SUPRAPUBIC CYSTOSTOIY: 
ITS FREQUENT UTILITY, AND AN APPLIANCE 
FOR PREVENTING THE CHIEF ANNOYANCE 
ATTENDING A PERMANENT OPENING 
IN THE BLADDER. 
By FREDERIC HENRY GERRISH, A. M., M. D., 
Fellow of the American Surgical Association ; 
Professor of Anatomy in Bowdoin College; 
Member of the Association of American Anatomists; 
Sometime President of the American Academy of Medicine; 
etc. 
(Rkfrintbd fbom thk Transactions of the American Surgical Association, 1892.) 
PORTLAND, ME.: 
William M. Marks, Printer. 
1892. SUPRAPUBIC CYSTOSTOIY: 
ITS FREQUENT UTILITY, AND AN APPLIANCE 
FOR PREVENTING THE CHIEF ANNOYANCE 
ATTENDING A PERMANENT OPENING 
IN THE BLADDER. 
EREDERIC HENRY GERRISff, A. M,, M. D., 
Fellow of the American Surgical Association ; 
Professor of Anatomy in Bowdoin College; 
Member of the Association of American Anatomists; 
Sometime President of the American Academy of Medicine; 
etc. 
(Reprinted from the Transactions of the American Surgical Association, 1892.) 
PORTLAND, ME.: 
William M. Marks, Printer. 
1892. SUPRAPUBIC CYSTOSTOMY: 
ITS FREQUENT UTILITY, AND AN APPLIANCE FOR PREVENTING THE 
CHIEF ANNOYANCE ATTENDING A PERMANENT OPENING 
IN THE BLADDER. * 
The operation of opening the bladder by an incision above 
the pubic symphysis is thoroughly established as a legitimate 
procedure, though its superiority to perineal incision in vari- 
ous cases is by no means fully appreciated by the profession. 
Its employment for the removal of calculi and vesical tumors, 
for prostatectomy, for the topical treatment of ulcerated sur- 
faces, tuberculous and other, for temporary drainage and rest 
of the organ, needs no special advocacy in this presence. In 
these classes of cases one object which the surgeon almost 
invariably has in mind is the ultimate closure of the artificial 
opening. In some instances, however, great benefit to the 
patient results from suprapubic-cystotomy, performed with the 
intention of creating permanent drainage. For example, in 
marked hypertrophy of the prostate, where as severe an oper- 
ation as prostatectomy is contra-indicated by the feebleness 
of the patient, or is prohibited by his ill-advised opposition, 
permanent drainage is often desirable—sometimes, indeed, 
imperatively demanded. To this procedure, undertaken for 4 
the especial purpose indicated, the name Cystostomy (Au<nvc 
-\-axbya) may properly be applied, as a term of convenience, 
signifying the formation of a mouth, or fistula, in the bladder. 
The objects of this paper are, first, to call attention to the 
importance of suprapubic cystostomy, as distinguished from 
cystotomy ; and, second, to describe a little device, which has 
served excellently in carrying out certain details of the after- 
treatment. The apparatus is so simple that it is quite proba- 
„ ble that it has been invented before; but it has not been my 
fortune to see, or even to meet with a description of, such an 
appliance. 
After the parts around the aperture have healed, and there 
is a perfect continuity between the mucous membrane of the 
bladder and the skin of the hypogastrium, if the intravesical 
difficulties have been relieved by the operation, the patient 
suffers only—or, at all events, mostly—from the constant 
flow of fluid over the abdominal surface. The apparatus is 
designed to prevent this annoyance, which is so serious as to 
make the patient’s life wretched by keeping the skin drenched 
with, and his person constantly odorous of, urine. 
It consists, first, of a plate of silver, about eight centimeters 
long and a little more than five centimeters wide. The cor- 
ners are rounded, and the entire marginal portion is grooved 
on the posterior surface, a transverse section of this gutter 
representing nearly a semicircle with a diameter of seven 
millimeters. Into this groove is cemented a piece of soft, 
pure-rubber tubing, with a diameter slightly exceeding that 
of the groove. One end of the tubing is fastened to the other 
end with cement, so that an air-cushion is formed. In the 5 
centre of the plate is a circular perforation, seven millimeters 
in diameter, surrounded by a narrow collar. On the front 
of the plate, midway between the centre and each end, is a 
silver bar, firmly attached at each of its extremities, and leav- 
ing a space of three millimeters between its hind surface and 
the anterior surface of the plate. A piece of thick-walled 
rubber tubing of suitable size and thirty centimeters long is 
secured in the central aperture. The plate is applied so as 
to centre on the stoma of the bladder, and is held in place by 
bands like those of the ordinary elastic truss—that is to say, 
first, by an elastic belt around the ilia, with tips of inelastic 
webbing, which are looped around the bars, and buckled to 
the proper degree of tension ; and, second, by two perineal 
bands of rubber tubing, fastened behind to the belt by loops 
of inelastic webbing, and in front to the bars by metal hooks. 
The tube from the central opening is conducted to the bag of 
a rubber .day-urinal, which is strapped to the inside of one of 
the thighs. The air-cushion on the margin of the posterior 
surface of the plate, being held firmly against the abdominal 
wall around the stoma—but at a sufficient distance from its 
edges to avoid chafing—prevents the leakage of urine, all of 
the fluid being carried off by the conduit to the urinal. 6 
FRONT VIEW. 
PROFILE. 
A. The central aperture, surrounded by a collar for the support of the tube 
leading to the urinal. 
B, C. The bars for the webbing loops at the ends of the belt, and for the 
hooks of the perineal bands. 
D. The air-cushion at the margin of the back surface. 
E. The rim, convex in front, concave behind, for holding the air-cushion. 
An illustrative case will emphasize the description, and 
also show the utility of the operation for permanent drainage. 
On the 6th of October, 1891, I was called to see a gentle- 
man, sixty-nine years of age, who had suffered for several 
years on account of an enlarged prostate. For two years his 
health had been failing, and during the recent months the 
decline had been rapid. He was obliged to empty the bladder 
at least every hour, and often much more frequently—a pro- 
cedure impossible without the aid of a catheter, and atro- 
ciously painful with it. A prominent surgeon had seen him 
in consultation with the local practitioner, and advised noth- 
ing in addition to the usual medicinal treatment, except daily 
washing of the bladder with boric-acid solution. The urine 
was as thick as turbid coffee, which it resembled in color, 7 
being heavily loaded with blood. The hemorrhage was so 
profuse, the pain so severe, and both so constant, that, when 
I first saw the patient, it seemed that he could live but a 
week or a fortnight, unless speedy relief could be afforded 
him. The suprapubic operation was proposed, as being the 
least serious and most satisfactory measure which offered 
hope ; but the idea was rejected. A night of rapidly aug- 
mented agony, however, produced a change of opinion, and I 
was summoned to do whatever I thought best. 
On entering the bladder, the finger discovered two cal- 
culi, as large as good-sized filberts, and they were removed. 
The mucosa was soft and pulpy; the prostate was enor- 
mously hypertrophied. Prostatectomy was not attempted, in 
consideration of the perilous debility of the patient. The 
margins of the vesical opening were stitched to the skin, 
and the patient was put to bed, with a flexible siphon extend- 
ing from the cavity of the viscus to a vessel beside the bed. 
The siphon kept the patient almost perfectly dry, flow of 
urine over the surface of the abdomen being only occasional 
and slight. 
For several days some anodyne was needed, but in pro- 
gressively diminishing doses. The bleeding ceased in a few 
hours, and did not recur. In about two weeks the appliance 
here described was adjusted, and the patient was able to sit 
up with comfort. His strength quite rapidly increased, and 
he was soon able to walk with ease, and to attend to office 
business. On the 25th of December he was attacked by the 
then prevailing epidemic of influenza, and, after an illness of 
only three days, died. But the two months’ trial was a per- 8 
feet demonstration of the value of the apparatus, and I see no 
reason for doubting that it would have continued to give as 
excellent satisfaction indefinitely. 
The siphon employed, while the mucous and cutaneous 
membranes were growing together at the circumference of 
the opening, consisted merely of a piece of rubber tubing 
with two holes cut in the sides near the bladder end. This 
tube was filled with warm water, and its extremities placed 
respectively in the bladder and the chamber vessel. It has 
worked so nearly perfectly in my practice that I am at a 
loss to account for the failure of surgeons generally to adopt 
this simple and useful device, in the place of sopping up 
the outpouring urine with voluminous cloths of absorptive 
material, or permitting it to inundate the abdomen, and form 
a pool in which the patient must lie. It is often, perhaps 
generally, desirable to use the siphon, instead of the other 
apparatus, when the patient is in bed, thus relieving him of 
the dangers attending uninterrupted pressure of the plate 
and its retaining bands. 
Summary.—The operation of establishing an opening in 
the bladder above the symphysis pubis for the permanent 
drainage of that reservoir is occasionally desirable, and should 
be performed much more frequently than it is at present. 
The name “Suprapubic Cystostomy” briefly, but sufficiently, 
indicates the character and purpose of the operation. 
The employment of the flexible siphon during the healing 
of the wound and afterwards, when the patient is in bed, is 
preferable to other methods of caring for the urine. 9 
The use of an apparatus such as is here described enables 
the patient to attend to light work with comfort, and pre- 
vents the annoyance and suffering, which, without some such 
device, must inevitably follow this useful and sometimes life- 
saving operation. 10 
SUPPLEMENTARY NOTE. 
In the six months which have passed since this paper was 
presented to the American Surgical Association opportunities 
for further study of the subject have been afforded, with the 
result of strengthening the opinion that Cystostomy is worthy 
of an extensive trial in the cases for which it is especially 
recommended, namely, those of prostatic enlargement, in 
which the usual remedies fail to give relief. 
Prostatectomy, either complete or partial, will probably 
always be a procedure of great peril—to some extent on 
account of the age of the patients, in a higher degree because 
of their debility, but mostly from the almost invariable pre- 
sence of chronic cystitis, which keeps the freshly-made and 
somewhat extensive wound-surface drenched with peculiarly 
foul pus. Cystostomy is, in comparison, attended with little 
danger; and, while it does not do away with the hypertrophy 
of the prostate, it relieves the patient to a large extent of the 
direful consequences of that condition—the retention and 
decomposition of the urine, the pain of micturition, the 
inflammation of the bladder, the formation of stones, the 
frequent hemorrhage, and the constant and ever-increasing 
danger of renal involvement. 11 
In. mild cases of prostatic enlargement the practice of aseptic 
catheterization with antiseptic irrigation will continue to hold 
the place of honor. But, in an advanced stage, where the 
suffering is great and the general health seriously implicated, 
and particularly where the conventional treatment is unsatis- 
factory, nothing else seems to me to offer as hopeful a pros- 
pect of relief as Cystostomy, which affords a ready means of 
removing calculi and of washing out the bladder, cures the 
cystitis by putting the viscus entirely at rest, takes away the 
liability of extension of the inflammation to the kidneys, con- 
verts the urinary reservoir into a channel, and substitutes a 
condition, which, at its worst, is only a serious inconvenience, 
for one which incapacitates the patient for labor, makes his 
life a wretched burden, and finally kills him by inches with 
pain and exhaustion. 
The men who recover after complete prostatectomy are 
cured, for the reason that the cause of their trouble is re- 
moved ; while those who submit to Cystostomy are never 
free from annoyance, because the obstruction which origina- 
ted their difficulties still remains. But a large proportion of 
the patients on whom the former operation is performed 
perish in consequence of it; and very few die on account of 
the latter. It becomes, therefore, a question between a very 
hazardous procedure with entire relief, and a very safe one 
with relief which is not perfect. That Cystostomy will be 
the choice of the large majority of those to whom this alter- 
native is fairly presented appears to me highly probable.