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ANNOUNCEMENT* 
UNIVERSITY OF PENNSYLVANIA PRESS 
PHILADELPHIA. PA. 
Orest Britain: Cawcll and Company. LoRdotr. 
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Om Ovum • t«u to M»nc» 
•to«to C»*U». T« EfeilUM* 
OCTOBER, 1893 
ON THE FEASIBILITY OF INTRAPERITONEAL CYS- 
TOTOMY, WITH THE REPORT OF A CASP:. 
By FRANCIS B. HARRINGTON, M.D., 
OF BOSTON. 
SURGEON TO OUT-PATIENTS AT THE MASSACHUSETTS GENERAL HOSPITAL; 
ASSISTANT IN SURGERY IN THE MEDICAL DEPARTMENT OF 
HARVARD UNUNuRSITY. ON THE FEASIBILITY OF INTRAPERITONEAL CYS- 
TOTOMY, WITH THE REPORT OF A CASE.1 
By FRANCIS B. HARRINGTON, M.D., 
OF BOSTON. 
SURGEON TO OUT-PATIENTS AT THE MASSACHUSETTS GENERAL HOSPITAL; 
ASSISTANT IN SURGERY IN THE MEDICAL DEPARTMENT OF 
HARVARD UNIVERSITY. 
THE interior of the bladder is ordinarily reached in one of 
three ways: 
By the urethra; 
By the perinaeum in the male, and by the vagina in the 
female; 
By the suprapubic incision. 
All of these methods are imperfect, and give the surgeon 
only a limited view of the bladder. If we wish to demonstrate 
the bladder on the cadaver in the clearest possible manner, we 
do it by laparotomy. 
If the bladder be distended, its superior surface presses 
against the anterior abdominal wall like the pregnant uterus. 
In the Trendelenberg position, with an incision from the 
umbilicus to the pubes, we get a clear view of the unattached 
portions of the exterior of the bladder. 
If, having thus opened the abdominal cavity, a median incis- 
ion be made in the most prominent part of the bladder wall, 
extending backward from two to three inches, we are able by 
means of retractors to see the interior of the bladder very per- 
fectly. The prostate, tumors and, if it be necessary, an entire 
section of the vesical wall can be removed with ease. The ure- 
ters can be seen and examined advantageously. 
The superiority of the intraperitoneal over the suprapubic 
1 Read before the Obstetrical Society of Boston, June io, 1893. FRANCIS B. HARRINGTON. 
incision, as a means of reaching and operating upon the interior 
of the bladder, is very decided, and were there no question of 
safety to the patient, the former incision would always be used 
The suprapubic incision is necessarily of limited extent, and the 
bladder and abdominal walls are closely united being, in fact, a 
part of the same incision. The control of the bladder is imperfect, 
the thick abdominal walls obstructing both sight and manipula- 
tion. 
Through the peritoneal incision the cut edges of the bladder 
can be drawn up toward the surface and even outside of the 
abdominal walls. 
With the finger in the rectum, the prostate or any portion 
of the base of the bladder can be lifted to within an inch or two 
of the external opening. By repeated trials upon the cadaver, it 
has been found that the bladder may be sewed up intra-abdomi- 
nally, so that it resists much distension, both by water and by air. 
The history of laparotomy is full of reports of accidental incision 
of the bladder, where suturing has been necessary. The reported 
results of these accidents are almost always favorable. The 
treatment of penetrating wounds and rupture of the bladder has 
been successful. The chief objection to intraperitoneal cystotomy 
must be the danger, or seeming danger, of septic infection. It is 
doubtful if the danger be as great as it has been supposed to be. 
The stomach, the gall bladder and the intestines (all having 
septic contents) may be opened and closed with safety. 
The uterus and the kidneys are removed through the peri- 
toneal cavity because of the greater advantages of this route. 
Why then should the bladder not be approached by the route 
which affords the greatest facilities ? 
The opening of the abdominal cavity, the escape of the urine 
and the imperfect closure of the bladder after operation are dan- 
gers which present themselves to the operator’s mind. 
With proper care it is probable that the bladder can be as 
certainly shut off as the stomach or intestines. Normal urine is 
not septic as it enters the bladder. The danger from an alkaline 
urine in contact with healthy tissues for a short time is not great. 
The flow of urine through the ureters is, as a rule, by drops, 
and can be easily taken care of by an assistant with sponges. INTRA PERITONEA L CYSTO TOM V 
3 
About the bladder a packing of gauze may be so placed 
that much urine might escape without soiling the peritonaeum or 
intestines. Experimentally, it has been found that more than two 
ounces of permanganate of potash solution may be poured into 
such a packing at one point without staining through. 
Intraperitoneal cystotomy may be performed for tumors of 
the bladder, for enlarged prostate, for disease of the ureters, for 
cases of stone in the bladder of great size and for sacculated 
stone. 
It must be remembered that cystotomy of any kind is under- 
taken only in cases of great gravity. There are advantages in 
the operation which certainly, at times, render it preferable to 
suprapubic cystotomy. It should be remembered that the mor- 
tality of this latter operation is not small. 
The writer makes the following suggestions for the perform- 
ance of intraperitoneal cystotomy : Prepare the patient as for 
ordinary laparotomy ; wash the bladder, if the urine be foul, for 
several days with a saturated solution of boric acid ; distend the 
bladder gently with this solution at the time of operation ; make 
the abdominal incision from the umbilicus to the pubes, being 
careful not to open the prevesical space. 
The intestines should be drawn out of the pelvis and the 
cavity packed with strips of sterilized absorbent cotton covered 
with gauze, the patient being in the Trendelenberg position. An 
incision in the median line of the bladder, beginning an inch from 
the junction of the abdominal and vesical peritonaeum, should be 
extended backward from two to three inches. 
The incision should at first only include the peritoneal coat, 
which should be dissected from the muscular coat for a quarter 
of an inch on either side of the incision. The fluid should now 
be withdrawn and the incision carried through to the cavity of 
the bladder. Bleeding may be controlled by haemostatic forceps. 
Having performed whatever operation is necessary upon the 
interior of the bladder, and having the haemorrhage under control 
the bladder may be closed. The method of closure should be 
by continuous suture of the muscular coat, the stitches being 
closely applied. FRANCIS B. HARRINGTON 
These stitches should not include the mucous membrane, 
They should be of silkworm-gut or of silk. The peritoneal coat 
of the bladder should then be closed by a continuous “ right 
angle ” or by “ Lembert ” suture. 
This gives a double row of stitches. The continuous stitch 
prevents stretching of the bladder wall when it is distended, and 
is a safeguard against leakage. Should there exist a bleeding 
within the bladder, which threatens to interfere with micturition 
permanent drainage can be made through the perinaeum, through 
the vagina or by the suprapubic route. 
The intraperitoneal operation does not interfere with supra- 
pubic drainage, should drainage be necessary. As a rule, how- 
ever, drainage will not be necessary except that which can be 
obtained by the urethra. 
The packing should now be removed from the pelvis and 
from about the intestines. The pelvic cavity should be wiped 
out with moist aseptic gauze and the abdominal wound closed. 
The bladder should be washed gently with boric acid solution 
two or three times a day, care being taken not to distend it nor 
to allow it to become distended with urine. 
A Case of Intraperitoneal Cystotomy.—Mrs. B., twenty-eight 
years of age. Mother of five children. 
tor nine months the patient had been suffering from haemor- 
rhagic cystitis. It began without apparent cause, with the symptoms 
of blood in the urine and an increased desire to pass water. This 
condition grew gradually worse until the bladder would not hold its 
contents, night nor day, for more than twenty minutes. The urine 
became more and more mixed with blood and small bits of calculi. 
The suffering was constant and extreme. 
The patient was blanched and very weak from loss of blood. 
Under ether the urethra was dilated and the finger introduced 
into the bladder. It was contracted, the mucous surface being very 
irregular and covered with incrustations. The feeling was of new 
growths covered with urinary deposits. The bladder was very thor- 
oughly curetted and large quantities of material were removed. The 
haemorrhage was considerable. 
Dr. Wm. F. Whitney reported, on microscopic examination, 
that only mucous membrane of the bladder and phosphatic deposits 
were found. INTRAPERITONEAL CYSTOTOMY. 
5 
After the operation the bladder was washed twice a day with 
antiseptic solutions. There was a decrease in the amount of blood 
for a short time, but the haemorrhage soon returned, notwithstanding 
the constant washing of the bladder. Four months later the condi- 
tion of the patient was worse than before. She was admitted to the 
Massachusetts General Hospital, where, by the kindness of Dr. John 
Homans, she came under my care. 
The urine was ammoniacal, contained much blood and was full 
of'sediment. She suffered constantly, was miserable from loss of 
sleep and pallid from loss of blood. It seemed necessary to take some 
radical measures to relieve the distressing condition. Intraperitoneal 
cystotomy was decided upon and performed in the manner previously 
suggested. The operation afforded great freedom for manipulation. 
The bladder wall was half an inch thick, but there was no trou- 
blesome bleeding. There was no difficulty in keeping the cavity free 
from urine. 
The mucous membrane was studded with ulcerations and with 
grayish-white patches in which were firmly adherent urinary deposits. 
The entire surface of the bladder was curetted with a sharp curette. In 
places it was necessary to use the knife or scissors in order to reach 
healthy tissues. 
It was thought best, as there was considerable oozing, to make 
an opening for free drainage into the vagina. 
The muscular coat of the bladder was first closed then the peri- 
toneal. When the packing in the pelvis was removed the peritoneum 
was found quite dry. The abdominal wound was closed in the usual 
manner. The bladder drained well through the vaginal opening and 
the urine soon became clear and abundant. After the operation the 
patient was troubled with nausea, and at one time had a very rapid 
and weak pulse, but otherwise made an excellent recovery. Four 
months after the operation the patient is in excellent condition and 
able to be about her housework. 
The opening in the vagina has almost closed. The urine is free 
from blood. 
Dr. Whitney’s report is as follows : “ The specimen consisted of 
blood clots and numerous small fragments, all but one of which con- 
sisted of masses of lime salts, incrusted on what seemed to be portions 
of the lining membrane of the bladder. One piece, larger than the 
rest, the inner surface of which was irregularly thickened and 
incrusted with lime salts, was composed of the muscular wall of the 
bladder largely infiltrated with round cells.”