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ford fairly prompt relief the danger of kidney infection should be recognized, and not too much risk assumed in permitting pyonephrosis or pyonephritis to creep in, a complication that often causes failure in the best-done operations, or thwarts complete recovery. Surgical kidney is the surgeon's greatest enemy.

In the use of instruments we should keep in mind the elongation of the urethra that results in cases of enlarged prostate. The rubber catheter is the first to be employed, and the silk-web catheter stands next in importance. The diagnosis and location of the point of obstruction is often advanced and made clear by the employment of the cystoscope. I have often relieved enlargement of the middle lobe or isthmus, with retention resulting, by the use of the catheter having a Mercier curve, or the bi-Coude distal extremity form. In bilateral enlargement I have succeeded favorably in some cases by using a flat rubber catheter, with or without the Mercier curve. It is well known to all of us that the prostatic curve, as it has been called, is often introduced with failure. Metal instruments are only to be used in cases where the soft instruments have failed. We have in the study of these cases to choose between that term just now so well understood, i. e., catheter life, or the doing of a radical operation. When we have lesions such as organic disease of the heart, some serious condition of the liver, or tuberculosis of the system, a radical surgical operation is not always possible, and the use of the catheter becomes necessary. Here medical treatment is of service in aiding, and, at times, relieving the bladder for weeks or months together.

Within a decade few operations have attracted more earnest attention than the one for relief of prostatic obstruction.

Prostatectomy, done with an instrument. somewhat like the lithotrite, with a cutting blade, has received the earnest attention of the profession, but not often employed. The Bottini operation, or use of the electric knife, yet has some advocates. I have done the operation a number of times, and occasionally have had. excellent results, but, in the main, surgeons have been led to do the more radical operation, with complete removal of the gland, or a large portion. We have had marked discussions in our surgical associations regarding the method of reaching the prostate, suprapubic or perineal. Here, again, the cystoscope is of service, and if we find the gland projecting markedly into the bladder, then the suprapubic method is the better procedure. If, on the other hand, this is not to be observed, but the lateral lobes are enlarged, are felt through the rectum very distinctly, and project downwards toward the perineum, then, in my opinion, the perineal route is decidedly best, and the simplest method of doing the operation, like all surgical procedures, is to be selected. Suprapubic operation does not require much more than the bluntpointed scissors and one's finger. When once the capsule has been opened we can enlarge and enucleate without any great embarrassment. When operating through the perineum one must always remember that the rectum is to be respected, and the hope is we may be able to complete the operation without injuring this portion of the intestinal tract. This, however, is the great embarrassment, and the opening into the rectum, in one or more cases, has deterred some surgeons from continuing with the perineal route. I have met with this complication, but the more expert one becomes, the less likely is it to follow. Injuries to the vas deferens

I do not consider of so much importance. The operation I refer to is as follows: With the rectangular staff I open the urethra through a medium incision just in front of the prostatic portion, and reach the neck of the bladder as promptly as possible. Then, withdrawing the staff, I am able to introduce Young's tractor into the bladder, bring down the gland to a considerable extent, and generally find that the capsule has been opened sufficiently for me to enucleate the lobes. without very great embarrassment. When I find I am delayed and the operation is not going on satisfactorily, in the way of enucleation, I have reason to fear I have come in contact with a case of carcinoma, and the history of the cases I am about to report I think bears out this experience quite decidedly. After enucleation of one or both lobes, and removal, possibly, of the middle lobe, as may be required at this time, we introduce into the bladder a T drain, putting deep sutures in the wound, with Dutch curved needle, to catch the artery of the bulb, close the external wound with one or more silkworm gut sutures, and do not pack unless there is a degree of venous hæmorrhage that seems to call for it. In three cases I have had quite severe hæmorrhage, one proving fatal on the fifth day. Aside from this last complication my patients have gone on very satisfactorily, and at the end of four or five days removal of the T drain becomes admissible. In the meantime have washed out the bladder once or twice daily. After removal of the drainage tube it is not usual to wash out the bladder, if the urine continues in a good, aseptic condition, believing it better for the patient to drink plenty of soft water and wash out from above. In the doing of this operation the sooner we get our patient

out of bed the better. The perineal wound will usually heal without any great delay, and I have seldom had any unpleasant complications associated with the incision made in the urethra.

That the amount of endurance possessed by some patients is exceedingly great is well illustrated by the following case: Mr. J. G., aged 77 years, dentist by occupation, at the age of 60 developed many symptoms indicating enlarged prostate, and within a few months had retention of urine. This was relieved by the use of a catheter, and he recovered the ability to urinate and was quite comfortable for five years; however, during the last year of this period there was considerable irritation of the bladder and he again had retention. I was called to see him at that time and found he had an enormously enlarged prostate, with all the symptoms of vesical calculi in addition. The size of the prostate was such it deterred me from doing a perineal section. I did a suprapubic cystotomy June 1, 1900, removed quite a number of stones and drained from above. From this operation he made a good recovery. The suprapubic drainage wound healed comparatively early and he was able to urinate quite comfortably. The great oedema of the enlarged prostate was relieved by this drainage.

The latter part of July, 1900, he suffered renewed symptoms and a good deal of distress in urinating. I reopened the suprapubic incision and removed. three calculi. He was fairly comfortable after this, although the drainage was quite annoying.

October 16, 1900, he re-entered the hospital, and after cleansing the bladder thoroughly I did a Bottini operation on the 20th. He was very reluctant to have a prostatectomy, therefore the Bottini

operation was resorted to. On entering the hospital the urine contained a great amount of oxalate of lime, triple phosphates and was dirty in appearance. He passed about 60 ounces in 24 hours. Two or three days before leaving the hospital the suprapubic incision re-opened and began to discharge. He improved, however, and was really quite comfortable for at least three years. He then began to show evidence of cystitis, with difficulty in washing out the bladder, and was suffering to such an extent he again presented at the hospital April 9, 1904, for more radical relief. I now did a perineal section, removing several stones through the perineum, putting in a T-drainage tube, and drained the bladder thoroughly well from below. The size of the prostate was so great I did not attempt to remove from below, believing we had carcinoma to deal with; however, he improved after this, and by thorough irrigation made himself quite comfortable. At times the wound from above would open and he would be able to wash out down through in this manner. He was able to do some office work and spent his winters South, dying there March, 1908, of pneumonia.

This would have been a most proper case for doing a prostatectomy, at the age of 60, or even 65, and with our modern methods of aseptic surgery he would undoubtedly have made an excellent recovery.

Mr. J. A. W., aged 63, for six years had had marked trouble in urinating, at times compelled to the constant use of the catheter for weeks, with some blood and considerable pus in the urine. He was very anæmic, much emaciated, and had all the evidence of a surgical kidney. Rapid operation seemed desirable in order to secure drainage. I did a perineal

section May 21, 1900, and found the left lobe of the prostate so easily enucleated I removed it at once, putting in a Tdrainage tube. At the end of 48 hours the patient began to show signs of suppression of urine and died of pyonephrosis. This belongs to a class of inoperable cases for prostatectomy, illustrates the danger of delay, and the infection of the kidney following the repeated use of the catheter.

The following case exhibits the embarrassment that is sometimes associated with stone, in the bladder: Mr. J. A. D., aged 66 years, presented at the hospital October 22, 1902, giving a history of having had trouble for six years; frequent desire to urinate, getting up every 15 minutes at night, 35 times in one night, previous to coming to the hospital. At the age of 63 passed bloody urine for two days. Examination revealed the prostate about three inches in width, hard to the touch, and the case was considered a proper one for prostatectomy, with removal of the prostate through the perineum. His urine was in a fairly normal condition, containing only a small quantity of pus and a few leucocytes. After removal of the prostate, and on washing out the bladder, I was somewhat surprised to find a deep pouch on one side, with evidence of stone. I introduced the forceps and removed a small calculus, then was greatly embarrassed in not being able to re-introduce the forceps. I had to do a suprapubic cystotomy, and removed a dozen or more calculi, each about the size of a hazel nut. Perineal drainage from above was introduced without any trouble. This patient made a good recovery, and was alive February, 1908, having remained in a very comfortable condition.

A case where I am satisfied suprapubic

prostatectomy would have been better for my patient is that of Mr. J. B., aged 62, who entered the hospital November 15, 1904. His trouble began eight years previously. He now had frequent desire to urinate, much distress in passing urine, and catheter had been employed. Rectal examination revealed the prostate very high up. The case seemed to me to be a proper one for the Bottini operation, which I accordingly did. The patient improved, but returned again February, 1905, for further treatment. At this time the continued use of the sitz baths and washing out of the bladder was continued, he did much better and returned home quite comfortable; however, he was never free from the use of the catheter, and died two years after from some acute stomach trouble.

I might speak of a number of cases that made prompt recoveries, and the comfort they have had since the operation of complete prostatectomy is very impressive.

That carcinoma develops fairly early is illustrated by the case of Mr. M. L., aged 54, who presented for treatment February 22, 1906, suffering from hæmorrhoids and all the evidence of enlarged prostate. I did a perineal prostatectomy and had considerable trouble in removing what proved to be a case of medullary carcinoma. This patient had a severe condition of hæmorrhoids which I removed at the time. He made a good recovery, was discharged one month after the operation, and when last heard from was doing well.

Two cases out of the number presented sinuses later, one the case of Mr. C. K., aged 70 years, who was operated upon September 27, 1906, for adeno-fibroma of the prostate. He made a good recovery, but a fæcal fistula presented, as

sociated with no great inconvenience to the patient and continued for nearly a year. Very little material would pass through at any time, and it would remain healed for some weeks, but the patient was very comfortable and complained very little. He died from cerebral hæmorrhage about 18 months after the operation, following an acute attack of pnenmonia.

The second case of fæcal fistula was that of Mr. M. M., aged 65 years, and perineal section done January 15, 1907, for removal of an adeno-myoma of the prostate. The microscopical examination of specimen removed showed it to be chronic inflammation of the prostate with beginning adeno-carcinoma. This operation was somewhat difficult and resulted in a fæcal fistula which has caused him some inconvenience, but aside from that he is in excellent condition, having gained some 12 pounds since the operation, looks well and is able to empty his bladder in a very comfortable manner.

A summary of the cases, as regards treatment, shows there were 67 in all, with 41 operations, 26 not operated upon, or incomplete records of operations.

Of the 41 operations 28 recovered, 7 recovered improved, I recovered unimproved, 5 died, of the latter the shortest period being two days after the operation, the longest nine months (of those remaining in the hospital.)

Of the method of operating there were 27 perineal; suprapubic removal, with drainage, 4; simple suprapubic drainage, 2; Bottini operation, 5; castration, 2; vasectomy, I.

Three cases sustained secondary hæmorrhage immediately following operation, one of which was fatal in five days, the other two making good recoveries.

Medicine usually relied upon, adrenalin

and irrigations of perineal wound with hot boric acid solution. In one case firm packing was done by means of gauze, and with benefit.

In the early cases the average time in bed was three weeks; in the last few years the average time in bed has been five to eight days.

Removal of perineal drainage tube in the early cases 10 to 12 days, latterly about five to six days.

It is most interesting to have noted the condition of the urine. In nine cases clean, dirty in 29, and infected, or unrecorded, in the early cases, 29.

Of the whole number there were heart complications in 13, the lesion so severe in a few of the cases as to utterly preclude surgical intervention.

Hæmorrhage seems to have been associated, particularly, with a malignant condition of the prostate, there being four cases, three of them being carcinoma.

Endocarditis, five cases, and associated, more particularly, with the cases of ascending pyonephrosis or surgical kidney.

The use of the catheter before operation was noted in 26 cases, averaging

from one catheterization up to its steady use for 12 years.

Medical treatment had been given to 37 cases, from three days up to 12 years.

Loss of weight was noticeable in six cases, after the marked symptoms began, averaging from 10 to 12 pounds in one year, and one of the cases of malignant trouble lost 25 pounds in three weeks.

Time in hospital, surgical cases, averaged four weeks; medical varied from two days to nine months.

In the cases where rise of temperature was noted it was largely due to systemic infection, especially of kidney origin, the kidney showing signs of pyelitis before or after the operation.

The complications existing at the time. of the operation, or presenting shortly after, are as follows:

Cystitis, 25 nephritis, 9; constipation, 23; general carcinoma, 3; locomotor ataxia, 2; general peritonitis, I; atony of bladder, 5 acute gonorrhoea, 2; hæmorrhoids, 4 (three being in a malignant condition of the prostate); endocarditis, 5; stricture, I; epididymitis, I; pneumonia, 1; vesical calculi, 2.

MEDICAL EDUCATION.

The Fourth or Physiologic Era in Surgery. — In a paper read by Dr. Robert T. Morris before the New York Academy of Medicine (Journal A.M.A.), the author closes as follows:

It seems to me that the object lesson of the results of conserving the patient's natural resistance, in cases of appendicitis with peritonitis, has opened the vista of a new epoch in surgery.

In the days of Hippocrates surgery was heroic. That represents the first era.

Then came Andreas Vesalius and the anatomists, and we had the second or anatomic era in surgery. Pasteur and Lister introduced the third, or pathologic,

era.

The pathologic era is the one now prevailing the world over. The dominant idea is to prevent the development of bacteria in wounds and to remove the products of infection by means of our art.

Appendicitis has been so refractory in response to the perfection of the art of the pathologic era that when the rubber

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