SUPRA-PUBIC CYSTOTOMY.
The revival of supra-pubic cystotomy is in a large measure due to the observations of Garsou,'" the practice of Petersen,'" of Kiel, and the advocacy of Sir Henry Thompson.'" I propose to refer to this operation in its application to (1) stone in the bladder, (2) tumors and growths, including hypertrophy of the prostate encroaching upon the interior of the bladder, (3) foreign bodies, and (4) other condi tions requiring the inspection of the interior of the bladder and drainage. In all these states, subject to some modifications, it has been applied with success. I will, first of all, describe the method of operating.
The patient may be placed either recumbent, as for an abdominal operation, or with the pelvis elevated, as in what is known as Tren delenburg's position. In the former case it was usual to distend the bladder with some ounces of water, and likewise the rectum by means of an elastic air-bag capable of inflation; the object of this being not only to make the outline of the viscus more prominent but to increase, as it is alleged, the space immediately above the pubes where the bladder is uncovered with peritoneum. Such measures are not now insisted upon, beyond retaining a few ounces of water, hardly amounting to distention. The rectum bag, in the majority of in stances, is unnecessary, unless it is used with the object of enabling the operator, after the bladder has been opened, to reach the poste rior, wall with his finger, which in corpulent persons would otherwise be impossible. I much doubt whether the area above the pubes, un covered by peritoneum, is increased by the combined distention of the bladder and rectum, as first proposed, unless it is practised with such an amount of force as to render the proceeding, in the case of a weak bladder, somewhat hazardous. Rupture of the bladder as well as the bowel has been caused in this way. A patient with a stricture and a distended bladder was placed on the operating table in Belle vue Hospital, New York, for the purpose of having the stricture re lieved.'" While struggling under ether the abdominal tumor sud denly disappeared, and the former area of dulness became tympanitic. At a post-mortem examination the bladder was found ruptured, with out ulceration or other alteration. No doubt the distention in this case was considerable, as two quarts and a half of bloody fluid were found in the abdomen. Air has been substituted for water in distend ing the bladder, on the grounds that it is less likely to do injury and is calculated to render the viscus more prominent. I do not think
there is much in this, and if the intestines happened to be flatulent there might be some difficulty in distinguishing the viscera. The bladder having been washed out, a few ounces of boracic solution be ing left within it, secured there by a ligature round the penis, and the pubes shaved, the operation may now be proceeded with. When Trendelenburg's position is selected, the patient is placed as shown in the illustration (Fig. It has some advantages, as the intestinal pressure tends to gravitate toward the thorax and away from the wound. The operator then proceeds to open the bladder, by either the vertical or transverse incision. In the former case, standing on the left side of the patient, he commences immediately above the bony margin of the pubis, and prolongs his incision for about two inches toward the umbilicus in the median line. This should be carried down to the intermuscular interval which is to be opened. On this being accomplished, the index finger should hook up the tissues above the upper portion of this dissection, so as to draw the perito neal reflection toward the umbilicus. I have in this way seldom seen the peritoneum, or even been conscious of its existence. There is generally some fat and cellular tissue between the muscle and the bladder, which can be scraped away with the finger, when the ante rior surface of the bladder will be seen. Care should be taken to avoid or to tie any large veins that may be met with, as they sometimes bleed freely, and have been known in elderly persons to cause secon dary hemorrhage. It is a good plan to pass a handled needle, with a stout silk thread, through the bladder wall before it is opened with the knife, so as to secure it. The knife should be inserted into the bladder in the median line, and the incision made in an upward di rection so as to admit the index finger; when this is accomplished it can be readily extended according to circumstances. I prefer holding the bladder wound open by a stout silk suture on either side rather than by forceps. The latter are more likely to cause a rough cicatrix afterward, which is a matter of importance. I have seen a little trouble arise by the surgeon merely puncturing the bladder with his knife, thus allowing the water to escape and the viscus to become ab solutely flaccid. When, for this reason, there is difficulty in finding the wound again, as is sometimes the case, a metal bulbous-ended bougie should be passed into the bladder, when the opening is readily discovered.