra- 
vesicular fat, carrying with it the veins and the peritonamm, 
may generally be quickly and easily stripped up with the 
finger. These may be small matters, but under some cir- 
cumstances rapidity of execution in the operation may be 
a necessity, as in the case of the patient aged sixty-nine, 
whose cardiac and nephritic conditions were such as to re- 
quire most careful watching. 
In one case I was obliged to find the bladder by means 
of a sound passed through the urethra. Why the rectal 
bag had failed was not ascertained till after the operation, 
when it was found fully distended (with § xvj of water) in 
the douche pan upon which the patient was lying. During 
the early administration of the anaesthetic and before my 
first incision was made he had evidently forced the bag out 
of his rectum. I had taken it for granted that the rectal 
bag had burst, and, not wishing to delay the operation, went 
on with the aid which 1 have described. It was gratifying 
to learn later on that such a distension of the man’s anus 
had had no ill effect. Lange reports a laceration of the 
rectal wall by the rectal tampon. 
From Eigenbrodt’s report from Trendelenburg’s clinic, in 
the “ Deutsche Zeitschrift fur Chirurgie,” Bd. xxviii, 1888, 
I learn that he thinks it unnecessary to resort to the rectal 
bag; nor does he dilate the bladder forcibly, but just enough CASES OE SUPRAPUBIC CYSTOTOMY. 
13 
to produce a dull percussion sound above the pubes. The 
preparatory treatment advocated by Petersen and Perier in 
cases of contracted bladder or cystitis when present— 
namely, repeated injections—I have not considered neces- 
sary, but have operated at once in order to remove as soon 
as possible the cause of the bladder symptoms. 
In none of my cases have I found it necessary to resort 
either to the transverse incisions or to the elevation of the 
pelvis, both of which are advocated by Trendelenburg. The 
interior of the bladder was always easily exposed by the use 
of uterine or rectal specula, which not only reflected a strong 
light upon the field of operation, but did not interfere with 
the manipulations. A wider experience may lead me to 
adopt one or both of these procedures. 
I have made no attempt to secure primary union of the 
whole wound in the bladder, but in cases where the latter 
seemed to be in good condition have sutured it, excepting 
the small portion for the drainage tube. In others, the 
wounds have been left open, together with the overlying tis- 
sues, in order that the whole might be healed by the process 
of granulation. Dr. Lange has lately recommended securing 
primary union of the walls of the bladder by means of a re 
tention catheter, and reports some excellent results. I doubt 
if any of my patients could have endured the presence of a 
catheter for a number of consecutive hours, nor do I think it 
advisable, in order to secure an insensitive urethra, to nar- 
cotize or semi-narcotize the patient by the administration of 
opium. It seems to me that the patient’s well-being and his 
healing forces should be preserved by avoiding narcotics, 
and using them only for the relief of violent paroxysmal 
pains from which some of these patients sutler for a short 
time after the operation. For the same reason I have not 
restricted the patients to any particular posture after the 
operation. I leave them to choose their own posture, and, 14 
CASES OF SUPRAPUBIC CYSTOTOMY. 
as you will remember, the old man, in the first ease report- 
ed, lay upon his side reading the newspaper on the second 
day after the operation. The abdominal decubitus which 
Trendelenburg recommended, I am glad to see, he no 
longer considers essential. I have tried different methods 
of drainage, and do not find any special advantage in the 
Trendelenburg T-tube. One or two straight fenestrated 
rubber tubes, kept thoroughly cleaned by an antiseptic so- 
lution, serve the purpose admirably. The siphoning sys- 
tem, as I have described it in reporting the cases, seems to 
be the most advantageous, but all methods seem to fail after 
three or four days. By this time granulations have gener- 
ally covered the wounds, and then I resort to pads of ab- 
sorbent cotton which, if changed with sufficient frequency, 
will keep the patient’s clothing and bed dry. I doubt if 
any system of drainage will prevent the sudden and violent 
expulsion by the side of the tube of a certain amount of urine, 
which soon by capillary attraction finds its way to the sur- 
rounding clothing. Later on, say after the first ten days, I 
have found that the patients are able to attend to the chang- 
ing of the absorbent cotton themselves. A roll of cotton 
within easy reach and a basin placed by the side of the bed 
for the reception of the soiled cotton, enable them to keep 
themselves comfortable with comparative trifling expense 
and trouble, for they soon learn when to change the cotton. 
It seems to me to be a good plan to get these patients 
out of bed long before the healing process is completed, for, 
in my judgment, the function of the urethra is more quickly 
restored and the openings in the bladder and abdomen are 
more quickly healed perhaps by the pressure which the ab- 
dominal contents exert when in the upright position. In 
each of two cases there w7as a fistula which may have been 
slowly healing, but which seemed, in spite of the otherwise 
good condition of the patients, to be inclined to persist. CASES OF SUPRAPUBIC CYSTOTOMY. 
15 
Reasoning that this might be due to the loss of tone of the 
urethra, I did the very simple thing of passing a sound, and, 
as you no doubt have noticed from the history, the largest 
and deepest fistula was healed in two days and the smaller 
one within a day after the use of the instrument. This 
seems a very simple method, but it may be scientific. At 
all events, one of these patients informed me that after the 
passage of the sound he made a stream larger and with 
greater force than he had done before. While I do not at- 
tach much importance to such statements from patients, un- 
less I have had the means of verifying them, I think this 
was true, and it leads me to suggest to my colleagues that 
even slight obstructions in the urethra may prevent the rapid 
healing of these troublesome fistulse. Hence in such cases 
the meatus and urethra should be carefully examined. 
12V East Thirty-fourth Street. REASONS WHY 
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