Selected cases from the surgical clinic of Frederic S. Dennis / reported by Thos. M'Cann.

Frederic Shepard Dennis

Date:: [1886?]

Credit: Selected cases from the surgical clinic of Frederic S. Dennis / reported by Thos. M'Cann. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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primary adhesion was found in all the wounds.) Case I. The first case to-day is one of stone in the bladder, which I will remove by the supra-pubic operation. The patient, T. P., eet. 24, single, and a cigar-maker by occupation, gives the following history, which presents some characteristic symptoms :— The family history is negative, with one exception, his mother having died of can. cer. The patient states that he has been troubled since he was five years of age. At that age he first passed bloody urine, and he has passed blood since then. He always ex- periences pain on micturition, and frequently the flow of urine stops suddenlj'. This stop- page is accompanied by severe pain in the end of the penis, and this is followed by a slow dribbling of the remaining urine. He has had periods of variable length, the long- est being two years, in which he has not suf- fered from symptoms of stone. His urine, HS a rule, is filled with stringy mucus. The pubes and hypogastrium having been shaved, the patient is anassthetized, lying on his back with his buttocks slightly elevated. I insert into the rectum, in the grasp of the in- tei-nal sphincter, a rubber bag, and distend it by injecting warm water (about ^xii). Next I throw into the bladder eight ounces of warm, weak solution of boro-salicylic acid to distend it. This new procedure has for its object the increase of the distance between the symphysis pubis and the anterior cul de sac, or pubo-vesical fold of the peritoneum. For it is through this space that we are to open the bladder without opening the peri- toneal cavitjr. I now make my incision through the skin and cellular tissue from a point three inches above the symphysis, and extend it on to the front of the symphysis, ex- posing the linea alba. I now cut through the linea alba on a director between the pyraraidales and recti muscles, dividing the transversalis fascia. I come upon a cushion of loose fat. If, as often happens, the pyra- midalis muscle is exposed, by dividing the sheath of the rectus instead of going exactly through the linea alba, you must bear in mind that there is no posterior sheath to these muscles in this locality, but merely the trans- versalis fascia. This fascia having been di- vided in either case, I tear through the underlying fat with two thumb forceps, the edges of the wound being retracted by my assistants. I have now exposed the wall of the bladder, with its veins and muscular fasciculi showing on the surface. I now pass a silver catheter into the blad- der and make its point push carefully the anterior wall of the bladder into the woimd. If uncertain whether or not the peritoneum is out of danger, you may carefully observe whether you have two sliding surfaces lying over the front of the wound. Having assured yourself that you have to do only with the wall of the bladder, you have it seized and held with two tenacula, while you make an incision between them into the bladder. Here, one is apt to be dis- concerted by finding the mucous membrane of the bladder very thick. Now, taking a probe pointed bistoury, I continue the in- cision with caution down to the symphysis, never below, towards the urethra. Next a stitch is taken in the bladder wall on each side of the incision, by which means the aperture may be conveniently held open. The finger is now introduced into the bladder, the stone found, and seized and removed with lithotomy forceps, since it is not so large as to necessitate crushing. The colpemynter hav- ing been removed, a finger introduced into the rectum may facilitate j^our manipulation at this point. The stone being removed, a cath- eter is placed through the supra-pubic wound, which is then closed by deep sutures extend- ing through the integument and muscles. Another catheter will be passed and re- tained in the urethra for forty-eight hours. Supra-pubic lithotomy was first performed by Pierro Franco in 1561. The rectal air bag was advocated by Peterson, Gosselin and Bois. For some reason, the operation fell into disre- pute, or at least disregard, from which it ha?^ been rescued only recently by Garson, of the Royal College of Surgeons, of London, who first suggested the water-bag col peurynter. and other experiments. It is to be, undoubtedly, the lithotomy of the future. It is especially

Selected cases from the surgical clinic of Frederic S. Dennis / reported by Thos. M'Cann.

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