2us li|j;;im.Hit( ltnn>iiitt+tit li^itfti!»'«ft"Hl""i"ii............iiiiiiiiituii-iiiii i! <•<■■';':,!, :,.:,,.., . ' * ; ''''"!'"".....i'i'Mii>mitiittiiiirii.ii.,iifn.M|.i„„.....,.„,....:.,. •.. ■■ . ! !1 ' i'l! i",t!""!,l,l,,,,,!|i,"!,,i'"i In'in until mt ' ■ 1 I NLM D510TM3M 0 NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY Section_______________........... Form 113c No. .."S^J...T...L?f..L. W. D.,S. Q. O. GOVERNMENT l'RIKTINO OJTICE DUE TWO WEEKS FROM LAST DATE GPO 322808 THE OPERATIVE TREATMENT OF THE HYPERTROPHIED PROSTATE. The Operative Treatment of the hypertrophied prostate. FRANCIS SEDGWICK WATSON, M. D. • « • SURGEON TO OUT-PATIENTS, BOSTON CITY HOSPITAL ; SURGEON TO DEPARTMENT OF GENITO-URINARY SURGERY, BOSTON DISPENSARY ; INSTRUCTOR IN MINOR SURGERY, AND THE SURGERY OF THE URINARY ORGANS, HARVARD MEDICAL SCHOOL. Delivered before the American Association of Genito-Urinary Surgeons, at the First Triennial Meeting of the Congress of American Physicians and Surgeons, Wash- ington, D. C, September igth, 1888. BOSTON CUPPLES AND HURD zwm V\HA Copyright, 1888, By F. S. WATSON. All rights reserved. Printed by CUPPLES & HURD at The Algonquin Press, Boston, Mass. CONTENTS. Preface . ............g Bibliography............. 11 Enumeration of Surgical Methods........17 Status of Contemporary Surgical Opinion . . . . . . 25 Absence of Rationale in Surgical Treatment . . . . . 27 Principal Objects of this Work.........27 Anatomical Data .........• ■ ■ 33 Inferences derived from their Study.......151 Clinical Data...... . . . . . .152 Immediate and Remote Results of Operations . . . . . 153 Author's Cases and Instruments . . . . . . . . .159 Conclusions, and Additional Note on one or two Points of Technique 164 LIST OF ILLUSTRATIONS. Preface. Dr. Physick's Prostatic Dilator......... Mercier's Prostatic Depressor ......... Leroy d'Etiolles' Ligature Carrier for Snaring Pedunculated Pros- tatic Growths ............ Text. FIG. i. Sir Henry Thompson's Instruments for Supra-pubic Drainage 2. Mercier's Prostatatome ......... 3. Mercier's Prostatectatome ........ 4, 5, 6. Bottini's Galvano-cautery Prostatatome...... 34 Plates of Specimens of Hypertrophied Prostates 7, 8. The Author's Perineal Drainage-tubes ...... 9. The Author's Galvano-cautery Prostatectatome . Dilator with Air or Water — Dr. Physick. Mercier's Prostatic Depressor. '-'•'-■■•-■■•' -~rr Ligature-Carrier of Leroy d'Etiolles for Detaching Pedunculated Tumors. PREFACE. Since the time of John Hunter, isolated attempts have been made by differ- ent surgeons to remove, by operations more or less radical, the obstruction offered to urination by the hypertrophied prostate, in various ways ; for instance, "Perforation of the obstructing portion by metallic sounds." " Destruction by caustics " (Ducamp, etc.). "Hydraulic compression, Physick." " Removal of median enlargement by lithotomy forceps" (Covillard, Desault, etc.). " Enucleation, etc." (Sir W. Ferguson and others). "Ligature and ecrasement" (Leroy, d'Etiolles). " Division of bar at the neck of the bladder " (Guthrie, Civiale, etc.). In 1857 Mercier proposed division or removal of the obstructing median enlargement by instruments passed from the meatus, and is said to have per- formed these operations upwards of four hundred times. And later in this country Professor Gouley, of New York, performed these operations successfully after the method of Mercier, and also through an external perineal urethrotomy. More recently, especially since the revival in Germany in 1881 of supra- pubic cystotomy by the method of Petersen, the prostate has been attacked through this route. Finally, injections of iodine into the substance of the gland (Heine and others), and electrolysis (Newman, Bicdert, etc.), have been brought to bear. In the study of this subject I was led to two conclusions, viz., that in spite of IO Preface. the meagreness of many clinical reports of cases, there was nevertheless sufficient material from reliable observers to be of value if collated ; and furthermore, that the profession is performing radical operations upon the hypertrophied prostate with greatly increasing frequency, but without having established any rational groundwork for the practice to rest upon. Further investigation led me to the belief that it was a simple matter to supply such a groundwork. And in the hope of furthering this subject, the investigation and its results are offered, together with some additional suggestions as to technique. F. S. WATSON, M. D., 127 Boylston Street, Boston. BIBLIOGRAPHY. Adler — Hypertrophy of the Prostate, accompanied by Profuse and Fatal Hemorrhage, "St. Louis Med. and Surg. Jour.," 1882, xliii. p, 629. Biedert — Uber Galvanopunctur der Prostata, " Ztschr. fur Therap.," Wien, 1883, 1, 85. Brosseau—Hypertrophic de la Prostate, "Union Medicale du Canada," Montreal, 1883, xii. 97. Braun — Ueber die behandlung der Urinverhaltung und eines gleichseitige vorhandenen falschen Weges bei Prostatahypertrophie durch die Urethro- tomie externa, " Centralblatt fiir Chirurgie," Leipzig, 1885, xii. 793. Bottixi — Arch, fiir Klin. Chir., xxi. p. 1, 1877. Bottixi — Thermo-Electric Prostatotomy, "Lancet," 1885, i. 582. Belfield — Digital Exploration of the Bladder, " Journal American Med. Assoc," 1886, vii. 253. Cabot — Two cases of Perineal Prostatotomy, "Boston Med. and Surg. Jour- nal," cxvi. 23, 559. Dittel — Blasenpunction und Nachtragliche resection des mittleren lappen wegen hochgradige hypertrophic der Prostata, "Wiener Med. Blatter," 1885, viii. pp. 270. Dittel — Blasenpunction, "Wien. Med. Wochenschr.," 1876,22-25; also 1876, ii. p. 2-6. Edwards — Enlarged Prostate, Dilated Bladder and Ureters, " Brit. Med. Jour.," 1883, i. 1068. Edwards — Prostatectomy (Mercier's operation) for Complete Obstruction to Micturition, " Lancet," London, 1-885, n- 57- Groves — Prostatotomy, "Canadian Practitioner," Toronto, 1887, xii. 240. Guyon —Annales de Mai. des Org. Genito-urinaires, Paris, 1885, iii. 1-16 et seq. 12 , Bibliography. Gouley — Prostatotomy, "Lancet," July 17, 1880. Gouley —Some Points in the Surgery of the Hypertrophied Prostate, "Gail- lard's Med. Jour.," New York, 1885, xl. 9-25. Howlett—On Drainage of the Bladder, with special reference to a post- prostatic operation, "British Med.-Journal," 1886, i. 289. Harrison — On Treatment of certain forms of Hypertrophied Prostate by section of the gland, International Congress, Sec. de Chirurgie, Copen- . hagen, 1884, 1885, viii. 42. Harrison —A Case of Prostatectomy, "Liverpool Med.-Chir. Jour.," 1883, hi. 139-Hi- Harrison — Surgical Disorders of the Urinary Organs, 3rd edition, 1887 (J. and A. Churchill). Harrison — Lettsonian lectures, 1887. Heine — Luskind — "Wiirtemburg Corr. Blatter," 2nd Nov., 1885, Cases of Hypertro- phied Prostate treated by Iodine Injections. Le Roy — Tumeur Enorme de la Prostate, "Prog. Med.," Paris, 1886, N.S., xiv. 7. Leisrink — Tumor Prostatae — Totale Extirpation der Prostata, "Arch, fur Klin. Chir.," Berlin, 1882, xxviii. 578. Landerer — Zur operativen behandlung der Prostatahypertrophie, " Deutsche Zeitschr. fiir Chir.," 1886-7, xxv. 5. Newman — Galvano-Cautery in disease of the Prostate, Urethra, and Bladder. "Journal Amer. Med. Assoc," 1886, vii. 228. Philadelphia Medical News (Editorial). — Prostatotomy and Prostatectomy, Oct. 3, 1885, p. 374. Rohmer — De la Cystotomie suspubieune dans le cours de l'Hypertrophie de la Prostate, "Annales des Mai. des Organ Genito-urin.," Jan., 1885. Schmidt's Jahrbuch, 1887, No. 8, p. 192. Socin — Smith — Clinical Remarks on Exploration of the Bladder by section through the Perinaeum, "Lancet," 1886, ii. 399. Bib Hog raphy. 13 Thompson — Diseases of the Prostate: their Pathology and Treatment, edition of 1886, Phila., P. Blakiston and Co., 249, 8vo. Thompson — Enormous Prostate, etc.: Permanent Drainage over the Symphysis Pubis, "Brit. Med. Jour.," 1887, ii. 1103. Thompson— Some important points connected with the Surgery of the Urinary Organs. Lectures, 1884. Teevan (Buckstone, Browne, Gouley)—discussion, "Lancet," 1880, June 5, 12, I9» July 3- Wile — A case of Retention of Urine from Enlarged Prostate and Occlusion of the Urethra : operation, recovery, "Brit. Med. Journal," 1886, ii. 909. Addenda. Real Encyclopadie — Nouveau Dictionaire de Med. et Chirurgie Prati, vol. 29, p. 754. Keyes — Genito-Urinary Diseases with Syphilis, edition 1888, p. 203. McGill —"Brit. Med. Journal," 1886, ii. 909. Atkinson — "Lancet," June 16, 1888, p. 1195. THE OPERATIVE TREATMENT OF THE HYPERTROPHIED PROSTATE. THE OPERATIVE TREATMENT OF THE HYPERTROPHIED PROSTATE. /^\F all men beyond the age of fifty-five years, we know that about ^^^ one in every seven has an hypertrophied prostate, and that one in every thirteen or so is conscious of it to a greater or less degree. The latter no doubt constitute the large majority of all patients with this disease, and for them the palliative forms of treatment, comprising hygiene, appropriate medication, the intelligent use of the catheter and of bladder washes, suffices. It is not to the consideration of this larger and important class of cases that this communication is addressed, but to the minority of greater sufferers afflicted with the more aggravated forms of the malady. What physician but that is familiar with such a clinical picture as the following: An elderly man has for some years been rising at night to urinate, owing to an hypertrophied prostate with its accom- panying residual urine. For a long time, perhaps, no further trouble ensues ; then, from one of the various exciting causes, he has an attack of retention or a cystitis begins. The retention may be relieved — but gradually, in spite of skilful catheterization and all the known palliative methods of treatment, the cystitis grows steadily worse, frequent and l& The Operative Treatment of painful catheterization becomes necessary, the bladder irritability increases, the urine becomes foetid or bloody, the kidneys become involved, a slow form of uraemia begins, and -finally the patient dies after weeks of torment. Now, the question I wish to answer in this study is this: Given such a case as that just described, or a similar one, can anything further be done for it than the palliative treatment indicated, and if so, what ? with what result ? and how ? And this brings us to the subject proper of this work. The operations that have been performed for the relief of the hypertrophied prostate are palliative and radical. The Palliative consist in draining the bladder through the perinseum or over the pubes. i. Perineal drainage. 2. Supra-pubic puncture, with retained canula. 3. Supra-pubic cystotomy, with retained canula. Radical Operations.— 1. Division of the median enlargement by cutting instruments passed from the meatus — urethral prostatotomy (Guthrie, Civiale, Mercier, Gouley, etc.). 2. Removal of a part or the whole of the median enlargement by the same channel — urethral prostatectomy (Mercier, Gouley, Teevan, etc.). 3. The same operations done through an external perineal urethro- tomy — perineal prostatotomy and perineal prostatectomy (Gouley, Harrison, Annandale, Keyes, Belfield, Cabot, etc., etc.). 4. Tunnelling the median enlargement through an external perineal urethrotomy (Harrison). 5. Supra-pubic cystotomy, and removal through this route of the the Hypertrophied Prostate. 19 median enlargement—supra-pubic prostatectomy (Dittel, McGill, Belfield, Atkinson, etc., etc.). 6. Division of the median enlargement by galvano-cautery through the urethra from the meatus (Bottini). 7. Injections of iodine into the substance of the gland (Heine, etc.). 8. Superficial cauterization of the deep prostatic urethra by galvanic action (Newman). 9. Electrolysis by needles in the substance of the gland (Biedert, Caspar, etc.). (The last three methods will not be considered in this article. The method of Heine has failed after numerous trials to establish a good claim to consideration; while those of Biedert and others have not as yet given sufficiently important results to give them the place of rivals to the other methods enumerated.) The technique of the various operations, palliative and radical, is as follows: — Palliative. — Perineal Drainage. An external perineal urethrotomy is performed in the usual way, the urethra being opened upon a grooved staff, and a large rubber drainage-tube or catheter secured in the bladder through the wound. A soft rubber catheter with a long rubber extension, having a stop-cock in its course, may be worn after the patient is once more on his feet. This device is employed by Professor Annandale of Edinburgh. When the patient desires to urinate the stop-cock is opened and the bladder empties itself through the tube. Supra-pubic Puncture, with retained canula, is performed by plung- ing a trocar into the bladder while full, above the symphysis pubis, and leaving the canula in situ, through which the urine drains away. 20 The Operative Treatment of Supra-pubic Cystotomy, with retained drainage-tube. A free opening is made in the anterior wall of the bladder, above the pubes, and a large drainage-tube inserted and held in place. A sort of compromise between the puncture and the cystotomy is employed by Sir Henry Thompson, who describes it as follows: — " The operation consists in passing a large sound, hollow throughout, with a strongly marked curve (as in the adjoining cut, A). Into this is Fig. i.—A, hollow sound, the end of which, when stopped with the stylet B, forms the point which guides the operator in finding the bladder in the last incision. Size about 12 or 13. B, Bulbous-ended flexible metal stylet. C, suprapubic tube of elastic gum about 2& inches long, with silver plate, introduced in its whole length into the sound when the end of it has been laid bare in the opening above the pubes, and when the stylet is removed. The with- drawal of the sound leaves the tube in the bladder. inserted a bulbous-ended stylet (B). The instrument is introduced by the urethra until the end can be felt just above the symphysis pubis. It is then confided to an assistant to retain in its place. The operator now makes an incision, not more than three quarters of an inch in length, more if the patient is very stout, enough to admit the index finger tightly (since a large opening becomes embarrassing subse- the Hypertrophied Prostate. 21 quently), in the median line, at the upper margin of the symphysis. The tissues are separated by the finger, and the linea alba being next slightly divided by the point of a bistouri, the finger is passed down closely behind the symphysis, and when the end of the sound is clearly felt, a little opening is made so as to expose its point. The operator now taking: the handle of the sound in his left hand, makes the end protrude in the wound; the bulbous end is withdrawn, and he passes the tube (C) in its whole length into the hollow sound ; he now with- draws the sound completely by the urethra, and in doing so neces- sarily ensures the passage of the elastic tube into the bladder." Radical Operations.— Urethral Prostatotomy and Prostatectomy [Mercier s operations). This operator secured division of obstructing bars at the neck of the bladder by the instrument which the accom- panying cut illustrates. -^2 4 Fig. 2. —Mercier's Instrument for dividing a Bar at the Neck of the Bladder. The instrument is passed through the urethra from the meatus with its short beak upward, like an ordinary sound. After entering the bladder beyond the median prostatic obstruction, it is turned over behind it, and pressed firmly against its posterior surface. The inner cutting blade is then drawn through the obstruction from behind for- ward, dividing it centrally. The second instrument of Mercier allows of the more radical measure of removing portions of the median prostatic enlargement. The cut explains itself. The instrument is passed as the previous one, and turned over, the inner blade is then dragged over the prostatic 22 The Operative Treatment of obstruction into the prostatic urethra, leaving the outer blade within the bladder, pressed against the posterior surface of the median en- largement ; in this way this portion lies between the two blades, and the part of it so included is bitten off by driving the inner blade home against the outer one; and being at the same time transfixed by Fig- 3- the arrow, is brought away with the instrument as it is turned upward again and withdrawn. Perineal Prostatotomy and Prostatectomy. — The same manoeuvres accomplished through an external perineal urethrotomy. Here, how- ever, the index finger inserted through the wound acts as a sentient guide to the knife. A short, probe-pointed bistouri is passed beside the finger inserted in the wound, and touching the median enlargement, which can thus be moderately divided, the wound being further separated by the finger (Harrison), or a V or |J shaped piece cut out of it according to the indication given at the moment by the form of the growth; or if pedunculated or salient in form the median portion can be seized with forceps and twisted off, or snared by wire ecraseur, used cold or heated by electric current; or Mercier's instruments can be employed from this point (Gouley, Teevan). Supra-pubic Prostatectomy. — As a preliminary step supra-pubic cystotomy is performed with Petersen's technique, viz., the bladder is the Hypertrophied Prostate. 23 washed out with an antiseptic solution (boracic acid, four per cent. preferably). Through the catheter used for this purpose ten ounces of the same solution are injected and retained in the bladder. A rubber bag, which has been previously inserted into the rectum, is then filled with ten ounces of water. This raises the bladder upward and forward sufficiently to bring its anterior peritoneal covering from two to four finger-breadths above the symphysis pubis (it is owing to this man- oeuvre that supra-pubic cystotomy has had such a revival during the last four years). The bladder wall is now exposed in the ordinary way by an incision through (if possible) the linea alba, and, after being fixed by threads or a tenaculum at the upper angle of the wound, is freely incised longitudinally. The edges of the bladder being held apart, its interior is explored gently with the finger and the nature of the prostatic obstruction is ascertained, and according to its nature is it cut off, or its central portion removed, or it is snared, etc. Bottims Prostatotomy from the meatus with galvano-cautery. This operation is practically the same as that of Mercier, except that divi- sion is accomplished by galvano-cautery action, as shown in the accompanying figures. Fig. 4. —Bottini's Apparatus. A Circuit-breaker for the Prostatome. 24 The Operative Treatment of Fig. 5. — Bottini's Apparatus. Circuit-breaker. Fio. 6. — Bottini's Apparatus. Prostatic Galvano-cautery. Galvanic Prostatatome. The above shows us, in outline, the ways in which the operations directed to overcome prostatic obstruction have thus far been carried out. INDICATIONS FOR OPERATION. Before proceeding further I wish to assume for a moment my case, so far as the advisability of operative interference in proper cases goes, as proven, in order to state clearly and succinctly the indications that call for the abandonment of the palliative forms of treatment and the adoption of operative measures, as follows: — Repeated Attacks of Retention (especially when the patient is not within reach of prompt, skilful, and antiseptic catheterization). Inability the Hypertrophied Prostate. 25 to urinate spontaneously, when attended by frequent, painful, or diffi- cult catheterization, impossibility of catheterization (especially when there is also present a purulent or hemorrhagic cystitis), and the failure of palliative treatment to alleviate such symptoms. The question very naturally arises here, If operations are to be undertaken to relieve prostatic obstruction, why should they not be applied at an early period in the development of the disease, rather than postponed until the prolonged effects of the disease have made them more dangerous ? If it could be shown that these operations, if undertaken early, carry with them but a very small risk to life, the answer would, I think, be, that they should be performed before the organic change has proceeded far. At present, however, a sufficient number of operations has not been done, at that period of the mal- ady, to warrant such a conclusion. Furthermore, we know that the majority of these patients live on comfortably, and often in excellent health, to an old age, under a palliative treatment. What the propor- tion of this latter class may be to those who, on the contrary, go on from bad to worse in spite of palliative treatment, is conjectural. It may be guessed to be two-thirds of the whole number. If this be true, it is evident that if all those in whom symptoms of prostatic ob- struction arose should be submitted to operation shortly after the ap- pearance of these symptoms, the proceeding will have been unneces- sary in two out of three cases. If in the future any of these operations shall become practically harmless, this opinion will of course be reversed; until then we are justified only in operating on those suffering from the severer forms of the disease. Status of Surgical Opinion of To-Day. The status of contemporary expert, surgical opinion in regard to 26 The Operative Treatment of the operative treatment of hypertrophied prostate maybe judged from the following brief quotations : — In the British Medical Journal, Nov. 17, 1887, Sir Henry Thomp- son reports a case of supra-pubic cystotomy, and permanent drainage over the pubes, for advanced prostatic hypertrophy in a person aged 64, with entire relief of all symptoms, and restoration to health, and advocates this method of treatment for similar cases,— the obstruction to urination of course remaining: unaltered. In the same meeting Mr. McGill reported three cases of supra- pubic prostatectomy in elderly men, all of whom recovered speedily from the operation, and were entirely relieved of their urinary symptoms. After which, Sir Henry Thompson is reported as saying that, in cases of prostatic hypertrophy of long standing, he did not believe that the removal of the growth would be of any permanent benefit. In the discussion which followed — Mr. Heath encouraged the plan of operation practised by Mr. McGill in his operation, viz., the supra-pubic one. Mr. Barwell advocated a more extended trial of the same method. Mr. Bryant thought it an open question whether it was better to attack these cases by the perineal or supra-pubic route. Mr. McGill said that the supra-pubic route was by far the best method to pursue. In 1887 Landerer advocated the extirpation of median prostatic enlargement through the perinaeum, and reports a case. Guyon remarks that if we examine the specimens of hypertrophied prostates furnished by autopsies it is extremely rare to find one of such form that it could have been benefited one iota by any plan of excision or incision, and in 1887 he entirely condemned all radical operations upon these cases. the Hypertrophied Prostate. 27 Dr. Belfield, of Chicago, in a most interesting article upon fifteen cases of bladder exploration, condemns the operations of Mercier and Bottini, and states that the supra-pubic route is greatly superior to the perineal in approaching these growths. Mr. Reginald Harrison believes in radical operations in suitable cases, either by tunnelling the median enlargement, or by dividing or removing it from the perinaeum, or from over the symphysis pubis, and reports some interesting cases, but gives no explanation of the reasons which should regulate the choice of operation in individual cases. Teevan favors Mercier's operation, as does also Gouley, though preferring to attack the growths through the perinaeum. Bottini advocates his operation with the galvano-cautery to the exclusion of others. Dittel and Billroth both favor supra-pubic prostatectomy in some extreme cases. Socin condemns radical operations. And so might be quoted many more to the same effect. Nor is any more well defined policy anywhere set forth. Now, my object in delaying to make these quotations at all is to bring out conspicuously what seems to be the very evident fact, viz., that in the first place, the best professional opinion is at variance as to the propriety of radical operations of any sort in this class of cases, and that from amongst those who afo advocate them, no well-formulated plan covering the whole ground, based upon scientific and compre- hensive data, has been brought forward. In other words, no rationale underlies the operative treatment. It is the chief object of this communication to supply, or at least to suggest, a rationale, based upon an analytical study of the actual conditions that are encountered, in the hope of placing this whole 28 The Operative Treatment of subject upon a rational basis, that may serve as a ground for future operative action. To do this, I have to offer data of two sorts. i. Anatomical. 2. Clinical. The anatomical collection consists of thirty specimens. This series agrees, in the main, in the relative frequency of the en- largement of the different portions of the prostate, with the well- known collections of Sir Henry Thompson, Dittel, &c, as will be seen in its enumeration below; and presents every variety of form in which the disease occurs. It may therefore be taken as a type of all cases of the malady, and inferences drawn from it are true of any conditions at all likely to be encountered. Class i. Median and lateral hypertrophy— fourteen specimens. Class 2. Median hypertrophy only — nine specimens. Class 3. Lateral hypertrophy only — with and without a bar con- necting the lateral lobes — four specimens. Class 4. Hypertrophy of median and one lateral lobe— two specimens. Class 5. Separate pedunculated tumors — one specimen. In studying these pathological specimens, there are three points, with reference to the choice of operation, that are important; upon their nature hinges (anatomically speaking) the decision for one or another method of attack. 1. The distance from the junction of the membranous and prostatic urethras to the most distant point of the median enlargement within the bladder. This I shall, for the sake of convenience, call the perineal dis- tance. the Hypertrophied Prostate. 29 If this length is not above three inches, the median enlargement can be reached by the finger passed through a perineal section of the urethra, and effectually operated upon in one of the various ways already spoken of {especially is this true if the median enlargement approaches the form of a bar). 2. The form of the median enlargement. If this be pedunculated or very salient, even if within reach from the perinceum, the supra-ptibic method will generally become that of choice. Furthermore, s?ich forms, especially if exaggerated, entirely prohibit the operations of Mercier or Bottini — which are only applicable when we know beforehand by investigations with the sound a7td lithotrite that we have to deal with a form approaching, at any rate, the bar at the neck of the bladder. 3. The small capacity and non-distensibility of the bladder in any given case, or the reverse condition, —for only under the latter condition can we perform the supra-pubic operation with its modem technique {already described imder supra-pubic prostatectomy). Bearing these three factors, then, in mind, let us look at the specimens and their accompanying text. They are all depicted of actual size, by the process of photogravure (Boston Photogravure Co., Boylston Street, Boston). EOSTON !*HOTOGR.«• .4 > 1 ' -vJ lV .... # '^..-j'^ /*.•• boston photogravure co PLATE XXX. PLATE XXX. CLASS IV. Enlargement of the Median and right Lateral portions of the Prostate. These two enlargements are here intimately connected, so that they really form one tumor. 2 inches = perineal distance. The bladder wall is greatly thickened. Bladder of very small capacity. Perineal prostatotomy clearly the operation of choice. 137- B09T0N PHOTOGRAVURE CO PLATE XXXI. PLATE XXXI. Perineal distance = 2 inches. An irregular median enlargement and slight enlargement of the right lateral lobe. Coincident a thick-walled, not distensible bladder. The perineal operation is that of choice in this case. 14X ^ PLATE XXXII BOSTON PHOTOGRAVURE CO PLATE XXXII. Separate Pedunculated Tumors. Perineal distance = 2k inches. In this Plate the growths are viewed from the urethral side, the bladder being turned over out of sight. A large growth springs from either side of the median portion, and above these two larger ones from the lateral lobes. The form of the growths here renders their successful extirpation doubtful by the perineal route; and the coincidence of a distensible bladder of large capacity makes the supra-pubic operation possible and that of choice. PLATE XXXIII. Shows the growths from the bladder side, the bladder being turned down to bring them clearly into view. H5 boston photogravure co PLATE XXXIV. PLATE XXXIV. This Plate illustrates a form of perineal drainage-tube which I have recently devised. The following objects are accomplished in its con- struction. First, its end occupies the lowest portion of the bladder, and is smooth and round. Its calibre is large. A smooth large eye is placed close to its bladder end, leaving no cul-de-sac beyond it for the lodg- ment of dirt, and giving exit to large clots. The direction of the shaft is such as to correspond with that of the posterior urethra,- and to fit it, while its external portion is parallel with the bed when the patient is lying on his back. This direction of the tube was estab- lished by measurements upon twenty cadavers, and will be found to fit the average case. To accommodate itself to the varying lengths that occur between the external perineal wound and the bladder, the plate, by which the tube is held in place by tapes led to a waistband, can be pushed for- ward or backward on the shaft of the tube, and will remain at any point at which it is placed. The tubes are of different calibres, and some are supplied with a ridge just over the eye, so that they may be converted into canula a chemise, if desirable. These tubes have proved useful to me in three cases of perineal section. 149 The Hypertrophied Prostate. I51 Fig. 7. Fig. 8. — Author's Perineal Drainage-tube*. To return to the anatomical specimens. What their study has shown us is this. That, contrary to the statement of Prof. Guyon, the large majority of specimens do present such forms as to render radical operations possible and often easy. That in twenty-seven of the thirty cases, the median enlargement formed the chief obstacle to urination. That in ten cases it formed absolutely the only obstacle to urination. Further, that in twenty-one of the thirty cases, or more than two- thirds of the number, the median enlargement could have been suc- cessfully reached and incised, or partially or wholly removed, through the perineal route, by any one possessing an index finger which has a working length of three inches or more. 152 The Operative Treatment of That in ten, or nearly one-third of all the cases, the bladder was so small and incapable of distention, owing to thickening and rigidity of its walls, as to render the supra-pubic operation impossible with its modern technique. On the other hand, in seven cases the great distance of the median enlargement from the perinaeum rendered the supra-pubic operation imperative, if any were to be done; and the pedunculated projecting form of the median enlargement in a few cases, and the consequent difficulties of successfully removing it in the cramped space offered by the perineal operation, makes the supra-pubic the operation of choice in these instances, even if they could be reached from the perinaeum. In other words, the anatomical forms and conditions are such that no one method is adequate for, or applicable to, all the varieties liable to be encountered. That, contrary to what would be inferred from the quotations of the various authors cited above, and others, we do not have our choice of a variety of operations in any given case, but are more or less compelled to one or another according to the conditions encountered in the individual instance, and for the definite reasons already laid down. ' CLINICAL DATA. Turning now to the clinical evidence of the various operations, let us look at them, with regard to their total mortality, their relative mortality, and the permanency of their results and the benefits derived from them. Before studying them in detail, a word of explanation with respect to them is necessary. One is struck to a greater degree than usual, in the perusal of clinical data, with the carelessness and omissions in the surgical reports of this class of cases. the Hypertrophied Prostate. *53 For instance, we learn on the authority of Teevan and Gouley that Mercier performed his operation upwards of four hundred times; but with the exception of fifteen of these cases, which Were submitted to a scientific jury for investigation, all detailed trace of these valuable experiences is lost; and of the fifteen examined we only learn that the results were most favorable, — a generality which is of but little service, even coming from such hands as Mercier's. Again, Dittel has performed the supra-pubic puncture with retained canula about one hundred times, and yet the details of only a small number of his cases appear; and we have to be satisfied with his statement that he is very much satisfied with the results of this opera- tion, as affording relief to distressing symptoms, although he says more than one-half the patients died soon after it was performed. In consequence of this vagueness, I have confined myself in the compilation of cases in the tables which follow to such instances as were reported with a fair accuracy of detail. PALLIATIVE OPERATIONS. Cases. Death*. 1 St. Supra-pubic puncture and retained canula . .12 9 2nd. " cystotomy " ..52 3rd. Median perineal drainage......8 1 Mortality = 48 per cent. 25 12 \ RADICAL OPERATIONS. PROSTATOTOMIES. Operators. Gouley, Langier, Agkof Pts. Previous History. Operations. Results. Gouley, Harrison, Keyes, Belfield, Mercier's operation. Recovery. Death. 6 _ 7 - 8 83 9 63 IO 55 n 80 12 59 Great suffering from urinary symptoms. Severe urinary symp- toms, failure of pal- liative treatment. Cvstitis several years, frequent catheter- izations, failure of palliative treatment. Stricture, cystitis, very ill at time of operation. Chronic cystitis for 15 years, repeated re- tention, frequent and painful urin- ation, chills, fever, and sweats,failure of palliative treatment. Prostate tunnelled from the perinaeum. Perineal prostatot- omy, lateral lobes of prostate incised. Perineal prostatot- omy. Perineal prostatot- omy. Perineal urethrotomy and drainage for 2 weeks, then prosta- totomy, with gal- vano -cautery through the perineal wound. Recovery. Symptoms of urinary obstruction recurred at the end of 2 years, up to which time the patients were free from symptoms. In the 1st, on the 16th day. 1 p -a In the 2d, on the 33rd day. J J PERINEAL PROSTATOTOMY. Atrophy of the prostate followed the opera- tion, perineal drainage-tube worn for 12 weeks, patient under observation for 3 years, in which time there were no urinary symptoms, and an entire restoration to health occurred. Under observation for two years, during which time he was free from urinary symp- toms and in good health, perineal drainage- tube worn for 4 weeks. Relief of cystitis, and alive and well 9 years afterwards; catheter however continued in use. Relief of cystitis, subsequently died of apo- plexy. No constitutional disturbance followed the operations, but entire relief to urinary symptoms, residual urine reduced from 8 oz. to 1 oz., death 6 months later from acute uraemia. Belfield, Cabot, Watson, Bottini, 13 68 14 60 15 62 16 74 17 68 18 19 - 20 - 21 — Cystitis for 7 years, patient in a very bad general condition. Painful urinary symp- toms for several years, catheteriza- tion once an hour, co-existing stone. Cystitis for 5 years, failure of palliative treatment. Bladder symptoms for 5 years, necessary catheterization for 1 year; for 6 months has had to catheter- ize every half hour day and night, hem- orrhagic cystitis, fetid purulent urine. Urinary symptoms for 4 years, failure of palliative treatment. As in last case, but not completed, ow- ing to faulty in- struments. Perineal prostatot- 01113', drainage-tube worn for 4 weeks, litholapaxy. Perineal prostatot- omy, drainage-tube worn for 2 weeks. Perineal prostatot- omy, length of pros- tatic urethra 3 in., small median en- largement, drainage tube worn for 8 weeks. Bottini's operation. Urinary symptoms mitigated during life, death from general exhaustion. Normal functions of the bladder almost restored, relief of cystitis, which, however, returned owing to continued phosphatic deposits and neglect of treatment by the patient, under observation 18 months. Partial incontinence of urine for some months, control subsequently re-estab- lished, under observation for 18 months, no return of urinary symptoms, but residual urine persists. This patient's bladder only capable of con- taining 2 oz. of fluid; he was sent home at the end of 3 weeks, entirely free from pain, haematuria had ceased, the urine was clear, voluntary urination not restored, but catheterization only necessary once in 2 hours, great improvement in general health and entirely comfortable, under observation 6 months, doing well, no re- turn of symptoms. Under observation for 6 months, one month passed before any relief to urinary symp- toms was noted, then entire recovery ensued. Entire relief to urinary symptoms, under observation for three months. PROSTATTCCTO MIES. ( )|'I'.K A TORS. Gou ey, Kdwards, 4 Keyes, 5 Gouley, | 6 7 Kcyes, 8 Har rison, 9 Bryant, Coulson, Billroth, 13 Landerer, | 14 15 Ar.ROF 1'TS. 53 65 So 67 68 60 I'RItVIOt'^ Hl^TORY. No urinary symptoms until asudiicn attack of retention, cathet- erism for 6 months, t.i.d. Necessary catheteriza- tion for 4 years. Stone and median en- largement, cystitis, necessary catheter- ization. Frequent and painful urination, hairna- turia. Frequent and painful urination, necessary cathcterism for 2 years. I hematuria and 6tone. Mercier's operation. Perineal omy. prostate"t- Lateral operation for 6tone, third lolie twisted off. Perineal prostatect- omy, a tumor of the median portion re- moved by (orceps. Median operation for stone, accidental re- moval of median enlargement with forceps, perineal drainage for 8 days. Lateral operation for stone, removal of the median enlarge- ment. Death. Recovery, Death. Recovery. > Restoration of bladder function. No constitutional disturbance followed the operation, discharged relieved of all urin- ary symptoms in 1 week. Restoration of normal urination and relief to all urinary symptoms. Amelioration of urinary symptoms. Spontaneous urination restored, cessation of cystitis, no drainage-tube. Cessation of haematuria and great relief to urinary symptoms, persistence of a urin- ary fistula. Permanent relief to urinary symptoms. Lived 10 days, autopsy showed chronic pyonephrosis. Discharged well in 2 weeks, perineal wound healed, normal urination restored. Ilamiaturia ceased. SUPRA-PUBIC PROSTATECTOMIES. ACF. OF Fts. Bennett, Bowlby, Dittel, Belfield, McGill, 16 17 7i 19 20 65 73 23 Previous History. Operations. Urinary symptoms for one year, necessary catheterization dur- ing the same time, cystitis, fetid urine. Necessary catheteriza- tion for one year. Difficult urination for 7 years, necessary catheterization for 7 months. Difficult urination for 2 years, acute cys- titis 2 weeks, fetid urine, failure of pal- liative treatment. Difficult urination 6 years, severe cys- titis 2 years, fetid urine, vomiting, diarrhoea. Perineal prostatect- omy failed to relieve, supra-pubic oper- ation done later, re- moval of a large median mass. Supra - pubic oper- ation for stone, re- moval of a median enlargementthe size of half an orange. Supra - pubic punc- ture, urinary infil- tration, supra-pubic prostatectomy, med- ian enlargement removed with ecra- seur. Supra - pubic prosta- tectomy. Supra-pubic prosta- tectomy, median enlargement size of a walnut removed with scissors and knife. Death. Recovery. Death. Recovery. Lived 3 weeks, died of exhaustion. Died some months later suddenly of renal calculus and its results, the urinary symp- toms having been relieved in the interval. Lived 6 days, chronic pyelonephritis, gran- ular kidneys. Restoration of voluntary urination, and relief to urinary symptoms. Restoration of voluntary urination, and relief to urinary symptoms. Speedy recovery in all, rapid healing of all wounds, disappearance of urinary symp- toms, and return of natural urination. SUPRA-PUBIC PROSTATECTOMIES— Continued. OC Operators. Atkinson, Atkinson, Watson, 24 25 26 Age of Pts. 66 7i 80 Previous History. Operations. Results. Remarks Difficult urination for 5 years frequent retention, haema- turia, difficult cath- eterization, failure of palliative treat- ment. Difficult urination for 2 years, retention for 4 days, haema- turia. Urinary symptoms for 10 years, necessary catheterization for 4 months, frequent catheterization and pain, false passages, failure of palliative treatment. Supra-pubic prosta- tectomy, median tumor size of cricket ball removed from right lobe, free hem- orrhage. Supra - pubic prosta- tectomy, 2 large masses removed from the lateral lobes, and a small one from the median portion. Supra-pubic prosta- tectomy, Petersen's technique, wounds left open, large double drainage tubes, a large cres- centic median en- largement partially removed. Prostatotomy from meatus . " perinaeum Prostatectomy from meatus " perinaeum Supra-pubic prostatectomy . Recovery. Death. Well in 3 months, subsidence of bladder symptoms, and return of voluntary urina- tion. Patient died after 6 weeks of an acute pleur- isy, after having recovered from the opera- tion, having been up and about. Died on the 4th day, having done perfectly well up to that time, sudden rise of tem- perature, unconsciousness, coma; the kidneys continued to secrete sufficiently until death; partial autopsy, genito-urin- ary tract only inspected, no suppuration in or about the wounds, no septic process, death from acute irritative urinary fever, no local lesion present sufficient to account for death. Cases. Deaths. IO 2 IO I 4 I 11 I 11 1 .1 Mortality = 17 per cent. 45 8 / The Hypertrophied Prostate. 159 PERMANENT RESULTS. First, supra-pubic cystotomy with permanent drainage, three cases, under observation for one year. All were restored to health and com- fort. Second, three cases of perineal drainage. Under observation for more than one year. Were entirely restored to health and comfort. Third, five cases of urethral prostatotomy. Under observation for two years. Well until then, when in three of them symptoms of uri- nary obstruction recurred. Five more were observed for six months; entire restoration to health and comfort during that time. Fourth, perineal prostatotomy. Four cases were under observation for two years, during which time they had no disagreeable urinary symptoms. General health was restored. One case more under obser- vation for six months. Perfectly comfortable during that time. Fifth, perineal prostatotomy. One case under observation for more than one year. Permanent relief of all urinary symptoms. Sixth, three cases of supra-pubic prostatectomy under observation eight months. Entire relief of all urinary symptoms. Restoration of bladder function and of general health. Of nineteen palliative operations by drainage, five were relieved, at any rate, for one year. Of forty-three well-recorded radical operations, eighteen were re- lieved, at any rate, for one year. It must be borne in mind that there are many patients who expe- rienced relief for the period during which they were observed, but who withdrew from observation at a time too early to judge of the final result. I have performed radical operations in two instances. The first, a supra-pubic prostatectomy in a patient of eighty years of 160 The Operative Treatment of age, who had been obliged to use a catheter for one year; symptoms of urinary obstruction had been present for three years. Shortly before he entered the Boston City Hospital, in the service of Dr. Bradford, a false passage had been made by catheter in the prostatic urethra, which made the passage of the instrument exceedingly difficult. A painful cystitis and frequent calls to use the catheter made his condition very miserable. Palliative treatment failed to relieve him. Rectal exami- nation showed a very large bilateral prostatic enlargement, and the short-beaked sound detected a median enlargement as well. A bladder of large capacity was present. Through the kindness of Dr. Bradford I had the opportunity to operate in this case, and chose the supra- pubic method. The bladder was filled and raised by Petersen's method, and a free cystotomy exposed the prostatic growth. The median lobe, in the form of a crescent, surrounded two-thirds of the vesical orifice and projected boldly backward into the bladder. A portion of this growth, a little to one side of its middle portion, was seized between the blades of a punch and bitten off. No bleeding of any consequence followed. Perrier's double drainage-tubes were inserted into the bladder, which was partially united by suture, as was the upper angle of the wound ; antiseptic dressings applied. The drainage-tubes acted perfectly in this case, keeping the patient entirely dry. No untoward symptoms until the fourth day, when he suddenly became unconscious, the temperature rose to 1060 F. and he died in twelve hours, — the quantities of urine continuing sufficient but of low specific gravity and containing a slight trace of albumen. A partial autopsy only was allowed. The examination of the genito- urinary tract showed no suppuration in or about the wounds. No the Hypertrophied Prostate. 161 peritonitis, no septic process, the healing processes were going on perfectly well. There were no grave organic changes in the kidneys. This patient died, I think, of acute irritative urinary fever (so called). The second case was a perineal prostatotomy in a man of seventy four years of age. Symptoms, — urinary obstruction six years; necessary catheteriza- tion three years; for three months catheterization every twenty min- utes, day and night; purulent and hemorrhagic cystitis ; systemic dis- turbance very marked. A very large bilateral hypertrophy was notice- able by rectal examination. The bladder, after the patient was anaes- thetized, could only be made to contain two ounces of fluid. This determined the choice of the perineal operation. The perineal distance in this case was at least four inches. By press- ing down on the fundus of the bladder, and thus forcing it and the prostate toward the outlet of the pelvis, I could just reach with my index finger (which is long) a bar-like median enlargement, and divide it with a probe-pointed bistouri centrally. The drainage-tube already figured (Plate XXXIV. and two following cuts) was inserted. The haematuria ceased on the third day; the bladder was irrigated thrice daily with hot boracic acid sol. of 4 per cent, strength. The cys- titis rapidly disappeared; at the end of ten days the urine was almost clear and subsequently became entirely so. The capacity of the bladder slowly increased, so that it contained at the end of six weeks five ounces, the drainage-tube was worn continuously for three weeks with entire comfort, and is permanently continued at night. Voluntary power of urination was not restored in this case, apparently owing more to lack of contractile power in the bladder wall than to the presence of any obstruction from the median prostatic portion. In the daytime the patient goes about his business, using every 162 The Operative Treatment of three hours a soft catheter passed through the perineal opening, and at night inserts the hard rubber tube (No. 24 French scale) through the same channel, and sleeps all night, while the urine drains away continuously. He has entirely regained his health and comfort, and, except for the annoyance of the catheter, is as well as ever. Before summing up the clinical evidence, and considering the various operations from this point and the anatomical one as well, in conclusion, I wish to describe a second instrument which I have devised to assist in the performance of these operations, that I think may prove of ser- vice. We are as yet only on the threshold of the technique of these opera- tions, and I propose this instrument as only one amongst others, to ac- complish the purpose in one way. Later we shall doubtless have other and better means at our disposal. This instrument I shall call the galvano-cautery prostatectatome. It is to be used through the perineal wound or through a supra- pubic cystotomy. It has the form of a short, broad-bladed lithotrite, each blade being reduced to a thin edge by a large central fenestrum 1 This Instrument was made by Messrs. Leach and Greene, Tremont Street, Boston. the Hypertrophied Prostate. 163 of oval shape. Each blade bears a rim of petrified wood {a, a) for the purpose of isolating the loop of platinum wire (b) which rests upon the surface of the inner blade, after emerging from the hollow inner shaft (c) through which the wires are conducted to the battery connections (d, d). The obstructing portion of the prostate may be grasped between the two blades and its central portion removed, or the whole taken away piecemeal, as its form may dictate, by pressing the blades together, the wire being heated by the electric current. Returning now to the examination of the clinical evidence, let us see what it has taught us. First, the total mortality of radical operations is comparatively high— about 16 per cent. But we must remember that we are dealing with old men and with extreme examples of the disease, with all that this implies. And furthermore, — and this is a point upon which I wish to lay especial stress, — can any one of experience doubt that a far greater number of deaths is due to letting these patients go without operation, or having them subjected to unskilful catheteriza- tion, with its frequent result of a hole bored in the prostatic urethra, and no drainage accompanying this proceeding. To which action (by no means uncommon) I do not hesitate to affirm that more deaths are due than can be laid to the charge of any of the radical operations I have mentioned. And I believe with Mr. Annandale, of Edinburgh, whom I lately heard make this statement: " If I were called to a case of pros- tatic obstruction, which would subsequently require the use of the catheter by hands that I was not confident were skilful, I should pre- fer to perform one of the radical operations at once, as being by far the safest thing I could do for the patient." Next, we see that the mortality of the palliative operations is greater than that of the radical ones,— supra-pubic puncture being the most l&4 The Operative Treatment of dangerous of all. This is due to the fact that the bladder end of the tube is liable to become stopped by the bladder wall or by clots or debris, upon which infiltration of urine takes place along its sides into the prevesical space, and, not having free exit, gives rise to septic phlegmon, peritonitis, etc. On this account it is safer, as Rohmer and others have pointed out, to perform a free supra-pubic cystotomy, and insert a large drainage tube into the bladder, as, for example, the double drains of Perrier, sub- stituting later, if it be desired to maintain permanent drainage by this route, an appropriate tube by which the flow of urine can be regulated at will by the patient (as was done by Sir Henry Thompson in the case already referred to, British Medical Journal, Nov. 17, 1887). The decided advantage of this method (if permanent drainage be contem- plated), as compared with that by the perinaeum, is that the position of the tube above the symphysis allows of freer movements by the patient than if it be worn in the perineal wound. A soft rubber drain can however be worn in the perineal wound, bearing a stop- cock in its course, and gives the patient practical freedom of move- ment. This device is practised by Mr. Annandale. CONCLUSIONS. Separated from the details of the study that we have just made, the sum and substance of the matter is this. Firstly, that the evidence before us is sufficient in quantity and suffi- ciently favorable to not only justify but to demand operative interfer- ence under the conditions already laid down. This granted, the choice of operation lies first between the palliative methods by drainage and the radical ones. the Hypertrophied Prostate. 165 If the patients condition is one of such exhaustion as to make the more prolonged and extensive radical operation almost necessarily fatal, a palliative, operation should be done rather than do nothing, and the patients condition may so improve as to allow of the further step later. ' In such a case, drainage through the perinczum is ordinarily the best. With this exception, the radical operations may be preferred at the outset. We have seeji that they are not more dangerous, and, if successful, accomplish far more. Of radical operations there are three. The objections to Mercier s or Bottini s, from the meatus, are that they are applicable to only a limited number of cases, viz., those in which the conditioji of a bar between the lateral lobes or a very small media7i en- largement is present, and then only when its nature has been accurately made out beforehand,— a difficult matter, as has been pointed out by Dittel and others. Moreover, they do not secure that free drainage of the bladder after operation which is a most important element. Their advantages over the perineal method, by which the exact condi- tion of the parts can be made out by the finger at the time, are not ap- parent. These operations^ therefore, may be set aside. This narrows the operative field to the perineal and supra-pubic methods. We have seen that every variety of the disease at all likely to be en- countered can be reached and successfully treated by one or the other of these two methods. Anatomically, two-thirds of all these cases are operable through the perinceum. Clinically the perineal operations are the safest. The mevitable conclusion from these facts is, it seems to me, this. In a given case open the meinbrauous urethra, put in your finger and ex- 166 The Operative Treatment of plore. Twice out of three times the operation can be completed by this route. In the other third of the cases, the long perineal distance, or the form of the median enlargement, will make the supra-pubic operation necessary. When this is the case, and if at the same time the bladder can be distended so as to allow of the operation being done with its modern technique, proceed to do it at once, or later, according to the patient's condition. The author has purposely avoided in this communication detailed descriptions of the various operations, wishing to concentrate the at- tention for the moment upon the more general principles underlying the operative treatment of the disease under consideration. Before, however, closing he wishes to call attention to three practical points in the operative procedure that are especially important. The neglect of the first two may quite defeat the object of the operation. The first is noted by Mr. Reginald Harrison, viz.: In performing a perineal prostatotomy with the blunt bistouri, the operator should be sure that the posterior limit of the median growth has been included in the in- cision, and completely severed. The second : in performing division or removal of the median growth through a supra-pubic cystotomy, care should be taken to include in the operation that prolongation into the prostatic urethra, at and beyond the vesical orifice, which the median portion of the prostate very generally presents. The third point is this. If in any case a digital perineal exploration reveals a perineal distance too great to be traversed by the finger, a supplementary exploration with a short-beaked sound may be undertaken with great ease ; and if a suitable median growth be found, an efficient opera- tion may still be completed from the perinaeum with the Mercier, Bottini's, or author's instruments, the Hypertrophied Prostate. 167 The objects sought in this work have been to lay down the lines which I believe should govern surgical action in regard to the hy- pertrophied prostate; — To set forth the reasons which shall govern the choice of opera- tion :— To demonstrate that operative treatment is surgically demanded in the appropriate cases — in the light of the evidence at our disposal, and in contravention of the opposite opinions of Prof. Guyon, Sir Henry Thompson, Socin, and others ; — To offer two adjuvants to the technique of the operations,—the perineal drainage-tube and the galvano-cautery prostatectatome ; — And to contribute two clinical experiences. *>'£'. ^;.';';'*'i ' •v.. -it V ;• -*1 '•> ■ -v ■'"• ' ■■■■* , fi ,.,_*("■■•-T» e\* uw^*Y^»-'«r» i-»«.•>!