Epicystic Surgical Fistula for the 
Relief of Vesical Catarrh. 
JOHN D. S. DAVIS, M.D., 
BY 
OF BIRMINGHAM, ALA. 
Read by Title in the Section of Surgery and Anatomy, at the Fortieth 
Annual Meeting of the American Medical Association, June, 1889. 
Reprinted from “ The Journal of the American Medical 
Association,” February 8, 1890. 
Printed at the Office of the Association. 
CHICAGO : 
1890. EPICYSTIC SURGICAL FISTULA, FOR 
THE RELIEF OF VESICAL CATARRH. 
The treatment of vesical catarrh by suprapubic 
drainage, irrespective of the causes producing the 
disease, is not only the most rational, theoretically, 
but the most available and successful. Such has 
been the palliative, restorative and curative effect 
of suprapubic drainage in cases of suppurative 
cystitis that I have treated by this method, that I 
have repeatedly resorted to it, with the happiest 
results. 
A close observation of my cases, though at first 
giving me much anxiety and apprehension, taught 
me the valued lesson of suprapubic drainage in 
cystitis. The epicystic fistula gives a desirable 
continuous drainage, I have not been able to get 
by any other method. The fistula possesses the 
ability, through the recti muscles, and a possible 
pseudo-sphincter, to control the urine at all times. 
The pseudo-sphincter muscle is formed, no doubt, 
by the fibres of the detrusor urinse. 
I have tried drainage of the bladder by perineal 
incision, in the treatment of vesical catarrh ; but 
in no instance did I get such results as in the 
cases treated by a direct opening into the bladder 
above the pubis. 
September, 1888, I was called by a physician 
friend, Dr. J. C. Dozier, to see a patient with him. 
The man, Mr. 8., had retention of urine from an 
impassable stricture of the urethra and enlarged 4 
prostate gland. I aspirated his bladder of 
pints of alkaline urine, containing pus and mucus. 
The patient was able to pass a very small stream 
of urine the next day and would not be operated 
on for the relief of the stricture. Three months 
later I was called to see him, and found him suf- 
fering from extravasation of urine into the scro- 
tum as the result of an unsuccessful attempt to 
draw his urine the day previous. The contusion, 
puncture, etc., resulted in an extensive extravasa- 
tion into the scrotum, perineum, and above the 
pubis. I found him with a severe chill, tempera- 
ture 1060, and pulse 140. I feared extravasa- 
tion into the peritoneal cavity and suggested to 
the family the possibility of having to open the 
peritoneal cavity at once. I, however, resorted to 
draining the bladder above the pubis. Seven days 
after the suprapubic puncture I performed internal 
urethrotomy for relief of penile stricture, and began 
the treatment of the enlarged prostate by electrol- 
ysis. The bladder was irrigated with hot water 
twice daily for ten days. Electrolysis was used 
on prostate every third day for ten times, when it 
was discontinued. The fistula was kept open for 
thirty days, when it was allowed to close by its 
own continuity and repair. This was accomplished 
in about ten days. The man is entirely well and 
at his business. 
Mr. A., set. 57 years, had been suffering from 
vesical inflammation for six months. For several 
weeks before he consulted me he passed his water 
with much pain. He had rigors and exhaustive 
night sweats. His temperature would go up for 
two or three days at a time, and would be fol- 
lowed by two or three consecutive days of only 
slightly elevated temperature. He had frequent 
lumbar pains shooting toward the bladder and 
hip, retraction of right testicle, and tenderness on 5 
pressure over the right kidney. Had frequent de- 
sire to urinate, with inability to pass his urine. 
Urethra competent. Prostate gland was slightly 
enlarged. Urine contained pus and mucus. Av- 
erage daily amount of urine 39 ozs. After the 
washing out of the bladder pus would soon accu- 
mulate in the viscus, which was conclusive to my 
mind that pyelitis was causing the progressive 
emaciation and hectic fever. 
Operated for the formation of the direct epi- 
cystic fistula for draining bladder and kidney. 
Bladder was washed out twice daily. Fever sub- 
sided on the second day. Patient is entirely re- 
lieved from pain; fistula well formed. He returned 
to his home on the thirtieth day. I hear from 
him, however, every second day, and he is im- 
proving all the time. If the pyelitis had been 
due to stone in the kidney it would not have dis- 
appeared so early. And, too, in such a case the 
fistula would offer but temporary relief to the 
bladder only. lam sure he will experience relief 
so long as he keeps the fistula open and washes 
out his bladder. By the use of my epicysticfistula 
plugx he will have no trouble in keeping the fis- 
tula competent. It is possible that he may in 
one or two years be able to let tbe fistula close in 
safety. It should not be allowed to close until 
every symptom of the disease has disappeared for 
many months. Specific gravity of urine June 5, 
1889 (forty-nine days after operation), 1020, no 
mucus and no pus. 
I was captivated by the enthusiastic reports of 
1 The author’s epicystic fistula plug is made to fill the fistula with- 
in one-third of an inch of viscus. The plug (which was first sug- 
gested to the author by his brother, Dr. W. E. B. Davis), is made of 
silver or vulcanized rubber and provided with a slight shoulder one- 
fourth of an inch from concavo-convex flange, which is grasped by 
the skin and held in position. Without the shoulder the recti mus- 
cles throw the plug out and prevent its retention. 6 
Dr. Hunter McGuire,2 otj his coffee-spout fistula 
for prostatic hypertrophy, and did epicystotomy 
for the formation of his coffee-spout fistula. Two 
cases have been reported,3 with no better results 
than have attended the direct suprapubic fistula. 
I adopted the coffee-spout fistula with the view of 
practicing it, but I am so thoroughly convinced 
that it does not possess the advantages attending 
the direct fistula, that I do not think I will ever 
resort to it again. 
In prostatic hypertrophy, where there is much 
distension of the bladder, due to retention of urine, 
and the bladder is prominent above the pubes, a 
sufficient opening can be made, by a single plunge 
of a large trocar or knife, for cystoscopic explora- 
tion and the formation of the fistula for intra-ves- 
ical treatment and drainage. If nothing more 
than drainage is necessary, the dread and shock 
of a technical epicystotomy (by a long incision) 
may be avoided, by giving the patient the benefit 
of a fistula in the manner suggested. I have re- 
sorted to this measure in cases of very old and 
feeble men, where I could not administer an an- 
aesthetic, with immediate relief to the patient. 
In conditions of the bladder where, by reason of 
a long-standing inflammation of the bladder, the 
viscus becomes contracted, it is necessary to make 
an incision through the integument, superficial 
fascia, muscles and transversalis fascia, sufficient- 
ly large to allow the bladder to fce opened for in- 
tra-vesical ocular exploration and operation. 
The technique of the operation for the forma- 
tion of the epicystic fistula, described in my recent 
paper4 before the State Medical Association of Al- 
2 Virginia Med. Monthly, October, 1888, pp. 445-456. 
3_Virginia Med. Monthly, April, 1889, pp. 1-5; Alabama Med. and 
Surg' Age, April, 1889, pp. 192-198; New York Med. Journal, April 
13, 1889, pp. 416, 417. 
4 “ Fpicystic Surgical Fistula for Cystoscopic Exploration, Intra- 7 
abama, and published in many of the leading 
journals of this country, was the result of my en- 
thusiasm over the coffee-spout fistula. My expe- 
rience with the formation of the direct and coffee- 
spout fistulae has taught me that the former is 
always practicable, as it can be quickly made in 
cases where an anaesthetic cannot be given with 
safety, and possesses every advantage attributed 
to the coffee-spout fistula, and is superior to it in 
the power to retain and expel the urine, by reason 
of a better power exerted through the recti mus- 
cles near the symphysis. 
Hence I consider it necessary to retrace my 
steps for the better consideration of the direct epi- 
cystic fistula, which I have formed for exploration, 
intra-vesical treatment and drainage, and recon- 
sider it under the following heads : 
I. Definition of epicystic surgical fistula. 
11. Surgical resources in the formation of the 
epicystic surgical fistula. 
1. Preparation for the operation. 
2. Anaesthesia. 
3. Position. 
4. Incision and opening bladder. 
5. Intra-vesical exploration and treatment. 
6. Toilet and after-treatment. 
111. Advantages of the epicystic surgical fis- 
tula. 
1. Cystoscopic exploration. 
2, Intra-vesical treatment. 
3. Drainage. 
1. Definition of Epicystic Surgical Fistula.— 
vesical Treatment and Drainage,” by John D. S. Davis, M.D., April, 
1889. Transactions of the State Med. Assoc, of Alabama, 1889; St. 
Douis Med. Review, May 4 and 18, 1889; The Journal of the Am. 
Med. Assoc., May 18, 1889, pp. 685-703; Ala. Med. and Surg. Age, 
May, 1889, pp. 247-256; Virginia Med. Monthly, May, 1889, pp. 147, 
148; Atlanta Med. and Surg. Jour., June, 18S9, pp. 204-212; The Amer. 
Prac. and News, May 11, 1889, pp. 294-298; Times and Register, May 
11, 1889, pp. 27-29; Cincinnati Med. News, April, 1889, pp. 217-224; N. 
Y. Med. Times June, 1889, pp. 87, 88. 8 
Epicystic surgical fistula is the title here given to 
a suprapubic fistula into the bladder, created by 
the surgeon ’for exploration, intra vesical treat- 
ment and drainage. A fistula which, acting as an 
artificial urethra, is capable of giving free access 
to the inside of the bladder for cystoscopic explo- 
ration, to provide a ready, convenient and com- 
fortable means of emptying the bladder at will; 
gives the surgeon a competent opening into the 
viscus for exploration of ureters; intra-vesical 
applications; drainage in pyelitis and in pyelo- 
nephritis. 
It constitutes an essential element in the speedy 
and complete evacuation of the contents of the 
bladder in all epicystic operations, and imitates 
nature in the restoratton of its own continuity 
and repair as the pathological changes within the 
bladder subside. 
11. Surgical resources in the formation of the 
epicystic surgical fistula. 
i. Preparation for the Operation.—All hair is 
to be shaved from the pubes, and all the details of 
antiseptic surgery are to be carried out so far as 
cleaning the pubes and abdomen. 
Except in those cases of hypertrophy of the 
prostate gland; paresis and atony; neurosis of 
the bladder, and in all forms of bladder inflam- 
mation accompanied with distension of the blad- 
der into prominence above the symphysis, where 
immediate epicystotomy, by puncture with a tro- 
car or knife, is necessary, two assistants, though 
not necessary, may be of valuable aid. 
A temperature of Bo° or 85° F. should be main- 
tained in the operating-room from the beginning 
to the end of the operation. The bladder is emp- 
tied and thoroughly washed with warm water. 
When the water returns clean, the bladder is 
slowly distended with warm sterilized water, 9 
thrown in by means of a fountain syringe, with 
nozzle in urethra—with a degree of pressure suf- 
ficient to distend the bladder to its utmost capac- 
ity—which can never be too great for the resist- 
ance of the bladder. It is better to fail in filling 
the bladder than to distend the bladder beyond 
the limit of competency. Indeed, it is not neces- 
sary to fill the bladder to any degree of resistance. 
I have operated when the bladder was in an irri- 
table condition and would not tolerate distension 
greater than the capacity of 2 ozs., and had no 
difficulty in avoiding the pre-vesical fold of peri- 
toneum or finding the bladder. The water is se- 
cured in the bladder by tying the penis at the 
base with a rubber tube. 
A colpeurynter is next to be well oiled and in- 
serted into the rectum—the rectum having been 
previously emptied by enema—and filled with 
warm water. This distension brings the bladder 
into view above the pubis. 
2. Anesthesia.—My preference for chloroform 
is the result of personal experience with it. It is 
not free from objection, as its depressing effect on 
the heart is well known. The operation usually 
occupies from five to ten minutes; and hence its 
prolonged use would be unnecessary and uncalled 
for. The objections to ether are the suppression 
of the excretions, and the frequency with which 
bronchitis is produced when administered to per- 
sons advanced in years. The best course to pur- 
sue, when the operation is prolonged, is to follow 
the use of chloroform by ether. 
In old men where there is much distension from 
retention of urine, due to hypertrophy of prostate, 
to avoid the dangers of an anaesthetic, I make 
the fistula by one plunge with a large trocar or 
with a knife, the shock never being noticeable. 
If the operation requires the administration of an anaesthetic, the patient must be kept profound- 
ly under its influence from the first incision until 
the superficial wound is closed. 
Position.—The patient is placed on the back on 
an ordinary operating table with the legs extend- 
ed, as if in a position of perfect comfort and rest. 
Many surgeons claim advantages in the position 
recommended Trendelenburg. Kigenbrodt em- 
phasizes the fact5 that the .elevation of the pelvis 
in Trendelenburg’s position0 helps the surgeon to 
avoid the prevesical peritoneal fold at the time of 
the incision of the bladder. 
It possesses no advantage over the ordinary 
flat-back position. With two openings in the 
bladder for a continuous stream of clear water, 
every part of the bladder may be illuminated with 
the electric surgical light, and thus the surgeon 
is enabled to examine the entire intra-vesical wall. 
Undoubtedly the position recommended by Tren- 
delenburg possesses advantages which to the au- 
thor, more than to myself, make it highly ideal. 
As for myself, I prefer and recommend the flat- 
back position. 
4. Incision and opening Bladder.—I have three 
methods for making the incision, viz,: 
a. When the distension is great and no intra- 
vesical operation necessary, the opening is made 
with a trocar, withdrawing the stylet and replac- 
ing it with a rubber catheter, after the introduction 
of which the canula is withdrawn, leaving the 
catheter in the bladder. It is necessary, some- 
times, to enlarge the external or cutaneous open- 
ing to prevent a closure of the catheter by com- 
pression and to render the external opening suffi- 
ciently large. 
51,. c., p. 72. Cf. Lang, Med. News, December 4, 1886. 
6 In Trendelenburg’s position the patient’s legs are held over 
the shoulders of an assistant with the body resting on an incline 
table, much in the position in which hogs are hung for spaying. b. The bladder may be opened, when distended, 
by a direct incision with the knife, in the median 
line, with cutting edge towards the symphysis 
pubes. The knife is withdrawn and a catheter is 
introduced, through the wound, into the bladder. 
c. A perpendicular incision, i or 2 inches, is 
made in the median line above the symphysis 
pubes. The recti muscles are separated to sym- 
physis. If the pyramidalis muscles are in the 
way, the fibres should be cut. The transversalis 
fascia is divided on a grooved director from sym- 
physis to upper margin of superficial wound. 
Instead of following Guy on’s manoeuvre, I catch 
the bladder with a tenaculum on a line with the 
symphysis, through the prevesical fat, and cut 
through with a bladder knife into the bladder 
with one smooth, clean incision, to prevent undue 
disturbance of the cellulo-adipose tissue between 
the bladder and pubes, and avoid infiltration. I 
have never seen a case where it was necessary to 
put up the prevesical fat, and with it the perito- 
neal cul-de-sac. If the bladder is caught on a 
line with the symphysis and cut downwards, no 
fears need be had for the peritoneum. Cutting 
this prevesical fat prevents its after dropping down 
over the opening into the bladder, and acting as 
a valve to prevent easy escape of urine and caus- 
ing infiltration. And, too, such a procedure gives 
a smooth incision throughout, and it is almost 
impossible to have infiltration, even when no 
drainage tube is left in the bladder, and the urine 
is left to flow out through the fistulous track and 
taken up by a layer of absorbent cotton. In 
making the incision into the bladder, little atten- 
tion is to be paid to any vein or veins which are 
sometimes met with. If cut, they will stop bleed- 
ing when the bladder is dropped back and the 
rectal bag removed. The operation is usually 12 
bloodless in the sense of haemorrhage. I have 
operated without the patient losing more than i 
drachm of blood. 
5. Intra-vesical Exploration and Treatment.— 
With the provisions of the puncture or incision 
the bladder can be examined with the cystoscope 
and surgeon’s light. If tumors be found, if prac- 
ticable they should be removed ; villous growths 
and any foreign body found should be removed. 
If nothing is found in the bladder, the fistula, in 
the absence of malignancy, will be all that is re- 
quired to remove the cystitis. 
Under the provision of the last incision, the 
finger is carried into the bladder and a thorough 
search made for any tumors, villous growths, or 
foreign bodies which should be removed. The 
rubber around the penis is now untied and the 
bladder emptied and washed out with hot steril- 
ized water. 
6. Toilette and After Treatment.—Under the 
provisions of the last method of making the in- 
cision, the bladder is now allowed to drop back 
into the pelvis, and the superficial wound so 
closed by two or more sutures (including the 
skin and superficial fascia only), in the upper 
portion of the incision, as to leave a fistulous 
track of equal size from the bladder to lower por- 
tion of the superficial incision. 
A large rubber catheter is now to be intro- 
duced into the bladder through the opening, and 
its distal extremity allowed to enter a urinal 
placed in the bed between the patient’s thighs, or 
preferably at the patient’s side. Prof. F. Tren- 
delenburg, director of the surgical clinic of the 
University of Bonn, proposed, for draining the 
bladder in supra-pubic lithotomy, the T tube in 
latero-abdominal position and open wound treat- 
ment as the simplest, safest and best. He makes 13 
an antiseptic dressing of iodoform gauze around 
the T tube. There can be no real necessity for 
a tube of any kind to be introduced into the blad- 
der for the purpose of conveying the urine from 
the bladder to prevent infiltration, except in the 
puncture operation, when it is necessary to let the 
catheter or canula remain in for a period of six or 
eight hours, for the formation of the fistula. The 
smallness of the fistula might be a cause for ex- 
travasation, though quite improbable. To pre- 
vent irritation of the skin, the urine is kept acid 
by the administration of citric acid or some other 
more palatable acid drink. No better antiseptic 
than the acid urine can be secured for the con- 
stant bath of the parts. It should be allowed to 
flow out through the wound and absorbed by a 
pad of absorbent cotton placed loosely over the 
wound, and removed as often as soiled by the 
outflowing urine. By this method of emptying 
the bladder, no possible small amount of urine 
can be impeded in its outflow, which is the case 
around and outside of the tube when catheter or 
tube is left in for any length of time—a source of 
no little annoyance at times. This little collected 
or retained urine, around the outside of the tube 
alone, I have seen produce a hard chill and ele- 
vation of temperature, and become for the time 
an immediate, alarming and aggravative source 
of trouble. I never have seen the skin made sore 
or chafed by the outflowing urine in epicystotomy, 
or from its after escape through the surgical fis- 
tula. 
The bladder should be washed out twice daily 
with hot sterilized water, by means of a fountain 
syringe, with its nozzle introduced into the 
urethra, the water escaping through the epicystic 
fistula and guided into a bed pan under the pa- 
tient. The superficial stitches are taken out at the 
end of one week, and intermittent catheterization 
by the fistula is then resorted to, for the sole 
purpose of training the fistula and to prevent its 
rapid closure. It is not necessary to catheterize 
for the purpose solely of drawing off the urine. 
In some cases I never drew the urine save for the 
purpose of analysis, but occasionally introduced 
a rubber bougie or fistula plug to prevent the 
closure of the fistula. The drainage by the fist- 
ula alone is admirable, and the fistula will be well 
formed in twenty or thirty days, competent to 
retain urine without dripping and to allow its 
escape in a good projecting stream at will. With 
no tearing of the tissues, and with a clean cut, 
the drainage is perfect and the dangers are nil, 
111. Advantages of the epicystic surgical 
fistula. 
i. Cystoscopic Exploration.—One of the great 
difficulties in the cystoscopic exploration of the 
bladder is the presence of pus, mucus and some- 
times blood, which renders it exceedingly difficult 
to maintain a translucency of the fluid used to 
distend the bladder. By means of a simple 
fountain syringe a constant current of clear water 
may be kept within the bladder, so essential to a 
complete observation of the trigonura Ifieutaudii, 
the most interesting part of the viscus, the ure- 
ters, and to examine any affection of that viscus. 
The fistula may be made for temporary purposes 
of cystoscopy. Diagnostic purposes are met by 
the possibility of immediate detection of all local 
conditions, such as tumors, calculi, foreign bodies, 
neoplasms, the collection of fluids from the ure- 
ters, etc. 
2. Intra-vesical Treatment.—Having, by means 
of the epicystic exploration, revealed the true 
nature of the intra-vesical trouble, the treatment 15 
resolves itself into the immediate necessities of 
the case. For instance, prostatectomy may be 
necessary; villous papilloma may be found, and 
should be remedied; pedunculated growths may 
be found, which should be removed by the scis- 
sors, or Paquelin’s cautery, etc. In such cases 
the opening in the bladder sufficient to introduce 
a finger, should be enlarged downwards under 
the symphysis pubes, and the operation indi- 
cated should at once be performed. The object 
of the formation of the permanent surgical fistula 
is to meet the after indications in such operations, 
the details of which do not properly come within 
the province of this discussion. However, it is 
sufficient to state, what is reasonable and practi- 
cable, that a better means by which the intra- 
vesical wall can be reached and treated thera- 
peutically has not yet been devised. 
3. Drainage.—Permanent after-drainage in all 
intra-vesical operations cannot be necessary, but 
it is highly essential to secure good and sufficient 
drainage until the paravascular tissue is disen- 
gorged, the cystitis is relieved and the urine be- 
comes normal and passes per urethra unob- 
structed. And until this end is obtained, com- 
plete artificial arrangement for the escape of the 
contents of the viscus must be made. In such 
cases of prostatic hypertrophy or malignant 
growths, when removal of the obstruction is im- 
possible or contraindicated, the epicystic surgical 
fistula is clearly indicated and essentially neces- 
sary. It meets every possible indication for 
local treatment and gives the only controllable 
ready and free drainage to viscus and kidneys. 
Urinary back pressure, as the result of incompe- 
tency of the urethra from the various immovable 
prostatic troubles, is often an immediate and 
remote cause of surgical kidney, which can only be removed or relieved by supra-pubic drainage. 
It is also indicated in conditions of the bladder 
of long standing cystitis, where capillary stasis 
attending the inflammatory process results in 
paresis. When the urethra is competent, the 
supra-pubic fistula affords the best means of 
washing out the bladder in chronic cystitis. 
The operation has been performed when the 
urethra would admit a number 30 (A) sound, 
simply for the purpose of washing the bladder 
without the necessity of introducing a catheter 
twice a day, which causes great irritation in these 
cases. As stated, with the fistula it is only 
necessary to introduce the nozzle of a fountain 
syringe into the urethra, when the water will 
pass into the bladder and out at the fistula, with- 
out irritation to the prostate and bladder, and 
always with great relief to the patient. The 
bladder can be washed for hours at a time, when 
the patient is suffering, with complete relief 
from all pain.