Page images
PDF
EPUB

is ready for the operation. With a small scalpel I make an incision through the skin and superficial fascia in the median line, commencing about two inches above the pubic bone and extending down to the level of its upper border. The recti muscles are now exposed, and I separate their fibres with the handle of my knife, and the wound is deepened to the transversalis fascia. This I incise, and you see the prevesical fat, which always lies just in front of the bladder. There are several large veins running through it, so I shove them aside without injuring them, and scratch through the friable tissue. My finger now rests upon the wall of the bladder, and I can plainly feel the fluctuation of the water it contains. Formerly I used to hook the bladder with a tenaculum before opening it, but this is unnecessary. I place the back of my knife closely against the upper border of the pubis, and boldly push its point through the wall of the bladder and cut upward about half an inch. You can see by the gush of water that its cavity has been entered. Before all the fluid can escape and the bladder contract, I introduce my finger through the opening I have made and examine the interior of the viscus. There is no stone. The prostate is greatly enlarged. The mucous membrane lining the bladder is 'thickened and hypertrophied. My assistant lets the water escape from the rectal bag, and removes it from the rectum, and the bladder sinks down in the pelvis to its normal position. I follow the bladder as it descends into the pelvis with my finger. I introduce a rubber catheter along the finger into the bladder, and, to prevent its slipping out, I take a stitch through its walls and the skin at the margin of the wound, and the operation is completed. It has not taken me more than two minutes, and I have used no instrument except this little knife. The loss of blood has not exceeded a teaspoonful, as the incision has been made through tissues which contain no vessel large enough to be dignified by a name.

The wound is dressed simply by laying some gauze around the catheter, and the patient is put to bed, and the free end of the catheter inserted into the neck of a bottle to catch the urine, which it will siphon from the bladder as fast as the kidneys excrete it. No stitches are employed, nor any effort made to approximate the surfaces of the cut. The wound will heal by granulation, and in two weeks only a fistulous tract will be left in the line now occupied by the catheter. You might naturally ask why the result which I accomplish could not be secured by distending the rectum, filling the bladder with water, plunging a trocar into it, and inserting a drainagetube through the canula. This has been tried, not by myself, but by

men who possess greater confidence and boldness, with disastrous results. Urinary infiltration occurred, and the lives of the patients were saved only by prompt and heroic measures.

FIG. 2.

The after-treatment of the patient I have operated on is simple. He will be kept in bed for two or three weeks until the wound heals, his urine kept acid by the administration of lemonade or drugs, and his bowels kept open by the regulation of his diet or the use of simple laxatives. At the end of two or three weeks the wound will have become cicatrized, and the artificial urethra lined with a coating closely resembling, if not identical with, true mucous membrane. The patient will then be allowed to get up, and a silver plug or stopper (Fig. 2) will be placed in the opening.

suprapubic urethra.

This plug should have a diameter of about a Silver plug for artificial No. 12, American scale, bougie, and should be just long enough to enter the bladder. Its purpose is to keep the opening patent, and to act as a stopper and prevent dribbling of urine. It should be constantly worn, and never taken out except when the patient wants to

make water.

Some sort of belt has to be worn to prevent the plug from slipping out and being lost, and the contrivance shown in the accompanying cut (Fig. 3) has been devised by one of my patients. It consists essentially of a belt which goes around the hips and passes over the plate of the plug, thus retaining it in its position. This belt is prevented from slipping up or down by being attached to a second belt above, which is supported by the hips, and by perineal bands which encircle the thighs.

The result of the operation for the formation of an artificial urethra has been

FIG. 3.

in suprapubic urethra.

very gratifying, both in my hands and in Apparatus for retaining silver stopper those of other surgeons. The patients

can retain their water without discomfort from three to six hours in the day, and from six to eight hours at night, cystitis rapidly dis

appears, and often the prostate shrinks so that the patient can again pass his water by the natural channel. In these cases the great anxiety of the patient to keep the artificial channel open, and the fear he shows of its closing, are strong attestations to its merits.

Only yesterday a patient came into my office for whom I had made this artificial opening in his bladder eight years ago, to consult me for some other trouble. He still passes his water through the suprapubic opening, and, although his condition is not entirely free. from annoyance, he has no pain or discomfort.

TENO-SUTURE AND TENDON ELONGATION AND SHORTENING BY OPEN INCISION; ADVAN

TAGES AND DISADVANTAGES OF THE VARIOUS METHODS.

CLINICAL LECTURE DELIVERED AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL.

BY H. AUGUSTUS WILSON, M.D.,

Clinical Professor of Orthopædic Surgery in the Jefferson Medical College and in the Woman's Medical College; Professor of General and Orthopædic Surgery in the Philadelphia Polyclinic and College for Graduates in Medicine, etc.

GENTLEMEN,-In a former clinic you saw the subcutaneous methods of dividing tendons demonstrated by suitable cases, and heard the merits of each one discussed and the disadvantages indicated. This morning I shall speak of the different open methods of splicing, shortening, and elongating tendons, and shall endeavor to point out clearly the advantages and disadvantages of each one, and illustrate them.

Subcutaneous tenotomy obviates, in a great measure, the risk of suppuration, but at times the disadvantage of failure of union obtains, whether from simple failure of the tendon ends to unite, or from nutritive or suppurative changes, or from muscular action disturbing the relation of the ends. Again, faulty union may occur from insufficient tendon surfaces being in contact, or from the united portions being too small and thin, thereby causing a weakness of the parts: so that in doing a tenotomy or a teno-suture many points must be carefully considered in order to insure safe and good results. In cases with inactive muscles the results are apt to be much less satisfactory than otherwise, as there is generally interference with nutrition.

Cases which have previously had cellulitis or traumatism about the tendon frequently prove very unsatisfactory because of the cicatricial tissue in the part and the danger of again exciting the inflammatory processes.

1 Reported by J. Torrance Rugh, M.D., chief clinical assistant of the Orthopedic Department.

Simple division of the tendon does not always allow sufficient correction of the deformity; for example, after an abscess in the foot, contractures, due to the adhesions about the tendinous parts and the extensive infiltration of the connective-tissue structures, prevent correction, even though tenotomy has been carefully and thoroughly done. In such cases the open method is much the safer and surer, as all other contracted tissues can thus be readily reached.

One of the first methods of elongating other than by simple division was suggested about six years ago by Dr. J. Neely Rhoads, of Philadelphia. It is done subcutaneously, and a knife (Fig. 1) for the pur

FIG. 1.

Allis' knife for Rhoads' operation.

pose was devised by Dr. O. H. Allis, of Philadelphia. This knife has a long shank and a short blade with a curved cutting edge. The method of procedure is as follows. After puncturing the skin above the upper point of division, introduce the knife-blade flatly between the skin and the tendon, turn it, and cut through the middle of the tendon, longitudinally, for the required distance, then cut out at one side and withdraw the knife. Introduce it at the lower end of the longitudinal incision and cut off the opposite half of the tendon. Elongation can thus be accomplished and the ends be allowed to overlap for tendinous union. No sutures are employed, as the entire procedure is subcutaDr. Rhoads also suggested the use of this method in lengthening nerves and bones. Where but a small amount of lengthening is desired, he suggested (Medical News, November 28, 1891) cutting half through the tendon at different levels and from opposite sides, leaving some longitudinal fibres to slip on each other, thus gaining slight elongation.

neous.

Where lengthening of the tendon is desired, and splicing and tenotomy are inadvisable, Dr. F. Lange, of New York, suggests (Medical News, January 9, 1892) cutting the tendinous portion in the fleshy part of the muscle. The muscular fibres are easily stretched the desired length, and there is no risk of non-union of the tendon.

Mr. Anderson, of London, on October 18, 1889, devised and practised a method (London Lancet, July 2, 1891) of tendon elongation, which, though the tendon is incised similarly, differs from and excels Dr. Rhoads' method in being done openly and with sutures through

« PreviousContinue »