SUPRAPUBIC CYSTOTOMY 
, FOR PURPOSES OTHER THAN 
THE EXTRACTION OF CALCULUS. 
BY\ 
JOHN H. PACKARD, A.M., M.D., 
SURGEON TO THS PENNSYLVANIA HOSPITAD AND TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
MAY II, 1887. 
PHILADELPHIA:' 
WILLIAM J. DORNAN, PRINTER, 
1887. SUPRAPUBIC CYSTOTOMY 
FOR PURPOSES OTHER THAN 
THE EXTRACTION OF CALCULUS. 
BY 
JOHN H. PACKARD, A.M., M.D., 
SURGEON TO THE PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
MAY II, 1887. 
PHILADELPHIA: 
WILLIAM J. DORNAN, PRINTER, 
1887. SUPRAPUBIC CYSTOTOMY FOR PURPOSES OTHER 
THAN THE EXTRACTION OF CALCULUS. 
BY JOHN H. PACKARD, A.M., M.D., 
SURGEON TO THE PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH'S HOSPITAL, 
PHILADELPHIA. 
So far as appears from the records, Nicholas Franco, of Lau- 
sanne, was the first surgeon who obtained access to the urinary- 
bladder by an incision made above the pubes. His operation 
was performed in 1560, for the removal of a calculus; and 
although it was successful, he is quoted as advising others not 
to follow his example. The history of the suprapubic section, 
for the three centuries and a quarter from that time to the 
present, is as curious as it is interesting. 
Soon after Franco's publication (in 1580), Rousset claimed 
to have discovered this method, in ignorance that any one had 
preceded him. Again, in 1719, it was rediscovered by Douglas, 
who, in turn, said he had known nothing of Rousset's invention. 
Douglas, somewhat extravagantly, says he " found innumerable 
instances, in authentic authors and army surgeons, of accidental 
wounds of the bladder being perfectly cured."1 Yet it does not 
seem to have occurred to him that access to the bladder by this 
route might be made available for any other purpose than the 
removal of stone. 
Proby, in 1700, had given an account of a case met with by 
him in 1694, in which he had extracted a bodkin from the blad- 
der of a young woman by incision above the pubes; but this was 
very analogous to a case of stone. 
1 Lithotomia Douglassiana, 1720. 4 
PACKARD, 
For whatever purpose intended, however, the suprapubic sec- 
tion of the bladder has been, until very recent times, regarded 
by most surgeons with a species of superstition, and my impres- 
sion is that in schools and by private instructors it has either 
been wholly passed over, or mentioned only with disfavor. Dur- 
ing my own pupilage at the University of Pennsylvania, from 
1850 to 1853, I do not think I ever heard any reference made to 
it; nor was my attention ever called to it as a thing to be done, 
until its performance in a case of stone by the late Dr. H. Lenox 
Hodge, extraction by the perineal wound having been found 
impossible. This was in 1874; the affair was much discussed 
by other surgeons of Philadelphia, and the procedure was 
generally condemned as a desperate and even foolhardy ven- 
ture. My opinion now is that it was eminently proper, and 
that the only mistake made was in not adopting it in the first 
instance. 
In November, 1883, I was called in consultation with Dr. 
Donnel Hughes in the case of a man who had a large piece 
(five inches long) of a shawl-pin in his bladder. I advised its 
removal through an opening above the pubes; and the ease of 
this operation, as well as of the after-treatment, and the prompt 
recovery of the patient, impressed me greatly. Since that time 
I have had occasion to reach the bladder by this route in a num- 
ber of cases, some of which will be presently detailed. This 
experience has led me to inquire into that of others, and my 
conviction now is that there is a weight of evidence in favor of 
such procedures, which must make it a matter of surprise that 
they are still looked upon so much askance by the great body 
of surgeons, and, indeed, are unknown to so many. That it is 
so, let me adduce two proofs : 
A writer in the British Medical Journal of January 2, 1886, 
asks for 
"The best way to use cocaine in a case of enlarged prostate, neces- 
sitating the use of the catheter nearly every hour. There are also great 
bearing-down pain and prolapse of the rectum. The patient is seventy- 
six years old. As he lives in the country, he will have to apply it 
himself. I would be thankful for any suggestion that would benefit SUPRAPUBIC CYSTOTOMY. 
5 
the patient, as he has had all the ordinary remedies, and nothing 
seems to have benefited him except morphine suppositories." 
Some very similar cases, wholly relieved by suprapubic sec- 
tion, will be presently given. 
Again, a deservedly prominent surgeon and teacher has lately 
expressed the opinion, after speaking of the perineal and supra- 
pubic sections into the bladder, that "extended experience alone 
will suffice to indicate clearly which should be regarded as pref- 
erable in the ordinary run of cases." He states further that the 
suprapubic operation has " disadvantages," but does not specify 
them. 
I do not wish to appear as an advocate of the suprapubic sec- 
tion as against all other methods of access to the bladder; but 
simply to discuss the question whether or not the objections 
which have prevailed to place it in the background, are shown 
by reason or by experience to be well founded. In so doing, it 
will be my endeavor to avoid bringing in the matter of hypo- 
gastric lithotomy, which has been so ably and so thoroughly 
handled by Dulles, of Philadelphia, and by others; but it will 
not be easy to leave it wholly aside. 
With regard to any proposed surgical procedure, the questions 
which must arise are : 
How far is it free from risk in itself? 
How fully does it effect the object in view? 
What are the difficulties attending its performance ? 
And in comparing any procedure with others having the same 
end, the same questions must arise, but in the comparative form: 
Is it more, or less safe ? 
Is it better calculated, or not so well, to effect the desired 
object ? 
Is it easier of performance, or more difficult ? 
In the present paper, as before said, my purpose is rather to 
inquire into the correctness of the prejudice, or neglect, under 
which the suprapubic section has been allowed to lie. I shall 
not undertake a comparison of this procedure with the other 6 
PACKARD, 
methods of entering the bladder, unless incidentally and in 
reference to certain points; the questions above stated will 
therefore be considered only in their first form. 
Now there are certain severe tests to which operative pro- 
cedures may sometimes be subjected. 
One is, the resort to them under very unfavorable circum- 
stances : as by the patient himself; by ignorant persons; by 
surgeons, with rude or inadequate appliances ; or when accident 
does roughly what the surgeon would do with care. If the 
results of such cases are found to be good, the fact constitutes 
a strong argument in favor of the value of any such procedure 
as a surgical resource. 
Another is, the resort to them in especially severe or difficult 
cases. A method or an operation, which in a great emergency 
is more available than those in common use, must have some- 
thing to recommend it when the stress is less urgent. 
The penetration of the bladder by the suprapubic route has 
been thus tested, according to the records. 
Carpue quotes from Rousset the history of a citizen of Orleans 
who, in 1560, was stabbed in the belly with a broad dagger; his 
urine for nineteen days and nights flowed through the wound, 
which healed easily after a catheter was passed through the 
urethra. 
Also the case of a man named Conrad, who, in 1558, had a 
ball shot into his body. It was extracted, with a quantity of 
calcareous matter; urine passed by the wound for twelve weeks. 
Also a wound of the bladder by a bull's horn, and another by 
a broad-sword ; both of which did well. 
Gross mentions the classical case of Jean de Dot, who, in the 
seventeenth century, cut himself in the linea alba, and extracted 
a stone the size of a hen's egg from his bladder. He also quotes 
rom Fodere a case in which a man " plunged a knife above the 
pubes into the viscus [bladder] to relieve a painful retention of 
urine. The peritoneum was not injured, and recovery ensued." 
(I did not succeed in finding this account in the only edition of 
Fodere to which I have had access.) SUPRAPUBIC CYSTOTOMY. 
7 
Treves and Sexton have each reported a case similar to the 
preceding; both occurred in sailors at sea, and no ill con- 
sequence ensued in either. 
As to the resort to suprapubic section in urgent cases, I need 
only mention here the many instances on record of the extrac- 
tion, by this method, of calculi too large for removal through 
the perineum; but shall have occasion later to cite other evi- 
dence of the kind, some of it from my own individual experi- 
ence. 
Permit me now to cite the opinions of authors as to the hypo- 
gastric operation in general, exclusive of its use as a method of 
lithotomy; then to see what the anatomists have to say about 
the region concerned; and next to test these views by the 
records of cases. I will then venture to state my own experi- 
ence ; and, finally, will offer some remarks upon the methods of 
procedure. 
To begin, then, with the opinions of surgical writers in regard 
to the suprapubic section, from the time when the first formal 
statement was made as to its employment in cases of retention 
of urine. Here, as well as in the subsequent citation of recorded 
cases, it has seemed to me best to follow a chronological order, 
and not to group the opinions or the experience as for or against 
the operation. Nor have I separated the different procedures- 
aspiration, puncture, or section. My object is to consider rather 
the route than the special method; to see whether peculiar 
dangers or difficulties attend the entrance into the bladder 
through the portion of its anterior wall uncovered by peri- 
toneum. 
Dionis, speaking of the high operation for stone, says : 
"I do not consider this operation so dangerous as one might 
imagine; on the contrary, I think it involves less risk than either the 
greater or the lesser apparatus; the duplicature of the peritoneum, in 
which the ancients placed the bladder, does not exist, as I have shown 
in my published Anatomy ; the bladder is situated outside of the peri- 
toneum, so that it can be opened without touching the membrane, or 
encroaching upon the cavity of the lower belly." 8 
PACKARD, 
Sharp, in 1761, was, as before mentioned, the first author of 
note, so far as I know, to speak of the suprapubic puncture for 
drawing off the urine. He says: 
" This method has been occasionally followed by some eminent 
surgeons for many years, and is still approved of, but it is not recom- 
mended as having those superior advantages which, in my opinion, 
belong to it. It is an operation of no difficulty to the surgeon, and 
of little pain to the patient, the violence done to the bladder being at 
a distance from the parts affected; it is equally applicable whether the 
disorder be in the urethra or the prostate gland." 
He then goes on to discuss the proper length of the canula 
to be left in the bladder, which he thinks should be two or two 
and a half inches; and the proper point for the puncture one 
and a half inches above the pubes. 
Lawrence Heister says: 
" Lastly, there is still another and most ready method of performing 
the operation according to the high operation, in which the trocar is 
passed into the anterior part of the bladder immediately above the 
juncture of the ossa pubis, where the incision is made for the stone in 
the high operation. Here the bodkin being extracted, and the urine 
discharged by the canula, the latter is to be secured in the wound by 
a bandage fastened round the body, that the urine may be retained or 
discharged at pleasure, until the cause of the suppression be removed ; 
after which the wound may be healed by the bals. capiv. covered with 
lint and a plaster. Though this operation is but seldom performed by 
surgeons in a suppression of urine, I must needs declare it, in my 
opinion, to be very necessary and convenient, where nothing extra- 
ordinary forbids, since it is also recommended by Rossetus, Riolan, 
and Tolet; and since it appears from anatomical experiments that the 
bladder may be thus safely perforated, when distended with wind or 
water, without incurring any dangerous symptoms. And accordingly 
we find it has been put in practice to a good purpose by Turbier, Mery, 
Douglas, and Middleton; which two last recommend this method of 
perforating the bladder to be more safe and easy than that in the peri- 
neum. We have an instance of the success of this operation given us 
by Werlhoff; but here the surgeon did not use the triangular bodkin 
or trocar. He first divided the integuments with a scalpel, and then SUPRAPUBIC CYSTOTOMY. 
9 
perforated the bladder near its neck with a large-sized lancet; after 
discharging the urine, he introduced a tube, and secured it in the 
wound for nine days. And thus the patient was happily cured. 
"When the cause of the disorder cannot be removed, in a person 
advanced in years, and when it proceeds from a callus formed from 
some fistula in the urethra, a scirrhus of the prostate, a large stone, a 
palsy of the bladder, or some other obstinate malady; in such cases 
the patient should constantly keep a silver pipe in his bladder as 
long as he lives, made with a valve and screw to open and shut, 
that his urine may not come away incessantly, but when the patient 
desires it." 
Frere Come, after discussing hypogastric lithotomy, speaks of 
puncture of the bladder for the evacuation of urine; he mentions 
the danger of wounding the opposite wall of the viscus, and re- 
commends a curved canula described in 1751, by the use of 
which, he states, several lives had been saved. It seems to 
have been a segment of an exact circle. 
A case in point is then given, which occurred in 1776. 
John Hunter, who died in 1793, spoke very favorably of the 
suprapubic puncture of the bladder, except where the patient is 
very fat, or the bladder greatly contracted. He does not refer 
to any dangers, but only to difficulty in the performance of the 
operation. 
Weldon, in 1793, speaking of the different methods of punc- 
turing the bladder, thinks that each one has its advantages. In 
the suprapubic, he regards the peritoneum as the only important 
structure endangered. He thinks that in corpulent subjects 
the bladder may not always be easily felt; and would prefer the 
anal operation if the natural passage is not likely to be easily 
restored. 
Dorsey, in 1813, speaks very highly of tapping the bladder 
above the pubes for retention, and quotes John Bell as saying 
that, as in strangulated hernia, delay is the greatest danger. 
Howship, in 1816, merely mentions the suprapubic proce- 
dure, and says the rectal is " infinitely superior to either of the 
other methods." 10 
PACKARD, 
Abernethy, in 1822, says: 
" All the experience I have had has tended to convince me that the- 
puncture above the os pubis is an innoxious and ready mode of dis- 
charging the urine when it cannot be discharged by the natural pas- 
sages. ' ' 
Sir Charles Bell, also in 1822, seems to think all the opera- 
tions equally good. 
Sir A. Cooper, in 1823, in a lecture, said that he had seen 
quite enough of the suprapubic operation, but gives no reason 
except that a Frenchman once exposed the intestine in per- 
forming it. 
In 1827, Ducamp describes this procedure as easily performed, 
attended with little pain, and preferable to either of the other 
methods of section. 
Segalas, in 1828, says that he had himself never yet found it 
" needful to adopt the extreme means, puncture of the bladder." 
But he gives the preference to the hypogastric method if any is- 
demanded. 
In 1832, Phillips says that the peritoneum is much more apt 
to be wounded in the recto-vesical operation, where we must 
trust to the finger as a guide, than in the suprapubic, where we 
have ocular demonstration. He says that in the latter method! 
there is less irritation, and that the canula causes less incon- 
venience ; and pronounces it " more certain, more easy, more 
convenient, and less dangerous." 
Amussat, in the same year, speaks very favorably of the 
method. 
Brodie agrees with the opinion of Weldon, before quoted. 
Guthrie, in 1834, positively objects to all forms of puncture; 
he says: 
" The operation above the pubes is dangerous, inasmuch as an ex- 
travasation of urine may readily take place after it, and lead to the 
formation of matter and other evils of serious magnitude; it should 
never, therefore, be had recourse to in cases of retention from stric- 
ture." SUPRAPUBIC CYSTOTOMY. 
11 
Parrish, in 1836, speaks very decidedly in favor of the tap- 
ping of the bladder above the pubes, from his own experience as 
well as from that of his preceptor, the eminent Dr. Caspar 
Wistar. Cases in their practice are elsewhere quoted. 
Malgaigne, in 1854, is said to have used these words : "punc- 
ture of the bladder is an operation as simple and as inno- 
cent as puncture of the peritoneum in ascites." The re- 
porter, M. Vangaver, quotes Malgaigne as especially in favor of 
puncture (suprapubic) in cases where the urethra is closed after 
instrumentation. 
Dr. F. H. Hamilton, in 1872, after describing the suprapubic 
operation, says: 
" The operation through the rectum is more easily performed and is 
comparatively safe, and ought always to be preferred unless some con- 
dition of the rectum or of the prostate should seem to render it unsuit- 
able." 
Gouley, in 1873, speaking of the suprapubic puncture, says: 
" This mode of relieving retention of urine has proved very efficient,- 
by giving time for the subsidence of congestive swelling in the prostate 
and in the vicinity of strictures of the urethra, so that in a few days 
the canal has become pervious to instruments. The punctures have 
healed readily in all the reported cases, and perforation of the perito- 
neum, and even of a loop of intestine, has not been followed by any 
untoward result." 
Gross, in 1876, says : 
" Puncture of the bladder above the pubes has generally been re- 
garded as even more objectionable than by any other route, not be- 
cause of any particular difficulty in the operation, but because of its 
greater liability, as has been conjectured, to be followed by an escape 
of urine into the peritoneal cavity and the surrounding connective 
tissue. Both events are to be dreaded, especially the former, which is 
almost certainly fatal in from thirty-six to forty-eight hours from its 
occurrence." 
He goes on to say that it is indicated " in cases in which an 
artificial outlet for the urine is desirable for a long period." 12 
PACKARD, 
" When the obstruction to micturition is complete, and the capacity 
of the bladder is greatly diminished, so that a resort to the catheter 
becomes necessary nearly every hour, rendering the condition of the 
patient one of extreme misery, with rapid failure of the strength, the 
permanent retention of a tube in the bladder above the pubes may be 
advisable to avert impending death. An opportunity is thus afforded 
to the water to drain off almost as fast as it is secreted, and the blad- 
der, placed in an easy, quiet state, is prevented from constantly con- 
tracting on its contents." 
Bryant, in 1879, expresses the opinion that in safety and effi- 
ciency the suprapubic puncture is not to be compared with that 
by the rectum. In his last edition (1885), however, he says that 
in cases of tumor the section above the pubes may be preferable 
in some cases, as " when the growth is at the fundus, or very 
large." 
Teevan, in 1880, says that the special risk of the hypogastric 
puncture is urinary infiltration, causing peritonitis. 
Mr. T. Smith, in 1881, speaks very favorably of the operation, 
from a large experience with it. His cases I have quoted else- 
where in this paper. 
Spence, in 1882, says: "The operation is not a satisfactory 
one; it is attended with some danger, and there are few who 
would consider it comfortable to be compelled to micturate 
through the front of the abdomen." He thinks a catheter can 
always be passed, by care and perseverance. 
Sir H. Thompson, in 1883, after describing several modes of 
opening the bladder by the suprapubic route, expressed the 
opinion that the perineal opening " bids fair to be on the whole 
more useful, and more generally available in most of the in- 
stances in which efficient surgical relief is demanded." 
Mr. Edmund Owen, in 1885, says with reference to the opera- 
tions for stone in children : 
" If a young surgeon did not consider himself competent to under- 
take the ordinary English operation (lateral lithotomy), he could 
hardly be trusted to resort to the high operation, even with protection 
of spray and gauze. ' ' SUPRAPUBIC CYSTOTOMY. 
13 
This expression would seem to indicate that the writer looked 
upon the suprapubic section as the more difficult procedure of 
the two; an opinion which can scarcely have been based upon 
practical experience in this matter. 
M. Drouineau, at the French Surgical Congress in the same 
year, is reported to have said : 
11 In cases of retention of urine complicated by false passage, hypo- 
gastric puncture of the bladder should be done immediately, in prefer- 
ence to recto-vesical puncture. In two cases I have subsequently 
had no difficulty in catheterism. In certain troublesome cases, one 
might then practise hypogastric puncture first, and afterward catheter- 
ism, rendered thereby easier." 
Erichsen, in 1885, says that the suprapubic operation can very 
seldom be required in enlarged prostate ; but in speaking of 
stricture he refers to it as " undoubtedly easy of performance, 
and sufficiently safe, though not free from the danger of infiltra- 
tion of urine into the tissues around the puncture, and the incon- 
venience of a fistula being left." 
Kapteijn, a Dutch surgeon, is quoted in the Lancet, in 1885, 
as advocating suprapubic aspiration in cases of retention. 
In 1886, Professor Chiene says that in retention of urine from 
the superaddition of acute inflammation with spasm to an old 
organic stricture, 
11 If after a fair trial with instruments he [the surgeon] fails to re- 
lieve the retention, he should aspirate above the pubes, continue the 
use of fomentations and sedatives, and on the following day he will 
find either that the retention is relieved, or that he is now able to pass 
an instrument along the urethra into the bladder." 
But he says further: " Repeated aspirations in bad cases of 
stricture with retention are not, however, to be recommended." 
In such cases he regards perineal section as preferable. 
Professor J. Greig Smith, speaking of the exploration of the 
bladder, and the removal of tumors, etc., says that he is con- 
vinced by his experience 
" that in the matters of affording greater facility in diagnosis, more 
freedom in operating, and fuller potentiality of extending the opera- 14 
PACKARD, 
tion to removal of portions of the bladder, the suprapubic is by far the 
superior surgical method." 
Professor Konig, at the Fifteenth Congress of the German 
Society of Surgery, in 1886, expressed an opinion, which I may 
be allowed to quote here, although he referred to cases of cal- 
culus only: 
"With regard to the high and perineal operations for removal of 
stone, it is stated that, whilst the risks of bleeding in the two pro- 
cedures are about equal, the latter is almost quite free from danger to 
life, whilst the former, both from its anatomical conditions and from 
the risk of septic phlegmon of the anterior abdominal wall, is by no 
means a safe operation." 
Mr. G. Buckston Browne, in a recent communication, refers 
to his statement in Heath's Dictionary of Surgery y that " fatal 
extravasation and abscess have been known to follow a second 
aspiration," and mentions Treves's case, reported in 1880. He 
■thinks repeated aspiration bad; but would substitute puncture 
with a trocar and canula, the latter to remain. He thinks aspi- 
ration would certainly be bad in the case of a " rotten" bladder. 
I desire next to ask your attention to the expressed views of 
leading authorities as to the anatomy of the hypogastric region, 
as concerned in this operation. And I may remark that it is 
,one of the evidences of the slight heed paid to everyday things, 
•that, although these parts are continually exposed, and even 
.examined in autopsies, there is little exact knowledge of them. 
The essential point of this inquiry is, of course, the relation 
of the peritoneum to the bladder-wall and to the parietes of the 
abdomen. If the risk of wounding the peritoneum is real and 
constant, it is not, even in these days of abdominal surgery, to 
be lightly encountered. 
By way of further proof that such an inquiry is not super- 
fluous, let me state that in the fifth edition of the well-known 
,and elaborate System of Practical Surgery, of the late Sir W. 
Fergusson, there are two cuts, made by one of the most accom- 
plished of anatomical artists. In one (Fig. 425, p. 689) the SUPRAPUBIC CYSTOTOMY. 
15 
•suprapubic portion of the bladder is represented as affording 
abundant room for puncture or incision between the symphysis 
and the reflection of the peritoneum. In the other (Fig. 459, 
p. 728), where the bladder is supposed to be equally distended, 
the reflection of peritoneum is represented as almost in contact 
with the symphysis. 
French anatomists have paid more attention to this matter 
than have those of any other country; and their views will 
appear from the following extracts : 
Malgaigne {Anat. Chir., tome ii. p. 477) says that when the 
bladder is full, 
" it rises up largely above the symphysis pubis, and applies itself 
against the anterior wall of the abdomen, pushing the peritoneum 
upward, an essential circumstance upon which are based hypogastric 
cystotomy and lithotomy. But, which it is not less essential to say, 
in proportion as the bladder rises, its fundus departs from the abdom- 
inal wall, and between the two there descends a fold of peritoneum 
which it is important to avoid wounding. Many surgeons, misled by 
the commonly received notion that the peritoneum never descends 
upon the anterior face of the bladder, imagine that it is sufficient to 
stretch this wall by means of the sonde-a-dard, or ordinary sound, to 
divide if safely. Nothing is more imprudent than such a course ; and 
in a recent concours, in which hypogastric lithotomy had to be prac- 
tised on the dead subject, most of the candidates, trusting to the sound, 
wounded the peritoneum. Fr^re Come, and Souberbielle, great 
lovers of the sound, added, however, a precaution infinitely more 
valuable, which, for my part, I hold to insure safety; it consists in 
carrying the finger along the anterior face of the bladder, and curving 
it, to push upward the fold of peritoneum, which is only connected 
with the bladder by loose and easily torn cellular tissue." 
Tillaux {Traite d'Anatomic Topographique, p. 841) discusses 
the whole question with his usual clearness and vigor. He 
dwells particularly on the importance of what he calls the 
" antevesical cavity," the mass of loose areolar tissue in front 
of the bladder, between it and the symphysis, and then goes 
on as follows: 
"What is the relation of the peritoneum to the anterior face of the 
bladder? 16 
PACKARD, 
"Let it be remembered that the urachus is fixed to the apex of the 
bladder, and that when the organ is empty, the peritoneum, reflected 
over this cord, passes directly over the posterior face of the bladder, 
in such a way that the anterior face is completely bare of it. It is 
generally taught that the bladder, in mounting up in the abdomen, 
pushes the peritoneum up above it, and comes to put itself in its whole 
altitude directly in contact by its anterior face with the abdominal 
wall, no serous membrane intervening between them. 
" Several anatomists, Malgaigne in particular, have contested this 
view, but M. Sappey, above all, has shown the incorrectness of this 
description. He has demonstrated that a portion of the anterior face 
of the distended bladder is covered by peritoneum; he has also 
pointed out that the bladder becomes distended mainly at the expense 
of its posterior face, and that it there undergoes a tipping movement, 
by which its apex is inclined forward. 
"These are the exact facts: As the bladder rises, it does form a 
cul-de-sac of peritoneum between its anterior face and the abdominal 
wall; but I [Tillaux] cannot admit the mechanism ascribed to it by 
Sappey, and still less the deductions he draws in regard to operative 
measures. 
" M. Sappey says : ' The peritoneum descends on the anterior face 
of the viscus in pushing back (rabattanf) the urachus against this, and 
it descends the more as the dilatation becomes more marked ;' and 
further, ' such is the mechanism in virtue of which the peritoneum 
drops between the abdominal wall and the bladder.' 
"No, the peritoneum does not descend; on the contrary, it rises. 
In swelling upward, the bladder carries with it the portion of perito- 
neum situated just above the pubes. In proportion as the bladder 
expands, its summit widens, so as to offer almost a superior face ; and 
the part of the bladder situated in front of the urachus covers itself 
with this portion of the peritoneum detached from the abdominal wall ; 
the more the bladder expands, the more peritoneum there is detached 
from the abdominal wall, and the more of the bladder covered with it. 
When M. Sappey says, ' the cul-de-sac descends lower in proportion 
as the dilatation becomes more considerable,' the fact is so, but it is 
equally true that the height to which the bladder is stripped of peri- 
toneum depends on {est en raison de) the depth of the cul-de-sac, since 
the portion which forms the cul-de-sac is precisely that which has been 
detached from the abdominal wall. From reading M. Sappey it would 
seem that the more the bladder is distended the less room there is to SUPRAPUBIC CYSTOTOMY. 
17 
penetrate into its cavity, since the more the peritoneum comes down. 
Now this is not correct; I repeat, the portion of peritoneum which 
invests the anterior wall of the distended bladder is no other than that 
which lined the anterior wall of the abdomen before the distention, as 
may be thus proved : measure the distance between the pubes and the 
peritoneal cul-de-sac, and that between the cul-de-sac and the apex of 
the bladder-that is to say, the insertion of the urachus-the distance 
is the same, and cannot be otherwise. Then the space uncovered by 
peritoneum is so much the larger as the cul-de-sac is deeper-that is, 
as the bladder is more distended. The peritoneum plays no active 
part in the distention of the bladder-does not descend-its role is 
purely passive ; the bladder crowds upward, and is but partly covered." 
Cruveilhier and Richet only briefly refer to the fact of the 
accessibility of the bladder above the pubes. 
Bourgeryand Jacob, in their splendid work, Traite Completde 
rAnatamie de V Homme, tome v., Pl. 55, Figs. 10 and 12, repre- 
sent the peritoneum as covering all except a very small portion 
of the anterior surface of the bladder. 
The subject is entered upon more at length by Jarjavay, who 
(Traite d'Anat. Chir., tome ii. p. 588) speaks of the loose 
cellular tissue which permits of distention as the bladder is 
full; but says that when from chronic inflammation lymph 
has been effused in its meshes, it is no longer distensible. 
" M. Petrequin, who has established this point by clinical as well as 
post-mortem observations, advises for this reason that the hypogastric 
puncture should be made immediately above the pubes. This practice 
differs from that prescribed by most authors, according to whom the 
place of election is at a distance of four centimetres (Malgaigne), of 
twenty-seven millimetres (Velpeau and Coster) above this bone. The 
danger of wounding the peritoneum justifies the counsel of the Lyons 
surgeon, in cases in which adhesions have engaged the bladder and 
prevented its upward development; but when the viscus is free, there 
exists between it and the symphysis a cellular interval where the trocar 
might go astray and pass into the pelvis without encountering the 
vesical wall. Thus, in the majority of cases, puncture at twenty-seven 
millimetres above the pelvic brim is preferable. 
" We have several times had occasion to remark that the anterior 
2 18 
PACKARD, 
face of the bladder is without peritoneal covering; and on this ana- 
tomical arrangement are based hypogastric puncture and lithotomy. 
Yet it has happened that the serous membrane has been wounded as 
the bistoury was carried upward toward the upper part of the bladder. 
"The gravity of this accident has certainly been overestimated. 
What renders it formidable is much more the effusion of urine into the 
serous cavity than the entrance of air. Now, upon contraction of the 
bladder, the two wounds-that in the anterior wall of the bladder and 
that in the peritoneum-no longer correspond, and, hence, effusion of 
urine into the serous cavity is less easily produced. According to 
Velpeau, Douglas, Thornhill, Frere Come, Souberbielle, Crozat, and 
Leonardon, each had the misfortune to wound the peritoneum, yet 
their patients made perfect recoveries. The employment of the sonde 
a dard, and the making the incision from above downward, may, to a 
certain extent, guard against this accident." 
This author in another work (Recherches Anat, sur I'u^etre de 
T Homme} gives three plates of sections of frozen bodies, and 
in them the peritoneum is represented as actually in contact 
with the symphysis pubis. The bladder is in each case con- 
tracted ; in plates vi. and vii. very much so, and its walls very 
thick. 
In the Philadelphia Medical Times of May 31, 1884, a report 
is quoted from the London Medical Record, of a discussion on 
the anatomy of the hypogastric region, the subject having come 
up apropos of a suprapubic lithotomy performed by Despres. 
This gentleman regarded the pyramidalis muscles as important 
landmarks, whereas MM. See and Bouley thought they varied 
in size and situation. 
"As to the relations of the prevesical cul-de-sac of the peritoneum 
to the upper border of the symphysis pubis, a careful dissection of 
thirteen bodies had led M. Bouley to the following conclusions: 
When the apex of the bladder is situated nine to thirteen centimetres 
higher than the symphysis, the height of the peritoneal fold above the 
same point can be found by deducting four centimetres from those 
numbers. When the bladder reaches five to nine centimetres above 
the symphysis pubis, three centimetres must be deducted. It is, how- 
ever, essential to remember that the peritoneal fold stands relatively SUPRAPUBIC CYSTOTOMY. 
19 
higher in fat than in thin people. M. Bouley has also repeated the 
experiments of Petersen, who had the idea of raising the peritoneal 
cul-de-sac above the symphysis by means of an India-rubber ball intro- 
duced into the rectum and distended by water; this process seems to 
answer well, especially in fat people. It is necessary to inject 400 to 
600 grammes (about one pint) of water." 
This estimate is for many cases too high. 
Holden {Landmarks, Medical and Surgical, p. 31) says that 
" With a bladder distended half way up to the umbilicus, there is a 
space of nearly two inches above the symphysis where the bladder may 
be tapped without risk of injury to the peritoneum." 
So far, the evidence of anatomy has been favorable. But the 
conditions are not always the same. They are, of course, well 
known to vary with age. Thus in children the bladder rises 
above the pubis, and is an abdominal rather than a pelvic organ ; 
while with later development the bony framework grows much 
more massive, and the bladder drops down behind it, so as to 
occupy the anterior part of the pelvis, and only to appear above 
the pubis when considerably distended. 
In a leading article in the Lancet for January 30, 1886, it is 
stated that 
" M. Polaillon recently showed at the Soc. de Chir. the urinary organs 
of a calculous patient, upon whom he had unsuccessfully attempted 
suprapubic lithotomy. The bladder was distended by an injection of 
150 grammes of fluid, and the rectum was distended in the usual 
manner-yet the peritoneum was found to extend over the bladder 
quite down to the pubes. He verified this by making an incision into 
the serous sac, through which he introduced his finger and exactly 
traced the reflection of the peritoneum. The wound was sewed up. 
The wound healed, and several months later the patient died of pyelo- 
nephritis. At the necropsy the bladder was found to be hypertrophied 
and contracted, fitting closely around a stone measuring in circumfer- 
ence four centimetres by two. The peritoneum passed quite down to 
the pubes. Ureters dilated." PACKARD, 
20 
It would obviously be a very awkward thing to attempt the 
tapping of a bladder so covered. I cannot but think, however, 
that the condition of things here mentioned was the result of 
some pathological change. Certainly it was altogether excep- 
tional; but the possibility of its occurrence should be borne in 
mind. 
Let us now look at the records of experience in the perform- 
ance of suprapubic operations. It is very possible, I must 
admit, that many cases of this kind may have occurred which 
have not been published; and if so, it is highly probable that 
among these unreported instances a large number were failures. 
For unfortunately, surgeons are too apt to let the world know 
of their triumphs, while they say nothing about their ill-suc- 
cesses. Yet it has seemed to me fair to present what records 
there are, and to draw from them such inferences as they seem 
to warrant. The length of time over which these experiences 
have extended was to me a matter of considerable surprise. 
1725. Daniel Turner, in his chapter on " Wounds of the Blad- 
der," speaks with high praise of the suprapubic section for 
stone, as performed by friends of his at St. Bartholomew's Hos- 
pital. He says: 
" I have been witness of the large solutions of continuity this part of 
the bladder undergoes; yet, by help of a medium furnished by its 
sides, after digestion, together with that from the superincumbent parts, 
the same in little time consolidates, and is perfectly agglutinated." 
He then cites three cases of accidental wounds of the bladder, 
successfully treated; and quotes in full the well-known and 
curious account of the operation done by Probyn, in 1694, for 
the removal of an ivory bodkin from the bladder of a girl. In 
this case the incision is stated to have been made at the outer 
side of the rectus muscle. 
Dionis, who was certainly one of the best informed and most 
intelligent writers of the last century, goes very fully into the 
subject of the treatment of retention of urine, and describes the SUPRAPUBIC CYSTOTOMY. 
21 
perineal operation ; but does not even hint at the possibility of 
affording relief by puncture or section above the pubis. Yet he 
gives a most excellent account of the high operation for stone. 
1761. Sharp had evidently been practically familiar with the 
suprapubic operation for the relief of retention of urine, which 
he says had " been occasionally followed by some eminent sur- 
geons for many years, and was still approved of; " but the only 
instance he mentions is one in which a trocar of too great length 
had wounded the rectum. 
176 8. Heister cites the experience of Turbier, Mery, Douglas, 
Middleton, and Werlhoff, but gives special mention to only one 
case, a successful one, in the practice of the last-named surgeon. 
He distinctly asserts that they had all obtained favorable results 
from the procedure. 
1775. James Lucas made a suprapubic puncture in the case 
of a man aged thirty, who seventeen days previously had re- 
ceived an injury to the perineum, followed by abscess. Recovery 
took place, but a year later the man had still a perineal fistula. 
1776. Frere Come operated with great success upon a gen- 
tleman who had, for twelve years, suffered severely from the 
effects of traumatic stricture; the patient himself wrote the ac- 
count of his case fourteen months after the cure was accom- 
plished. 
1788. Sir E. Home gives details of a casein which he assisted 
John Hunter in performing suprapubic puncture in a man aged 
thirty, strictured for nine years. Cellulitis ensued, and there 
was a suspicion of peritonitis. On the removal of the tube from 
the bladder, at the end of forty days, it brought with it a slough, 
which was followed by nearly a pint of pus. Several abscesses 
formed, and sloughs came away, but in thirteen weeks the man 
was well, and continued so fifteen years afterward. 
1789. Francis Turner treated a boy aged three, for retention 
of urine from obscure cause. Puncture above the pubes was 
resorted to on the third day, and again on the fifth, when the 
canula was left in place. On the eleventh day urine passed by 
the urethra, and on the thirteenth the canula was withdrawn. 
An abscess afterward formed in the scrotum. Two and a half 22 
PACKARD, 
months later, the general health began to fail, and death ensued 
in about four weeks. An obscure account is given of a tumor 
found at the autopsy. 
1790. Cheston recorded a case of retroversion of the pregnant 
uterus obstructing urination, in which relief was obtained by a 
suprapubic opening. He refers, in a note, to another case in 
which the uterus was punctured by too long a trocar, with fatal 
result. 
1793. Noel reports three cases, of men aged sixty, sixty-six, 
and sixty-seven, respectively ; in the first there was on the eighth 
day "suppurative gangrene" of the perineum and scrotum. On 
the removal of the canula the wound healed. 
The third case is remarkable, in that the surgeon states that 
the canula was changed every tenth or twelfth day. He had in 
other cases feared to do this, because he believed 
" That the bladder, in emptying itself, would leave the inner wall of 
the hypogastric region to go down again into the pelvis, and that in 
consequence of this displacement the opening made in the bladder 
would no longer correspond with the outer wound, which would not 
only render the reintroduction of the catheter almost impossible, but 
would moreover subject the patient to the danger of infiltration of 
urine." 
1804. Pascal Baseilhac (nephew of Frere Come), in a work 
published in defence of his uncle's views, asserts that supra- 
pubic puncture of the bladder had been very frequently resorted 
to, not only by Frere Come, but by himself, by Souberbielle, 
and by their pupil, M. Pot; and gives several cases, in one of 
which the patient was eighty-two years of age. 
1813. Dorsey records a very favorable case. 
1814. Vise, another very favorable case. 
1819. Carpue, after a very brief description of the suprapubic 
puncture, says: 
" My first objection to this operation is, that the urine is not evacu- 
ated from the bottom of the bladder. I remember, in a case where a 
common trocar was used, I dissected the parts; the bladder fell on the 
sharp edge of the trocar; this produced inflammation of the bladder SUPRAPUBIC CYSTOTOMY. 
23 
and peritoneum, which occasioned the death of the patient. In 
another case, a gentleman plunged a trocar through the linea alba; 
not any water followed. He passed a probe through the canula; he 
declared there was no urine in the bladder. The symptoms continued. 
The attendant surgeon was of the opinion that there was water. The 
patient died. The gentlemen examined the body; the bladder had 
burst. In truth, the trocar had pushed the bladder from its connec- 
tion with the posterior part of the pubes, where it is slightly attached." 
It seems to me that the unfairness of thus condemning an 
operation because of gross blunders in its performance, needs 
scarcely to be insisted upon; it is strikingly incongruous with 
the excellence of Mr. Carpue's book as a whole, and the more 
remarkable since he was a strong advocate of the high operation 
for stone. 
1824. Gibson performed the high operation for stone, he 
thought, for the first time in this country. The patient lost his 
life, it would seem, through his own imprudence, a few days 
later. 
1827. Lawrence is reported by Fereday to have twice tapped 
the bladder in the same man, for retention. The account given 
is not full or satisfactory. 
1828. Parrish opened the bladder above the pubes after the 
failure of two attempts at rectal puncture, in the case of a man 
aged thirty-five, with injury of the perineum and scrotum. The 
relief given was immediate and complete; but a few days later 
the scrotum sloughed, bedsores formed, and death finally took 
place from hectic. 
He relates also the case of an old gentleman, treated by his 
preceptor Dr. Wistar, for enlarged prostate, in whom a gold 
tube was introduced through a suprapubic opening, and worn 
for two years. The patient was completely relieved, so as even 
to ride on horseback. Thinking himself cured, he removed 
the tube; the symptoms recurred and he died. 
1837. S. Oliver operated with success on a woman aged 
thirty-five. The account given is obscure. 
Betton reported a case of rupture of the urethra by trauma- 
tism, in which suprapubic tapping of the bladder gave great 24 
PACKARD, 
relief, but on the seventh day the patient died, it is stated, " from 
mere exhaustion and debility." At the autopsy " the mem- 
branous portion of the urethra was found lacerated for about the 
space of two and a half inches; a great deal of blood effused in 
the cellular tissue of the perineum." Free incisions in the latter 
region would probably have saved the man's life. 
18 39. Velpeau mentions a case in which he practised supra- 
pubic puncture twice in three days. The patient died of peri- 
tonitis on the sixth day, and a small blackish spot was found in 
the hypogastrium in front of the bladder. 
Yet he quotes a case in which the operation was twice done 
in the same patient; in 1828 by M. Vaust, and in 1834 by M. 
Voltem. The man wore a rubber tube, and had no trouble. 
He quotes also from M. Nick the case of a man aged seventy- 
two, on whom hypogastric puncture was performed for an 
ischuria. The patient wore a canula until he died, a period of 
twelve years. 
1841. Toogood published an account of a case of enlarged 
prostate, with retention of urine for four days; suprapubic punc- 
ture gave relief; the wound was carefully closed at once, and 
healed. About a year later, the irritation of a calculus in the 
bladder gave rise to fatal peritonitis. 
1842. Macilwain operated on a man aged sixty-seven, for 
retention due to enlarged prostate. The patient was the subject 
of double inguinal hernia. There was no difficulty in the opera- 
tion, which gave relief; but the patient died of exhaustion in 
forty-eight hours. 
1844. Heylaerts reported a favorable case. 
Chassaignac performed suprapubic section in a man aged 
sixty-four, who had had several previous attacks of retention 
from stricture. Urination was thereafter performed by the 
hypogastric opening. 
In connection with this case Chassaignac proposed extraduc- 
tion of a catheter, or as he calls it retro-urethral catheterization. 
The idea was strongly advocated, he says, by Rognetta, in the 
Annalcs de Therapeutique et de Toxicologic for October, 1844. It 
has been promulgated by Brainard and others, but has never, I SUPRAPUBIC CYSTOTOMY. 
25 
think, been fully appreciated by surgeons, or duly noticed by 
authors. 
1848. Syme reported a very favorable case in which this pro- 
cedure was resorted to, on the fourth day, after rupture of the 
urethra, in a youth. 
Brown recorded a case operated on by Mr. Luke; a man, 
aged fifty-four, strictured thirty-four years. A canula was in- 
serted, and retained for one hundred and sixty-two days, when 
a cure had been effected by catheterization. 
1849. Brainard published a case which deserves special men- 
tion. The man had suffered from gonorrhoea and gleet for 
eleven years. On the 8th of December, 1848, he was tapped, 
and a long canula left in. On the 9th of February following, a 
bougie was passed through the bladder forward into the urethra, 
and the stricture thus dilated. The canula was withdrawn 
March 4th. 
I believe this was the first recorded instance in this country, 
of this excellent mode of practice. Chassaignac's case has 
been already noted.1 
185 0. Gisborne gives a case of distention and partial paral- 
ysis of the bladder from enlarged prostate, in a man aged 
sixty. Suprapubic puncture was resorted to with success. 
Wakley operated in a case of retention from injury in a child 
aged twenty months. The canula was kept in for three days, 
when catheterization was found to be easy, and in eight days 
the child was discharged cured. 
1851. Manson operated on a mulatto man aged thirty, crushed 
under timber. The bladder was paralyzed; for some unexplained 
1 In a leading article in the Med. Times and Gazette of July 15, 1876, mention is 
made of the fact that Volkmann had performed " posterior catheterization " in a boy 
aged six and three-quarters years, for the relief of rupture of the urethra; and it is 
claimed that the procedure had been adopted by Hunter, and by Verguin in another 
case of rupture of the urethra. In a later number, September 30th, Ranke claims 
to be "the experimenter in regard to this operation;" but he also says that Ver- 
guin's case was reported thirty years before the publication of Hunter's work on 
Syphilis. Neither Chassaignac's nor Brainard's case seems to have been known 
to the writer of the article, or to Volkmann and Ranke. 26 
PACKARD, 
reason a catheter could not be passed. A tube was kept in about 
one month. 
Monod reported a case in which, suprapubic puncture for re- 
tention being performed, the middle lobe of the prostate was 
wounded by the trocar. 
1852. Maund employed this procedure in a case which proved 
fatal from rupture of the kidney. 
1854. Waddell reported the case of a man aged seventy, with 
old stricture. Rectal puncture was tried unsuccessfully, and then 
a suprapubic opening was made, and a silver tube inserted en per- 
manence. 
Williams, in the case of a man aged thirty-two, with stricture 
and a ruptured urethra, made a suprapubic section with a view 
to the extraduction of a catheter. Failing in this attempt, forced 
catheterization was resorted to. A slough came away, and the 
suprapubic wound closed by the twenty-seventh day. 
18 56. Cazenave reported a similar case. 
Van Buren was called upon to treat a man aged thirty-five, of 
very bad habits. He had been strictured for six or eight years, 
and had been twice subjected to perineal section, and twice to 
suprapubic puncture; he had also a large hernia. The opening 
above the pubes was renewed with a trocar. Death ensued from 
peritonitis, ascribed partly to extravasation of urine. 
Lacroix gives the history of two successful cases in his prac- 
tice in 1853, and refers to others. 
Fox reported the case of a boy aged thirteen, with injury to 
the perineum. Suprapubic puncture (section ?) was done on the 
fifth day, and seven days later, the extraduction of a bougie. 
Nine days after this, an abscess burst between the bladder and 
the rectum ; a perineal opening ensued from sloughing, but the 
boy recovered with only a large cicatrix. 
1858. Nelaton spoke of suprapubic puncture as the method 
most frequently adopted in retention of urine; recommending a 
trocar and canula, the latter to be retained in place by tapes. 
1859. Norman reported the case of an elderly man with en- 
larged prostate, in whom, after suprapubic puncture, the wound 
cicatrized around the catheter, which was withdrawn. The man SUPRAPUBIC CYSTOTOMY. 
27 
used a bit of bougie as a plug, and occasionally drew off his water 
with a female catheter. He lived several years. 
Mr. Thomas Paget, after mentioning four cases, says of supra- 
pubic section for retention: " This operation I have seen and, 
practised for fully forty-five years." 
1859-60. Mr. Sloan reports a case of fracture of the pelvis 
and rupture of the urethra, in which suprapubic tapping was 
done, but death from peritonitis occurred on the fourth day. 
1861. Norton records a successful case in a child. 
1862. Chassaniol reports a case in which he resorted to 
suprapubic tapping twice, at an interval of seven years. Two 
months after the second operation the man died, " of gradual 
absorption of urine." Is it not likely that there was disease of 
the kidneys, and failure of their function ? 
1863. Gason published an account of a managed sixty-eight, 
who had for twelve hours been subjected to attempts at cathe- 
terization ; false passages had been made, and much damage 
done. He died about thirty-six hours after suprapubic tapping, 
probably of secondary shock. There was sloughing, and per- 
haps pyaemic peritonitis. 
1866. Callender gave the history of a man aged twenty-six, 
with retention from stricture. He had had gonorrhoea for over 
seven years. Suprapubic puncture was performed March i8th, 
and an elastic catheter kept in the wound. All went well until 
April 20th, when diffuse suppurative inflammation of the scrotum 
began, and was treated by free incisions. A silver canula was 
now substituted for the elastic one, and was left in for three 
weeks. It became encrusted, and the opening had to be en- 
larged. Sinuses had formed. October 2/th, extraduction of a 
catheter was practised, a straight instrument was passed by the 
meatus, and the two were joined by dissection. After this the 
case was treated like an ordinary perineal section. Some cal- 
culi were extracted through the suprapubic opening, which soon 
closed afterward. 
According to Keyes, "Maisonneuve was in the habit of punc- 
turing bladders in this manner, with an ordinary fine trocar, at 
the Hotel Dieu, Paris." 28 
PACKARD, 
18 67. Mackie operated on a man aged forty, who had had 
for thirty hours retention from stricture. A gum catheter was 
left in the bladder for forty-eight hours. On the second day 
urine passed by the natural route. 
1870. Hulke, in the case of a man aged forty-two, found the 
suprapubic puncture very difficult on account of the patient's 
obesity, which was thought to preclude perineal access to the 
bladder. The trocar and canula penetrated two and one-half 
inches of fat. The canula was removed on the ninth day. 
Draper reported the case of a man aged sixty-five, with en- 
larged prostate, in whom puncture, with the retention of an 
elastic tube, gave entire relief: death, however, occurred from 
exhaustion a week later. 
1871. Sexton reports the remarkable case of a sailor who, 
while at sea, and suffering from retention, relieved himself by 
puncturing his own bladder above the pubes with a knife. 
Calhoun saw at Langenbeck's clinic at Berlin a case of reten- 
tion from enlarged prostate, in a man aged sixty-eight, in which 
suprapubic puncture was resorted to with perfect success. 
1872. Stevens performed suprapubic aspiration upon a young 
Bengalee, for retention ; next day the catheter was used, and 
later the stricture was cured by Holt's method. 
A notable case was recorded by Sewall in the same year. A 
man aged seventy-two had retention for thirty-six hours, from 
stricture. Suprapubic section was performed, and a gum- 
catheter inserted; at the end of four days this was replaced by 
a silver tube, which was worn for ten weeks. The wound 
healed in three days after this tube was removed. Eight 
months later the patient caught cold, and suffered from reten- 
tion again; another puncture was made, and the tube worn 
three or four weeks, when the cure was complete. 
18 73. Whittaker reported the case of a lad of eighteen, with 
rupture of the urethra; suprapubic aspiration was done, and re- 
covery ensued. 
Loomis reported the case of a man aged seventy-one, with 
retention from enlarged prostate, for which suprapubic aspira- 
tion was done five times; death taking place from pneumonia, SUPRAPUBIC CYSTOTOMY. 
29 
the parts were examined, and it was found that some of the 
punctures had wounded the peritoneum, but there had been no 
peritonitis. 
Mr. Joseph Bell reported a case which had occurred under 
his care, in which a man of sixty-five, who had been cut for 
stricture in i860, suffered from retention, and was relieved by 
aspiration above the pubes. This was thought to be the first 
operation of the kind in Scotland. 
1874. Taylor reported a case of retention from enlarged pros- 
tate in a man aged seventy-four. Suprapubic aspiration was 
done seven times. After death, fifteen days later, no trace of 
the punctures could be perceived. 
Rose reports the case of a man, aged sixty, with retention 
from enlarged prostate; a canula was inserted above the pubes, 
and remained ten days; the wound healed in two weeks. 
Whitehead gives an account of a man, aged fifty-eight, with 
enlarged prostate and subacute cystitis; retention coming on, 
was relieved by suprapubic cystotomy, the edges of the wound 
in the bladder being stitched to those of the wound in the skin. 
Death ensued from diarrhoea on the fourteenth day. Septi- 
caemia was suspected. 
Angelot reported a case which had occurred in M. Demar- 
quay's service; a man, aged sixty-five, after being punctured 
seven times above the pubes for retention, died on the eleventh 
day. No trace of the punctures was discernible after death. 
Hall, in the case of a man aged seventy-eight, performed 
suprapubic aspiration nineteen times in seventeen days. 
A case is reported by Speir, in which the operation was 
repeated fifteen times; one by Guthrie, in which it was done 
eighteen times; and one by Brown, in which it was done fifteen 
times. 
18 75. La Garde reported a successful case of aspiration done 
with a hypodermic needle, a rubber tube, and a bottle with a 
canula passed through the cork. 
Mixon reported the case of a man, aged sixty-eight, with reten- 
tion for twenty hours, in whom the bladder was opened above 30 
PACKARD, 
the pubes with a bistoury, and a female catheter inserted. Re- 
covery was rapid and complete. 
Taylor treated a case of retention from enormous hypertrophy 
of the prostate, in a man, aged eighty, by suprapubic aspiration. 
It was thrice repeated, with relief, but the patient died. 
18 76. Dora recorded the case of a clergyman aged sixty- 
four, with prostatitis, greatly relieved by suprapubic puncture, 
although death ensued from exhaustion about ten days later. 
Porcher reported a case in which the operation was done 
thirteen times for retention. 
Mention is made in the same year of a case in which Dr. 
Malherbe, of Paris, had the misfortune to break the aspirator 
tube in the bladder; the fragment was unextracted, and caused 
death. (It certainly seems strange that in this case the idea of 
direct section did not suggest itself.) 
Volkmann reported the case of a boy, aged six and three- 
quarters, with rupture of the urethra, in whom he performed 
suprapubic section, with posterior catheterization. He thought 
that a similar operation had been done by Hunter, as well as 
by Verguin. Ranke, however, states that Hunter only made 
the suggestion, and that Verguin had reported his case thirty 
years before Hunter's work {On Syphilis) was published. 
1877. Peixoto reports a case of old stricture of the urethra, 
with false passages; complete retention of urine, relieved by 
suprapubic puncture ; vesical hemorrhage from over-distention ; 
urethrotomy; cure. 
Shepherd reports the case of a man aged sixty-two, in whom 
retention (probably from enlarged prostate ?) was relieved by 
suprapubic aspiration done at least once in twenty-four hours 
for thirteen days. He says he has repeatedly adopted this 
course with satisfaction. 
J. W. Browne reported a case in which a man aged forty- 
three, affected with stricture, was subjected to suprapubic punc- 
ture ; the canula was removed after two days, and later, a punc- 
ture by the rectum was performed. 
1878. Gay published the case of a man aged twenty-eight, 
for thirteen years the subject of stricture, who had retention, SUPRAPUBIC CYSTOTOMY. 
31 
and on whom suprapubic aspiration was done nine times in four 
days. 
Howse reported the case of a young man aged twenty-two, 
whose urethra had been ruptured, with fracture of the pelvis. 
Seventeen months after, perineal section was done, and seven 
months later, suprapubic section, with extraduction of an instru- 
ment, and division of the stricture. A good result was secured. 
In the discussion on this case, Mr. Teevan is reported to have 
said that " numerous deaths had been recorded after suprapubic 
sections." 
Wick gives the history of a man aged fifty-eight, with reten- 
tion from enlarged prostate; catheterization was found impos- 
sible ; suprapubic puncture was performed six times, each time 
at a different point; recovery ensued. 
Vanderveer recorded the case of a man aged sixty-two, with 
retention from enlarged prostate; suprapubic aspiration was 
resorted to twelve times, then a canula was inserted, and by 
means of it a rubber tube. The result was excellent. 
18 79. Styll gives an account of a case of stricture with reten- 
tion, in a man aged thirty-seven; aspiration above the pubes 
was done every twelve hours for three days, with good result. 
Mr. Hulke also records a case of old stricture in a man aged 
forty, in which, after aspiration, the bladder was tapped above 
the pubes, a canula fastened in and retained four weeks. An 
instrument was then passed from behind forward, another from 
before backward, and the intervening tissue divided. 
1880. Treves published a case in which retention was relieved 
by suprapubic puncture. The patient went out on the third day, 
but returned within a week, very ill. About three weeks later he 
died, and at the autopsy no trace of the wound in the bladder 
was found; there was suppurative pelvic cellulitis. 
Campbell reported a case in which, after suprapubic aspiration 
on two successive days, on the third internal urethrotomy was 
resorted to. In a day or two there was inflammation at one of 
the punctures, followed by abscess, peritonitis, and death. 
18 81. Mr. Thomas Smith gives nine cases of suprapubic 
puncture, and says that he has, on other occasions, employed 32 
PACKARD, 
the same means of relief for prostatic retention. He speaks 
of three cases of children, in which retention caused by the 
pressure of tumors had been thus remedied. In one case of 
stricture, in a man aged fifty-seven, puncture was resorted to, 
and on the second day pneumonia set in, which proved fatal. 
Mr. Smith had no idea that there was any connection between 
the operation and the issue of the case. 
Stein quotes a case of Liston's, in which a man had a cyst 
which caused dysuria by falling into the urethra. The cyst was 
removed through a suprapubic opening; the wound was closed, 
and the man recovered, living for some time. 
Also from Billroth, the case of a boy aged twelve, in whom 
perineal cystotomy was done for a tumor. A suprapubic 
incision was then made, both recti muscles were cut across, and 
a transverse incision was made in the bladder wall. The tumor 
was removed; through drainage was kept up until the fifth day, 
and in thirty-four days the wound had closed. 
Also from Volkmann, the case of a man aged fifty-four; the 
operation was the same as in Billroth's case, except that the 
upper wound was " made on the finger passed through the peri- 
neal wound." A tumor having been removed, the upper wound 
was closed by sutures, and a drainage tube was placed in the 
lower. Peritonitis ensued, and death on the third day. 
Also from Marcacci, the case of a man, aged fifty-four. An 
incision thirteen centimetres in length was made, an enormous 
tumor removed, and the wound in the bladder closed with four 
catgut sutures, that in the abdominal wall with metallic sutures; 
antiseptic dressings were applied. On the tenth day the metallic 
sutures were removed, and a few drops of urine escaped from 
the openings where they had been. Urinary fistulae remained, 
and the " patient died within two months after the operation, 
from extravasation of urine, pelvic abscess, and peritonitis." 
Gross mentions the case of a farmer, in whom the wound 
made, through which a tube was worn for several months, 
reopened after fourteen years, the integuments having been 
the seat of erysipelatous inflammation. Urine flowed through SUPRAPUBIC CYSTOTOMY. 
33 
the opening for about four weeks, or until the patient died from 
constitutional exhaustion. 
1883. Anger reported a case in which suprapubic section was 
performed for the relief of cystitis; on the third day an abscess 
of the kidney burst into the peritoneum, with fatal effect. 
Hyatt recorded the case of a man, aged sixty, whose bladder 
he opened above the pubes for the extraction of a piece of 
metallic catheter. The peritoneum was opened, the orifice 
being three-quarters of an inch in extent; its edges were brought 
together and stitched to the abdominal wall. Recovery was 
complete in four weeks. 
18 86. Treves published the case of a man aged fifty-five, 
admitted to the London Hospital in August, 1885, with com- 
plete retention for thirty hours. He had had traumatic stric- 
ture for nineteen years, and for seven years his urine had drib- 
bled away, the bladder having been during all that time so 
distended as to be visible above the pubes. Suprapubic puncture 
with a trocar was done, and a few days later a soft rubber tube 
was inserted in place of the canula. In May, 1886, he reported 
that he had worn the tube ever since, with a cork. 
Southam gave an account of a case of papillomata of the 
bladder in a man, aged forty-one. Exploration was first made 
by means of a perineal opening; free access was then obtained 
by a suprapubic section, the tumors removed, and bleeding 
checked by means of hot water and tincture of iron. A good 
cure resulted. 
Pitts reported to the Clinical Society of London a case of 
tumor, in a man, aged forty-five, removed by suprapubic section, 
with a good recovery. Sir Henry Thompson, on the same 
occasion, spoke of three similar cases. 
Wile reports a case in which suprapubic aspiration was done 
twice a day for four days, with good result. 
Harrison quotes a case from the practice of Mr. Mitchell 
Banks, in which suprapubic tapping was done at sea four days 
after a rupture of the urethra. Six days later, the man arriving 
at Liverpool, Mr. Banks made a perineal opening and through 
drainage. The patient made a good recovery. 
3 34 
PACKARD, 
Dr. W. H. Bennett recently reported to the Royal Medical 
and Chirurgical Society the case of a man aged thirty-eight, 
who had had retention of urine for three days. Aspiration was 
performed above the pubes, and extra-peritoneal rupture of the 
bladder immediately occurred. The abdomen was laid open, 
and the bladder thereafter drained by a perineal incision. For 
forty-eight days the patient did well; then an opening formed 
between the bowel and the prevesical cavity, and he sank. 
In connection with the previous case, Mr. Bryant cited that of 
a man aged thirty, in whom suprapubic aspiration was done for 
retention, and later a perineal section. After death, suppurative 
peritonitis, with a sloughing abscess from extravasation of urine, 
was found. 
He also mentioned the case of a man aged seventy-eight, with 
retention from enlarged prostate; suprapubic puncture was per- 
formed seven or eight times, and after death it was found that 
each of the six openings " would allow of the escape of urine 
into the peritoneum." (I must confess that this statement puzzles 
me, if the operations were properly performed). 
Prof. Humphry referred to a case of enlarged prostate with 
retention, in which suprapubic puncture was followed by fatal 
extravasation of urine. 
Mr. Baker has published an account of a man aged fifty-five, 
affected with sarcoma of the bladder, for which a perineal opera 
tion was done October 1i, 1884, and part of the growth removed. 
It however grew rapidly, and on January I, 1885, suprapubic 
puncture was made, and a red elastic catheter introduced, with a 
tube converting it into a siphon, so as continually to draw ofif 
the water. January 16th, this began to be painful (by increase 
of the tumor?) and it was removed, a pad of absorbent wool 
being substituted for it. Death took place January 19th. 
Mr. W. Thomas reports a curious case of obstructed micturi- 
tion in a boy aged four, from congenital malformation at the 
meatus urethrae. Suprapubic section was done, and on the 
introduction of the catheter a valve-like septum was discovered 
and divided, after which a cure was readily effected. 
He gives also a case of ruptured urethra in a boy aged eleven, SUPRAPUBIC CYSTOTOMY. 
35 
treated by perineal incision and suprapubic aspiration, with 
success. 
Sheild gives his experience as decidedly in favor of the supra- 
pubic puncture in cases of retention, and quotes the expression 
of one patient, that it was the easiest way in which he had ever 
had his water drawn. 
1885. Thistle gives six cases, five of retention from stricture, 
and one of retention from enlarged prostate, in which the bladder 
was entered above the pubes. Three were aspirated, and three 
tapped, one of the latter being the patient with enlarged pros- 
tate, who was seventy-three years old. 
In all the procedure was successful. 
1887. Fairbanks reports a case in which a man aged seventy- 
six, after slight trouble for some weeks, had retention, which 
was for three days relieved by the use of the catheter; then this 
became impossible, and suprapubic aspiration was relied upon 
for fifteen days, during which all the urine was drawn off in this 
way, except once, when the catheter was used. Aspiration was 
performed thirty-two times. After this the catheter could be 
again passed, and by degrees the bladder resumed its function. 
I propose now to give the results of my own experience in, 
this direction; some of the cases, as will be noted, were ex- 
tremely unfavorable, and yet the patients did well. Several of 
them, it seems to me, could not have been successfully dealt 
with in any other way than by suprapubic section. 
I have already referred to the case which I saw with Dr. 
Donnel Hughes, in November, 1883, in which we opened the 
bladder above the pubes for the purpose of removing a foreign 
body, the patient making an uninterrupted recovery. 
For several years it has been my practice, in cases of reten- 
tion from stricture such as we ordinarily meet with, after the 
failure of a fair attempt at relief by catheterization, to draw off 
the urine by aspiration. Very generally an instrument has 
passed readily within the twenty-four hours succeeding the 
operation. I do not now remember having had occasion to do 36 
PACKARD, 
this more than once in any one case, but my records in this 
respect are unfortunately quite imperfect. 
One patient, with greatly enlarged prostate, was much relieved 
by the aspiration, and next day I succeeded in passing a catheter. 
His family, however, called in another surgeon without notice 
to me, and in a day or two I heard of the patient's death-from 
what cause I do not know. This is the only instance within my 
personal knowledge in which there was any ill consequence fol- 
lowing aspiration, and here I see no evidence connecting the 
operation with the fatal event. 
On the 7th of July, 1885,1 was called by Dr. R. B. Okie, of Berwyn, 
to see Mr. G., aged sixty-five, at Howellville, Chester Co., on account 
of retention of urine from enlarged prostate. 
Mr. G. was a man seemingly in good health, but much distressed by 
frequent ineffectual calls to urinate, and by distention of his bladder. 
With a very long catheter I drew off his urine, but he wanted more 
permanent relief, as there was no medical aid within several miles of 
his residence. 
I therefore, with the aid of Drs. Okie, Rickabaugh, and Roberts, on 
the same day etherized Mr. G., and performed the suprapubic section, 
putting in a glass ovariotomy tube, curved for the occasion. Dr. Okie 
made an ingenious arrangement with a piece of the thin gum-cloth 
known to dentists as "rubber dam," by means of which the urine as it 
flowed from the tube was prevented from coming in contact with the 
skin. 
Two or three nights afterward the patient had a curious attack of 
almost maniacal excitement, which however soon passed off, and he 
became quite himself again. He began to sit up, and to be about his 
room; and was beginning to learn to pass the catheter for himself, 
when, on July 19th, making some slight effort, he fell dead. 
A post-mortem showed the heart to be fatty, with vegetations on the 
mitral valve. There was an immense lobulated prostate, but the wound 
in the bladder was quite healthy and free from irritation. 
Jacob O. C., aged forty-three, was admitted into the Pennsyl- 
vania Hospital, January 21, 1885, on account of retention of urine. 
He had been a hard drinker; had gonorrhoea at seventeen, for the 
first and only time ; became strictured at twenty-two, and in 1873 
was "cut " for this. About a year after this operation he could pass SUPRAPUBIC CYSTOTOMY. 
37 
a No. 7 instrument, but has had occasional attacks of retention ever 
since. 
On admission, he confessed that he had been drinking hard, and 
he was very much broken down. His bladder was greatly distended 
and very tender; no instrument could be passed ; urine was forced out 
in a very small twisted stream, with great effort. He had frequent 
chills, alternating with profuse sweating. 
A large poultice was applied to the abdomen ; opium and belladonna 
were given by suppository; and he was put upon nourishing diet, with 
a certain allowance of stimulus. 
On the next day, January 2 2d, Dr. Morton made a perineal incision 
and passed an instrument, which was felt in the hypogastrium. Pus 
flowed very freely. By a happy chance the catheter entered the 
bladder, and a very large quantity of urine was drawn off, to his great 
relief. 
On the 23d the bladder was again distended, and the orifice could 
not be hit with the catheter. I recommended suprapubic section, to 
which Dr. Morton agreed, and asked me to operate, as he had a sore 
hand. I made a free incision in the median line, and laid open first 
an abscess cavity, then that of the bladder. A catheter was now 
easily passed from the suprapubic wound through the bladder into the 
urethra and out at the perineal opening. A drainage tube was sub- 
stituted for the catheter, and left in place. Poultices were applied, 
and he was put upon opium and tonics, with liquid diet and stimulants. 
His condition steadily improved. Free drainage took place from the 
bladder, and in a few days carbolized oil was substituted for the 
poultices. 
February 4. He has been feeling weaker for several days, his appe- 
tite has left him, and he is chilly. 
On the 6th he was quite ill, with thirst, vomiting, a dry tongue and 
anxious face, sordes in the mouth, and high temperature. Ordered 
champagne. 
On the 7th a mass of slough came away from the suprapubic opening. 
From this time he had no serious drawback. 
The drainage tube was kept in until March 6th, when it was 
removed, and a catheter passed through the whole urethra and 
secured. 
The wounds gradually healed, and on the 21st of April he was dis- 
charged cured. 38 
PACKARD, 
Harry F., aged forty-three, was admitted into the Pennsylvania 
Hospital, April 28, 1886, with retention of urine, which, however, 
dribbled from him. He said that on the 24th he strained himself 
in trying to urinate, and had passed no water since. His condition 
on entrance was very critical; the penis and scrotum were enor- 
mously swollen, the prepuce oedematous; the skin of the lower third 
of the abdomen was swollen, tense, and dusky red; the skin round 
the under surface of the root of the penis was purple, and on the 
eve of sloughing; the swelling had invaded the perineum. 
I at once had ether administered, and made free incisions into the 
swollen tissues, giving exit to semi-purulent urine. I then exposed 
the distended bladder, and passed a trocar and canula into it; on with- 
drawing the trocar, an immense flow of urine took place. Enlarging 
the opening, I then substituted for the canula a rubber tube, putting a 
silk stitch through the side of this and the wall of the bladder. One 
silver wire suture was applied at the upper part of the wound, which 
was dressed with iodoform and carbolized gauze. 
Next day, the symptoms being greatly relieved, I performed a 
perineal section, in doing so passing through an abscess cavity which 
seemed to surround the neck of the bladder. 
The man did very well; on the 2d of May some sloughs came away 
from the suprapubic opening, and a silver tube was substituted for the 
rubber one. Exactly how long this rubber tube was kept in, I can find 
no memorandum, but it was several weeks. 
On the 4th of June a small bougie was easily passed through the 
urethra into the bladder, and thereafter instruments of a larger and 
larger size were used until July 13th, when he was discharged, the 
canal readily admitting No. n of the English scale, and his urine 
flowing freely. I have seen him repeatedly since, in perfect health, 
and attending to an active outdoor business. 
Mr. S., aged sixty-three, had suffered from enlarged prostate for 
several years, with frequent attacks of severe hemorrhage. He was a 
very large and stout man, well nourished. I was called to see him in 
the country, August 13, 1886. His bladder was very largely dis- 
tended, and he was in great suffering. An instrument could be passed 
only with extreme difficulty, and brought away no water, but clots of 
blood. The prostate was enormous. 
He was etherized, and I performed suprapubic section, opening the 
bladder freely. The subcutaneous fat was very thick, and, of course. SUPRAPUBIC CYSTOTOMY. 
39 
the bladder lay very deep ; yet there was no difficulty. A very large 
nodulated prostatic growth could be felt with the finger. Great relief 
was given by the operation. A tube was inserted, first of soft rubber, 
and then a glass one, as more easily kept clean. 
On the 17th he was able to transact some very important business 
affairs. The great difficulty was to keep him dry and clean, as the 
capacity of the bladder was so reduced as to cause the urine to over- 
flow continually. He was also much troubled by flatulence, and by 
the annoyance of using a bedpan. His strength continued to fail, 
and he died worn out on the 29th, sixteen days after the operation. 
William E., aged seventy, was admitted into my ward at the 
Pennsylvania Hospital, April 24, 1887, suffering intensely from reten- 
tion of urine. He had for many years had increasing difficulty in 
urination, from enlarged prostate; his feet and legs had occasionally 
been oedematous. On admission his bladder was distended as high as 
the umbilicus; his clothing was saturated with blood, which was still 
flowing from the meatus, as the result of strenuous efforts at cathe- 
terization made the previous evening. His pulse was weak and thready, 
and his mind confused. My colleague, Dr. Morton, saw him at the 
time, and thought the case so urgent that the resident surgeon, by his 
direction, at once performed suprapubic cystotomy. The wall of the 
bladder was found very dark, as if gangrene was commencing. A 
small incision was made, and a very large quantity of putrescent urine 
flowed away. Some large clots were removed. An exploration with 
the finger revealed a very large and hard bilobed prostate. A rubber 
tube was passed into the bladder through the wound, and a No. 10 
silver catheter was passed by the urethra and left until the second day. 
The urine contained about one-half albumen, a good deal of blood, 
and some granular casts. 
Great relief followed the operation, but it was found impossible to 
keep him dry, partly because of his restlessness. He wandered a good 
deal in mind after the third day, and passed into a typhoid condition, 
which terminated fatally on May 8, the fourteenth day after the 
operation. 
An autopsy showed much thickened bladder-walls, and the prostate 
enormously enlarged, as well as altered in structure, apparently by 
cancerous deposit. The kidneys were enlarged, cystic, and seemed to 
have been the seat of chronic parenchymatous inflammation. The 
pancreas was very large and hard. No sign of peritonitis appeared. 40 
PACKARD, 
The heart was hypertrophied, with atheroma of the mitral and aortic 
valves. 
Another case was admitted on the evening of the same day. Richard 
W., aged forty, had gonorrhoea ten years ago. Has now double 
inguinal hernia, and double hydrocele. A year ago he was admitted 
with retention, but was then readily relieved by the catheter. On 
admission, he had passed no urine for fourteen hours, and was suffering 
greatly. 
He was fully etherized, and catheterization attempted without suc- 
cess. I, therefore, performed suprapubic section under antiseptic 
precautions. A rubber tube was introduced through the wound, and 
connected with a urinal. He is doing extremely well, and passes some 
water through the meatus; but as no instrument can be made to enter 
the bladder, I propose, in a day or two, to perform perineal section, 
and probably extraduction, so as to restore the urethra. [This course 
was carried out. The perineal section being made, an instrument 
was carried into the bladder, and kept there for several days; extra- 
duction was, therefore, not necessary. Urination took place freely by 
the lower wound and through the urethra; and the suprapubic wound 
quickly closed. The man is, at the date of this note (June ist), 
almost well, the stricture of the urethra still, however, requiring treat- 
ment.] 
My colleague, Dr. Morton, permits me to refer to the case of 
an old gentleman, upon whom I assisted him in performing 
suprapubic cystotomy on February 19, 1886. The patient was 
the subject of enlarged prostate, and had to have a catheter 
passed at intervals of not more than an hour, always with in- 
tense pain, night and day. A glass tube was left in, and un- 
stopped from time to time. Greater relief than he obtained 
could hardly be imagined. He has lived a comfortable life 
ever since, gaining flesh and strength, and going out as much 
as at his advanced age is desirable. 
I have assisted Dr. Morton in at least two other cases in which 
the benefit was well marked, but the patients had had less 
suffering, and retained less vigor of constitution. Both of these 
died within a week or two, with sloughing from infiltration of 
urine. SUPRAPUBIC CYSTOTOMY. 
41 
Now in looking back over this array of cases, it seems to me 
that the absence of evidence of peritonitis, infiltration of urine, 
and urinary fistula is very striking. In not one is there mention 
of troublesome hemorrhage encountered during the operation. 
Let me say that I have personally examined the records 
wherever they have been accessible to me, and that cases quoted 
as second-hand are so noted. I am aware that there are other 
published accounts, but they have been beyond my reach. 
I can recall to mind a number of instances that have come 
under my notice in former years, in which, from the results of 
the practice of suprapubic section above noted, I believe that 
it would have been attended with success ; and I should cer- 
tainly have performed it, had it then been among my resources. 
Had time and space permitted, I should have been glad to 
give the details of a number of these cases of prevesical ab- 
scess, of enlarged prostate, of foreign bodies or tumors in the 
bladder. But I cannot doubt that almost every surgeon will 
have met with like experiences, and will be reminded of them 
by this brief mention. My own intention is to add no more 
to the sad list of such failures. 
We may now consider the details of the methods of procedure 
in opening the bladder above the pubes. 
I do not hesitate to declare that the fullest antiseptic precau- 
tions should be observed in these cases. Surgeons have asked 
me "What is the use of all this, when the urine will be flowing 
through the wound ? " But in the first place, the urine does not, 
in the majority of instances, flow through the wound. And in 
the second place, if it does, it is rendered less irritating and less 
hurtful by being rendered antiseptic. Moreover, experience has 
shown me that the early healing and the prevention of suppura- 
tion thus secured have been of direct and striking benefit in 
the subsequent progress of the cases. 
I therefore have the parts shaved and cleansed as carefully 
and thoroughly as for an amputation or for the removal of a 
tumor; the instruments and everything which comes in contact 
with the wound and surrounding region must be rigidly clean 42 
PACKARD, 
and antiseptic; when the bladder must be distended, boric acid 
solution is used for the purpose. 
As to the necessity of distending the bladder, most of the 
cases in which I have myself been concerned have not required 
any such preliminary, the organ being already in danger of 
bursting from the pressure of the contained urine. And it seems 
to me that the mistake may readily be made of throwing too 
much into it. One of the reasons given by Cheselden for his 
abandonment of the high operation for stone, was that he had 
seen the bladder burst, and Carpue says that the patients com- 
plained bitterly of the distress caused by the bulk of liquid 
which it was thought needful to inject. In these days of anaes- 
thesia, our patients know nothing about any such annoyance; 
but may there not be even more danger, especially where the 
walls of the bladder are weakened by long-standing disease, of 
taxing them too severely ? 
I do not believe the operation is facilitated by such energetic 
distention ; the bladder need merely be distinctly felt, and for 
this purpose f§vj or fSviij of boracic solution will be found 
amply sufficient. Especially is this true when the rectum is 
distended by f§xij to f$xiv of water thrown into the rubber bag. 
With regard to the distention of the rectum, it seems to me 
there is less risk and more advantage. By thus preventing the 
recession of the bladder into the pelvis until all the arrange- 
ments for drainage are securely made, one possible source of 
embarrassment and danger is set aside. 
In order to retain the fluid which has been injected into the 
bladder, Douglas, in 1719, had the penis compressed by flexion 
downward by the hand of an assistant. This seems to me 
preferable to the modern custom of tying a rubber tube or band 
around the root of the penis. In the female, should an opera- 
tion of this kind be called for, the urethra can, of course, be 
readily compressed against the pubic bone. 
By many writers (Chelius, Gross, Agnew, Sir H. Thompson, 
Keyes, and G. B. Browne) it is recommended that the bladder 
should be steadied by the hands of an assistant, when the incision 
or puncture is made. I cannot but think this not only needless, SUPRAPUBIC CYSTOTOMY. 
43 
but objectionable. The patient lies on an ordinary operating- 
table, or in his bed, and the surgeon stands at his right, facing 
him. If the assistant stands on the other side, he is just as apt 
to pull the bladder out of place as to keep it steady. 
The incision through the skin should be free enough to give 
ready access to the deeper parts. In fat persons, it must be 
about three inches; but when the abdominal wall is thin, two 
inches in length will suffice. When the cut is made exactly in 
the median line, no vessels of any importance can be encoun- 
tered. The conjoined tendon being divided, the recti muscles 
present as a solid mass, and the interspace between them must 
be made with the knife or its handle. A layer of yellow fat 
comes next, and on cutting or scraping through this, the smooth 
dome-like shape of the bladder is seen at the bottom of the 
wound. 
Before puncturing the bladder, it is very desirable to get con- 
trol of it in some way, lest it should, as the urine flows away, 
collapse and settle back into the pelvis; the orifice made by the 
surgeon may then be very difficult to find, and it may be still 
more difficult to insert a canula. A small double hook, recurved 
and set at a right angle on a stem, has in my hands proved very 
convenient; it is applied to the wall of the viscus, exactly in the 
median line, and gives a very secure hold. A small tenaculum 
may answer much the same purpose, but its point may damage 
the operator's fingers. I have passed a double ligature, by 
means of a sharply curved needle, through the bladder wall, and 
held it by means of this. 
When a large opening is to be made into the bladder, for 
purposes of exploration, the ligature is perhaps the best of these 
devices. 
In cases of retention, the curved trocar and canula may now 
be at once pushed through the bladder wall, and the trocar 
withdrawn, leaving the canula in place, to be substituted later 
by a rubber tube. 
The sonde a dard, an instrument of ancient date, like a staff, 
was formerly passed up through a perineal opening and made to 
thrust the anterior wall of the bladder; it has been revived 44 
PACKARD, 
within a few years by Sir Henry Thompson, who, however, 
passes it into the bladder through the urethra. But if the 
exposure of the wall of the bladder has been effected as de- 
scribed above, this instrument is unnecessary. If the incisions 
have not been made, it is entirely possible for a fold of peri- 
toneum to be engaged on the point of the sonde a dard, and 
thus to be cut through. 
A curious proposition has been made by Duchatelet, and is 
quoted with approval by Villeneuve, that the opening should 
always be purposely made through the peritoneum, and thus, as 
he says, that " plasticity should be substituted for friability." 
Considering the fact that the danger of wounding the perito- 
neum has always been one of the strong objections to the supra- 
pubic operation, it is only the boldest of the bold who would be 
likely thus to take the bull by the horns. 
Having secured the control of the bladder, my own practice 
has always been to open it with a sharp-pointed bistoury close 
to the hook or ligature, making this orifice just about large 
enough to pass the tube which it is proposed to use. For pur- 
poses of exploration, it may easily be enlarged with a probe- 
pointed bistoury. 
Von Antal has proposed to make an oval section of the mus- 
cular wall of the bladder, the long diameter of the oval parallel 
with the axis of the body; then holding the knife flatwise, he 
dissects off the included part of the muscular wall, exposing the 
bluish-gray translucent mucous membrane, which is to be divided 
vertically. Or he makes a vertical section first, and then intro- 
duces an elastic sac, which being dilated stretches out the edges 
of the orifice so as to admit of their being pared away. The 
sutures are carried through the outer and middle layers only of 
the bladder-wall, in order to avoid incrustation upon them; and 
the mucous membrane is supposed to act as a valve to prevent 
the escape of urine. 
This procedure, which is certainly ingenious, is intended for 
sections made for the removal of calculi, when the bladder is to 
be at once sewed up. It might be applicable in other cases also, 
but could, I think, be simplified. SUPRAPUBIC CYSTOTOMY. 
45 
As to the proper point for entering the bladder, it seems to 
me that some of the older surgeons, in avoiding Scylla, steered 
into Charybdis. They were so afraid of injuring the peritoneum 
that they made the opening as low down as possible, and when 
the collapsed bladder sank, the orifice was carried down behind 
the pubis, so that the urine could hardly fail to find its way into 
the loose areolar tissue of that region, causing infiltration and 
all its attendant evils. 
It seems to me that the proper point, as nearly as it can be 
indicated, would be about at the middle of the exposed portion 
of the wall of the bladder. This would be nearly in accord with 
Sharp's direction-an inch to an inch and a half above the 
symphysis pubis. 
The next question is as to the arrangement for drainage. My 
own preference is usually for a soft rubber tube, of a length to 
be determined for each case. It should go well into the bladder 
even when this is collapsed, and should have lateral openings 
only near its inner or vesical end. It should be large enough to 
fill up the opening in the bladder wall without stretching it; and 
if it projects well out of the wound it can, if desired, be closed 
with a cork, or by means of a clip, or by bending its extremity 
double, and putting on a clamp of any kind. 
I have twice used a glass tube with great satisfaction in cases 
of old men with atonied bladders. By means of a sheet of 
"rubber dam" slipped over the tube before its insertion, the 
patient can be kept perfectly dry, the urine being drawn off by 
a rubber tube into a urinal, or received in a mass of sublimated 
cotton, or in a large carbolized sponge. The glass tube is like 
that used in ovariotomy cases, but smaller, and curved in the 
arc of a large circle. 
Metallic canulas may answer very well, in the absence of 
other tubes. Velpeau, writing at a period when rubber tubes 
were not to be had, declared the canule a demeure more dan- 
gerous in the suprapubic than in the rectal operation. He says 
of it: "Too long, it ulcerates the organ; too short, its tip, 
abandoned by the retracted bladder, becomes engaged in the 
surrounding tissues." In cases of enlarged prostate, it may 46 
PACKARD, 
readily be imagined that any rigid tube, reaching the bas fond, 
might be a source of great irritation, its tip being continually 
rubbed against as the bladder expanded or contracted. 
One or two writers have suggested the placing of the patient 
on his belly in order to favor drainage; but this would involve 
so much discomfort, and even risk, that I can hardly suppose 
the idea would be seriously entertained. 
If a large opening has been made into the bladder, as for the 
purpose of exploration, the application of two or three catgut 
ligatures will suffice to close it around the tube. My own 
experience has been that here, as in cases of tracheotomy, the 
tendency of the wound is to heal quickly, except where the 
tissues, as well as the general system, are in a bad condition. 
The edges of the wound in the skin can be apposed with 
sutures of catgut or silkworm gut, and, if necessary, a catgut 
suture can be passed through the wall of the rubber tube, and 
attached to the nearest suture, or to a strip of rubber plaster 
applied to the skin, and crossing the wound. Healing by first 
intention has taken place in several of my cases. 
A few words only, in conclusion. My endeavor has been to 
examine fairly and without prejudice into the case for and 
against the suprapubic section of the bladder, apart from 
lithotomy; to trace the course of opinion with regard to it, and 
to ascertain how far the recorded experience of the profession 
is in support of that opinion. 
It would seem that there has been a mixture of tradition and 
of a sort of superstition in the feeling with which this procedure 
has been generally regarded. If the dangers attributed to it 
were real, one would expect them to appear prominently in the 
histories cited. Yet, in fact, the proportion of absolute successes, 
so far as I can calculate them, is something over eighty per 
cent.; the failures about seven per cent., and the instances in 
which bad consequences were ascribed to the operation about 
eleven per cent. And looking at the cases in detail, it certainly 
seems to me that on all the counts of the indictment, danger of 
peritonitis, danger of infiltration of urine and urinary abscess, 
danger of urinary fistula, a verdict at least of " not proven " 
might fairly be asked for. SUPRAPUBIC CYSTOTOMY. 
47 
But it may be said that the other side is not heard; that the 
-statistics of operations through the perineum and through the 
rectum should be given, and a comparison instituted between 
them and those now presented. My answer to this must be, 
that I am not concerned to advocate one operation more than 
another. Finding the suprapubic operation easy, available in 
very grave cases, and attended with good results in my own 
trials of it; regretting that it had not been earlier known to me 
as a resource, and believing that it has not met with the degree 
of favor it deserves at the hands of either writers or practitioners, 
it occurred to me to gather the evidence in regard to it for your 
inspection. I would say that it seems to me to be adapted to 
cases of retention from difficult stricture, especially with false 
passages, with prevesical abscess, or from traumatic cause; to 
cases of rupture of the urethra; to those of enlarged prostate 
with irritability, of tumors or foreign bodies within the bladder, 
and in some instances of intravesical hemorrhage. 
The suprapubic operation does not by any means, in any case, 
preclude the perineal, as is shown in a number of cases cited in 
this paper. On the contrary, it often prepares the way for it. 
One question I would ask: If the suprapubic section had 
been first tried and generally adopted, is it likely that the 
perineal operation would have been afterward preferred on 
account of its greater ease, simplicity, or efficiency ? 
It is a matter of satisfaction to me that the suprapubic opera- 
tion, and my attempt at its defence, are now submitted to judges 
whose knowledge and experience must insure impartiality in 
their decisions, and leniency in their criticism. 
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