FI$E CAS ES OF SUPRAPUBIC‘

QYSTOTO MY :

Three for S tone, One for Tumor in the Bladder, and One

for Explora tion with Catheterism o f the Ureters

One Dea th .

w . w .

‘

KEEN ,M .D. ,

PRO FES S O R O F T H E PRINC I PLES O F S URGERY , JEFFERS O N M EDICA LCO LLEG E . PH I LA DELPH IA .

T H E M E D I C A $ N E W S ,I

Apri1 1 8 ,1 891 .

[Reprin ted from T HE M EDICA $ N EW S, Apri l 18 , 1 891 ]

FI $E CAS E S O F S UPRAPUB I C CY S T O T O M Y :

Three for S tone , One for Tumor in the and One

for Exp/ora tion with Ca theterism o f the Ureters ;

One Dea th .

1

B Y W . w . KEE N,M .

$

DPRO FE S S O R O F T H E PRINCI PLES O F S URG ERY , JEFFERS O N M EDICA L

CO $ $ EGE ,PH I LADELPH IA .

CASE I . S ton e in the snpmp zzhz’

c cys

tatamy ; prosta tectomy ; recovery—I was cal led to

$ i ne land , N . j . , Sep tem ber 1 2 , 1 8 8 8 , by Dr . C . R .

Wiley, to see Mr . B ., aged si xty - fi ve . He had had

the usual symptoms of s tone i n the bladder for sixyears : A Petersen ’s bag was in ser ted i n the rec tumand d istended wi th ten oun ces o f warm water . T hebladder was inj ec ted w i th s ix ounces o f water wi thfour grains of boric ac id to th e ounce . S uprapubi cdulness then exis ted to two i nches above the pubes .The operat i on was done by the u sual vertical incision , and two stones were removed , weighingtoge ther 763 grains . The prostate proj ec ted somuch in to the bladder at the mou th of the ure thrathat I removed a p iece a slarge as the last j oi n t ofthe finger

,by the sci ssors . The bleed ing was sl igh t .

The bladde r was no t su tured . A drainage—tube wasinserted and removed on the ten th day : a cathe terwas re tained i n the bladder for four days more .

The patie n t recovered wi thou t any trouble,his

1 Read befo re th e Ph i lade lph ia A cademy o f S u rgery, Apri l 6 ,

I 890.

2 K E E N,

h ighest temperature being fal l i ng to normal ,both morning and even ing

,wi th in a week . The

wound heal ed enti rel y i n four weeks .In July , 1 8 89, he had a return of h is old symp

toms,and Dr . Joseph W . Hearn

,be in g i n $ i n e

land , was asked by Dr . Wiley to see h im again .

Dr . Hearn having detec ted a s tone by the sound ,reopened the former wound by d ilating a smal lfi stula wh ich

‘

had appeared , then crushed and re

moved two stones , weigh ing 4 1 2 grain s i n al l . Afterthat t ime he was well un ti l h is death recen tly fromanother d isease , as Dr. Wi l ey i n forms me .

I have no ques ti on that the stones removed byDr . Hearn had formed since the firs t operat i on , forthe en t ire i n terior of the bladder was i nspec ted at

that t ime and no further stone was detec ted .

CAS E II . A nhy/osz'

s of the hn ee ; ston e in the Na zi

(ier ; supmpn hz'

e eystoto zny ; recovery .—R . B . , of

Bridgeton , N . J ., fi rst consul ted me June 19, 1 8 88 .

A tall , spare man , aged forty - three,wi th ankylosis

o f the le ft knee from a whi te swel l ing twelve yearsago . Has also suffered cons id erabl y from rheumaticgout

,and has a deformed right hand fol lowing i t .

There i s also consid erable ankylosi s of bo th elbows .He passed a s tone from the bladder for the firstt ime i n 1 8 7 6 , and since then has passed dozens o fthem , mostl y phosphat ic , and he has had also renaltrouble from gravel

,at tended wi th haematuria , seven

or eigh t years ago . He has passed no stone by theurethra for eigh teen months

,but h is presen t attack

of vesi cal i rri tati on has existed for three years . Heis obl iged to empty the bladder from one to fourt imes an hour . U r ine

,specific grav i ty 1 01 1

, smal lamount o f pus and albumin

,wi th phosphates ; re

ac t i on fain tly alkal ine .

S U P R A P U B I C CY S T O T O M Y . 3

Opera tion , [o ne 4 , 1 888 . The pati en t des iredthat the high operat i on should be done i n orderthat the condi t i on of the bladder could be exploredb v the eye and the finger at the same time that thes tone was removed . T he ankylosis o f the knee , aswel l as h is wi sh , made me decide to do the suprapubi c operation . The rec tal bag was d istended wi thten ounces of warm water , and the bladder wi th sevenounces of wate r wi th four grains of bori c acid tothe ounce . The dulness of the d istended bladderextended two inches above the pubes . An i nci s i ontwo and one -half inches l ong was made and thebladder eas i l y reached , except for the di fficul tywi ththe anaes thet ic , as men ti oned later . An inc is iontwo i nches long was made i n the bladder and thes tone was extrac ted . Its shape was that of a flattened sphere ; i t weighed 4 2 1 grains when dry , andi ts surface was qu i te smooth except at the edges .The bladder wound was then closed wi th e igh t

st i tches o f i n terrupted fin e chromic catgu t . Thebladder was now inj ec ted wi th warm water comb ined wi th the bori c ac id i n order t o tes t the ac

curacy o f th e closure of the wound . No waterescaped . The wound was th en fi lled wi th waterand the bladder was inj ected wi th n ine ounces ofair

,when instan tly a leak was d iscovered by the ai r

bubbl i ng up through th e water . A s t i tch closedthi s

,and made the bladder bo th ai r and water

t igh t S ix s t i tches closed the wound i n theabdom inal wal l , which included wi th care theaponeurosis of the abdominal musc les . The perito n eum was not recogn i zed during the operat ion .

A flexible catheter was i nser ted in t o the bladder ,and i ts end was at first corked up and the bladderemptied every hour ; but , as th is caused some pain ,the cathe ter was uncorked and con ti nuous d rainagei n to a ur inal substi tu ted .

4 K E E N,

6th (2d day) . He has h i d n o pain ; his h ighes ttemperature is he i s hungry

,and has slept

wel l . The wound was re -dressed yesterday,when

everything looked wel l .Four days after the operation there was con

siderab le l ocal tenderness and irri tat ion , and on thes ix th day thi s was so marked that I removed thes ti tches and evacuated some uri ne and pus,wh1ch hadformed as a resul t o f the giving way of the s t i tchesi n the bladder . The wound was drained for a fewdays and then closed , and he wen t home on the2 5 th , three weeks after the operati on . S i nc e thatt ime he has had no trouble .

REM ARKs .—No other operatio n than the supra

pubic could have been done in this case on accoun tof the ankylosis of the knee . The operation was anextremel y d iffi cul t one , because un less he was deeplyanaes the tized he was struggl ing, wi th the abdominalwalls as tense as boards

,and i n order to relax them

anaesthesia had to be carr ied to a poi n t which I

fel t i nvolved serious danger . Between S cyl la andCharybd is i t Was very d ifficul t to steer a safe course .The d ifficul ty was especially great in suturing the

bladder. In fac t, I th i nk i t would have been wiserhad I not at tempted to d o so

,bu t had simp l y

drained .

CASE III . S ton e in the o/adder sargz'

ea/ htdneysdea th from sudden (edema of the ta ngs .

—W . H . C.

was referred t o me by Dr. Jul ius A . Johnson,of

E aston , Md . , December 1 1 , 1 889. His age i s fiftyn ine his weight two years ago 1 85 pounds at present abou t 1 35 pounds . S even to eight years ago hefirs t n ot iced that h is water was passed very sl owly

.

Four years ago had a brief attack of apparen tly acu te

S U PRA I’U B I C C Y S T O T O M Y . 5

i nflammation of the bladder . Two years ago an otherattack of acute i nflammation , wi th very thick urine ,and requi red catheteri zat ion ; has used a Nelatoncathe te r h imsel f more or less ever s ince . Passes h iswater abou t ten t imes i n the twen ty - four hours ; hasn ever passed any blood , except as a resul t of the useo f the catheter

,he th inks . Has no pai n i n the

small of the back,but suffers severely in the bladder

and perineum , for wh ich he has taken from one -hal ft o one grain o f morphia a day for about two years .In sp i te of hi s wast in g , his appeti te i s good , and alsoh i s sleep , except ing that i t i s in terrup ted by th enecess i ty of passi ng his water .E i gh t years ago , whi le brush i ng his tee th , he

touched a nerve , he th i nks , and for a few minutesh i s face was $ drawn .

$From one to two years

later , whi le going home to d inner , his l eft arm andleg became weak , and he had n o use o f them for afew minutes . He did not fal l

,but sat d own , and

after a short t ime walked home . A few times s i ncethen he has felt as i f a simi lar weakness was comingon ; se i z in g his wris t s topped i t . In O c tober, 1 888 ,on a S aturday he had a fever and a chi l l from exposuret o co ld . O n the fol lowing Tuesday his wi fe gaveh im a hot toddy . A l i t tle whi le afterward , whiles i t ti ng i n a chair

,a queer l ook $ came over h is

face , so h i s wi fe states , and for a few minutes h e$ talked thick ,

$ but after that had no furthertrouble . He has never had an y headache .

He has had at l east three cons iderabl e haem or

rhages from the bladder . He i s n o t qu it e sure,but

thi nks that the haemorrhages came on on ly at theend of mi c turi t ion , except the las t t ime , when theurin e was un i formly bloody from the beginn ing .

The longest of these haemorrhages con t inued for twoto three days . By spel ls the u ri ne has been al tern a tely c lear and bloody , and i ts passage at tended

6 K E E N

wi th considerabl e soreness , which passed away assoon as the haemorrhage occurred .

O nce he passed a small cal culus the si ze o f a pea ,and probably one hundred of about the si ze of api n - head these last at varying t imes .Opera tion , Deeemher 26 , 1 889. I was assis ted

by Professor B ri n ton and Drs . Horwi tz and Copl in . O wing to the bad condi t i on of hi s kidneys ,chloroform was given instead of e ther . The fieldof operat i on was thoroughl y prepared th e daybefore . Pete rsen ’s bag was i n serted in to the rec tumand d isten ded wi th twelve oun ces of warm water . Ihad n ot examin ed hi s bladder ins trumental l y before ,as i t gave him great pai n even to i n troduce a softi nstrum en t

,and i n $ i ew of hi s general poor heal th

and the damaged cond i ti on of h is kidneys , I de termined n o t to give an anaesthet ic twice . In orderto fi ll the bladder as wel l as to explore i t , I nowintroduced a si lver catheter . The instan t i t en teredI struck an eviden tly large stone . A fter wash ingout the bladder

,n ine oun ces o f warm , boi l ed water

were i n troduced through the cathe ter ; as soon asthi s l imi t was reached the water began to escapealongside o f the catheter

,and to preven t i ts further

escape,rubber tubin g was t i ed around the pen i s .

Notwi thstand ing th i s d oubl e d ilatat ion , th e bel lywas s t i l l resonan t down to the pubes , though theresonance sl ightly d imin i shed as the pubes wereapproached . An i nci si on w as m ade ln the middlel in e from the pubes three inches upward . A S soonas the bel l y wal l was cu t through

,the peri toneum

was encoun tered , reaching al l the way to the pubes .I t was read i l y l i fted to the u pper end of th e in c is i on

,

bu t as i t was more than usual l y th in,and requ ired

an add i t i onal assistan t,I de termined at once to ge t

rid of th i s necessi ty and danger,by plac in g the

pati en t i n T rendelenberg’

s posi t i on . A tal l,s tout

S U P R A P U B I C C Y S T O T O M Y . 7

nurse,wi th his back to the pati en t ’s peri n eum , t ook

the pat i en t ’s knees over h is sho ulders and thus l i ftedthe pelvi s abou t a foo t from the table . The perito neum at once d isappeared at the upper extremi tyof the inc is i on . The bladder was s t i l l so deep thata possib i l i ty , even , of i ts rupture from the inj ec ti onsugges ted i tsel f to me . I t was found , ch iefly by theai d of the catheter wh i ch had been placed i n i t , ata depth of three i nches from the sk in . Several largevei ns were firs t l igated , both on the bladder -wal land i n the con nec t ive tissue i n fron t o f i t . Thebladder was then open ed , and one large and th reesmal l s tones removed . The smal l s t ones were abou tthe si ze o f $ ima bean s ; th e large one crum bleddown

,under the grasp of the forceps , i n to a numbe r

o f fragmen ts ; the stones were phosphat ic . Theweigh t of all that was recovered was j us t 600 gra in s ,and I estimated that fifty or s ix ty grains were los ti n th e debris i n washing out the bladder . T he

wal l of $ the bladder was much pocke ted , and thethree smal l s tones were found i n these pockets ,and would almost i nevi tabl y have been overl ookedhad any other operat ion than the suprapubic beendone . They were read i l y ex trac ted by the finger i nsearchi ng for fragmen ts . The prostate , which hadbeen found but l i t t l e en larged toward the rec tum ,

was greatl y enlarged on the vesi cal aspec t , the eh

l argemen t be ing ch iefly i n the middle l i ne and tothe righ t , formi ng a un iform , roun ded mass , bulgingi n to the bladder jus t behi nd the orifice of theure thra

,but not blocki ng i t . Prostatec tomy , there

fore , was not done .The walls of the bladder were rugose and about

three t imes thei r n atural th ickness . The wound i nthe bladder was no t cl osed . A drainage - tube ofsoft rubber wi th a bulbous end was i n t roduced i n tothe bladder . A s there was so large a space be tween

8 K E E N,

the bladder and the abdomi nal wal l,I th ough t i t

pruden t also to i n troduce a second drainage - tubefor the first forty - eigh t hours i n to the pre - vesi calspace . The abdominal wa ll was then closed byin terrupted sut ures

,the two drainage - tubes coming

ou t toge ther at one i n terspace .

3 1 st. Reac ted very wel l from the operati on . Fo r

two days he had sl igh t vomi t ing , and on th e thi rdand four th days cons ide rable hiccough

,whi ch

yiel ded to one - quarte r grain doses of cocaine . H IS

temperature fluc tuated between andonl y on ce reaching The wound was i rr igatedth rough the dra i n age - tube wi th warm bori c aci dsolu tion . The pre - vesical d rainage - tube was re

moved a t the en d of forty—e i gh t hou rs .When I l e ft h im at 5 P . M . on the 30th (th e

fourth day) I fel t very wel l sati sfied wi th hi s cond it i on and qui te assured of his recovery . So far ascould be j udged , the amoun t of urine secre ted w asample , and there was n o danger apparen t l y fromthe kidneys . A t P . M . on the n igh t of the

3 o th acu te oedema of the lungs se t i n,followed by

death i n s $ ven hours . No post -mortem could beobtai ned .

REM ARKS —This O perati on was onl y undertakenin v iew

l

o f the urgen t symptoms The bad cond it ion of the ki dneys and his ser i ous an teceden this tory o f ce rebral d i s turbance o f course con traind icated operat ion

,but hi s su fferi ng from the

s tones i n the bladder was so in tense tha t rel ie f wasabsolu tel y necessary . That l i fe was terminated bythe sudden oed ema i s no t to be wondered at i n viewof the renal compl i cati on s .

N0 case ever showed me be t ter th e value of Tren

delenb erg’

s pos i t i on . The momen t he was placed

S U P R A P U B I C C Y S T O T O M Y . 9

i n that posi t ion , not on l y d id the peri toneum fal ldown and away , but the bladder was made accessibl e ,al though being so deeply placed . Nei ther the rec talbag nor fi l l i ng the bladder wi th water raised i t tothe abdominal wal l

,and I was ser iousl y afraid that

the bladder had been ruptured,al though n o more

water was inj ec ted than the capac i ty of the bladdereasi l y perm i tted .

CASE I$ . P apz'

t/onza of the M adden ; rem ova l oysaprapaoz

'

e eyetotonzy ; reeooery.—M r. S .

,aged fi fty

seven . (The fol l owing h istory was furn ished byDr . $ orin i , his med ical attendant . ) Famil y hi storynegati ve ; no cancer . He had malaria i n the s ix tieswi th bi l iary fever . He had marked t rouble wi thhi s gal l -bladder from 1 8 78 to 1 88 1 , and visi tedCarlsbad , s in ce which t ime he has had n o return o fthe trouble . There i s n o h istory o f uri nary calcu

l us or gravel . In 1 885 he had an attack of cysti ti swi th blood i n the urine for a few days . He wasc i rcumc ised i n‘

1 8 8 7 . For th i rty years he has hada sense of d isc omfort in the smal l of th e back .

About August 1 , 1889, after a horseback ride atO cean Beach , N . J .

,bl eed in g from the bladder

began,bu t yie lded to i n ternal remed ies after two

days . August 1sth ,another attack came on and

cont i nued for a few days,but y ie lded agai n to the

same remed ies . In January , 1 890 , a th ird at tacklasted for n i n e weeks

,i n spi te of i n ternal remedi es

and the actual cau tery over the back . In Apri l andMay hi s bladder waswashed out wi th bori c ac id andn i trate o f si lver solution s of various s trengths . Afterfive days the bleed ing stopped

,but re turned agai n

abou t the m idd le o f Jun e,and con t i nued up to the

m idd le of August,i n sp i te of the use of the n i t rate o f

si lver and boric ac id soluti on . He spen t the summer

10 K E E N ,

i n Maine and gain ed greatly i n heal th . The capac i tyof the bladder was und imin ished

,and the uri ne

con tained nei ther casts nor albumi n when there wasno blood . There was sl i gh t prostati c tenderness .The blood was always thoroughl y mixed wi th theurin e from the very start , whether drawn by catheter or voided volun tari l y . C l ots were passed fromt ime to t ime . These were of irregular shape andseemed to b e fewer and smal ler when he led a n ac tivel i fe

,more numerous and larger when he rested . No

shreds o f t issue have ever been found , in sp i te o fthe most care fu l watch ing , except o n e minu te specim e n ,

which was thought to be papi l lomatous , andthe deeper cells poss ibly sarcomatous , by Dr . F . A .

Packard .

N ooemher 13 , 1 890, the haemorrhage re tu rnedmore profuse l y than ever

,and has con t inued to the

presen t t ime,i n sp i te of i n ternal remed ies

,washi ng

ou t the bladder , hypodermics of ergo ti ne , e tc .

S ta tus preesens, Dec. 7 , 1 890. When I saw himfor the fi rst t ime , at th i s date , I found a short , s toutman who appeared to be in good heal th

,but wi th an

anaemic , pale sk in , and who was evidently suffe ri n gfrom the men tal depress i on inc id en t t o the continued haemorrhage . He had lost but l i t t l e flesh , andhis anaemic appearance , as was s tated to me by Dr .$ orin i , who h ad known him for many years , andunder whose care he now was , was habi tual and n ota resu l t of the bleed ing , a rather surpris i ng fac t i nvi ew of the amoun t of bl ood los t . I saw him voidhi s uri n e , which was porter - colored from the fi rstdrop . There were some smal l c l o ts of i rregularshape

,and from the amoun t o f ur ine passed and i ts

color and clo ts I est imated that the amount o f bloodlo st was not far from hal f a pin t a day . Dr . CrozerGriffith examined a spec imen o f the u ri n e for me .

I t showed no casts 5 a large amoun t o f blood was

S U P R A P U B I C C Y S T O T O M Y . I I

presen t , wi th an excess o f wh i te blood - cells , whichi n some places were adheren t t o each o ther i nmasses , as i n cyst i ti s and other suppurat ive processes . No epi thel ial cells were found . Fragmentsof poss ibl e ti ssue were examined and found to beonl y c l ots which had rested somewhere i n theuri nary trac t suffic i en tl y l ong to become largel yfib rin o us. T he urine con tained 2 per cen t . of urea .

T he blood coun t Showed blood cells, 5 3per cen t . of haemoglob in , and n o plasmod ia . A

careful examinat io n o f the region both o f theb ladder and the kidneys

,not only by mysel f but by

Drs . $ orin i,W . J . Taylor , J . Will iam Whi te , and

Wi l l iam Pepper,was en ti re l y negat ive . There was

n o dulness , no tendern ess , no pai n , but simpl yhaematuria and noth ing more . O n December 1 3 ,1 890 , I attempted to examine the bladde r by thecystoscope , but was unsuccessful i n de tec t ing an ything . The bloody urine was fi rst drawn and re

placed wi th a warm boric ac id soluti on , bu t i n spi teo f the most carefu l use nothing further could beseen .

The day after the use of the cystoscope he oh

served ih uri natin g that some ai r or gas bubbledou t . I attributed th is natural l y to some ai r wh i chhad been i nj ected in to the bladder wi th the fluid ,but he cal led my atten tion to thi s d ifference : thatat the presen t time the gas produced no pai n , butthat when air was i nj ect ed i t produced dist in c t pai nas i t often had done a year ago when

'

washing ou thi s bladder . Thi s d ischarge o f ai r or gas has contin ued up to the presen t t ime . I t does n o t occurwi th each ac t o f uri nat ion , but occurs at leas t oncea day , and takes place at the end of urinat ion , no tat an y other time . I t i s especial l y n ot iced whenhe strai ns to press out the last few drops from the

bladder . So far as he can observe the gas has n o

K E E N ,

odor,and I have observed that the uri ne has n one ,

n or have the c l o ts that have been pas sed . He hashad no pai n i n hi s bladder or rec tum .

His wife t el l s me that she th i nks there i s a d i st i nctl oss o f s trength i n the las t few weeks , and also thatfor the last year or more he has been more d rowsythan formerl y .

Opera tion ,Deeern her 29, 1 890 . Ass is ted by Drs .

J . Will iam Whi te,Wil l iam J . Taylor , O rvi l l e Hor

witz , J . C. Da Costa and Dr . $ orin i , h is physi c ian .

The bladder was first washed out and then fi l ledw i th 9 ounce s o f a boric solu tion , a drachm to thepin t . T he Petersen bag i n the rec tum was then d il ated wi th warm water

,bu t as soon as the capaci ty o f

e igh t ounces was reached the res i s tance became s ogreat that I des i s ted from in troduc i ng any more . Ani nci s ion i n the median l i ne d isc losed the bladder ,which was secured by two l igatures and then incised .

As soon as the finger was i n troduced I perce ived asmal l tumor near the right ureter . Wi th the elec tr i cl ight i t was i nspected , though wi th some l i t tle difficul ty . In doing so I used both Watson ’s vesicalspeculum and my own

,but each had to be sup

plem en ted by a long pai r of forceps to push backthe posteri or wal l o f the bladder . T he tumor wasabou t the s ize of the end of the forefinger , say al i t tle over hal f an inch i n d iameter

,and abou t the

same i n elevati on . I t was strawberry - l ike i n i tsappearance , though not qu i te so red . Near to i twere two other small el evati ons o f the s ize o f amoderate pi n - head , which were though t possibly tobe the begi nn ing of sim ilar growths . There w ereseveral o ther very minute growths , but so smal l asto make i t d oubtful whether they were norm al orpathol og i cal .The tumor and the two smal l elevat ion s near i t

were se i zed by the forceps and drawn forward som e

S U P R A P U B I C CY S -T O T O M Y . 13

what forc ibly,and the mucous membrane for some

l i tt le d i s tance around the base was removed wi th thetumor by curved sc issors . The bleed ing was verymoderate and required no special means for i ts c ontrol .O ne s t i tch was put i n the wound i n the bladder

and four st i tches i n the abdominal wal l . Twodrainage - tubes were i n troduced

,one i n to the pre

ves ical space and the o ther in to the bladder, bothsecured i n place by st i tches i n the skin . A l argewood -wool dressing was then appl ied over thewound , and aris tol o i n tmen t sp read over the abdomen under the dressing . The dre ssin g was to bechanged whenever i t was wet

,and the bladder to

be washed ou t wi th a warm bori c acid solu t ion .

He was put to bed i n a very fai r cond i t ion . During the operati on T ren delenb erg

’

s posi t ion was alsotried , bu t i ts a dvantages were n o t very mani fest .S ti l l there was

,I th ink

,sl igh tly greater ease o f ac

cess t o the bladder . The ureters were seen and anattempt was made to catheterize one o f them , butwi thou t obtain ing any urine . In j us t ice to the procedure

,however

,i t should be said that we did no t

persis t long enough , probabl y , to make the attemptvaluable . We had found suffic ien t to accoun t forh i s cond i t i on , and we d id no t deem i t j us t to h imneed lessl y to prolong the operat i on .

No commun i cat ion was d i scovered between thebladder and the bowel

,though the in ter io r was

care fu l l y exam ined at every poi n t .

j a nu ary 1 , 1 891 (the th ird day) . S in ce theoperat ion , now three days , he has gone on stead i lyimprov ing . His highest temperature was on then igh t fol lowing the operat ion

, S i nce which t ime i thas been 99

° and a frac ti on . The wound looks perfectly wel l . O n the second day he developed spasmod ic pain , which he re ferred to the pros tate , the

14 K E E N

attacks of whi ch were qui te severe . Thinki ng that i tm ight be due to the pressure of the en d of the drainagetube i n the bladde r

,I removed thi s rubber tube and

replaced i t wi th a shorter tube of glass , but duringyes terday , his pains be in g so severe , Dr . Whi te , asI was absen t from the c i ty

,removed the t ube from

the pre - vesi cal space . This was not fol l owed byimmediate rel ief, bu t wi th some amel iorat i on ofthe attacks

,and finall y the i r d isappearance at the

end of abou t twenty - four hours . T he tube i n thebladder I removed tod ay . His appet i te i s verygood , so that he enj oyed a smal l chop yes terdayand a small beefs teak to - day . His sleep has beenve ry fai r .

3 d (fi fth day) . He has had a good deal of vesi calt enesmus

,for which I cannot see any reason . The

wound l ooks wel l . Two of the four st i tches wereremoved tod ay ; some sm all shreds of S l ough ingcon nec tive t issue came away . In exami n ing the

rec tum a few days ago Dr . Whi te th ought he detec ted a n ipple - like prominence

,j us t as would exis t

i f there were a fistulo us open ing i n the rec tum ,and

at the operat ion a pouch i n the posteri or wall ofthe bladder was d iscovered

,which possibly corre

spo nds to th is , al though no open ing or o the r lesi oncould be detec ted ei ther at the operat ion or si n ce .

A large enema yes terday empt ied the bowels thoroughly

,and there has not been , either from the

bladder or from the bowels , any evid ence o f comm un ica tio n between the two .

From this t ime on he improved very rapid l y . Hispai n quickly lessened and the wound c losed at theend of five week s . S i n ce that t ime he has been

perfec tl y we l l . The re has bee n no escape of faecesor of gas from the urethra , nor has there been thel eas t return of the bleed ing .

The tumor was examined by Dr . J . P . C rozer Grif

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I 6 K E E N,

amoun t o f albumi n i s presen t when there is bloodin the uri ne , but when there i s no blood the ur in ei s absolutely free from albumin .

Dr. Hearn examined the pat i en t some mon thsago , and bel ieved that there was a papi l loma in th ebladder . I admi tted him to the Jefferson Hospi tali n December, 1 8 89, and watched the urine wi thgreat care . No long

,sl ender cl o ts were at that

t ime found , but on ly irregular - shaped clots . Smal lfragments o f a possible papi l l oma were watched forcarefull y

,bu t only one or two were found at i n te r

vals , which were bel i eved by Drs . $ ongstreth andCopl i n to be fragments of a doubtful papi l loma .

The renal symptom s we re prac ti cal ly n it, for thepain i n the l oin was but sl igh t

,and scarcely more

marked on one side than on the other . No in creasei n the dulness over e i ther k idney was noted , norwas there any tend erness on pal pat i on by one handn or on bimanual exam inat i on . The tenderness n earthe an terior superior spine only existed when therewere c l ots i n the bladder

,and there i s no tender

ness at presen t .First operation , j anuary3 , 1 890. I explored the

bladder by the bouton n iere open ing . As soon asthe finger en tered the bladder , I foun d at the upperright wal l posteri orl y a soft , velvety mass . Whethe ri t was a tumor or the bladder-wal l I was not abledefin i tel y to decide . I in troduced a pai r o f smoothbladed stone - forceps unt il the bladder -wall wastouched , then wi thdrawing them hal f an in ch andc losing the jav

‘

vs I found that I had grasped someth ing

,which by trac t ion gradual ly yielded wi th a

sensat ion as i f th read after thread was being torn .

In the j aws of the forceps was a flori d mass,l ookin g

not un l ike a bl ood - cl o t,but traversed by th reads

whi ch looked l ike fibrous t issue . Nothing l ikem ucous membrane was seen . A number of smal l

S U P R A P U B I C C Y S T O T O M Y . 17

masses were removed in this way,amoun t ing i n al l

to a mass about tw i c e as large as an E ngl i sh wal nu t .Tw i c e I tri ed S i r Hen ry Thompson ’s serrated tumorforceps

,but bo th times

,i n spi te of using every pre

cau ti on , I found that I had caugh t the b ladder -wall ,as was man i fested by i ts n o t yi e ld i ng after the samegen tl e trac t i on as be fore , and by the mucous m em

bran e be i ng d rawn i n to the wound . The bleed ingwas i nconsid erabl e . Watson ’s perineal drainagetube was i nserted .

He recovered from the O peration w i thou t diffic ul ty , the wound clos i ng i n twen ty days , at whichtime he wen t home . The urine at first cl eared up considerably, though afterward i t agai n became blood y ,bu t two months later i t wasalmost cl ear. T he massremoved was again submi t ted to Drs . $ ongstre thand Copl i n , but i n spi te of careful examinati on theywere s t i l l doubt ful whe the r the masses were bloodclots o r fragments of a papi l l omatous growth ,al though rather i ncl i ned to the latter opi n i on .

M ay 23 d. He has gain ed fi fteen pounds i nweigh t

,fee ls much be tter , a nd has had no pain

sinc e th e operati on . The urine has general l y beenc lear un t i l the last two or three week s , when thebl ood has reappeared , wi th smal l c lo ts . I haverepeated l y see n h im pass h is wate r

,both be fore the

operation and s ince,and i t i s uni forml y bl oody

from the star t .N o z/ernoer 15 th . I examined the bl adder by the

cystoscope , bu t coul d only see a un i formly redand apparen tl y heal thy bladder -wal l .S eco nd opera tion ,

N ooenzher 1 8 th , at the Jefferson Med ical Co l lege Hospi tal . N i ne ounces o fwarm boric - acid solut i on (four grai ns to the ounce)were inj ected i n to the bladder

,and eleven ounces

o f warm wate r i n to the rec tal bag . The i nj ec t i oni n to the b l adder alone produced dul ness of bu t one

18 K E E N

finger’

s - bread th above the pubes . This was inc reased , by fi l l ing the rec tal bag

,to i nches .

A three - i n ch i nc i s i on i n the midd l e l in e di sc losed

F1G . I .

M O$AB$E

the bladde r ve ry read i ly . The peri t oneum was n otseen . T he bladder was opened

,and th e edge s of

the openi ng caugh t wi th two haemostati c forceps . Aspec ial retractor , which I had devised (Fig. was

S U P R A P U B I C C Y S T O T O M Y . 19

th en inserted , i n order both to separate the rec t imuscles and the edges o f the open ing i n the bladder

,

and a small, hooded , two -candl e power e lec tric l igh twas used to examine the bladder . A pri or examinat ion by the finger the momen t that the bladder wasO pened gave an en ti rel y negative resul t . The examination by the el ec tr ic l ight was extremely satisfac tory ; on the righ t upper and poster io r wall o fthe bladder was seen a scar about one and o n e -hal fi nches in d iameter , ev ide n t ly the resul t o f the firstoperati on . I t was smooth and heal thy . I found a

good deal o f d ifficul ty in examining the posteriorwall , in asmuch as the bladder co n trac ted ‘

as soon asthe water escaped , and was thrown i n to d eep folds .By, in serting the angular large haemostat i c forcepsor ped i c l e forceps

,and O pen ing the blades

,I was

able to push the bl adder upward and unfold th ecreases in i ts wal l . To obviate th is d i fficul t y I havelatel y d evised another i nstrumen t (Fig . 2) which asye t I have no t had an opportun i ty to t es t . I thend iscovered between and above th e orifices o f theureters a smal l ulcer , a scant quarter of an inch i nd iame ter , possibl y tubercular . A piece of thebot tom o f i t was p in ched off for examinat ion mi crosc0pically, but showed n o bac i l l i .I found that I could exami ne the pos teri o r wal l o f

the bladder a great deal better when th e rec tal bagwas removed . The or ifices of the two ure ters wereseen , and both suc cessfull y catheteri zed . From the

l e ft u re ter bloody urine was obtain ed,and from the

right one clear u rin e .

When th e urin e escaped in to the bladder no d ifference i n the urine from the two ureters was percept ible , as the red wal l o f the bladder made both lookal ike . But when they were col lec ted i n a Smal l glasscup the d i ff erence i n thei r appearanc e was instan tl ypercep tible .

20 K E E N,S U P RA P U B I C C Y S T O T O M Y .

F IG . 2 .

B ladde r- di lat ing in s trum en t .

To fac i l i tate th is ureteral cathe terism I have devised an angular catheter wh ich I bel i eve wi l l be ofservi ce (Fig .

The open ing in the bladder was then st i tched ,except at i ts l ower end , where a drainage - tube wasi nser ted . The external wound was part l y c l osed .

Deeernher 8 (three weeks) . The patien t wen t hometo -day . The drainage - tube was removed on thesecond day afte r the operation . The res t o f thewound healed very we l l , but the openin g i n the

bladder d id not cl ose un t i l two weeks after theoperat ion . U nt i l that t ime the urin e had bee nmuch freer from blood , bu t i t n ow became muchmore blood y. No espec ial i nc iden t at tended hisrecovery . He s t i l l has bloody uri ne . Wheneverh e i s ready I in tend to explore th e le ft kidney .

2 2

REM ARKS —In the case o f M . H . (Case $ . ) I havebeen a good deal puzzled as to what i t was that Iremoved at the firs t operat ion . Ce rtai n i t was thatthe mass was adheren t to the bladder wal l

,and cer

tai n i t was , also , that it was no t the mucous membrane . The d i fferen ti at i on by means o f the twokinds o f forceps was perfectl y c lear. In some waythe blood - cl o t apparen tl y became attached to th ewall of the bladder and suffic ien tly at tached for i tsremoval to leave a vis ible scar .T he catheteri zat i on of the ure ters i n th is case by

the aid of the e l ec tri c l igh t was per fec t . I b eg tocal l especial at ten ti on to the fac t that the d i fferencei n the color of the ur ine from the two kidneyscould not b e n oti ced so long as the urine escapedi n to the bladder , for the un i form redness o f th e

mucous membrane preven ted the true col or frombei ng detec ted . O nly when the water was drawni n a glass was the d i fference betwe en the two d istin c tly perceptibl e . Whether the haematuria whi chi s now determined to be from the left kidney i s acase of haemophi lia, pure and simple , for whichBrown 1 has recen tly done a successful neph rec tomy

,

or whe ther there i s any true d isease o f the l eftkidney I do not know. I t was on ly after the catheteriz atio n of the ureters that the sign ificance of the

slender , cyl indrical clots was real ly known . I t i strue that the quest ion of ure teral c l o ts had beenconsidered , but ye t when I saw him noth ing had

been seen that resembled them ,nor was i t at all

1 Am er ican Jou rn al o f th e M edical S cien ce s , No vem be r, 1 890,

p . 5 2 2 .

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