PAY TO THE ORDER OF Orange County Savings a^id Trust Co. DR. J. M. BURL-EIW J. M. BURLEAA/ PAY TO TM J OF Orange Gmtjr j. M. BURL_E:W M. BUR LENA/ DEAVER BY THE SAME AUTHOR APPENDICITIS Its Diagnosis and Treatment. Fourth Revised Edition. Illustrated. Octavo. Cloth $5.00. By JOHN B. DEAVER, M.D., and ASTLEY P. C. ASHHURST, M.D. SURGERY OF THE UPPER ABDOMEN Second Edition. With 9 Colored Plates and 198 Text Illustrations. Octavo. Cloth $11.00. By JOHN B. DEAVER, M.D., and JOSEPH MCFARLAND, M.D. THE BREAST Its Anomalies, Diseases and Their Treatment. With 8 Colored Plates and 285 Text Illustrations. Octavo. Cloth $11.00. P. BLAKISTON'S SON & CO. PHILADELPHIA MEDIAN SAGITTAL SECTION OF THE PELVIS AND THE LOWER ABDOMEN, SHOWING THE GENERAL RELATIONS OF THE PROSTATE TO THE BLADDER, THE URETHRA, AND THE RECTUM. ^ENLARGEMENT OF THE PROSTATE ITS HISTORY, ANATOMY, ETIOLOGY, PATHOLOGY, CLINICAL CAUSES SYMPTOMS, DIAGNOSIS, PROGNOSIS, TREATMENT; TECH- NIQUE OF OPERATIONS, AND AFTER-TREATMENT BY JOHN B. DEAVER, M.D., LL.D., Sc.D., F.A.C.S. John Rea Barton Professor of Surgery, University of Pennsylvania; Surgeon-in-Chief to the Lankenau Hospital, Philadelphia ASSISTED BY LEON HERMAN, B.S., M.D. Urologist to the Methodist Episcopal Hospital, Philadelphia; Assistant Surgeon to the Penn- sylvania Hospital, Philadelphia; Instructor in Urology, University of Pennsylvania SECOND EDITION WITH 142 ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET COPYRIGHT DECEMBER, 1922, BY P. BLAKISTON'S SON,& Co. PRINTED IN U. S. A. BY THE MAPLE PRESS YORK PA TO THE MEMORY OF J. B. D., JR. WHO DEPARTED THIS LIFE AT THE THRESHOLD OF MANHOOD, AND WHO I HAD HOPED WOULD TRAVEL IN MY FOOTSTEPS THIS BOOK IS AFFECTIONATELY DEDICATED PREFACE TO THE SECOND EDITION Since the appearance of the first edition of this book, the surgery of prostatic obstruction has been perfected to a remarkable degree. The underlying principles of prostatectomy however, have not changed materially. It is an impressive fact that the operation, which, we advised in the previous edition, should be performed "only after all palliative means had been tried without success," is now justifiable as a primary pro- cedure, and one far safer in the average case than any form of palliation. This radical change in point of view is dependant upon factors Other than the mere technical problems involved, and it was with this thought in mind that the present revision was made. The reader who desires to learn the technique of prostatectomy will find ample descriptions of the various methods employed; he will find, Nrnoreover, a practical discussion of the preoperative and postoperative k methods of treatment. It has been our aim to make the book essentially practical, there- V|ore, we have omitted in large part, theoretical considerations, and for the same reason, have preferred to omit many proposed refinements I .irTtechnique, which are, in our opinion, of minor value. Further, we - have confined our descriptions to those laboratory tests which have 1 proved personally satisfactory in our daily work. The chapter on diagnosis has been fully revised and a section on < the use of the cystoscope in prostatic hypertrophy added. The section on embryology has been rewritten and the physiological problems related to prostatic enlargement are dealt with in a separate chapter. In the present edition the question of prognosis is discussed at consid- erable length, our conclusions being based on the study of a large series of collected cases. Herein is shown the comparative importance of the various phases of treatment, the overwhelming importance of painstaking preoperative treatment, and the comparative mortality and morbidity rates with the different operative techniques. Comparison is made between the operative mortality, as reported by recognized leaders in prostatic surgery, with that obtaining at less experienced ix x Preface hands. A careful survey of the figures presented will promote caution and care in the practice of this important branch of surgery. The two-stage operation of supra-pubic prostatectomy is fully described and an attempt made to give it a proper place among the various techniques. If we can impress our readers with the fact that the success of prostatectomy is dependant upon the proper selection and preparation of cases, and can guide them to this attainment, the revision of this book will have been well worth while. About forty illustrations have been added which with the series of original drawings designed for the former printing serve to elucidate the pathological, clinical and operative phases of the text. The author again gladly acknowledges his indebtedness to his co-workers in this particular field of study for their kindness in replying to his questionnaire and for other courtesies extended to him. As on other occasions, Miss. A. M. Jastrow has again rendered valuable assistance in furnishing references and translations from foreign literature, as well as in the preparation of hospital statistics. Grateful acknowledgement is tendered to Dr. A. D. Whiting for the preparation of the index. PREFACE TO THE FIRST EDITION The surgery of the prostrate gland has acquired within the last few years such a conspicuous position in both surgical literature and practice, that the publication of another text-book on the subject can scarcely be a matter of surprise. And as the author has had consider- able experience, both operative and otherwise, with prostatics, it was not unwillingly that he complied with the request of his publishers to write a monograph on this subject. In preparing this volume, the aim has been to produce a work fully representative of the subject of which it treats. While the results of the author's own experience have been included, he has taken pains not to remain uninformed of the opinions of other surgeons. A con- scientious search and study of prostatic literature has therefore been made, to the end that no personal bias should infect the principles of diagnosis and treatment which it has been endeavoured to inculcate. The present work, therefore, claims to be more than a mere compilation of the ideas of others; the author has not hesitated to hold his own opinions when these have seemed preferable, and he has tried to present the reasons for these opinions in such a way as to command the attention which he thinks they deserve. The illustrations have been chosen with great care. They are in most cases original, but where it proved impossible to obtain material, selection has been made of those which most nearly presented the requisite characteristics. Although an attempt has been made and, the author ventures to think, not without success to illustrate every important phase of prostatic surgery, both pathological and clinical, as well as operative, yet in no instance has a plate been introduced which was not considered illustrative of the text. All the illustrations have been drawn by Mr. C. F. Bauer, except the microscopical plates, which were prepared by Mrs. J. D. Z. Chase, under the direction of Dr. A. O. J. Kelly. The treatment, other than operative, has been discussed in greater ' detail than may seem warranted to some; but realizing that this forms by far the largest part of actual practice, it has seemed wise to the author to consider it at length. xii Preface In concluding a work which has occupied much of his time for over a year, the author desires to express a hope that the volume will prove of real value to those surgeons and family physicians who have pros- tatics under their care, and will serve in some little degree to elucidate the principles of surgical treatment of one of the most distressing maladies of mankind. 1634 WALNUT STREET. CONTENTS PAGE CHAPTER I i History. CHAPTER II 17 Embryology; Comparative Anatomy; Gross and Microscopical Anatomy; Applied Anatomy. CHAPTER III 61 Physiology. CHAPTER IV 72 Etiology and Predetermining Causes, in Benign Hypertrophy of the Prostute. CHAPTER V 84 Pathology; Gross and Microscopic. CHAPTER VI 105 Clinical Pathology; Effects on Urethra, Bladder, Kidneys, Urine and Rectum. CHAPTER VII 123 Symptoms; Subjective and Objective. CHAPTER VIII 136 Diagnosis; Differential Diagnosis; Cystoscopic Diagnosis, and Functional Studies of the Kidneys. CHAPTER IX 171 Prognosis. CHAPTER X 190 Treatment; Constitutional; Catheterism; Prevention of Complications; Treat- ment of Complications. CHAPTER XI 230 Local Palliative Treatment; Urinary Fistula; Gibson's Operation; Intra-urethral Operations; Perineal Galvano-Prostatotomy (Chetwood;. CHAPTER XII 259 Indications for Radical Treatment by Suprapubic and by Perineal Prostatectomy. CHAPTER XIII 271 Technique of Operations, Including the Preparation of the Patient and the After- treatment. GENERAL INDEX 347 ENLARGEMENT OF THE PROSTATE CHAPTER I HISTORY It is a remarkable thing that any part of the human body liable to such important pathological changes as the prostate gland should have acquired a conspicuous place in surgery within such comparatively recent years. Its very existence was unknown until the beginning of the sixteenth century, and it is only within the last twenty-five years that its operative surgery has been deemed of sufficient magnitude to require exposition in monographs of any size. The symptoms of prostatism, if we may believe Sir Everard Home, have been recognized from time immemorial. This ingenious author surmised that the enlargement of the prostate gland met with so univer- sally in old age is "alluded to in the beautiful description of the natural decay of the body, in the Bible, in the book of Ecclesiastes, the i2th chapter, the 6th verse, where it is written, 'or the pitcher be broken at the fountain, or the wheel broken at the cistern/ expressive of the two principal effects of this disease, the involuntary passing of the urine, and the total stoppage." From scattered observations among the works of the classic authors it appears that these writers considered that patients with prostatic hypertrophy suffered from "excrescences" or " carnosities " at the neck of the bladder; and that when these outgrowths offered obstruction to the evacuation of the bladder, their destruction was attempted with metallic instruments, introduced, of course, through the penile urethra. Certain of the ancient authors recommended incision of the neck of the bladder through the perineum in patients with retention of urine who were "nearly dying with the pain," when the urethra was much inflamed, and therefore impassable to the catheter, even if no calculus existed to serve as an excuse for lithotomy; but it is not known that they actually performed such an operation. The ignorance of the ancients as to the anatomical existence of the prostate may be explained on the hypothesis that they did not practise 2 History dissection of the human body. According to Galen, Herophilus first employed the term "prostate," which he, however, appears to have applied to the seminal vesicles (aSevoetSets Trpoo-rarai, "prostatae glandu- losae"), while the term x'P^oetSeis Trpoen-aTcu, "prostatae cirsoides," appears to have represented the ampullae of the vasa deferentia. It should be recalled, to excuse Herophilus for his apparent confusion of terms, that the prostate gland of the lower domestic animals, as well as that of monkeys, is a bifid organ, much resembling in some cases the human seminal vesicles. Except for this brief reference, no mention whatever of the prostate gland is to be found until the sixteenth century. Its discovery is attributed to Nicolo Massa, a Venetian physician, who died in 1563. Riolanus, about the middle of the sixteenth century, was the first to suggest that the bladder could be obstructed by a swelling of the prostate. In several cases of urinary retention this surgeon successfully practised incision of the neck of the bladder through the perineum, but it is not recorded whether the cause of the retention was enlargement of the prostate gland. John Hunter, Sir Everard Home, Brodie and others, both recom- mended and practised tunneling of the obstructing body by the catheter ; but this remedy was finally abandoned as dangerous. Chopart records that when Astruc, ten years before his death, which occurred in 1766, was attacked by retention of urine, his attendant, Lafaye, attempted to introduce a catheter, but met with an obstruction from a tumor in the neck of the bladder. He therefore perforated this with a lance- shaped stylet introduced through the catheter, which was open at the end; and by this means succeeded in forcing the catheter into the bladder and drawing off the urine. The catheter was retained fifteen days. This false passage through the obstructing body persisted, and a cath- eter was introduced by it as occasion required through the remaining ten years of Astruc's life; and the condition of the parts as described was finally confirmed by the post-mortem examination. Chopart himself tried tunneling of the prostate several times, but with fatal results. Billroth's experience was likewise disastrous in the only case in which he used forced catheterization. Systematic compression to maintain a patulous urethra was first proposed by Physick, of Philadelphia. His method consisted in the introduction of an elastic hollow tube through the compressed prostatic urethra, as a catheter, and then its distention by fluid pressure. Some success attended this remedy; and it was repeated every two or three Compression of the Urethra 3 days, the pressure being applied for as long a time as the patient could endure, usually from five to fifteen minutes. Leroy d'Etiolles and Mercier also made use of compression, in an effort to reduce the size of the prostate, or at least to mould it in its growth. Their plan FIG. i. TUNNELING THE PROSTATE. A FALSE PASSAGE HAS BEEN MADE IN THE DILATED PROSTATIC URETHRA. (Cruvetthier.') consisted in introducing a flexible catheter, and then plunging into it a straight stylet, which forcibly overcame the natural subpubic curve of the urethra. Special instruments were designed for this purpose; but the remedy was so extremely painful in its application that it met with little general favor. The contemporary English surgeons, more- 4 History over, contended, and apparently with an element of truth, that no more was thus accomplished than by passing an ordinary steel sound through the urethra until its curved extremity was wholly within the bladder, when its straight staff would tend to depress the internal orifice of the urethra to its normal position. But probably the best- known advocate of systematic compression was Mr. Reginald Harri- son, of London. This surgeon, in 1881, devised special olivary bougies, of gum elastic, from two to four inches longer in the stem than the ordinary instruments, and having an expanded portion an inch FIG. 2. MERCIER'S PROSTATOTOME AND PROSTATECTOME. from the tip, which was made to enter the bladder. By this means the olivary swelling caused dilatation of the urethra and compression of the prostate both as the instrument was introduced into the bladder and again as it was withdrawn, it being allowed to remain in place for several minutes. As is the case with every other department of surgery, operative treatment was at first undertaken only in emergency cases where retention of urine existed; or incidentally as part of another operation such as lithotomy. Perineal operations came into favor earlier than those by the suprapubic route, owing probably to the greater familiarity of surgeons with operations in the former region, due to the then widespread Perineal Operations 5 practice of perineal lithotomy. Covillard in 1639 successfully operated by perineal cystotomy, and removed a hard mass, not a stone, crush- ing and destroying it during extraction with the forceps. This was an isolated case, not undertaken for urinary retention, and does not represent the usual practice at that date. Sir Henry Thompson in referring to this case, asserts that the "hard mass" was a true tumor of the bladder; but Gouley seems to have considered it prostatic. Chopart describes how Desault, who died in 1795, found and twisted off a tumor in the bladder, after removing a calculus by peri- neal lithotomy; and Sir William Blizzard several times before 1806 performed perineal prostatotomy for enlargement without any cal- culous formation. It has been denied by some writers that Sir William Blizzard's operations were anything more than the opening of prostatic abscesses; but he distinctly says that his object in performing such an operation was to reduce the size of the gland by incision, irrespective of the presence of pus, which he says may have been absorbed, only induration remaining. Perineal prostatotomy combined with lithotomy was by no means infrequent in the early part of the nineteenth century, and was sanctioned by Sir William Fergusson, who employed this procedure before 1848. Amussat removed a calculus and a protruding mass of the pros- tate by suprapubic cystotomy before 1832. But the first regular surgical procedure was established in 1834 by Guthrie, under the name of "division of the bar at the neck of the bladder," this bar in some cases being produced in his opinion by a fold of mucous membrane stretched taut across the vesical orifice of the urethra by symmetrical enlargement of the two lateral lobes of the prostate. He accomplished his purpose by a catheter carrying a concealed blade. Where marked prostatic enlargement coexisted, he advised perineal prostatotomy, but it is not certain that he ever per- formed it. Mercier, whose name is pre-eminent in the early days of prostatic surgery, devised in 1837 special instruments called by Gouley "prostatotome" and "prostatectome" and at later dates modified them in various ways. These instruments resemble the punch devised by Young; the principles governing their use being quite the same. Leroy d'Etiolles as well as Civiale claimed priority over Mercier in the invention of instruments for the operation (urethral prostatotomy) since known by the latter 's name; but it appears that their claims are ill founded. Indeed, so occupied were 6 History they with one another's claims that they seem to have at times entirely overlooked the fact that Guthrie was the originator of the method. A further improvement on Mercier's method was that intro- duced about 1873 by Bottini, then of Pavia, who aimed to avoid the hemorrhage attendant upon Mercier's operation by the use of a galvano-caustic incisor. Gouley, however, who had considerable personal experience with Mercier's method, which he nevertheless preferred to apply through an external urethrotomy wound, asserted that the bleeding was trifling, and that therefore Bottini's modification was unnecessary. Although the Bottini operation was enthusiasti- cally practised by its originator and a few other Italian surgeons during the twenty years or more following his first description of it, yet it by no means met with general favor until after the publication in 1897 of the well-known paper by Freudenberg, who introduced many improve- ments in the requisite apparatus. This surgeon, four years later recommended the addition of a centimeter scale to the shaft of the Bottini cautery, in order that the operator might have a more definite idea of the position of the beak of the instrument when in use. Further modifications of the galvano-caustic apparatus were introduced by Dr. H. H. Young, of the Johns Hopkins University, the greatest advantage being that the slipping away of the prostate from the beak of the in- strument was rendered nearly impossible, and that thus the risk of burning through the bladder wall instead of through the hypertrophied gland was minimized. In America Dr. Willy Meyer, of New York, and Dr. Orville Horwitz, of Philadelphia, were among the most prominent advocates of the Bottini method to the practical exclusion of all others. Belfield in 1886 advocated the employment of Bottini's method through a perineal wound. His advice has been reiterated by Watson (1888), Keyes, Jr. (1902), Wishard, Chetwood (1902); while Watson, (1888), Bangs (1898), and Bouffleur (1902) also recommended the the employment of a cautery through a suprapubic opening. Chet- wood's modified galvano-caustic incisor is used by some surgeons at the present time in the treatment of contractures at the vesical neck; this method is described in the chapter devoted to the local palliative treatment of prostatism. Meanwhile various other methods of treatment had been intro- duced. Of these, the most important are those that arose from the practice of tapping the bladder in cases of retention of urine where passage of the catheter proved impossible. Simple catheterization to Puncture of the Bladder relieve the bladder of its residual urine had long been employed; Home had even used continuous catheterization for periods of from one to three months for the relief of the cystitis. It is interesting to note that the clever maneuver of increasing the curve of the catheter by partially withdrawing the stylet as its beak approached the obstruc- tion was practised and taught by Physick, the Father of American Surgery, long before it was accidentally discovered by Mr. Hey. Dorsey figures in his "Surgery," published in 1818, a catheter with the well-known prostatic curve, which is in this case exaggerated, and, as Dorsey says, is probably as great as will be found necessary in any case of enlargement of the prostate. The instrument known as the "elbowed catheter" of Mercier, originally of silver, and devised by him as a modification of the stone searcher, is now usually made of webbing, and has been found most useful in gaining access to a bladder with prostatic obstruction by the facility with which its point rides over the projection at the vesical orifice of the urethra. Where it was found impossible to introduce the catheter, the bladder was punctured, either suprapubically or through the rectum. Perineal puncture, though practised during the seventeenth and eight- eenth centuries, fell into disuse during the early part of the nineteenth, the rectal being then the favorite route. Suprapubic cystotomy for urinary retention is an operation over three hundred years old, having been advocated by Rossetus in 1590; but it was feared by most sur- geons, in the early part of the nineteenth century, that in employing suprapubic puncture there would be great danger of urinary infiltration among the layers of the abdominal wall; and since it was found that in many instances, even after the cannula was withdrawn, the rectal puncture served fairly well for micturition until the urethra again became patulous through the subsidence of inflammation, this was the operation usually adopted. Toward the middle of the last century some surgeons returned to the suprapubic route, while others con- sidered a perineal puncture the only sensible treatment; and rectal puncture was almost wholly cast aside. From these various procedures arose finally a new method of treatment that by urinary fistula; and from the concomitant drainage of the bladder it may be considered a distinct advance in therapeusis. Needless to say, some of the patients treated as above described, by puncture of the bladder for retention of urine, developed fistulous tracts which failed to heal. Thus Parrish records that a patient whose bladder had been tapped suprapubically for prostatic retention by Dr. 8 History Wistar (who died in 1818) wore a gold tube in the fistula for two years; at the end of this time normal urination through the penis returned, and the tube was discarded, with the result that death soon followed from a recrudescence of the bladder troubles. This operation had been done, like innumerable others, for prostatic retention where the urethra was impassable; and Sir Henry Thompson narrates that he saw some patients of Mr. Thomas Paget, who had had their bladders punctured suprapubically, completely relieved of the tenes- mus and other distressing features by wearing a cannula or a catheter in the suprapubic fistula; and that this sight gave him encouragement to try the effect of permanent drainage even in patients where retention of urine was not complete, and where the urethra was still open to instrumentation. When a suitable case presented itself, he accord- ingly introduced through the urethra a long curved metal catheter, whose point was closed by a conical obturator; and, making this point impinge upon the wall of the bladder above the pubic symphysis, cut down upon it with a small incision. He then caused the catheter to protrude through the suprapubic wound, withdrew the obturator, passed a cannula like a tracheotomy tube into the point of the catheter, and by withdrawing this latter through the penile urethra, left the suprapubic tube in the bladder. Sir Henry Thompson's observations were first published in 1875, and in many cases in which he employed this method the relief afforded was marked, but he later abandoned this plan of treatment for drainage through the perineum. Dittel, Keyes, and Swinford Edwards were among the other surgeons who at one time or another recommended the suprapubic fistula. An important improvement in the method of forming the supra- pubic fistula was that introduced in 1888 by Hunter McGuire. He formed an artificial urethra in the hypogastric region by establishing a fistulous tract upward from the bladder, so that the fistula "bore the same relation to the bladder that the spout of a coffee pot does to the bowl." By this procedure McGuire was able to completely relieve his patients of their cystitis and residual urine, no involuntary leakage occurring even in the supine position, and the patients in some in- stances being able to project the stream of urine in a parabolic curve to a distance of several feet by voluntary contraction of the bladder. The urine was retained for from two to six hours. Morris, of New York, in one instance clothed the fistulous tract with skin by trans- ferring narrow cutaneous flaps into the wound at the time of operation. Poncet and Delore have exhaustively studied the subject of supra- Urinary Fistula 9 pubic fistula as a means of treatment for patients with enlarged prostate; and the reader is referred to their work for further infor- mation. It is interesting to note that Delore collected three cases where patients who had had urachal fistulas in childhood had these open again spontaneously when in old age they developed prostatic retention. A complete review of the literature on urachal fistula will be found in Cullen's book, "The Umbilicus and its Diseases," Phila- delphia, 1916. The treatment by perineal fistula developed as a natural con- sequence of puncture by the perineum, and from the practice of perineal cystotomy for calculus complicated by enlarged prostate. Besides the mere cystotomy, it was customary to do a prostatotomy, and even a digital divulsion of the obstructing organ. The establish- ment of a perineal fistula with perineal prostatotomy was a method largely employed by Reginald Harrison, commencing in 1881, his first operation having been performed on November 4th of that year. He used a small perineal incision, opening the membranous urethra; then the prostate was incised; and a metallic perineal tube introduced and retained for from six to twelve weeks. If the natural channel was not eventually restored, the fistula persisted. Prof. Gouley, of New York, claimed priority over Harrison in the re-introduction of perineal prostatotomy, his first operation in which, however, he left no instru- ment in the bladder having been performed April 27, 1880; and his third operation, in which he left a large-sized rubber tube in the peri- neal wound, having been done in January, 1881. Whitehead and Braun were likewise among the earlier advocates of the treatment by a more or less permanent perineal opening. Various other methods of treatment, supported by different sur- geons, have, at one time or another, claimed the attention of the profession. Heine recommended the injection of iodine into the prostate, and Langenbeck and Iversen the subcutaneous use of ergo- tine, in the hope of causing a reduction in the size of the gland. The parenchymatous injections were given through the rectum, but in some cases treated by Heine's method it was found that suppuration and even death followed, so that this practice was never very generally employed. Electricity has been employed in these cases, and at times with a certain measure of success; although the cases so reported are open to the criticism of having possibly been merely those of chronic prostatitis, and not of true enlargement. This method has been carefully studied by Cheron and Moreau-Wolf, to whose excellent monograph the reader is referred. io History Excision of the obstructing parts of the enlarged prostate by supra- pubic cystostomy was first widely advocated by McGill of Leeds, in 1887. Before this date he had practised permanent suprapubic drainage, which he preferred to that by the perineum. Belfield, in America, had done suprapubic prostatectomy before this time, his first operation being in October, 1886; Dittel in 1885 had removed a portion of an obstructing prostate through a previously existing suprapubic fistula, which he enlarged for the purpose; Trendelenburg, in May, 1886, and Benno Schmidt, in August of the same year, had employed this route for removal of pieces of the prostate; but to McGill has always rightly been attributed priority in bringing this procedure prominently before the profession. The most enthusiastic supporters of McGill's operation were Buckstone Brown, Kiimmel, Atkinson, Keyes, and Fuller. As originally practised, this operation consisted in cutting off, through the usual incision of suprapubic cystotomy, by means of scissors, or of rongeur forceps, twisting off with bladder forceps, stran- gulating with an ecraseur or crushing with a lithotrite, any projecting masses of prostatic tissue. It was, however, in time extended so that portions of tissue, forming the so-called prostatic tumors, were enu- cleated with the finger, either alone, or aided by the scissors or other instrument, from their position deep within the gland. Many surgeons have labored to prove that Freyer's operation intro- duced in 1901, is not only surgically, but even anatomically impossible, assailing Mr. Freyer's claim to originality, and asserting that he is labor- ing under a grave misapprehension if he thinks he is the first person to have operated in this manner; insisting that his method is nothing more than the removal of very large prostatic tumors from the substance of the gland, leaving behind the outer margin of glandular tissue which by the growth of these tumors has been compressed into a thin capsule-like layer. Thus Wallace says: "The more rapidly growing areas (of the diseased prostate) increase at the expense of the more slowly growing ones, which are compressed and stretched over the surface of their quickly growing neighbors. By this process a capsule is formed, ill-defined at first, but later becoming more distinct. The elements forming this capsule show in process of time a lamellar disposition. The adenomatous mass can now be easily enucleated, and not only presents a smooth surface, but also leaves behind a smooth cavity." One "capsule" which he describes, left behind after the post-mortem removal of the prostate, showed within its layers a small lenticular focus of glandular tissue. Suprapubic Prostatectomy n He therefore concludes: "These facts . . . seem to leave no reasonable doubt that the so-called total prostatectomy is nothing more than the removal of adenomatous masses." Yet he admits that "if during life the urethra had been sacrificed, and the whole central mass removed, the operator would have been justified in believing that he had removed the entire organ; certainly nothing recognizable as prostate would have been left behind." Taylor entirely concurs in the opinion above expressed by Wallace, to the effect that total enucleation of the prostate gland is an impossible operation; but Roberts, as the result of a careful examination of the structures left after a post-mortem enucleation of the prostate gland by Freyer's method, is of the opinion that the whole gland can be removed during life, since in his experience just alluded to no trace of prostatic tissue could be found remaining behind. The studies of J. W. Thompson Walker confirm the opinion of Roberts. It seems a pity that so many controversies in regard to surgical priority are so constantly arising, and it appears that prostatic surgery is particularly unfortunate in this respect. Riolanus bitterly denounced his contemporaries for claiming as their own operations which had been employed before their grandfathers were born, and even for a hundred years before that time. Mercier asserted that Civiale and Leroy d'Etiolles had assumed the credit of operations which were not their own, and, with that delightful tendency toward the argumentum ad hominem characteristic of the French nationality, added that Leroy had also assumed a name to which he had no right, since in reality Leroy was from Paris, not from Etiolles. Gouley spoke almost venomously against Mr. Harrison; and we think Mr. Freyer would be well able to respond to his critics as Harrison did to Prof. Gouley: "I see that Dr. Gouley claims priority for the proceeding just described; what is of more importance is that it has received his approval." The fact that we now know that the entire prostate is not removed by Freyer's operation is of very little consequence; who first performed such an operation is of less. To Mr. Freyer is undoubtedly due the credit for bringing prominently before the medical world a plan of operation whereby an attempt is made to remove the entire gland. Some recent writers, among them, Guiteras, claim and apparently on the best of grounds, that Fuller of New York was the first to do a "total" suprapubic prostatectomy. Guiteras states that Fuller "enucleated the lobes in their entirety" for the first time in 1895. As an aid in the enucleation process, Fuller made counter-pressure with the fist in the perineum. At this time Guiteras had the same geni to-urinary service 1 2 History in the City Hospital so that he was in a position to follow the results of Fuller's work very carefully. Guiteras soon saw the advantages of exerting counter-pressure on the prostate with the middle and forefingers introduced into the rectum. This modification of Fuller's operation he described in August, 1900, at the International Medical Congress in Paris. The full text of this paper is reproduced in Guiteras' book on Urology. If the reader is interested in the historical side of prostatic surgery he will profit by reading this interesting account of the operation as it was performed by one of the pioneers in this field of surgery. Prostatectomy by the perineal route followed close on the practice of perineal prostatotomy, and preceded by a number of years McGill's introduction of the suprapubic method. Employed first for malignant disease (by Kiichler in 1866, by Billroth in 1867, by Demarquay in 1873, by Langenbeck in 1876, by Spantonin 1882, andbyLeisrink,ini883),its field of application was soon broadened so as to include benign enlarge- ment. At first, as in the parallel case of the suprapubic operation, portions only of the prostate were removed. Many prominent surgeons have advocated the perineal route, including Harrison (1881), Ashhurst (1882), Annandale (1888), Zuckerkandl (1889), Watson (1889), Dittel (1890), Goodfellow (1891), H. Morris (1895), Ferguson (1901), Syms (1901), Albarran (1901), Petit (1902), Moore (1902), Murphy (1902), Bryson (1902), Young (1903), Senn (1903), and Proust (1903). The simplest perineal operation is done through a straight median incision. In order to gain more room some surgeons supplemented the median incision by an oblique cut on each side of the anus, making an in- verted Y-shaped incision; this method was advocated by Murphy, Baudet, and Senn; while Zuckerkandl advised a transverse semicircular incision, making a flap toward the rectal aspect, this tube being sepa- rated from the anterior structures by blunt dissection. A similar though less extensive skin flap is employed by Albarran, Proust, and other French surgeons, as well as by Young, who closely follows their technique. Dittel aimed to get still more room by an incision completely encircling the right side of the anus from the coccyx, and continued forward in the median line of the perineum; by this approach he was enabled to remove a wedge-shaped piece of each lateral lobe. The coccyx may be excised if more room is required for completing the operation. The position used for these variously modified operations differed somewhat: thus, although the usual lithotomy position sufficed for most surgeons, many preferred to have this much exaggerated, while Combined Operations ^ Proust mounted his patients on a sort of framework, so that the peri- neum was completely inverted. Dittel employed either the right lateral decubitus, or else had the patient placed on the table in the prone posi- tion, with the thighs hanging vertically downward. These perineal operations all differed in some minor details of technique, as to whether the urethra was opened or not, whether an attempt was made to preserve the ejaculatory ducts, and as to the special instruments employed; some of these matters will be discussed in the last chapters of this book; but for such as appear of purely historical interest the reader must consult the original articles referred to in the appended bibliography. Combined operations, by the perineal and suprapubic routes, also found a number of supporters. Nicoll (1895) an d Alexander (1896) removed the gland through the perineum, aiding its extraction by push- ing the prostate down with the fingers of one hand introduced into the bladder through a suprapubic wound. Bryson (1899) an d Guiteras (1901) employed a perineal operation in which counterpressure is afforded by the fingers introduced through a suprapubic incision only into the space of Refczius; while another enthusiastic surgeon (Syms), thinking the extraperitoneal opening of an infected bladder too danger- ous an operation, proposed freely opening the peritoneal cavity and conducting the manipulations for counterpressure through the unopened bladder-walls, while the prostate is extracted through the perineum. Fuller (1895) did a suprapubic prostatectomy, and then drained by means of a perineal cystostomy, completely closing the suprapubic wound on the removal of its drainage on the fourth day. Other operators devised special instruments by which to draw the prostate down into the perineal wound without making any supra- pubic opening. Murphy employed hooked retractors which grasp the gland from its lower surface; and Syms used a special hollow rubber retractor, introduced into the bladder through a perineal incision in the membranous urethra, the instrument being kept in place by dis- tending its bulbous extremity with water. Proust employed a de Pezzer tractor for the purpose of bringing the prostate downward towards the perineal floor. This instrument has been modified by Young and is now used almost universally by perineal prostatectomists. A mode of treatment by castration, advocated in 1893 by J. William White, though widely employed by some surgeons for several years, has long since been discarded. White suggested this method in June, 1893; in September of the same year Ramm, of Christiania, published 14 History the results of castration on two patients, on whom he had operated the preceding April. Boeckmann had done a similar operation in May, 1893, an d it appears that Tupper, on two occasions, in 1882 and 1886, had performed this operation with the deliberate intention of relieving prostatic troubles, after having seen the effect produced by the removal of the remaining testicle from a patient whose first testicle had been removed for other causes. Ssnitzin, had employed this operation in 1886. Launois, according to Moullin, suggested this form of treatment to Guyon in 1884; and Mr. Moullin himself discussed its advisability with a patient in 1892. All of these observations were much antedated by those of John Hunter, who, in experimenting on animals, had shown that double castration in young animals prevented the development of the prostate, and that in adult animals it caused the fully developed gland to atrophy and waste away. It had, moreover, been known for many years that in certain animals, such as the mole, which have stated periods for sexual intercourse, the prostate is much diminished in size during the intervals, and hence it was inferred that a continuous abeyance of the sexual function would cause atrophy of the prostate in men. Vasectomy was suggested by Mears as a less severe and mutilating operation. The mortality from castration for enlarged prostate was at least 18 per cent. (White), taking all cases together; and in selected cases was reduced only to about 8 per cent. Griffiths and Mansell Moullin were its chief advocates in Great Britain. Ligation of both internal iliac arteries to induce ischemic atrophy of the prostate was proposed in 1893 by Bier, and employed by him in three cases, one of the patients, operated on intraperitoneally, dying from septic peritonitis. Of eight patients subsequently operated on intraperitoneally by Bier, two died. Willy Meyer practised this operation in three cases; the first patient recovering, after secondary hemorrhage and partial gangrene of the left foot; but the second died apparently of renal disease, eight days after the operation; while the third was not benefited by his experience. Konig also reported one patient, operated on by another surgeon, in Chicago, no change in the urinary condition being produced. Of those patients who survived (eleven out of fifteen) , eight are said to have had their bladder troubles more or less relieved, while three received no benefit whatever, and four died; a mortality rate of over 26 per cent. Derjuschinsky investigated this method of treatment by conducting experiments upon dogs, and demonstrated that although primary decrease of the size Castration I e of the prostate occurred, but at about the end of eight months' time it had regained its original volume by virtue of the establishment of the collateral circulation. Among the more important of the older monographs which have appeared at various times, treating of diseases of the prostate gland, mention should be made of those by Sir Everard Home (1811), Leroy d'Etiolles (1840), Coulson (1840), Adams (1851), Hodgson (1856), Thompson (1858), Gant (1872), Harrison (1884), Guyon (1888), Rouchaud (1888), Watson ( 1 888) , Vignard ( 1 890) , Moullin (1894), Poncet and Delore (1899), Freyer (1901), Petit (1902), Socin and Burckhardt (1902), and Proust ( 1 903) . A careful study of these works will well repay the efforts of the student who is interested in the history of prostatic sur- gery; indeed they contain much that will prove of the greatest practical value to the surgeon. In the bibliography will be found references to those authors, contemporaneous and otherwise who have made note- worthy contributions to the literature of prostatic hypertrophy. REFERENCES (CHAPTER l) Albarran: Presse Medicale, 1902, No. 42, 17-24. BelBeld: Jour. Amer. Med. Assoc., 1887, viii, 303. Billroth: Clinical Surgery Translation of New Sydenham Soc., London, 1881, p. 282. Bottini: II Galvani, 1874, x. La Galvanocaustica nella Practica Chirurgica, Novara, 1873, and Milano, 1876. Cheron and Moreau-Wolf : Des Services que peuvent rendres les Courants Continus Con- stant dans I'lnflammation, PEngorgement et 1'Hypertrophie de la Prostate, Paris, 1870. Chetwood, C. H. : The Practice of Urology, 1916, New York. Chopart: Traite de Maladie des Voies Urinaries, Nouvelle Ed., Paris, 1830, ii, 86. Cullen: The Umbilicus and Its Diseases, Phila., 1916. Delore: Centrabl. f. d. Krankh. d. Harn. u. Sexualorg., 1899, x, 343. Dittel: Wien. Med. Blatt., 1885, viii, 270, 301. Fergusson, Sir Win., Lancet, 1870, i, i. Freudenberg: Berliner klin. Woch., 1897, No. 46, S. 1002. Freyer: British Med. Jour., 1901, ii, 125. Ibid, 1902, i, 249 and ii, 245; 1492. Ibid, 1903, i, 898. Gouley: Trans. Amer. Surg. Assoc., 1885, iii, 179; 184; 190. Guiteras, R. : Urology, ii, p. 291, New York, 1913. Guthrie: Anatomy and Diseases of the Neck of the Bladder and of the Urethra, London. 1834, p. 252. Harrison: The Prevention of Stricture and of Prostatic Obstructions, London, 1881. British Med. Jour., 1881, II, 1882. Home, Sir Everard: Trans. Philos. Soc. London, 1805, Paper viii, quoted in his "Works," London, 1811, i. "Practical Observations on the Treatment of the Disease of the Prostate Gland." McGill: Trans. Clin. Soc., London, 1888, xxi, 52. McGuire, Hunter: Trans. Amer. Surg. Assoc., 1888, vi, 349. Mears, Trans. Am. Surg. Ass., 1893, xi, 210. 1 6 History Mercier: Recherches sur le Traitement des Maladies des Organes Urinaires, Paris, 1856, 36; 213. Moullin, C. W. M.: Hunterian Lectures on Enlargement of the Prostate, London, 1892. Physick: See Dorsey's Surgery, Phila., 1818, ii, 161. Poncet and Delore: Traite de la Cystostomie Sus-Pubienne chez les Prostatiques, Paris, 1899. Proust: Manuel de la Prostatectomie Perineale pour Hypertrophie, Paris, 1903. Ramm: Centralbl. f. Chirur., 1894, xxi, 387. Rossetus, Francessus: YSTEPOTOMOTOKTAS (id est) Caesarei Partus Assentes His- torologica, Parisiis, 1590. Testea Tractahunculo, p. 263. Taylor, Brit. M. J.: 1902, i, 774. Thompson, Sir Henry: Lancet, 1875, i, 3. Wallace: British Med. Jour., 1902, i, 764. White, J. Win.: Trans. Amer. Surg. Ass., 1893, xi, 167. Young, H. H.: Jour. Amer. Med. Ass., 1913, lx, 253; ibid.; 1902, xxxviii, 86. EMBRYOLOGY: COMPARATIVE ANATOMY : GROSS AND MICROSCOPICAL ANATOMY: APPLIED ANATOMY Embryology. It will be recalled that the genito-urinary tract is developed from three main sources the Wolffian bodies and ducts, the Miillerian ducts, and the allantois. This last structure, the earliest of the three to be formed, juts forth in the Second week from the primitive gut near its posterior extremity, develops forward and protrudes at the umbilicus, forming a reservoir for waste materials. The allantois in the human embryo is never a free vesicle as it is in the lower mammalian forms. Emerging from the ccelum at the umbili- cus it grows into the body stalk, a mesoblastic structure that constitutes a primary and permanent connection between the embryo and' the chorion. In the third week the Wolffian bodies appear, one on each side of the body cavity, as a series of tubules, caudal to the region of the heart, and lying approximately at right angles to the Wolffian ducts and in the long axis of the body cavity. The Miillerian ducts, one on each side, appear about the fifth week, and lie parallel to the Wolffian ducts. Both pairs of ducts empty into that portion of the allantois closest to the gut. In the sixth week one can see that the allantois has expanded slightly between its points of departure from the body cavity at the umbilicus and the point at which it receives the two pairs of ducts the Wolffian and the Miillerian. This expanded part of the allantoic tube forms the future urinary bladder, and growing out from it practically parallel with the two pairs of ducts, is now observed a third pair of tubes, these being the ureters. The ureters are primarly formed as outgrowths from the Wolffian ducts; they originate from the latter at some distance from their termi- nation so that when these structures are subsequently drawn downward to be included in the expanding urinary tract, the openings of the Wolf- fian (ejaculatory) ducts occupy a position distal to that of the ureteral openings. The altered position of the allantois into which the Miillerian and Wolffian ducts enter is termed the urogenital sinus. From this the entire female urethra is developed; in the male it gives rise to that portion of the urethra situated between the internal vesical sphincter 2 17 1 8 Anatomy and the openings of the ejaculatory ducts. The portion of the male urethra situated distal to the openings of these ducts is formed in con- junction with the penis and is, therefore, primarily separate and dis- tinct from the portion contributed by the urogenital sinus. As is well known, the Wolffian ducts persist in the male and form the vasa deferentia, while in the female the Miillerian ducts persist, coalesc- ing in their lower portions to form the uterus and the vagina, but in the upper part remaining distinct, and constituting the Fallopian tubes. In the male, although the Miillerian ducts in great part disappear their lower coalesced extremity persists, and is found in the adult as a small diverticulum from the prostatic urethra, known variously as the sinus pocularis, utriculus, uterus masculinus or organ of Weber. Considerable difference of opinion exists regarding certain phases of the embryological development of the prostate gland, although the studies of Lowsley, and other recent investigators, seem to have cleared up a number of hitherto uncertain steps in the process. It has been the belief of many anatomists that the initial step in the formation of the gland concerns the development of its capsule and the stroma through a process of condensation of the mesoblastic tissue that sur- rounds the urogenital sinus and the genital cord. This, it has been held, is first discernible in the third month of fetal life when it can be recognized as "an annular mass of mesoblastic tissue that surrounds the lower end of the Wolffian and Miillerian ducts . . . and subse- quently becomes differentiated largely into unstriped muscle . . . into this (the condensed mesoblastic tissue), penetrate solid epithelial out- growths, from the lining of the urethra, which expand into branched cylinders that give rise to the prostatic glandular tissue. These outgrowths are arranged in three groups, a ventral, an upper dorsal, and a lower dorsal. The ventral group gives rise to the glandular tissue in front of the urethra, which at first is relatively abundant, but soon suffers reduction, and in the adult organ is often almost wanting. The dorsal groups produce the important glands of the median and lateral lobes. For a time the latter are arranged as two separate lobes, but afterwards become consolidated by the capsule and broken up by the invasion of the fibro-muscular septum." (Piersol.) The origin of the musculature of the prostate and of its stroma has been the subject of wide discussion. Most observers have held the view expresssed by Piersol and quoted above, namely that these structures develop from a thickening of the mesoblastic covering of the genital cord the name given to the connective tissue contain- Embryology IC; ing the Wolffian and the Miillerian ducts. Griffiths, who studied the development of the prostate in considerable detail, taught that no part of the prostate arises from the genital cord. W. G. Richardson, from his more recent studies is of the same opinion. Griffith described the prostatic tubules as invading the muscular fasciculi'of the thickened posterior half of the external circular unstriped muscle coat of the urethra in this situation, the invaded portion of the musculature contributing the permanent muscle content of the prostate gland. Many of the observations recently reported by Lowsley relating to the development of the prostate are at variance with the generally accepted views. The organ, he says, " originates from five groups of tubules which begin as solid epithelial outgrowths and which later de- velop lumina. These various groups arise from the floor of the urethra between the ejaculatory ducts and the bladder, from each prostatic furrow, from the floor of the urethra outward from the ejacu- latory ducts, and from the ventral wall or roof of the urethra, and become the middle right and left lateral, posterior" and anterior lobes respectively." As the prostate develops, certain well-defined changes occur not only in the morphology and structure of the gland, but also in the relation of the orifices of its tubules to the urethral walls. This is already evident in the child at birth, although at no stage of develop- ment do the five original groups of tubules lose their identity, as has been well shown by Lowsley who continues in his description as follows: "The tubules grow, with few exceptions, back toward the bladder, and by the sixteenth week are surrounded by developing muscle fibres which in later stages become quite thickly disposed. In early stages the five lobes of the prostate are well separated from one another and later development decreases the separation between the lateral and middle lobes . . . although the independence of these lobes is discernible. The lateral lobes make up the largest portion of the gland. The posterior lobe lies behind the ejaculatory ducts and becomes separated from these and the middle and lateral lobes by a plane of connective tissue. The tubules making up the anterior lobe are at first as large as other tubules and are quite numerous; but at the sixteenth week they are reduced in size, comparatively speaking, and after this time appear to shrink into insignificance. All of the tubules of the prostate seem to be firmly bound together within its capsule, with the exception of those of the middle lobe whose upper ends in some cases seem to extend beyond the capsule, lying freely be- tween the vasa deferentia and the bladder." 20 Anatomy Evidently therefore, in the opinion of Lowsley, the glandular portion of the prostate is derived from five sets of tubules, in contradistinction FIG. 3. DEVELOPMENT OF THE GENITO-URINARY TRACT (DIAGRAMMATIC). i. Body wall. A. Allantoic stalk at umbilicus. B. Urinary bladder. C. Cloaca. G. Primitive gut. 5. Symphysis pubis. M, M'. Mullerian ducts. W, W. Wolffian bodies and ducts. U, U'. Ureters with kidneys attached. to the views held by Pallin and others that but three groups of tubules are concerned in its development. The former seems to have definitely established the independent origin of the median lobe tubules which have Embryology 21 been looked upon by Pallin, Evatt, Jores and their followers as outgrowths from the lateral lobes. Until comparatively recent times, all so-called median lobe obstructions at the vesical outlet were supposed to take origin in prostatic tubules, whereas in fact the majority of these arise in the subcervical group of glands (Albarran's tubules subcervical glands), and are not of prostatic origin at all. FIG. 4. FCETAL PROSTATE, WITH LOWER HALF OF BLADDER ATTACHED. Natural size, and ten times natural size. (From a six months' foetus in the Museum of the Lankenau Hospital.) Sir Everard Home took credit to himself for discovering a third (middle) lobe, although both John Hunter and Morgagni had recognized median lobe 'obstructions which may or may not have been of prostatic origin. Home's observations passed practically unchallenged among English surgeons, and enlargement of the third lobe became the most common pathological change to which the prostate gland was subject. In France, however, surgeons were not ready to acknowl- edge so important a discovery, as this seemed to be, by a foreign author; and they rather grudgingly designated this portion of the prostate the 22 Anatomy third or median "part," being unwilling to accord it the dignity of a distinct lobe. Sir Henry Thompson, writing in 1858, opened the controversy anew by pointing out that Home's observations were not numerous and that he had not found his third lobe in every case. Sir Henry therefore came to the conclusion that this middle lobe was merely a pathological formation, and did not normally exist at all. Congenital absence of the median tubules does undoubtedly occur but the rarity of such mal-development is shown in the investigation of Lowsley who found only one among ninety-eight autopsy specimens from dissecting room cadavers and fetuses with absence of the middle t Genital body ,{ Wolf flan Ducts Mu fieri an Ztucts Peritoneum Uret/i ra Prostate tfponeurosis J)enonuittiers FIG. 5. DEVELOPMENT OF THE APONEUROSIS OF DENONVILLIERS. (Cuneo and Veau.) lobe tubules. Home, and later Griffith, found orifices of prostatic ducts on the floor of the urethra proximal to the verumontanum. The secretion which was emitted from these orifices on pressure, the latter found, came from glandular tissue situated between the urethra and the ejaculatory ducts. This collection is now known to have an independent origin from the remaining tubules of the prostate and to retain this independence more or less perfectly throughout life. It is the belief of Tandler and Zuckerkandl that benign prostatic hyper- trophy mainly concerns this group of tubules. A further embryological fact of importance is the formation of a bursa between the prostate and the rectum by the obliteration of the Comparative Anatomy 23 upper end of a serous process extending downward from the peritoneum. The fascial walls of this closed serous cavity between the prostate and the rectum is widely known as the "aponeurosis of Denonvilliers. " In the adult, although separable into two layers, these processes of tissue no longer enclose a distinct cavity. Comparative Anatomy. All mammals possess a prostate, but in birds, according to Strieker, there is no analogous organ. In certain of the batrachians he states that the pelvic and anal glands swell up during the procreative season, and discharge their secretion into the cloaca; these glands are supposed to represent the prostate and the glands of Cowper. In fishes there are aggregations of acini that communicate with the vas deferens through ducts. Owen states that insects have three pairs of prostates. Although all mammals are endowed with a prostate, yet it is by no means identical in form in all. In some mammals the prostate develops around the lower extremity of the Wolffian ducts, and when fully developed retains its close relation to the vasa deferentia, but as two distinct glands, and is not, as in the human adult, applied around the first portion of the urethra embracing the ejaculatory ducts only incidentally. Moullin states that even in man the situation of the prostate was probably originally around the Wolffian ducts, but that its place has become shifted in the course of racial development. In the bull, the buck, and other of the ruminants, indeed in almost all the forms of mammalian life below the human, including the monkey, the prostate continues throughout life a bifid gland. The close resemblance which it bears in some of these animals to the seminal vesicles may account both for the ignorance of the ancients respecting the existence of the human prostate gland, and for the habit of the earliest of the modern anatomists of referring to it as the "glandulae prostatae." W. G. Richardson has called attention to the location of the acces- sory glands of generation the prostates, the seminal vesicles, and the Cowperian glands in various animals. He finds that the seminal vesicles are constantly in relation with that part of the genital tract developed from the Wolffian ducts, that the prostates are placed next, in relation with that part developed from the urogenital sinus, while the glands of Cowper are furthest away from the testicles, in relation with the bulbous urethra. This same general arrangement exists in the human being, the glands of Cowper discharging their secretion into the bulbous urethra, the prostate glands into the prostatic urethra, and the seminal vesicles pouring their secretion into the vasa deferentia 2 4 Anatomy before these latter have joined the urethra. In the lower animals the accessory genital glands differ much in relative size and importance, all three sets not always being present. In the civet cat, for example, Cowper's glands are exceptionally large, apparently to compensate for the entire absence of the seminal vesicles; while in the guinea-pig the seminal vesicles are of immense size, and the glands of Cowper very in- significant in comparison. In the squirrel, on the other hand, the Cowperian glands are very large, and the seminal vesicles are small. FIG. 6. TESTES, PROSTATES, AND PROTOMETRA OF THE GOAT. Below are seen the prostates. Between the vasa deferentia is seen the uterus mas- culinus. which is bifid; its two horns diverge and continue, closely applied to the vasa deferenua, as far as the epididymis of each side. (After Owen.) Genitalia of the goat (Fig. 6) approach most nearly to the primi- tive or indifferent sexual type. Here the Miillerian ducts persist throughout their length, as well as the Wolffian ducts, and we have the unusual sight of the uterus masculinus extending as a bifid organ from the urethra to the epididymis. Nor do the lower ends of these persist- ent Miillerian ducts pierce the prostate to empty into the urethra ;-on the contrary, the prostate glands, one on each side of the urinary chan- nel, are far removed from the situation of the uterus masculinus, being much nearer the bulbous urethra. This satisfactorily disproves the theory formerly held by some that the prostate gland was the homologue of the female womb. Comparative Anatomy 25 In the hyena the genitalia (Fig. 7) approach more nearly the human in type, but conclusively show that there is no necessary con- FIG. 7. ACCESSORY MALE GLANDS AND PROTOMETRA OF HY^NA STRIATA. Above is seen the bladder. Emptying into the prostatic urethra are the vasa def- erentia on each side of the minute uterus masculinus (protometra). The prostate glands are large, somewhat kidney-shaped bodies, in no way connected with the uteius mascu- linus. Emptying into the penile urethra below are seen the immense glands of Cowper. Natural size. (After Otven.) nection between the uterus masculinus and the prostate. The Cowperian glands of the hyena are of extraordinary size. 26 Anatomy In mammals who have a rutting season the prostate gland enlarges noticeably at this period, and at its close again diminishes to its former size. John Hunter studied the prostate gland in moles, and found that while it was small and insignificant during winter the period of quiescence in the rutting season it became very large and was filled with mucus. His observations have been confirmed by Owen and by Griffiths. The last-named author also studied the pros- tates of hedgehogs, and found them to have the same characteristics. Such observations as these, taken together with the facts that castration in animals has long been known to produce a certain amount of prostatic atrophy; that failure of development of one vas deferens has usually been found associated with a prostate which is small and ill- formed on the affected side (see Fig. 8); and the theory of "displace- ment" in the course of racial development, adopted by Mr. Mansell Moullin on the authority of Schafer; leave no reasonable doubt that the prostate is physiologically a part of the genital and not of the urinary apparatus. This idea may be further strengthened by a consideration of the ornithorhyncus, or duck-mole. In this animal, a small oviparous mammal of Australia, the urine is discharged through the cloaca, in common with fecal matter, as is the case in birds; and the penis with its contained urethra serves solely and entirely for the trans- mission of the semen and the fluids from the accessory generative .glands. And although, unfortunately for the complete proof of our theory, this interesting animal is not endowed with a prostate, yet it is clear that were a prostate present, its secretion would be discharged along with that coming from Cowper's glands, which, as well as the lower ends of the vasa deferentia, are considerably enlarged. No sem- inal vesicles are present either, but the enlargement of the lower ends of the vasa deferentia is evidently to compensate for this lack. In connection with the comparative anatomy of the prostate, a few words in relation to its comparative pathology will not be out of place. It is well known that of all animals the dog is most prone to prostatic enlargement. According to Ciechanowski, it is also the only domestic animal which suffers from an infectious urethritis. From this fact he draws an argument in favor of his theory that all prostatic over- growth is due to an inflammatory change. In other animals castration invariably causes prostatic atrophy; whereas in dogs it frequently fails to have any effect, although it was until recently about the only method of treatment applicable for their Gross Anatomy 27 relief. Perineal prostatectomy has also been employed; and Loumeau states that a veterinary surgeon, a friend of his, had employed ten times successfully an operation precisely similar to Freyer's suprapubic prostatectomy, before learning from Loumeau that the same operation had been practised upon man. Gross Anatomy. The shape of the prostate is approximately that of a truncated cone, and has often been compared to a Spanish chestnut or a horse-chestnut, having its apex down and forward, and its base beneath the urinary bladder. In size, the gland is normally about four centimetres from base to apex, a little larger in transverse diameter, and from two "to two and a half centimetres in depth or height. Its weight varies from fifteen to twenty-four grammes. The greatest increase in the size of the gland takes place during the second decade of life so that by the beginning of the third decade it has reached its maximum normal development. The variations in size of the prostate at different ages have been tabulated by Lowsley from a study of 224 specimens, as follows. TABLE SHOWING THE CHANGES IN SIZE OF THE PROSTATE GLAND AT VARIOUS AGES IN A SERIES OF 224 CASES (LOWSLEY) Age Number of cases Length, centimetres Width, centimetres Height, centimetres Variations Average Variations Average Variations Average ist Decade i-io years.. . . 38 i . o to i . 7 1.2 I . tO 2.0 i-S 0.7 to 1.3 09 2nd Decade 10-20 years.. . . 10 2 5 to 3 . 5 3- 3-8 i . 8 to 2.4 2.1 3rd Decade 20-30 years. . . . 40 2.8 to 4.0 3-3 3 . 6 to 5 . 2 4-i 2 . o to 3 . o 2. 4 4th Decade 30-40 years. . . . 33 2 . 4 to 4 . o 3-15 3 . o to 5 . o 4.1 i . 6 to 3 . o 2-55 5th Decade 40-50 years.. . . 42 3.0 to 4.6 3-45 3.6to 5.0 4.0 2.3103.8 2.65 6th Decade 50-60 years.. . . 29 2.4104.5 3-65 3-3to5.o 4-37 2.4103.4 2-75 Old Age 60 years . . . 32 2.6 to 4. 5 3-23 3 . o to 5 . o 4.12 2.0 tO 3.6 2.47 28 Anatomy The prostate consists of glandular acini and ducts embedded in involuntary muscle; the latter supported by fibrous tissue, constituting the stroma of the organ. This stroma forms, by a peripheral condensa- tion, a capsule for the gland which is distinct from its sheath, the latter being derived from the pelvic fascia. Opinions differ as to the existence of a distinct prostatic capsule. By the use of the term capsule, we do not mean to imply the presence of a definite envelope of tissue that surrounds and is easily separable from the glandular tissue proper. The true prostatic capsule is merely the condensed peripheral portion of the fibro-muscular stroma. This is intimately blended with its intraglan- dular portion, while externally it is inseparably bound to the anatomic capsule, a fibrous connective sheath which is a part of the pelvic fascia. The capsule referred to in surgical writings as surrounding the ade- nomatous or enlarged prostate, is, we believe, formed in association with the neoplasmic process. It is, therefore, a structure separate and distinct from those described above. The fibro-muscular stroma comprises, according to Kolischer, from one-half to two-thirds of the bulk of the prostatic gland. Walker, on the other hand, believes that the prostate is composed of about three- fourths glandular substance and one-fourth stroma. Certain other writers distinguish between a glandular and a muscular type of organ according to the prominence of one or the other element in the histo- logic picture. In the majority of instances, the s|roma constitutes slightly more than half of the bulk of the prostate. Piercing the prostate from base to apex, a little anterior to its central axis, runs the urethra, whose first part, extending from the vesical orifice behind to the deep layer of the triangular ligament in front, is called "the prostatic urethra." This portion of the urethra is sometimes spoken of as the urethral surface of the prostate gland. Beyond the vesical wall which surrounds its most proximal portion, the pars prostatica is entirely surrounded by the prostate gland. This is the most distensible portion of the entire urethra; when fully distended it is roughly fusiform in outline. When at rest its lumen is effaced through -apposition of the anterior and posterior walls. Its lumen is reduced by a spindle shaped elevation to which the terms caput gallin- aginis, urethral crest, verumontanum, and colliculus seminalis have been applied. This structure which averages 2.0 cm. in length, 0.41 cm. in width and 0.3 cm. in height extends along the dorsal wall of the prostatic urethra from the uvula of the vesical trigone above to the membranous urethra below. Gross Anatomy 29 The summit of the colliculus is situated at about the mid-point of the prostatic urethra, the lumen of which appears crescentic in outline at this point in transverse section. The colliculus exists as a result of an elevation of the floor of the urethra caused by the ejaculatory ducts and the presence at this point of the prostatic utricle, sinus pocularis, or uterus masculinus, the various terms given to a tubular diverticulum whose slit-like mouth occupies the forward declivity of the colliculus. The mouth of the utricle which averages 0.17 cm. in width leads into the utricle proper, which has an average depth of 0.5 cm. Its axis is directed obliquely to that of the prostatic urethra, although lying in the middle line, and its cavity looks forward, so that a small catheter or sound passed along the floor of the urethra may catch in its orifice. A catheter or probe may be easily inserted into the utricle for therapeutic purposes, through an endoscopic tube. Its cavity leads upward and backward into the substance of the prostatic gland. The term uterus masculinus is appropriately applied to it since it represents the fused lower ends of the Miillerian ducts of the embryo, and is, therefore, regarded as the morphological equivalent of the vagina and the uterus. On each side of the verumontanurh are found the orifices of the ducts coming from the prostatic acini. The depressed portions of the urethra on each side of the verumontanum into which the lateral lobe tubules empty, are known as the prostatic sinuses. The number of prostatic ducts probably varies within wide limits, being usually from fifteen to twenty. The anterior lobe tubules open on the roof of the urethra at a point opposite the verumontanum. On the sides of this structure and sometimes on its summit to the outer side of the openings of the ejaculatory ducts, are situated the openings of the posterior lobe tubules. The middle lobe empties itself through ducts which open on the floor of the urethra between the internal vesical sphincter and the verumontanum. The position of the prostatic duct openings in relation to the mouths of the ejaculatory ducts insures thorough admix- ture of the various constituents of the seminal fluid at the time of ejaculation. Emptying into the floor of the prostatic urethra, and con- sequently coursing through the posterior portion of the prostate gland, are found the ejaculatory ducts of the vasa deferentia and the seminal vesicles. The latter enter the prostate through a transverse crescentic cleft, situated at the junction of its inferior and basal surfaces, and unite within the substance of the gland to form the ejaculatory ducts. These tubes lie close together in their passage through the prostate, their muscular walls blending with each other and with the prostatic stroma. 30 Anatomy The latter is well defined in the region of the ducts and serves to separate the lateral and middle lobe tubules from those composing the posterior lobe. Thus is explained the backward displacement of the ejaculatory ducts that takes place in adenomatous enlargements of the middle and the lateral lobes. The intraglandular portions of the ducts run anteriorly on a gradual slant until they reach the colliculus, where, as Porosz has shown, they FIG. 8. CONGENITAL ABSENCE OF THE LEFT VAS DEFERENS AND SEMINAL VESICLE, ASSOCIATED WITH IMPERFECT DEVELOPMENT OF THE PROSTATE ON THE SIDE AFFECTED. r (Socin, after Launois.) bend upward, then curve downward and there open laterally on the declivity of the colliculus. He further states that the curve is often a double one, suggesting a hook bent on itself. The lumen of the terminal part of each duct becomes much constricted, and at this point the ducts are said by Porosz to have a complicated sphincter muscle surrounding them which is a part of the prostatic stroma. The mouths of the ejaculatory ducts are protected by small valve-like folds of mucous membrane that effectually close the distal portion of the ducts Gross Anatomy 31 when distension of the prostatic urethra occurs. Slight congenital variations in the position of the openings of the ejaculatory ducts are common, and in rare instances they have been found within the margins of the uterus masculinus. The prostate gland is formed by the coalescence of five lobes around the urethra although in adult life the two lateral lobes compose the bulk of the organ. The comparatively small portion of the prostate lying on a plane anterior to the urethra belongs to the lateral lobes which are joined together in front of the urethra by the anterior commissure. The anterior lobe tubules undergo early and often complete atrophy. The exact depth in the prostate at which the urethra is found largely depends upon the extent of the forward growth of the lateral lobes. In some few instances the urethra merely grooves the anterior or upper surface of the prostate; but in the majority of cases it is situated with one-third of the organ in front and two-thirds back of the urethra. The wedge-shaped part of the gland situated between the floor of the urethra and the ejaculatory ducts constitutes the middle lobe, while that portion bounded anteriorally by the ejaculatory, laterally by the median surface of the lateral lobes, and inferiorly by the inferior surface of the gland comprises the posterior lobe. The inferior or rectal surface is grooved by a median furrow be- tween the lateral lobes; this marks the location of the posterior com- missure. Grossly the normal adult prostate seems to consist merely of the two lateral lobes coalesced around the urethra. It is important nevertheless to keep in mind the location of the middle and the posterior lobe tubules. The inferior surface of the prostate is rather flat, and rests upon the rectum. In addition to the longitudinal groove, mentioned above, there is also a transverse crescentic slit at the juncture of the inferior and basal surfaces. This, as already mentioned, gives pas- sage to the ejaculatory ducts which sink into the substance of the prostate. The superior surface is more convex, and is placed about two centimetres or less behind the lower part of the symphysis pubis. The base rests against the "neck" of the bladder, and the apex is in con- tact with the deep layer of the triangular ligament of the perineum. The axis of the prostate makes an angle of about 45 degrees with the horizon when the individual is in the erect position. Sheath of the Prostate. Tracing the transversalis or pelvic fascia down along the sides of the pelvis, we come to the white line of origin 32 Anatomy of the levator ani muscle, which stretches from the neighborhood of the pubic symphysis in front to the spine of the ischium behind. At this FIG. 9. MEDIAN SAGITTAL SECTION OF THE LOWER ABDOMEX AND PELVIS, SHOWING THE GENERAL RELATIONS OF THE PROSTATE TO THE BLADDER, THE URETHRA, AND THE RECTUM. white line the pelvic fascia divides into two sheets, the inferior or ex- ternal (called the obturator fascia), passing between the obturator internus and the levator ani, and later giving off two processes one, Prostatic Sheath 33 on the outer wall of the ischiorectal fossa, encircling the internal pudic vessels and nerve; while the inner layer covers the inferior or Bladder Prostate fleet urn [acii!atory duct Recfo-uesical fascia Otifaratorint. ftjjbicbonc levatorAni Ixhium Glutens tnazimuJ Obturator fascia Int. Pudic vessels & nerve Analfasda yschio-rectal fossa, -ct. Sphincter Ani fnf. Sphincter Ani FIG. ic. TRANSVEBSE SECTION OF PELVIS, SHOWING THE GENERAL RELATIONS OF THE PROSTATE TO THE PELVIC WALLS. LOOKING FORWARD TOWARDS THE SYMPHYSIS PUBIS. The plane of section is nearly horizontal with the subject in the erect posture. external surface of the levator ani, and is called the anal fascia. The second original division of the pelvic fascia, called the recto-vesical 34 Anatomy fascia, arising at the white line, passes over the superior or internal surface of the levator ani muscle, and subdivides into three layers: (i) The superior layer passes along toward the median line, above the prostatic plexus of veins, and over the upper surface of the prostate, and coalesces with the external coat of the bladder. (2) The middle layer of the recto-vesical fascia passes below the prostatic plexus of veins, beneath the prostate and bladder, and above the rectum, and joins with its fellow of the opposite side. (3) The third and last layer of the recto-vesical fascia hugs the superior or internal surface of the levator ani, and blends with the outer coat of the rectum. The two layers last described form together the aponeurosis of Denonvilliers which lies between the prostate above and the rectum below, and is really a serous sac originally derived from the peritoneum, although more conveniently described here as part of the recto-vesical fascia. These three layers of the recto-vesical fascia are distinguishable only at the sides of and below the prostate. Toward the median line above they are not separate, but form the pubo-prostatic ligaments, intervening between the most anterior fibres of the levator ani muscle (levator prostatae of Santorini) and the space of Retzius, and blending at the median line, between these muscular fibres (where they contain the dorsal vein of the penis), with the fascia on the outer side of these muscles the deep layer of the triangular ligament of the perineum, which is itself a prolongation of the obturator fascia. Between this sheath of the prostate and its capsule various fibrous prolongations pass, surrounding the venous plexus in a mesh, and binding the prostate in place. Above the prostate these fibrous prolongations form a more or less firm septum, separating the pericap- sular space around one lateral lobe from that about the other, and also serving as a medium of support. In cases of long-standing prostatitis and periprostatitis the strength of these fibrous partitions extending among the venous plexus becomes much increased, and great force may be necessary to tear the prostate out of its enveloping sheath. Thus it is seen that the prostate is enclosed more or less concen- trically first, in its own capsule; then within its venous plexus at the sides and anteriorly, and by the bladder above; and, finally, outside of the venous plexus again, passes the sheath of the prostate. The Prostatic Plexus. The dorsal vein of the penis passes beneath the subpubic ligament, being provided just before its passage with valves, sometimes three in^number; and then divides into two branches Nerves and Vessels . 35 which clothe the sides of the prostate. Here it is joined by veins from the substance of the prostate, and by other minor tributaries, forming the venous plexus of Santorini. No tributaries, however, come from the parietal veins of the pelvis. This plexus lies chiefly on the anterior and lateral aspects of the prostate, and its veins, like others in the pelvis, and in spite of the large number of valves present, are prone to become engorged. In the aged they frequently become varicose, and the formation of phleboliths is not at all uncommon. This plexus lies within the meshes of the sheath of the prostate, entirely outside of its capsule. Its veins travel backward, receiving veins from the the sides and base of the bladder, and from the cellular tissue about the rectum, and finally empty into the internal iliac veins. Fenwick has shown that this important plexus has three dis- tinct sets of valves, which all tend to prevent backward pressure. One set is found at the commencement of the system; one at the end, in the internal iliac veins; and a third set, which is less constant, about the middle of the plexus. . Practically all the veins which enter this plexus are valved, so that Fenwick compares the condition to that of a series of rooms with many different entrances, but only one exit, the result being that the direction of the current is normally always straight onward. The branches received from the internal pudic veins and from the perirectal veins are powerfully valved, so that normally no regurgitation into the hemorrhoidal circulation can take place. The Arteries. The arteries of the prostate are numerous but insig- nificant. They arise from the internal pudic, the inferior vesical, and the middle hemorrhoidal arteries. The largest is the prostatic artery, de- rived from the hypogastric axis, passing along on the lower part of the sides of the bladder to the prostate. The twigs given off from this artery on the surface of the prostate in part supply its substance, piercing its capsule, and in part anastomose with twigs from the corresponding artery on the opposite side, above the prostate. There are seldom many communicating branches below the gland, while the branches from the internal pudic and middle hemorrhoidal are rarely of sufficient size to be noticed. Sometimes the internal pudic artery is smaller than usual, and its terminal branches are then derived from the vesico-prostatic, or from an accessory pudic artery, rising from the internal pudic artery just before its passage through the great sacro-sciatic foramen. When they are derived from the accessory pudic, they may be wounded in opera- 36 Anatomy tions on the perineum; but when springing from the vesico-prostatic, they lie above the prostate and urethra, and are not so liable to injury. Nerves. In the section of this work devoted to the physiology of the sexual organs, we have referred to certain differences of opinion that exist among experimentalists regarding the location of the spinal centres controlling erection and ejaculation. And so it is with the peripheral nerve pathways carrying fibres to and from the spinal centre or centres. The prostate gland is innervated by fibres largely derived from the sympathetic system through the pelvic or inferior hypogastric plexus, some medullated fibres being also found. The bladder, the urethra and the cavernous tissue of the penis are said to receive their nerve supply from this same source, thus explain- ing the reflex pain felt at the end of the penis in certain affections of the bladder. To this statement should be added that the verumontanum, the ejaculatory ducts, the vasa deferentia, and the vesiculae seminales are similarly innervated, and that the functions of erection, ejaculation, and urination are presided over by nerve fibres running in these same pathways. According to Eckhard, contraction of the prostatic musculature is dependent upon impulses carried by both the nervi erigentes and the hypogastrics; the former being purely motor, whereas the latter are both motor and secretory. The nervi erigentes were found by Eckhard to arise in the dog from the first and second sacral nerves, and sometimes also from the third sacral nerve. Stimulation of these nerves caused, among other phenomena, expulsion of prostatic fluid. Loeb found that stimulation of the hypogastrics caused contraction of the prostatic tubules; Nuslowsky and Bormann not only con- firmed this observation, but also demonstrated that stimulation of these nerves promotes secretory activity in the glandular cells of the prostate. Langley and Anderson, on the contrary state, that the internal genera- tive organs of the cat and of the rabbit are not influenced by stimulation of the sacral nerves. In these animals, they found that the nerves to the genital organs are carried in the anterior roots of the third, fourth, and fifth lumbar nerves and sometimes also the second. The fibres pass through the sympathetics to the inferior mesenteric ganglia and continue their course by way of the hypogastric nerves. Stimula- tion of these nerves is said by them to have caused emission of semen from the urethra. Microscopic Anatomy As regards the innervation of the human prostate, the weight of the evidence seems to favor the nervi erigentes of Eckhard together with the hypogastrics. The Lymphatics. The lymphatics are both deep and superficial. The former occupy the smaller vessels in the stroma of the gland, while the superficial series lies with the venous plexus between the prostatic capsule and its sheath. These are eventually joined by the deep vessels to form a network on the lower and posterior surface of the organ. This network is drained by two trunks on either side a superior and a lateral. The upper and smaller trunks are afferent to the obturator lymph nodes of the pelvic wall, while the lateral and larger ones terminate in the internal iliac nodes. Microscopic Anatomy. Historically the prostate is classified as a compound tubular gland. The acini are embedded in a meshwork of involuntary muscle and fibrous tissue, the latter extending as septa inward from the prostatic capsule, which latter is formed by a peripheral condensation of the stroma of the organ. Among the muscular and fibrous tissues and around the acini are found the arterial twigs, the venous radicles, and the deep set of lymphatic vessels. The ultimate distribution of the nerves is not definitely known. The glandular tissue is most marked in the two lateral lobes and is in greater evidence toward the base than toward the apex of the organ. During the development of the prostate gland three of its original groups of tubules become overshadowed by the greater development of the remaining two groups, the latter forming the lateral lobes which constitute the major portion of the adult gland. Nevertheless it is possible, as Lowsley has shown, to demonstrate microscopically the presence of gland groups in the adult prostate which are distinct and separate from those forming the lateral lobes. These from their loca- tion in respect to the position of the lateral lobes are termed anterior, middle, and posterior lobes, respectively. These collections of tubules are not grouped together in such manner that they form lobes which can be recognized in the gross specimen, but they are of more than academic interest for the reason that their participation in neoplastic diseases of the prostate changes materially the clinical picture. To understand the mechanics of prostatic obstruction at the vesical outlet one must appreciate the part that neoplasms originating in each of the five groups of tubules play. The number of tubules in each of the five lobes varies within wide limits. Lowsley studied many specimens in serial section following each 38 Anatomy tubule from its most peripheral portion to the duct orifice; his findings are tabulated as follows: Middle lobe O-12-average-io Right lateral lobe 10-23 -16 Left lateral lobe 11-23 -16 Posterior lobe 6-12 - 9 Anterior lobe 2-14 - 7 The total average number of tubules he found to be fifty eight, which is a far greater number than is generally ascribed to the organ. The number of tubules is somewhat greater in young specimens but after the age of puberty the number of branches is markedly increased and the complexity of the gland structure is far greater than it is in younger specimens. Branching of the prostatic tubules is most marked near the periphery of the organ. The tubules, as Lowsley has demon- strated, "run obliquely through the muscular and elastic tissues which form the bulk of the gland, and upon reaching the peripheral fourth spread out in many small branches nearly all of which point posteriorly or toward the base of the prostate and resemble very closely a wind- blown umbrella tree with the forward half of its branches removed." The ducts from each of the five original groups of tubules empty into the portion of the urethra from which they originally developed. In the actively functioning prostate the glandular portion constitutes approximately one-third of the bulk of the organ, due in part to the greater number of tubular branches present, and also to the disten- tion of the tubules with glandular secretion. The ducts are lined close to their orifices in the urethra with a prolongation of the transitional epithelium with which the prostatic urethra is lined; deeper in they are lined with a single layer of columnar epithelium without a distinct base- ment membrane. The acini themselves are paved with simple colum- nar epithelium which though usually in a single layer, is frequently stratified, smaller polyhedral elements filling up the crevices between the columnar cells. The cells lining the acini are often granular in appearance, and the nuclei are placed nearer to the basement membrane than to the free end of the cells. The prostatic tubules comprising the various groups differ very slightly in minute structure. Their distribution within the glandular stroma and the relationship which they bear to each other is interesting. The following description of them is largely based on Lowsley's careful and thorough microscopic studies of the actively functioning gland. The anterior lobe is composed of from two to fourteen short tubules Microscopic Anatomy 39 which are surrounded by a thin muscular and connective tissue stroma. The ducts open on the ventral wall of the urethra above the point where the ejaculatory ducts open. Lowsley quotes Kuzuitzky as having found a persistent ventral lobe in one out of every fifteen adult prostates. Two cases are mentioned which showed benign hypertrophy of the anterior lobe. The middle lobe is made up of ten tubules on the average. They are markedly branched resembling in this respect the tubules of the lateral lobes. The middle lobe occupies that portion of the gland bounded by the bladder, the ejaculatory ducts, the urethra, and the two lateral lobes. The middle lobe tubules are quite distinct from those of the lateral and posterior lobes, being separated from them by definite fascial planes. Their ducts open on the floor of the urethra posterior to the verumontanum. The tubules project upward behind the sphinc- ter of the bladder, some of them lying in contact with its fibres but none of them actually projecting within the sphincter muscle. This relationship is important to remember in the study of intravesical growths originating from the middle lobe. The lateral lobes are the largest of the prostatic lobes. Each lateral lobe consists of sixteen large and branching tubules whose ducts open into the urethra in the prostatic furrows on either side of the verumon- tanum and is on the sides of the structure. These tubules extend upward behind the sphincter but are contained within the fibrous capsule of the gland, differing in this respect from the middle lobe tubules some of which penetrate and extend beyond this envelope. The capsule of the prostate is very thin in the region of the base of the gland especially at the point where the urethra enters it. This point of weakness in the sheath explains, in part at least, the tendency of neoplasms originating either from the middle or the lateral lobes, to invade the bladder by way of the urethral orifice. The majority of the tubules of the lateral lobes are directed upward, a few project toward the triangular ligament and occupy the apical portion of the gland. Practically all of the duct orifices are found on a level with, or distal to the openings of the ejaculatory ducts and are therefore distinctly separated from the openings of the middle lobe ducts which open on the floor of the urethra proximal to the verumontanum. The posterior lobe consists on the average of nine tubules. This is the least definite of the lobes in the adult specimen. The tubules comprising it are in intimate association with the lateral lobes; 4O Anatomy its ducts as well as those of the lateral lobes open in the prostatic furrows and on the sides of the verumontanum distal to the openings to the ejaculatory ducts. Lowsley compares the posterior lobe to a wedge "with its base at the apex of the prostate, its apex being found posteri- orly from the point where the ejaculatory ducts begin their oblique passage through the prostate." The boundaries of the posterior lobe are, the ejaculatory ducts and the lateral lobes anteriorly, the base of the prostate above, the apex of the prostate below, and the lower or rectal surface of the prostate posteriorly. In some places a thick sheet of fibre-elastic tissue separates the lateral and the posterior lobe tubules, but elsewhere the dividing line is most indistinct. According to the investigations of W. H. Boyd and of J. T. Geraghty, benign hypertrophy rarely if ever originates in the poste- rior lobe, while primary cancer rarely or never begins in any other portion. After careful dissection of forty-two specimens, including a number of bodies of patients upon whom prostatectomy had been performed in one instance two years before Tandler and Zuckerkandl conclude that generalized hypertrophy of the prostate does not occur and that hypertrophy of the posterior lobe is practically unknown. The middle lobe, on the contrary, was so often found the seat of adenoma- tous growths that these investigators conclude that the middle lobe tubules are chiefly concerned in prostatic hypertrophy, and that much of the remaining portion of the gland suffers pressure atrophy as the result of the encroachment of the enlarging tumor mass. A further proof that the posterior lobe tubules are not involved in benign hypertrophic processes is found in the fact that in practically all cases the ejaculatory ducts are displaced posteriorly. This would not occur if the tumor mass took origin in the posterior lobe tubules which lie posterior to the ejaculatory ducts. Lowsley calls attention to the fact that in the performance of a perineal prostatectomy the thick surgical capsule which must be cut through before exposure of the adenomatous masses can be made, is composed of the compressed tubules and the stroma of the posterior lobe. Histologically the posterior lobe tubules differ only slightly from those of the lateral lobes. Accessory Glands. Certain glandular structures of independent origin, and probably having no functional relationship with the prostate gland, are found in the region of the internal vesical sphincter. The Microscopic Anatomy 41 most important of these are the subcervical group of Albarran, which consists of thirty or more branched tubules whose ducts open in the mid-line of the floor of the urethra proximal to the verumontanum. The tubules grow entirely within the sphincter muscle of the bladder and occupy for the most part the mucosa, some few penetrating into the submucous coat. They differ from the prostatic tubules in that they are simpler in structure and are lacking in a definite muscular and connective tissue stroma. Their importance lies in the fact that they are subject to frequent pathological changes resulting in enlargement, and consequent obstruction to the vesical outlet. In twenty-four per cent, of post- mortem specimens taken from men over thirty years of age, Lowsley found these glands enlarged sufficiently to cause demonstrable signs of obstruction in the bladder. The same writer describes a second group of glands, which he calls the sub trigonal group of tubules, as follows: "They occur in the mucosa of the trigonum vesicae usually below the central point and are found as far anteriorward as its apex. They are for the most part simple tubules which extend to the submucosa and somewhat into it. In the younger specimens there are no branches, but some of those found during the middle age period show one or two small branches. There is nothing distinctive about the structure of the members of the sub trigonal group. The mucous lining is composed of transitional epithelium similar in type to the vesical mucosa. The cells are much piled up, in some cases five or six deep. Their lumina are quite small, as a rule. These tubules are of importance on account of two facts: because their position is such that an overgrowth or enlargement from any cause will bring about a disturbance in the emptying of the bladder; secondly, because an enlargement of the group does occur in a small percentage of cases. I have observed six non-malignant tumors of the trigonum vesicae intra- vitam and three in post-mortem specimens. The number of these finger formed tubules increases markedly after birth but are found in the embryo after the fourth month. More than twenty of them are observed in every specimen older than four years." Young has described cases with pedunculated tumors originating from the subtrigonal group of tubules which caused obstruction by blocking the vesical outlet. Verumontanum, Caput Gallinaginis and Uterus Masculinus are terms applied to an elevation situated on the floor of the prostatic urethra at about its mid-point. The verumontanum averages 2.0 cm. 42 Anatomy in length, 0.41 cm. in width and 0.3 cm. in height. It is covered with a mucosa identical in structure with the general lining of the prostatic urethra. The mucous membrane is thrown into longitudinal folds above and below the verumontanum; the upper folds, varying in number from one to five, are in continuity with the uvulae vesicae, the lower folds continue downward to the membraneous urethra. The verumontanum is merely a mound caused by the elevation of the floor of the urethra as the result of the passage beneath it at this point of the ejaculatory ducts and the presence between them of the utriculus prostaticus or sinus pocularis, whose walls contribute to the formation of the verumontanum. The sinus pocularis represents the remains of the fused Miillerian ducts and is therefore the homo- logue of the female uterus. The sinus pocularis is a narrow canal lined with mucous membrane whose mouth, which averages 0.17 cm. in width, opens on the summit of the verumontanum. It extends upward and backward for a distance varying from o.i cm. to 0.7 cm. The lining membrane is clothed with stratified, ciliated columnar epithelium. Eight or more compound tubular glands are in communi- cation with the cul-de-sac. .The tissues surrounding the sinus pocu- laris were at one time believed to be erectile, and turgescence of these tissues was supposed to cause the verumontanum to increase in size and to prevent the reflux of semen into the bladder during ejaculation. The presence of erectile tissue in this region is now disproved. The ejaculatory ducts begin well within the glandular portion of the prostate, being formed by the junction of the vasa deferentia and the ducts of the seminal vesicles. They lie quite close together and the peripheral portion of the muscle fibres surrounding them intermingle. The ducts pass forward on a gradual slant until they reach the posterior border of the verumontanum in the substance of which they run parallel with the axis of the urethra. At the mid-point of the verumontanum they turn sharply lateralward and open on the sides of this structure. These ducts which are approximately two centimetres in length are surrounded near their orifices by sphincter muscles which are merely a thickening of the common circular coat. Their openings are further protected by valve-like folds of mucous membrane which serve to close their lumina when the intra-urethral pressure is elevated. The ejacu- latory ducts near their terminals are lined with transitional epithelium which is replaced by cuboidal epithelium at deeper levels. The musculature of the prostate is in intimate anatomic, and, possibly, physiologic relationship with the musculature of the pros- Microscopic Anatomy 43 FIG. ii. URETHRA AND BLADDER LAID OPEN FROM ABOVE, SHOWING IN THE BULBOUS URETHRA, THE ORIFICES OF THE DUCTS OF COWPER'S GLANDS, AND IN THE PROSIATIC URETHRA THE ORIFICE OF THE UTERUS MASCULINUS, WITH THE OPENINGS OF THE PROSTA- TIC DUCTS ON EACH SIDE OF THE VERUMONTANUM. NOTE THE ORIFICES OF THE EJAC- ULATORY DUCTS ON THE MARGINS OF THE ORIFICE OF THE UTERUS MASCULINUS. 44 Anatomy tatic urethra and bladder. These relationships are discussed at some length in the chapter devoted to the physiology of the prostate gland. Suffice it to say here that the muscular fibres of the prostate are arranged in a compact layer around its periphery, forming with the contiguous fibrous tissue, the true capsule of the gland. Wallace asserts that striped as well as unstriped muscular fibres are found among the gland- ular elements of the normal prostate. Prolongations from the capsule penetrate between the glandular elements, thus providing the gland with fkrifoneum Ant. layer f Triangular liga Post, layer fT/ianyular li FIG. 12. SHEATH OF PROSTATE IN SAGITTAL SECTION (DIAGRAMMATIC). a fibromuscular stroma. Each branch of every tubule is surrounded by a heavy muscular envelope. According to Walker, the circular muscle fibres surrounding the acini are more developed, while the ducts are provided with more robust fibres longitudinally disposed. The terminals of the prostatic ducts are provided with sphincter muscles: these are merely localized, thickening of the circular fibres which elsewhere are poorly developed. Walker has described collections of small round cells in the prostate gland. These he regards as lymph-nodes, but the presence of lymph channels has not been demonstrated except at the periphery of the gland. Weski has studied these structures in human prostates and Microscopic Anatomy 45 believes them to be normal anatomic structures; Waldeyer found similar structures in the prostate gland of the dog. Collections of round cells are not found in the prostate before the \cfo-uesical fascia *^^ . Division > ^ j \ ,2 Tad. Division -^r j , 3rd. Division ^ FIG. 13. SHEATH OF PROSTATE IN TRANSVERSE SECTION. LINE OF SECTION SHOWN IN THE LOWER DRAWING. (DIAGRAMMATIC.) age of puberty, so that many observers regard them merely as evidence of inflammation. Elastic tissue is demonstrable in the prostate gland. It encircles the urethra and sends processes in the form of a figure eight to sur- round the prostatic ducts, just beneath the mucous membrane. 46 Anatomy The Lymphatics. The lymphatics are both deep and superficial. The former accompany the smaller vessels in the stroma of the gland, while the superficial series lies with the venous plexus between the pros- tatic capsule and its sheath. These are eventually joined by the deep vessels, and together they empty into the lymphatics along the course of the internal iliac vessels. D FIG. 14. NORMAL URETHRA, SHOWING DILATABILITY. A. Fossa navicularis. D. Bulbous urethra. B. Membranous urethra. C. Prostatic urethra. The Prostatic Urethra extends from the bladder above to the deep layer of the triangular ligament below, where it becomes the membranous urethra. Its course is at first downward, but toward the termination -of the membranous portion it has commenced its upward journey, which is continued in the bulbous portion until the penile urethra is reached, when the curve again changes, and here has its convexity upward. The prostatic urethra is from two to two-and Microscopic Anatomy 47 FIG. 15. CORONAL SECTION OF THE PELVIS, THROUGH THE PROSTATE AND THE MEMBRANOUS URETHRA, SHOWING THE TRIANGULAR LIGAMENT OF THE PERINEUM. VIEW OF THE ANTERIOR SURFACE OF THE POSTERIOR SEGMENT OF THE PELVIS. (Spalteholz.) FIG. 16. VIEW OF THE PELVIS FROM BEHIND. Note the white line of origin of the levator ani; the relations of the ureters, vasa deferentia, and seminal vesicles. The prostatic sheath is well shown, also the two layers of the recto-prostatic fascia (aponeurosis of Denonvilliers), and between them the deep layer of the triangular ligament. 48 Anatomy a-half centimetres in length, and normally has its sides in contact. Its floor is raised by the verumontanum or caput gallinaginis so that on cross-section it presents a crescentic outline, with convexity above. Its internal diameter is about eight millimetres, but it is the most dilat- able part of the whole canal. On its superior wall, just beneath the mucous membrane, are numerous good-sized veins, which, when engorged, may easily be ruptured by a catheter carelessly passed. The mucous membrane of the prostatic urethra is convoluted into longi- tudinal folds when no urine is passing, and hence is readily adapted to changes in calibre of this canal. Relational or Applied Anatomy. Although the state of the parts surrounding the prostate is of greater anatomic interest to the sur- geon when altered by disease, yet a clear understanding of such pathologic changes can only be acquired by a thorough knowledge of the normal relations. Placed in the true pelvic cavity, below the bladder, above the rectum, and about one-and-a-half centimetres behind the lower margin of the pubic symphysis, the prostate is held quite firmly in place by the supporting fascia?. From the bladder it is separated only by a thin layer of fascia (the first of the three subdivisions of the recto-vesical fascia) which becomes blended with the outer coat of the bladder and, in the middle line, with the capsule of the prostate. Hence on incising the mucous membrane of the bladder, as soon as the muscularis mucosae is divided, this layer of fascia presents itself, forming the sheath of the prostate; and as there are in this situation no veins of any size between the prostatic sheath and its capsule, the sheath and capsule are here practically in contact. When the prostate becomes much enlarged, this layer of fascia atrophies or is pushed to one side, and the pro- static capsule presents itself immediately beneath the vesical mucous membrane. To the rectum the prostate is rather firmly attached by fibrous connective tissue, which may, with care, be separated into two layers, prolongations of the recto-vesical fascia; the lower layer blends with the fibrous covering of the rectum, while the upper sends processes around the seminal vesicles and ampullae of the vasa deferentia, besides passing below the prostatic plexus of veins to join a similar layer from the other side. This layer remains after the removal of the gland by suprapubic prostatectomy, and, with that immediately subjacent, effectually prevents urinary extravasation into the perirectal and Applied Anatomy 49 subperitoneal cellular tissues. These two layers of fascia together form the aponeurosis of Denonvilliers, and the rectum cannot be safely stripped back from the prostate in the operation of perineal prostatectomy until the inferior layer, which is the stronger, has been divided; by so doing the surgeon is admitted into the "espace de- collable retroprostatique," so eloquently described by Proust. The recto-vesical fascia forms two thicker bands of fascia in the median line anteriorly, known as the pubo-prostatic ligaments or anterior true ligaments of the bladder. These are attached above to the pubic bones on each side of the symphysis, and are inserted below into the capsule of the prostate on its upper surface, and into the anterior surface of the bladder. When we say inserted into the capsule of the prostate, we wish it to be understood that here, as elsewhere, the prostatic plexus of veins lies immediately outside the capsule of the prostate gland, and that the insertion above described takes place by processes of fascia sent between the veins where they are numerous, and by a coalescence of the sheath with the capsule where the veins are absent. The dorsal vein of the penis, after perforating the deep layer of the triangular ligament of the perineum, lies in the interval be- tween the two pubo-prostatic ligaments, and as they pass on to their insertion into the bladder, it subdivides beneath them into the pros- tatic plexus. Because fibres of involuntary muscle, prolonged from the bladder-wall, are found beneath the pubo-prostatic ligaments, they are also called the pubo-prostatic muscles. In the median line anteriorly the recto-vesical fascia (pubo-pros- tatic ligaments) is in contact beneath the pubic arch with the deep layer of the triangular ligament of the perineum (the dorsal vein of the penis intervening) ; but to each side of the median line these structures are separated by the most anterior fibres of the levatores ani muscles, which in this situation were denominated by Santorini the levatores prostatse. These muscular fibres descend upon the sides of the pros- tate, and unite beneath it; in this situation they blend with the fibres of the superficial transverse perineal, and external sphincter ani muscles, forming the central tendinous point of the perineum. The deep layer of the triangular ligament, it should be remembered, is really one of the ultimate subdivisions of the pelvic fascia, being the continuation toward the median line of the obturator fascia, which lies between the levator ani and the obturator internus muscles. The urethra emerges from the prostate gland at its apex, about one-and-a-half centimetres below the pubic arch, and passes through 4 50 Anatomy the posterior or deep layer of the triangular ligament to become the membranous urethra. This layer of fascia is firm and tense, and accordingly the apex of the prostate gland is its most fixed portion; enlargement of the organ necessarily extends backward, upward, or downward, never forward. There is no sharp ring where the urethra Prostatic Urethra 51 penetrates the triangular ligament, as this membrane, instead of ter- minating abruptly at the circumference of the urethra, is reflected along its surface toward the prostate, and blends with its fibrous coat. Thus a catheter is not liable to be arrested by any ring-like constriction outside the lumen of the urethra. FIG. 18. SIDE VIEW OF THE PELVIS SHOWING THE MUSCLES AROUND THE BLADDER AND PROSTATE. A. Triangular ligament. B. Levator ani muscle of right side. C. Deep transversus perinei muscle of left side D. Cut edge of levator ani muscle of left side. E. External sphincter ani muscle. F. Bulbo-cavernosus muscle. G. Left ureter. H. Vas deferens (left). K. Coccygeus muscle (right). L. Pyriformis muscle (right). The bladder and prostate have been displaced upward so as to expose the levator ani. The prostatic urethra is normally about eighteen centimetres distant from the external urinary meatus. Any obstruction seated nearer than this to the meatus is not likely to be caused by disease of the prostate. About three centimetres within the anus the prostate may be felt 52 Anatomy as a rounded, firm body of about the size of a horse-chestnut or a little larger. By combined examination with a sound in the urethra and a finger in the rectum much information as to its size and shape may be obtained. FIG. 19. SIDE VIEW OF THE PELVIS, SHOWING THE RELATIONS OF THE PERITONEUM TO THE EMPTY AND THE DISTENDED BLADDER. (After Gerrish.) . It is well known that the anterior wall of the rectum undergoes a sharp flexure just within the anus, so that the axis of the rectum is practically at right angles with that of the anal canal. This angle of the anterior rectal wall is produced by its attachment to the triangular ligament of the perineum by certain muscular fibres described as the recto-urethral muscle. The external sphincter of the anus, it will be Anal Sphincter 53 recalled, is attached anteriorly to the perineal centre, meeting there with the superficial transverse perineal muscles from the sides, with the anterior fibres of the levatores ani muscles from a deeper plane poste- FIG. 20. DISSECTION OF THE PERINEUM. The attachment of the external sphincter ani to the perineal centre has been divided, and the fascia of Colles has been reflected, exposing the superficial vessels and nerves of the perineum, the superficial transverse perineal muscles, the ischio-cavernosus and the bulbo-cavernosus muscles. Posteriorly, on each side of the anus are seen the leva- tores ani muscles, clothing the sides of the rectum; on the subject's left the internal pudic artery and branches of the pudic nerve are seen. riorly, and with the bulb of the urethra anteriorly. On a plane just beneath these structures are met the recto-urethral muscle posteriorly, 54 Anatomy and the triangular ligament containing the deep transverse perineal muscles anteriorly. To understand how the levator ani, which between the space of Retzius and the pubic symphysis is on a deeper plane FIG. 21. DISSECTION OF THE PERINEUM. The superficial transverse perineal muscles, the bulbo-cavernosus muscle, and the right ischio-cavernosus muscle have been removed, together with part of the right cor- pus cavernosum and a section of the corpus spongiosum and urethra. The superficial layer of the triangular ligament, the dorsal vein, artery, and nerves of the penis, and the arteries of the corpus cavernosum are thus exposed. than the triangular ligament, can become superficial to this structure and the recto-urethral muscle, it must be remembered that the levator ani is like a sling, and hangs down from the pubic bones to surround the Perineum 55 lower part of the rectum, being deficient in the median line under the pubic arch, and only becoming superficial to the triangular ligament back of the posterior border of this structure, where its fibres from the FIG. 22. DISSECTION OF THE PERINEUM. The superficial layer of the triangular ligament has been incised, exposing the deep transversus perinei muscle on the left side, and the internal pudic vessels and nerve on the right side of the cadaver The duct of Cowper's gland of the right side is seen as it enters the bulbous urethra, after piercing the superficial layer of the triangular ligament. two sides of the prostate unite at the perineal centre. The accompany- ing illustration shows these relations very well. When the bladder is empty, the recto-vesical fold of peritoneum reaches as far as the base of the prostate, or nearly so; but when the bladder is distended with a moderate amount of fluid, the peritoneal 56 Anatomy reflection is probably always at least three centimetres above the base of the prostate gland. This explains why the bladder was formerly tapped through the rectum with such success, and shows that in any ordinary operation on the prostate through the perineum no fear need be entertained of opening the peritoneal cavity. FIG. 23. DISSECTION o* THE PERINEUM. The bulb of the urethra and the left deep transversus perinei muscle have been re- moved. On the subject's left the deep layer of the triangular ligament is exposed. On the right Cowper's gland is seen. The anterior vesical fold of peritoneum is carried up about five centimetres above the upper margin of the symphysis pubis by moder- ate distention of the bladder; but as in suprapubic operations the peritoneum is usually recognized with ease, and may readily be stripped Perineum 57 off from the bladder if more room is desired, the relations here are not of such practical interest. The ampullae of the vasa deferentia lie between the two seminal FIG. 24. DISSECTION OF THE PERINEUM. The deep layer of the triangular ligament, with all structures superficial to it, has been removed, exposing the perineal portion of the levator ani muscle and its anterior fibres known as the levator prostatae. The urethra has been cut off at the apex of the prostate gland. The fibres of the levator ani passing underneath the rectum are shown as in the preceding plates. vesicles upon the rectum, and beneath the neck of the bladder, just above and lateral to the prostate gland, where they can be felt with the finger in the rectum. The ureters run lateral and parallel to the vasa deferentia where the latter are in contact with the bladder wall; at a 58 Anatomy higher level the ureters lie medial to the vasa deferentia, the latter having crossed beneath the ureters, and ascend lateral to them. In the small area between the prostate anteriorly, the vasa deferentia at FIG. 25. DISSECTION or THE PERINEUM. The recto-vesical fascia, forming the sheath of the prostate, and the levator ani muscle, have been incised from the symphysis to the anus, and the rectum has been turned backward The prostate, the seminal vesicles, and the vasa deferentia are ex- posed. Note the vesico-prostate plexus of veins in the meshes of the recto-vesical fascia. The wall of the bladder is seen above the prostate. the sides, and the peritoneal reflection above or posteriorly, the bladder is in fairly close relation with the rectum. This is the spot where, when fluctuation could be detected, the bladder was formerly punctured for retention of urine. Perineum $g The combined ejaculatory duct of the vas deferens and the seminal vesicle of each side penetrates the prostate gland through a transverse fissure on its inferior surface; the two ducts then run forward, and empty into the prostatic urethra on either side of the verumontanum. According to Mr. Freyer, when the prostate undergoes marked adeno- matous change, its two lateral lobes tend to become separated again, as they were during fetal life. What is of greater practical importance is the fact that the ejaculatory ducts are displaced backward in the hypertrophied state of the prostate. The intraprostatic portions of these ducts are contained in a fibromuscular septum separating the middle and lateral lobes in front from the posterior lobe behind. En- largement of either the middle or the lateral lobe would therefore neces- sarily displace the ducts backward toward the inferior or rectal surface of the gland. In the suprapubic operation of prostatectomy for benign enlarge- ment of the gland not only are the ejaculatory ducts outside the line of cleavage, but their terminals are not disturbed if care is taken to cut across the urethra proximal to the verumontanum. In conserva- tive perineal prostatectomy Young takes advantage of the posterior displacement of the ducts in that the bridge of tissue containing them is not disturbed by the incisions made to expose the enlarged lateral lobes. REFERENCES (CHAPTER II) Albarran: Maladies de la Prostate, 1902, p 526 Boyd, W. H.: Jour. Am. Med. Ass., 1912, Iviii, 620. Ciechanowski: Annales des Maladies des Organes Gen.-Urin., 1901, xix, 536. Denonvilliers : Propositions d'anatomie, de physiologic et de pathologic, Paris Thesis, 1857. Derry, D. E.: "On the Real Nature of the So-called Pelvic Fascia." Jour, of Anat. and Physiol., 1908, xlii, 107. Eckhard: Beitrage zur Anat. und Physiol., 1863. iii. Evatt: Jour. Anat. and Physiol., 1909, xliii, 314. Fenwick: Jour. Anat. and Physiol., 1885, xix, 320. Freyer: Stricture of the Urethra and Hypertrophy of the Prostate, 2d ed., London, 1902. Griffith: Jour. Anat. and Physiol., 1889, xxiii, 374. Ibid., 1889, xxiv, 27 236, Lancet, 1895, 1. Hada, B.: Studien zur Entwickelung und zur normalen pathologischen Anatomic der Prostata mit besondere Beriicksichtigung der sogenannten Prostatahypertrophie. Fol. Urol., 1914-15, ix, 65. Home, Sir Everard: Trans. Philos. Soc. London, 1805, Paper viii, quoted in his "Works," London, 1811, i. "Practical Observations on the Treatment of the Diseases of the Prostate Gland." Hunter, John: Works on the Venereal Disease, ed. by Palmer, London, 1835, 279 Jores: Virchow's Archiv. f. path. Anat., 1894, cxxxv, 224. Kolischer: Die Urogeritalmuskulatur des Dammes, 1900. Langley and Anderson: Jour, of Physiol., 1891, xii; Ibid, 1895, xix, 71. 60 Anatomy Loeb: Inaug. Dissert., Giessen, 1866. Lowsley: Jour. Amer. Med. Assn., 1913, Ix, no; Medical Record, 1915, Ixxxviii, 383; Amer. Jour. Anat., 1912, xiii, 299; Surg., Gynec. and Obstr., 1915, xx, 183. Lourneau: Annales des Maladies des Organes Gen.-Urin., 1904, xxii, 126. Morgagni: Adversaria Anatomia, Lib. 4, Animadversio, 14. De Sedis et Causis Morborum, Lib. 3, Epist. 41, A. 19. Moullin, C. W. Mansell: Enlargement of the Prostate, London, 1899, 2d ed.; 1904, 3d ed. Medical Record, 1916, xc, 3. Nassetti, P.: Clin. Chir., 1912, xxx, 1194. Nuslowsky and Bormann: Centralbl. fur Physiol., 1898, xii. Owen: Lectures on the Comparative Anatomy of the Invertebrate Animals, London, 1843; The Anatomy of the Vertebrates, London, 1868, iii, 641. Pallin: Beitrag zur Anatomic und Embryologie der Prostata und der Samenblasen, Arch. f. Anat. u. Physiol., 1901, i, 135. Piersol, George A.: Human Anatomy, vol. ii, p. 1979. Porosz: Daten zur Anatomic der Prostata, Arch. f. Anat. u. Physiol., 1913, Sup. clxxii; Fol. Urol., 1914, viii, 569. Proust: Manuel de la Prostatectomie Perineale pour Hypertrophie, Paris, 1903. Richardson, W. G.: Development and Anatomy of the Prostate Gland, London, 1904. Riidenger: Zur Anat. der Prostata, des Uterus masculinus und der Duchte ejaculatorii; Festschrift d. Arztl. Vereines Miinchen, 1883, 47-67. Rytina, A.: The Jour, of Urol., 1917 i, 231. Santorini, Jo. Dominicus: Observationes Anatomicae, Venetiis, 1724; Cap. 10, Sect. 5, f. 181; Jo. Dominicus: Ibid., loc. cit., Sect. 19, f. 199, seq. Smith, G. E.: "Study of the Anat. of the Pelvis with special Reference to the Fascia and Visceral Supports." Jour, of Anat. and Physiol., 1908, xlii, 198. Strieker: Human and Comparative Histology. Translation of New Sydenham Soc., London, 1872, ii, p. 300. Tandler and Zuckerkandl: Folia Urologica, 1911, v, 587; ibid., 1912, vi, 635. Thompson, Sir Henry: Diseases of the Prostate, London, 1868. Versari: Ric. d. lab. d. Roma, 1907, xiii. Wade, Henry: Annals of Surgery, 1914, lix, i. Waldeyer: Quoted by Piersol. Walker, George- Johns Hopkins Hospital Bulletin, 1900, xi, 242. Walker, Thomson: Jour. Anat. and physiol., 1906, xl, 189. Med. Chir. Trans., 1904, Ixxxvii, 403. Brit. Med. Jour., 1904, ii, 62. Wallace: British Med. Jour., 1904, ii, 62. Young, H. H.: Quoted by Lowsley, Jour. Amer. Med. Assn., 1913, Ix, no. CHAPTER III PHYSIOLOGY In describing the anatomy of the prostate gland we purposely omitted that detailed description of the urethra and urinary bladder which is necessary for a clear understanding of the physiological functions of these parts. The ancient view that the prostate gland took an active part in the act of urination is no longer tenable. Never- theless the bladder and proximal urethra are so closely associated anatomically with the prostate, and the successful surgery of pros- tatic enlargement is so largely dependent upon the preservation or restoration of normal urinary function, that the anatomy and physi- logy of the lower urinary tract are worthy subjects for intimate study. Structure of the Bladder and Urethra. The bladder is a muscular sac lined with a mucous membrane and covered on its upper surface with peritoneum. A thin layer of connective tissue uniting the mucous membrane to the underlying muscle coats constitutes a sub- mucous stratum. The mucous coat consists of several layers of transitional epi- thelium resting upon a fibre-elastic tunica propria. It presents marked variations in thickness, being quite thin over the vesical trigonum ; when the bladder is fully distended it measures only about .1 mm. In the empty bladder, the smooth trigonal mucosa of the distended viscus is thrown into longitudinal folds; under these circum- stances the mucosa may attain a thickness of 2 mm. or even more. The trigonal glands to which Waldeyer, Kolischer and others called attention, and which Lowsley has described at some length, are con- sidered by Piersol to be merely tubular depressions and not true glands at all. Young and others have, however, described peduncu- lated tumors taking origin from glandular structures situated in the trigonal mucosa. The submucous coat is so designed as to permit free movement of the mucous membrane on the underlying muscular wall. It is a loosely woven substance composed for the most part of fibrous tissue interwoven with elastic fibres which are not easily separated from the mucous and the muscular coats. 61 62 Physiology The submucosa is wanting in the trigonal area, hence the mucosa is more fixed at this point than elsewhere. The blood vessels and nerve plexuses are found in the submucosa. The muscles of the bladder wall are involuntary in type and are arranged in three layers, viz. a thin outer longitudinal, a thick middle circular, and an incomplete inner longitudinal layer. The muscular coat is robust and in a contracted state of the bladder measures about i cm. in thickness. Enormous hypertrophic thicken- ing of the musculature occurs in certain cases where the bladder is ob- structed and infected. When the bladder is distended, the musculature is proportionately thinned out. The outer longitudinal layer of fibres is most prominent on the upper and lower surface of the viscus. This layer is not complete, the spaces between the individual bundles of fibres being filled in with connective tissue. These interf ascicular spaces constitute points of weakness in the bladder wall through which the mucosa may herniate, and when there is an obstruction at the vesical outlet or in the urethra result in acquired diverticula. Muscle fibres from the outer layer are continued anteriorly to the body of the pubic bone, constituting the pubo-vesical muscle; poste- riorly the rectum is attached to the bladder by fibres extending from the anterior layer the recto-vesical muscle. The circular layer is the best developed and the strongest of the three layers of muscles above the level of the urethral orifice; below this point the circular layer is imperfect so that the trigonal area re- ceives few fibres from this layer. The inner longitudinal muscle coat is well developed in the region of the trigonum. Elsewhere it is composed of indefinite and indis- tinct groups of fibres blended with the connective tissue of the sub- mucosa. At the apex of the trigonum the muscle fibres of this layer are condensed and, in conjunction with fibres contributed by the proximal portion of the urethra, form the internal vesical sphincter. Descriptions of the muscular structures in the region of the vesical outlet are likely to be confusing because of the intimate relationship of the vesical, the urethral, and the prostatic musculature. The proximal two-thirds of the prostatic urethra is derived, as is also the trigonal area of the bladder, from the cloaco-allantois, while the prostate gland forms from tubular evaginations from the primitive urethra, which invade the undifferentiated mesoblastic tissues surrounding the, as yet, undeveloped urethra. This mesoblastic tissue later gives origin to the intrinsic musculature of the prostatic urethra and to the Bladder and Urethra 63 prostatic stroma. A close association betweeen these structures continues to exist in the adult. The intrinsic musculature of the male urethra, involuntary in type, is directly incorporated with the walls of the canal. It is divided into two layers,, the internal longitudinal layer and the robust external circular layer. The internal layer is continuous with the internal longitudinal muscle layer of the bladder, and extends forward to the openings of Cowper's ducts. The circular muscular coat of the ure- thra is in intimate relationship with the internal vesical sphincter, although the latter is in reality derived from the middle muscular layer of the trigonum. Muscular fibres within the capsule of the prostate gland intermingle with the fibres composing the circular coat of the proximal urethra, so that there is no sharp line of differentiation between the two sets of fibres. The circular coat is best developed near the vesical orifice gradually diminishing in thickness as it extends forward as far as the termination of the membranous urethra. The musculature surrounding the prostatic ducts is likewise inti- mately associated with the circular muscle coat of the urethra. In the removal of an adenomatous prostate by the suprapubic route the musculature of the proximal urethra can hardly escape injury, but the internal sphincter is preserved because it has become displaced outward by the invaginating tumor. In some instances the tumor mass pushes at least a portion of the fibres of the sphincter ahead of it, so that they are liable to injury during the enucleation of the tumor. A groove formed on the surface of the tumor mass denotes the line of separation between the intra-vesical and the extra-vesical portions of the mass, and marks the points of contact of the internal vesical sphinc- ter and the margin of the prostatic sheath. The latter is deficient in the neighborhood of the urethro- vesical junction. The extrinsic muscles of the urethra are important factors in the physiology of urination and ejaculation. The compressor urethrae muscle, which is contained between the layers of the triangular ligament within the deep perineal interspaces, passes from side to side and encir- cles the membranous portion of the urethra. It is a voluntary muscle which maintains itself in a state of tonic contraction. Its nerve supply is derived from the internal pubic, which also supplies the remaining extrinsic muscles of the urethra. Continuous with this muscle above, and considered by some to be a part of it, is the external vesical sphincter. The latter muscle com- prises encircling bundles of striped muscle fibres which surround the 64 Physiology urethra at the apex of the prostate and are intimately associated, not only with the sheath and the musculature stroma of the gland, but also with the pelvic fascia, which at this point stretches between the pelvic rami to form the deep layer of the triangular ligament. Above the external vesical sphincter, the extrinsic muscle fibres lie entirely in front of the urethra. Although the external vesical sphincter is normally held in a state of tonic contraction the strength of its contractions may be increased by the influence of the will. The nerves of the bladder and of the prostatic urethra comprise both sympathetic and spinal fibres; they are connected with the cord, as are also the nerves of the prostate gland, by means of the hypogas- tric plexus. From the latter the nerve fibres take two courses, one to the sacral cord by way of the N. erigens, the other to the lumbar cord through the N. hypogastricus. The majority of the fibres from the sacral cord are carried in the ventral branches of the second, third, and fourth sacral nerves. The spinal fibres are distributed chiefly to the trigonal and urethral regions of the bladder, by far the most sensitive portions of the viscus. The sympathetic fibres, which go to the muscles, follow the blood ves- sels and break up into fine strings which end in microscopic ganglia. Some of the terminals are found in the substance of the muscle, while others penetrate the submucosa and terminate in ganglia which lie between the epithelial cells of the mucosa. The urinary function is presided over by a centre or centres in the lumbar cord which in turn are connected with higher centres all the way to the brain cortex. The fibres are said to cross at the level of the fifth lumbar nerve, and a second crossing is said by Langley and Anderson to occur in the inferior mesenteric ganglia. Various centres in the cerebral cortex have been described, and it has been shown that stimulation of any sensory nerve or of any part of the spinal cord will cause contraction of the bladder muscles. The bladder, the prostate, the seminal vesicles, and the prostatic urethra derive arterial branches from the inferior vesical and middle hemorrhoidal arteries; the bladder in addition is supplied by the superior vesical artery, a branch of the internal iliac artery, and by branches from the internal pudic and obturator arteries. These structures are drained by veins which pass into the large prostatico- vesical plexus at the sides of the bladder and thence into the internal iliac veins. Urination 6- The lymphatics of the bladder begin within the muscular coat through which they pass and collect to form a subperitoneal plexus. Efferent lymph channels pass, in company with the arteries, upward from the fundus and downward from the apex or body of the bladder and eventually drain into the internal iliac nodes and nodes situated at the bifurcation of the aorta. The majority of the prostatic lymph- atics are also tributaries of the internal iliac group of nodes, but some of them drain into the obturator nodes of the pelvic wall. The Physiology of Urination. Under normal conditions the urine is retained within the bladder cavity by the action of the internal vesical sphincter. No matter how great the desire to empty the bladder may be, the muscle does not relax until the act of urination is begun; the deep urethra does not, as was formerly supposed, become a part of the bladder cavity when the latter viscus is distended. (This ancient belief is now discarded; indeed the results of experiments undertaken to prove the correctness of this theory have been shown to have been wrongly interpreted.) The contention of Finger and of Oppenheim that the fully distended bladder is pear-shaped because of the inclusion of the deep urethra in the bladder cavity, was first refuted by von Zeissl whose arguments were based on the study of cystograms. Since the publication of von Zeissl's observations, a host of other authors have confirmed his findings, and at the present time it is a generally accepted fact that the internal vesical sphincter retains the urine in all normal circumstances. In the presence of long-standing obstruction in the membranous urethra the parts proximal to it may become dilated so that eventually the internal sphincter may become perma- nently inadequate to retain the urine, but in normal individuals it is the internal sphincter alone which closes the bladder Normally the length of catheter necessary to draw the urine is the same whether the bladder is fully distended or comparatively empty. This would obviously not be the case if the prostatic urethra became continuous with the bladder cavity in a state of marked urinary distention. In some instances the internal vesical orifice is held open by an invading prostatic nodule which prevents the sphincter muscle from functioning normally. Under these circumstances the deep urethra may become continuous with the bladder cavity, and either incontinence results or the urine is retained within the prostatic urethra and the bladder by the action of the ex- ternal sphincter muscle. The final proof controverting Finger's theory came with cystographic demonstrations that the distended normal bladder is an oval or rounded 66 Physiology structure in which there is no suggestion of a vesical neck. Inconti- nence of urine following prostatectomy usually means injury to both sphincters. Normally the internal sphincter muscle is held in a state of tonic contraction under the control of the hypogastric nerves. The urine accumulates, distending the bladder and putting the detrusor muscle on the stretch. The latter muscle contracts rhythmically sending impulses to the cord and thence to the brain where they are translated into a conscious desire to void. The inhibitory influences of the spinal centre, which latter maintains the tone of the internal sphincter, is removed and the muscle relaxes. Synchronous with this relaxation, the detrusor muscle is stimulated to greater activity and, together with voluntary contractions of the abdominal muscles, elevates the intravesical pressure and the urine is caused to flow with rapidity into the urethra. Thereafter the act is continued reflexly probably as the result of stimuli which arise from contact of the urine with the urethral mucosa; the act, however, is under the control of the will and the reflex action is always subject to intrusions of cerebral influence. The prostatic gland is entirely passive during the act of urination which is a function of the neuro-muscular system of the bladder and the urethra. The Physiology of Ejaculation. The sexual orgasm is essentially a reflex action the centre being located in the lumbo-sacral region of the cord. The reflex is maintained after transverse section of the cord above this level. According to Miiller, only the lower part of the cord need be retained in order to preserve the erection reflex. The afferent nerve fibres to the penis, and probably also to the prostate and the vesicles as well as the bladder are carried in the nervi erigentes and hypogastrics. Eckhard was the first to show that the penis of the dog could be erected experimentally by stimulation of the nervi erigentes which come from the first and second sacral and sometimes also from the third sacral nerves. The orgasm results from the reflex discharge of erector impulses which follow one or more fixed pathways from the erector centre in the spinal cord. The afferent impulses are brought to the cord along widely different pathways. Erection and even ejaculation can be induced voluntarily by stimuli conveyed from the brain. In the treatment of abnormalities of the sexual function supposedly dependent upon pathologic processes in the sexual glands, the physician will do well to bear in mind the psychologic factors involved in so complex a physiologic process. Prostate Gland 67 The emission of the semen, which in the male marks the culmination of the sexual impulse, denotes the termination of a series of muscular contractions; these are said to begin in the walls of the vasa efferentia of the testicles and to pass to the canal of the epididymis and thence along the vasa deferentia. The vesiculae seminales contract simul- taneously expelling their contents into the vasa, and the mixed fluid passes out through the ejaculatory ducts into the prostatic urethra. The prostatic muscles contract at the same time and in addition to expelling the secretion of the prostate also assist in emptying the ejacu- latory ducts. The final discharge of semen from the urethra is brought about by rhythmic contractions of the intrinsic and extrinsic muscles of the canal. In describing the innervation of the prostate gland attention was called to the fact that this gland receives two sets of nerve fibres: one from the nervi erigentes which are purely motor, the other through the hypogastrics which are mixed nerves. Stimulation of the nervi erigen- tes will cause contraction of the prostatic musculature and the expulsion of prostatic fluid into the urethra. Loeb, by stimulation of the hypo- gastric nerves, also obtained contractions of these muscles as well as increased secretory activity on the part of the glandular epithelium. Contractions of the muscles of the seminal vesicles and the vasa defer- entia are said to follow stimulation of the hypogastric nerve. Langley and Anderson have shown that the internal generative organs of the cat and the dog are supplied by fibres running in the anterior tracts of the second, third, fourth, and fifth lumbar nerves and thence by way of the hypogastrics. Stimulation of these nerves causes strong contractions of the musculature of the vasa deferentia and uterus masculinus; the contractions being strong enough to produce the emis- sion of semen from the urethra. Marshall calls attention to the fact that the ejaculation of semen is of some complexity involving more than one centre in the spinal cord. He is of the opinion that the centre for the final expulsion of semen must be the same as that for erection since the muscular mechanisms con- cerned are to a large extent the same. The contractions of the prostatic musculature are governed by the same spinal centres and the same nerve tracts. The Physiology of the Prostate Gland. The chief function of the prostate gland is to furnish a liquid medium chemically and physio- logically suitable to the needs of the spermatoza in their passage from the genital glands. Whether it is an inert medium or one without 68 Physiology which the spermatozoa could not function normally, is not definitely known. Fiirbinger and Kolliker were the first to maintain that the prostatic fluid has a stimulating effect on the motility of the sperma- tozoa. Steinach contributed the observation that prostatic fluid when added to the spermatozoa suspended in normal saline solution prolongs their lives. Iwanoff, on the contrary, has shown that Spermatozoa uninfluenced by prostatic fluid are capable of fecundation, while a host of other writers attest the activity of sperm derived directly from the testicles by aspiration. These observations would seem to indicate that the prostatic fluid is not vitally important to the spermatozoa. Testicular fluid is alkaline in reaction, and as pointed out by Adams, that of the prostate is acid in reaction, hence it may be in- ferred that the prostatic fluid has an important neutralizing effect on the testicular secretion. Fiirbinger has shown that excessive amounts of prostatic fluid have a lethal effect on spermatozoa. Steinach, moreover, has demonstrated that removal of the seminal vesicles and the prostate gland from white rats, while not diminishing the sexual passion and the ability to perform the sexual act, including the actual discharge of spermatozoa, prevents entirely the fertilization of the ova; removal of the seminal vesicles alone markedly weakens the fertilizing power of the semen. It is not known whether the prostate furnishes an internal secretion to the body; that it furnishes one of any considerable consequence is at all events unlikely. Serrallach and Pares have contributed the results of experimental work indicating that the prostate secretes an internal secretion which controls the testicular functions and regulates the process of ejacu- lation. It is stated that removal of the prostate causes spermato- genesis to cease, and causes also a cessation of the secretory activity of the accessory sexual glands. The results of these experiments have not been enthusiastically supported. That there is a close physiological relationship between the secretory activities of the several genital glands is not to be questioned, and it is reasonable to suppose that internal secretions are the media of control; that the most important internal secretion is of prostatic origin is, however, extremely unlikely. Macht has reported some highly interesting observations on the influence of dessicated prostatic substance on the growth and develop- ment of tadpoles, which seem to indicate the presence of an internal prostatic secretion. Prostatic Secretion 69 Various tadpoles were fed with prostatic tissue obtained from human operative specimens as well as from certain of the lower animals and the results were controlled by comparing them with the effect on other tadpoles with various other glandular substances. The results of feeding with prostatic tissue, which were striking, manifested them- selves not only in stimulating normal growth and differentiation of the larvae, but, what seems to us of more significance, in stimulating growth to a size above that which is normal. Macht draws' the following conclusions from his work: (a) "It was found that prostatic tissue feeding tended to stimulate both the growth and metamorphosis of the larvae of the frog, toad and salamander. (b) These observations speak in favor of an internal secretion of the prostate gland." Griffith has shown that the prostate gland in the hedgehog under- goes definite cyclical changes. In both man and animals the growth and development of the prostate gland would seem to depend upon the maturation of the cells lining the seminiferous tubules, since full development occurs only. after the establishment of puberty. It will be recalled that the operation of double castration for the cure of prostatic hypertrophy was based on the theory that the abnormal growth was dependent upon an internal secretion supplied by the tes- tes. Atrophy of the normal prostate occurs after castration in patients who have passed the age of puberty. Much experimental evidence has accumulated which proves that this function of the testes is inde- pendent of its spermatogenic function. Familiar clinical examples are found in cases of cryptorchidism in which normal prostatic devel- opment has taken place and in which the secondary sexual character- istics have developed normally with unimpaired sexual potency in the complete absence of spermatogenesis. The sterility caused by #-rays is due to the specific action of the rays on the spermatogenic cells; the cells of internal secretion are not affected by them. That there is an internal secretion elaborated by the prostate gland, the function of which is to stimulate spermatogenesis, is ex- tremely doubtful. The Prostatic Secretion. The normal prostatic fluid is a thin opalescent fluid containing numerous minute, round, homogenous bodies, lecithin, a few large granular elements, and a moderate number of leucocytes and round and columnar epithelial cells. According to Gley and Camus, the prostatic secretion contains 70 Physiology a ferment, vesiculose, the action of which causes clotting of the seminal fluid. In certain rodents the seminal clotting is said to be for the purpose of preventing the escape of the spermatozoa from the female passages, thus helping to ensure fertilization. Lataste was the first to call attention to the clotting of seminal fluid within the female passages and refers in his writings to the clotted seminal fluid as the "bouchon vaginal" the formation of which is now attributed to a ferment elaborated by the prostatic cells. The prostatic secretion is alkaline to litmus and acid to phenol- phthalein. According to Fiirbinger, it contains spermine, which when brought into contact with the phosphates secreted by the other genital glands produces Bottcher's crystals. Concretions are frequently found in the prostatic acini in advanced life and also sometimes in the prostates of young men. These concretions, or corpora amylacea, occur also in the alveoli of the lung. Their nucleus is probably mucoid material and broken down epithelial cells; while the concentrically arranged layers of prostatic concretions are formed either by the stratified accretion of the hyaline debris of cells or of inspissated prostatic secretion. The amount of solid matter in corpora amylacea has been estimated at from 46 to 86 per cent. The prostatic fluid contains only about 1.5 per cent, solids which are mostly proteids and salts. REFERENCES (CHAPTER III) Barringer and MacKee: Radiographs of the Bladder and Bladder Neck. Trans. Amer. Urol. Assoc., 1912, vi, 408. De Bonis, W.: Ueber Sekreticnserscheinungen in den Driisenzellen der Prostata. Arch. f. Anat. u. Phys., 1907, Anat. Abt., i. Eckhard: Beitr. zur Anat. und Physiol., 1863, iii. Finger: All. Wien. med. Ztschr., 1893, xxxviii, 427; 439; 452. Fischel and Kreelich: Ueber Prostata Sekretion, Wien. klin. Wchnschr., 1911, xxiv, 901. Frankl-Hochwart and Zuckerkandl: Die nervosen Erkrankungen der Blase. Nothnagels spez. Path. u. Ther., 1898, Bd. 19. Fiirbringer: NothnageFs Pathologic u. Therapie, 1895, xix; Berliner klin. Woch., 1886, xxiii, 476. Gley and Camus: C. R. de Soc. de Biol., 1897, iv, 787. Griffith: Jour. Anat. and Physiol., 1888, xxiii, 374; Ibid., 1889, xxiv, 27; 236. Guyon: Physiologic de la Vesic., Gaz. Hebdom. de Med. et Chir., 1884. Physiologic der Retentio urinae, Zentrabl. fur die Krankheiten der Harn und Sexual Organe, 1890, ii, 7. Hada and Gotzel: Wechselbeziehungen zwischen Hoden u. Prostata. Prager. med. Wochnschr., 1914, xxxix, 433. Hyman: Ann. Surg., 1914, lix, 544; Med. Record, 1918, xciv, 610. Isihara, M.: Ueber das Lipoidpigment der Prostatadrusen. Folia Urol., 1915, ix, 280. Iwanoff : Jour, de Phys. et de Path., Gen., 1900, ii, 95. Iwanow and Andrew: Recherches sur les fragments de la liquide spermatique du chien. Compt. rend. Soc. de Biol., 1916, Ixxix, 85. References 7 1 Kolischer: Quoted by Piersol. Kolliker: Zeitschr. f. wiss. Zool., 1856, vii. Langley and Anderson: Jour, of Physiol., 1891, xii; Ibid., 1895, xix, 71. Lataste: Zool. An., 1883, vi. Launois: Annal. d. Mai. d. org. gen.-urin., 1894, xii, 721. Leedham- Green: British Med. Jour., 1906, Ii, 297. Legueu and Gaillardot: Toxicite gene"rale des extraits de la prostate hypertrophie. Jour. d'urol., 1912, ii, 50. Loeb: Inaug. Dissert., Giessen, 1866. Lowsley: Jour. Amer. Med. Assn., 1913, Ix, no; Medical Record, 1915, Ixxxviii, 383. Macht, D. I.: Physiological and Pharmacological Studies of the Prostate Gland. Jour. of Urolog., 1920, iv, 115. Marx; M.: Quelques consideration sur 1'hypertrophie de la prostate au point de vue genital. Gaz. med. de Paris, 1915, bcxxvi, 21. Oppenheim and Loew: Der Mechanismus des Blasenverschlusses im Rontgenbild, Centralbl. f. d. Krankheiten der Harn and Sexual Organe, 1906, xvii, 66. Piersol: Human Anatomy, p. 1909. Porosz: Archiv. f. Anat. u. Physiol. Anat., Leipzig, 1913, Anat. Abt., (Supplement-bd.) 172. Posner, H. : Prostatalipoid und Prostatakonkretion, Zeitsch. f. Urol., 1911, v, 722. Posner and Scheffer: Beitrage zur klinschen Mikroskopie u. Mikrophotographie. Berl. klin. Wchnschr., 1909, xlvi, 254. Rehfisch: Virchow's Arch. f. path. Anat., Berl., 1897, cl, in. Rytina: The Verumontanum with Special Reference to the Sinus Pocularis; its Anatomy, Histology and Physiology. Journal of Urology, 1917, i, 231. Schlagenhaufer: Ueber Lipoide doppelbbrechende Substanzen in Prostatakarzinomen. Verhandl. d. d. Path. Ges., 1009, 332. Sehrt, E.: Ueber das Vorkommen einer doppeltlichtbrechenden Substanz als normaler Bestandteil der Prostataepithelzelle des Menschen und Farren. Virchow's Archiv., 1913, ccxiv, 132. Serrallach and Pares: Rev. de med. y drug., 1908, xxii, 115; 139; 183. Slutzow: Sur la composition biochemique de la liquide spermatique. Compt. rend. Soc. de Biol., 1916, Ixxix, 208. Steinach: Archiv. f. d. gesammte Physiologic, 1894, Ivi, 304 Strassberg, M.: Zur Frage des Prostatsekretes, Arch. f. Dermat. u. Syph., 1914, 120, Orig., 90. Timofeew: Ueber die Nervenendigungen der mannlichen Geschlechts-organen von Saugetieren und Menschen., Kasan, 1896 (Russ). Uhle: Tr. Am. Ass. Genito-Urin. Surg., 1913, viii. 303 Uhle and MacKinney: Observations upon the Mechanism of Urination. The Urol. and Cut. Rev., 1913, xvii, Tech. SuppL, 271. Voelcker andLichtenberg: Muenchen. med. Wchnschr., 1905; Beitr. z. klin. Chir., 1907, lii, i. Waddell, J. A.: The Pharmacology of the Uterus Masculinus; J. Pharmacol. and Exp. Therap., 1916, ix, 171; The Pharmacology of the Prostate. Ibid., 179. Waldeyer: Quoted by Piersol. Wallace: A Note on the Sphincteric Control of the Bladder. British Med. Jour., 1911, ii, 1405. Watson: Jour. Urology, 1917, i, 543; Surg., Gyn. and Obstetr., 1919, xxvm, 569- Young, H. H. : Quoted by Lowsley. von Zeissel: Wien. med. Blatt., 1902, xxv, 155. CHAPTER IV ETIOLOGY AND PREDETERMINING FACTORS OF BENIGN PROSTATIC HYPERTROPHY Etiology. We are tempted to dismiss the subject of the etiology of benign prostatic enlargement as did that most experienced of all modern prostatectomists, Mr. Freyer of London, by confessing our complete ignorance of the cause of the condition. It is undoubtedly true that but little has been added to our knowl- edge of the etiology of prostatic hypertrophy within the past fifty years; certainly the true cause or causes of the adenomatous form of the disease have not been demonstrated. Careful statistical studies of large series of cases and of specimens removed at operation which would, it was hoped, throw some light on the etiology of the disease have failed to reveal the exciting cause of prostatic hypertrophy. Indeed, the most diverse views are held re- garding the anatomical characteristics of the disease. Yet practically everyone is agreed that there do exist two main pathologic types of benign enlargement of the prostate which give rise to urinary obstruc- tion in men past the age of fifty years: one in which there is a dis- proportionate increase in the size of the prostate due to the formation within the organ of tumor-like masses which are composed of tissue whose elemental structure is identical with that of the normal prostate, and a second type in which there is a disproportionate increase in the fibrous tissue content of the prostate which sometimes causes an increase in the size of the gland, while in other instances it is either not enlarged or is actually smaller than normal. The latter type was at one time looked upon as an end-product in the pathologic evolution of the adeno- matous prostate but there is very little doubt among the majority of pathologists that the two processes are separate and distinct, the one being in all probability a true tumor disease whose etiology is shrouded in that same mystery which envelopes neoplastic diseases as a class, the other consequent upon inflammation, usually bacterial in origin. The factors that predetermine bacterial growth in the prostate may not differ from causes that predispose to tumor formation in this organ. To further complicate matters the two types of disease often coexist in the same prostate each adding its influence to the production 72 Tumor Theory 73 of urinary obstruction. The inflammatory lesion is, we believe, fre- quently engrafted on a prostate already the seat of a neoplasm, for here as elsewhere tumors are prone to become secondarily infected. It must not be supposed that all benign diseases of the prostate gland causing urinary obstruction are easily divisible into the foregoing types. Examples are frequently met with in which neither adeno- matous tissue nor fibroblastic elements are recognizable and the pros- tate which is small and indurated is found on minute examination to consist largely of fibromuscular stroma which has become increased, often to a marked extent, at the expense of the secreting structure. The condition is obviously not a true hypertrophy, neither is it neoplas- tic or inflammatory in nature. Personally we believe that, excepting those cases presenting the fibroblastic evidence of true chronic inflamma- tion, all cases of benign senile enlargement of the prostate result from some perversion in the normal involution of the gland. The fact that a mass fulfilling all the requirements of our modern definition of tumor is found in certain instances is due, I believe, to environmental influences. If we accept the tumor theory of the origin of the adenomatous form of the disease it is encumbent upon us to discuss at some length the theories of tumor genesis in general. This subject is largely of academic interest, however, and one un- suited for detailed discussion in a book of this kind. If the reader is especially interested in the subject he is advised to consult the chapter on the etiology of tumor diseases written by Professor McFarland for our book, "The Breast, Its Anomalies, Its Diseases and their Treat- ment." To those who adhere to the inflammatory theory, the etiology both as regards the exciting cause and the predetermining factors is not a matter of perplexity because the varieties of bacteria and the causes inviting their lodgment and development in the prostate gland are well known. Ciechanowski was the first, and now oft-quoted, advocate of the theory of antecedent inflammation as the cause of senile prostatic enlargement. According to this writer, the modus operandi of the inflammatory factor is a purely mechanical one, the initial step in the process being chronic inflammation of long standing with scar tissue formation about the ducts which results, secondarily, in dilatation of the glands. The historical evidence for or against infection as the cause of prostatic enlargement is not convincing, nor does the fact that Al- 74 Etiology and Predetermining Factors barran found microscopic evidence of inflammation in all of one hun- dred cases of hypertrophy prove conclusively that the inflammation was the causative, factor in these cases; it is quite as probable that the round-cell infiltration which he found in association with the enlarged prostate was caused by the presence within the organ of the abnormal tissue. Among the more recent advocates of the inflammatory origin of glandular development in the prostates of old men are Wilson and McGrath. There is no doubt that inflammatory changes taking place in the subcervical group of glands (Albarran's glands) will lead to urinary obstruction either as the result of glandular development or of de- posit with organization of inflammatory exudate, but we cannot believe that adenomatous nodules occurring in the prostatic lobes are the results of inflammatory stimulation. We agree with Wilson and McGrath when they say that the greater part of the bladder troubles of old people are due more to exacerbation of chronic prostatitis than to hypertrophy, but we cannot agree with those who attribute the formation of adenomatous nodules within the prostate to chronic inflammation. Many clinicians including Rovsing, Pilcher, Young, and Keyes oppose the inflammatory theory basing their conclusions on the following facts: The usual result of inflammation is atrophy rather than hyper- trophy; many patients with hypertrophy of the prostate never had antecedent inflammation of the organ; the early stages of hypertrophy have no constant time relationship with the late stages of gonorrhoea or other inflammatory processes; and hypertrophic processes begin very late after the apparent cure of an antecedent gonorrhoea. Lymphoid hyperplasia undoubtedly exists in association with the hyperplastic element comprising the enlarged prostate in a large per- centage of cases, but the inflammatory element is probably engrafted upon a pre-existing hypertrophy and due in many instances to primary degeneration of the nodules within the gland. Henry Wade has offered an interesting hypothesis which bases the origin of benign prostatic enlargement on some alteration in a normal internal secretion. Wade classifies the disease as inflammatory in type and suggests for it the name "chronic lobular prostatitis" in dif- ferentiation from "chronic interstitial prostatitis," the end-product of which is the sclerotic gland. Tumor Theory 75 He calls attention to the fact that senile hyperplasia occurs in both chronic lobular prostatitis (hypertrophy) and chronic cystic mastitis (abnormal involution). The term chronic lobular prostatitis is just as unfortunate for senile enlargement of the prostate gland as is the term chronic cystic mastitis when applied to the abnormal involu- tionary changes that occur in the senile breast. In neither instance is the pathologic evidence supporting the inflammatory theory sufficiently clear and convincing; in neither disease does fibroblastic proliferation occur with sufficient constancy to justify the assumption that the condition is an inflammatory one. We are in accord with Wade when he expresses the opinion that the disease is probably due to the abnormal action of one or more internal secretions; we entirely disagree with him when he employs the term "chronic lobular prostatitis" to imply the presence of inflammatory products in the enlarged prostate. Wade denies the neoplastic nature of the hyper- trophied prostate. It is entirely probable that so-called prostatic hypertrophy begins similarly to abnormal involution of the breast, but owing to environmental changes, the hyperplastic areas in the prostate become transformed into more or less discrete circumscribed nodules, which, from the physical characteristics that they sooner or later may present, such as distinct encapsulation, may, for all practical purposes, be looked upon as tumors. Many of the factors that are now considered as predetermining the creation of the sclerotic prostate were once considered etiologic influences in the development of the hypertrophic form of the disease. These factors, which include errors in alimentaion, sexual excesses or irregularities, febrile diseases, etc. will be discussed later. Velpeau held that prostatic hypertrophy is analagous to fibroid disease of the uterus, basing the analogy on a supposed common embryological origin of the two organs. The French school headed by Guyon and Lauriois maintained that prostatic hypertrophy is a local manifestation of general arterio- sclerosis. This theory lost cast when it was demonstrated that narrowing and obliteration of the prostatic arteries is rarely found in association with benign senile enlargement of the gland. The discarded theory of Reginald Harrison who regarded the en- largement of the prostate as compensatory adjustment of a disturbance in the mechanics of urination caused by primary descent of the bladder floor, has been resurrected for the purpose of illustrating how indefinite our views were regarding the condition just a few decades ago. 76 Etiology and Predetermining Factors The true etiologic factors involved in simple enlargement of the prostate gland will probably be found to be identical with those giving rise to benign neoplasms and abnormal involution of the senile breast. Predetermining Factors. In the present inexact state of our knowl- edge of the pathology of prostatic enlargement, it is impossible to speak authoritatively on the factors that are supposed to predispose an individual to this disease. Obviously, if it 'becomes an established fact that the enlargement of the prostate is a late sequel of inflamma- tion and that we are really dealing with a form of chronic prostatitis, the factors that predispose the individual to the condition are those that predispose to inflammation generally. In addition, to those fac- tors peculiarly prone to cause congestion of the prostate gland thus inviting the activity of bacteria, must be attributed a predisposing influence in the hypertrophic changes that occur later in life. On the other hand, if later studies disclose the neoplastic nature of prostatic hypertrophy, the predetermining factors deserving special consider- ation will be those to which we now attribute a predisposing influence to tumor formation elsewhere. At the present time we cannot hope to reach any definite conclusion as to the influences exerted by occupa- tion, personal habits, previous disease of the generative organs and similar possible causes of prostatic enlargement. Race. It does not appear probable that race per se that is, apart from the personal habits characteristic of any particular race exerts special influence in predisposing to the disease in question. The negro race has been held to be rather less predisposed to this affectjon than is the white. Conner expressed this opinion; Schultz we believe has made a similar statement; but the opinions of both sur- geons appear to have been based on general impressions rather than on accurate records, and must hence be accepted somewhat guardedly. Our own impression agrees entirely with theirs, but is based on no more substantial grounds. The well-known salaciousness of the negro, how- ever, should, if all theories are correct, render him rather more liable to prostatic enlargement than the white man; since it is held that prostatic overstrain and former inflammations of the gland are among the most probable of causes for its overgrowth. In natives of India there is probably little doubt that prostatic enlargement is abnormally frequent. Wanless has given considerable attention to this matter, and his experience shows that enlargement of the prostate with complete retention of urine is quite common in that country. He is of the opinion that the chief cause lies in the Race and Age 77 excessive sexual excitement, "for the reason that sexual intercourse is begun earlier and continued later in life than ... in western coun- tries. " Among other possible causes, he mentions the excessive use of curry and hot spices, so common in India. These condiments produce, by their habitual use, constipation and engorgement of the portal cir- culation; and thus a chronic congestion of the hemorrhoidal vessels arises, which, as already pointed out, tends to impede the circulation in the varicose prostatic plexus. The complete urinary retention which he observed so often in India occurred chiefly at the time of the monsoon rains, when exposure and chilling were almost unavoidable; and in practically every case of urinary retention the cause was pros- tatic obstruction. Still another cause, and one which favored the formation of phosphatic calculus, was the concentration of the urine due to prolonged work under the hot tropical sun; so much of the bodily fluids being thrown off by the sweat glands that the urine excreted was abnormally concentrated. In Turkey, also, prostatic troubles are comparatively frequent, chiefly due, according to Wishard, to excessive sexual activity. In China and Japan, however, they are considered to be extremely rare; but probably not alone on account of the absence of the same exciting cause. Age. Age appears to exert a marked influence, although it is not any longer regarded as a cause sine qua non. More and more it is becoming recognized that it is not the prostatic enlargement which develops first in old age, but that it is the symptoms of this disease which begin to manifest themselves only in the decline of life. Some fifty years ago or more, prostatic troubles in men under sixty years of age were next to unknown. Sir Henry Thompson stated that enlarge- ment of the prostate never occurred under fifty- three years of age; but McGill operated on two men, aged fifty-three and fifty-four years respectively, in whom enlargement must have existed for some time before the patients were seen by him. McGill later reported another patient in whom enlargement existed at thirty-five years. Moullin mentions the age of one of his patients as forty-nine years, and refers to one of Henderson's patients aged forty-eight years, and to other patients of forty-one and thirty-six years; while Mudd reported cases occurring in a young negro of twenty-seven, in a child of five years, and in an infant of thirteen months. But in spite of these unique examples, the fact remains that symptoms due to enlargement of the prostate under fifty years of age are very seldom observed. The 78 Etiology and Predetermining Factors researches of Thompson, Dittel, and others have shown that appre- ciable enlargement exists in about one-third of persons over sixty years of age, but that it produces manifest symptoms in only one out of every twenty. When the seventieth year has passed without enlarge- ment of the prostate, subsequent trouble from it is very unusual. Humphrey stated that only seventeen out of seventy-two patients between the ages of eighty and ninety years, and only one out of thirty patients over ninety years, presented symptoms of prostatic enlargement. Hunter McGuire held that while enlargement of the prostate might exist in younger men, yet the symptoms were not manifested until the urinary tract, in company with the rest of the body, showed the results of senile changes. Such an explanation as this is in accord with the fact that natives of India and other tropical countries, as a rule, show symptoms of prostatic enlargement some fifteen or twenty years earlier than do the inhabitants of more temperate climes, their span of life being so much shorter than ours. The collection of many series of statistics within recent years estab- lishes the fact that prostatic hypertrophy is essentially a disease of senility; age being by far the most important predisposing factor in its development. True examples of the disease are found in comparatively young men, but these are rare exceptions to the general rule that prostatic hypertrophy is a disease of the declining years of life. We have re- moved an enlarged prostate by the infrapubic route from a man aged 29 years and have operated on several others under the age of forty, but as shown in the tables given below, the vast majority of our patients have been men well advanced in years. Prostatism dependent upon lesions involving Albarran's group of tubules, or due to inflammatory infiltration around the vesical neck is frequently met with in young men. Statistics based on the clinical records of operative cases differ somewhat from those dealing with autopsy material; in the latter the percentage of obstructive factors is likely to favor the extra-prostatic causes, of which abnormalities in the Albarran's group of tubules is most important. Undoubtedly the disease process in the prostate leading to hyper- trophy begins long before the advent of the first clinical signs of its presence appear but, as the following tables show, the majority of pros- tatics present themselves for operation after the age of sixty years. Race and Age 79 AGE INCIDENCE OF PATIENTS WITH BENIGN PROSTATIC HYPERTROPHY TABULATED FROM THE RECORDS OF THE LANKENAU HOSPITAL OF PHILADELPHIA 45 5 55 60 65 70 75 80 Total.. So 55 60 65 70 75 80 85 7 20 33 7i 52 5 18 8 269 1 9. 6 per cent. 45 . 7 per cent. 25.3 percent. Figures approximately the same as the foregoing are reported by Wilson and McGrath from the Mayo Clinic. 50 60 70 80 Total.. 60 70 80 90 65 194 116 12 387 17 percent. 50 per cent. 30 per cent. 3 per cent. Lowsley in a careful study of 224 autopsy specimens has given the percentage incidence of the various causes of obstruction at the vesical outlet together with the age incidence of these abnormalities. His tabulated statistics are here reproduced. .a tl . 3 'C ^ V, Hypertrophy of General 8 C Albarran's group hypertrophy 8 a i ft i 3 i-i ,0 bi 1 " i g > "8 ^ "o Age ft &> i M S M 0) C >, o N Z -a 01 * ^3 a v "3 a 2 3 Large Medium Small Large Slight 11 K'8 8 o C to > "-i 8 8 . t-, || si! o C t. t-i O IU a) M a. c 'J a; . 4) g w * * (^ PH | OH ~ ~ OH First decade, i- 10 years .... o o o o o o 38 o O Second decade, 10-20 years. . . o o 10 o o Third decade, 20- 30 years .... o o 2 o i 40 S.o 2.5 7.5 Fourth decade, 30-40 years. . . 2 o 7 4 i 33 27.3 12. 1 3.0 42.4 Fifth decade, 40- 50 years 4 2 4 i 6 o 42 23.8 16.7 o 4 5 Sixth decade, 50- 60 years i 2 2 2 i I 29 17.2 10.3 3-4 39 Old age, 60 years and older r 3 3 3 7 I 32 21.9 31.2 30 56.1 Total for all ages 8 7 18 6 19 3224 Percentage of Albarran's hypertrophies, all ages considered 14 -7 Percentage of general hypertrophies, all ages considered Percentage of Albarran's hypertrophies, after the 2oth year Percentage of general hypertrophies, after the 2Oth year Percentage of Albarran's hypertrophies, after the 3Oth year Percentage of general hypertrophies, after the 3Oth year 17-5 8o Etiology and Predetermining Factors Occupation. It is not probable that occupation exerts very much influence over the development of prostatic troubles. Some of the earlier writers thought that excessive horseback riding caused enlarge- ment of the prostate; and in more recent times, bicycle or motor cycle- riding, has been held responsible for the production of this condition in certain patients. Probably of more real etiological value in this respect than such direct causes are factors which exert their influence indirectly, such as a sedentary life, or other habits which predispose to pelvic congestion. Social Habits. Under the title of " high-living" may be grouped a certain number of influences which undoubtedly make the patient prone to prostatic troubles. The gouty, the rheumatic, the lithemic; the man with hepatic and portal congestion, with a tendency to hemor- rhoids, or to varicose veins of the legs, is a not infrequent victim of enlarged prostate; and thus, as Wanless has pointed out, in the case of the Indian noted above, dietetic habits or errors may become potent though indirect causes of enlargement of the prostate gland. In many respects the causes of this malady and those predisposing to the forma- tion of vesical calculus are the same, and the concurrence of the two affections is frequent. Over-indulgence in sexual intercourse has long been considered a possible factor. From the enlarged and tender prostate of the young masturbator, to the similar organ of the old man who marries a young wife it has been common to blame the sexual excitement as the effi- cient cause; but, as remarked by J. William White it is probably quite as logical, if not more so, to blame the enlarged prostate with exciting unnatural desires. In accord with this view was the recommendation of Tobin, who regarded persistence of sexual desires in old men as an indication for double castration. Lydston teaches that enlargement of the prostate is in great part due to its "overstrain," which he defines as hyperfunctional activity of the organ; this overstrain, he thinks, may have occurred in early or middle life (from prostatitis, urethritis. congestions from masturbation or ungratified sexual desires, etc.), and yet may not show itself until past middle life, when a general sclerotic tendency arises as an old injury to the knee, for example, will only begin to give permanent symptoms when gout, rheumatism, arthritis deformans, or some similar disease make its appearance. Harrison, arguing along lines somewhat opposed to the overstrain theory of Lydston, said: "That the withdrawal of a portion of that function of the prostate in which it has been the most actively engaged, should be Social Habits 81 followed by a continued activity in which growth is substituted for secretion, is not, I consider, pathologically illogical." But Hodgson, on the other hand, thought the enlargement might well be due to the necessity which the prostate was under of supplying a fluid for sexual intercourse after the secretion of the testicles had become insufficient for that purpose. The whole subject of the relations of the testicles to the prostate is quite obscure, and many very contradictory and apparently irreconcil- able facts are at hand. The testicles undoubtedly furnish to the economy an internal secretion, the action of which at the advent of puberty produces the sexual characteristics of the individual. If the testicles are removed before puberty, the boy remains of neutral sexual characteristics, and the prostate and seminal vesicles fail to develop. If the testicles are removed after puberty, the sexual characteristics which were then acquired do not disappear, but in some instances atrophy of the prostate and seminal vesicles occurs. Cryptorchism in no way prevents the development of the .sexual characteristics, show- ing that these depend upon the internal secretion of the testicles for their manifestation, and not upon the power of procreation possessed by the individual. From certain observations it seems probable that the prostate is more closely connected with the epididymis and the vas deferens than with the testicle, since some persons have been observed with two normal testicles, but with an undeveloped vas deferens on one side, the corresponding half of the prostate being rudimentary. Likewise a unilateral development of the prostate has been noticed where the kidney and ureter on the same side were absent. Remete was of the opinion that only normal prostates are caused to atrophy by castration; and that the more hypertrophied a prostate is, the less likely is castration to produce any beneficial effect upon it. It is certainly true that removal of one testicle does not usually cause atrophy of the corresponding half of the prostate, even when this latter organ is normal. Moreover, Moses observed a case in which prostatic enlarge- ment developed for the first time some years after double castration. MacEwen, similarly, advocated the theory that the testicles furnished an internal secretion which regulated the growth of the prostate, and that enlargement occurred when the testicular atrophy of age caused this influence to be in abeyance. It is interesting to note the observa- tions of Ciechanowski in this connection. He showed that dogs are the only domestic animals which have an infectious urethritis. It is well known that of all animals dogs are most prone to enlargement of 82 Etiology and Predetermining Factors the prostate. Moreover, in other animals castration invariably causes prostatic atrophy, but in dogs it often fails to produce any beneficial influence. If the influential internal secretion comes from the testicles, it is difficult to see how ligation or excision of a part of the spermatic cords or vasa deferentia could cause atrophy of the prostate, unless it were by first producing a change in the testicles themselves; indeed, it seems not impossible that the atrophy is due entirely to the physiological rest which is obtained for the prostate through the absence of sexual desire. But, on the other hand, it must be remembered that castration does not always cause a loss of sexual desire. Mere subsidence of con- gestion is a much more usual result of castration than is actual atrophy. A further fact in favor of physiologic rest being the cause of prostatic atrophy, however its action is obtained, is the observation of Hodgson of a patient, aged thirty-five years, whose penis had been amputated some years before his death : in this case the autopsy showed the pros- tate, the seminal vesicles, and the testicles all much reduced in size. All these considerations really bring us back to the proposition with which we started, that excessive sexual intercourse is probably a fre- quent predetermining factor in enlargement of the prostate gland. It is not, however, the only cause, nor in all probability the most important one. This affection, as is well known, has at times afflicted the most moral and continent of men. Previous Diseases. Probably the most prevalent of all causes is a preceding inflammation of some kind. The views of Ciechanowski and others on this subject have already been discussed, and a mere reference to the question is here required. Naturally the most frequent of these inflammations is the gonorrhceal; and although many patients of over sixty years may have forgotten it, or may be unwilling to acknowledge it, yet a negative history in this respect cannot carry too much weight. Even if the inflammation of the deep urethra and the prostate have not been of gonorrhceal origin, repeated attacks of conges- tion and catarrhal exudation, from other causes, frequently occur in this part of the human frame. Stricture of the urethra has been thought by some authors rather to militate against prostatic obstruction, from the increased fluid pressure which exists behind the seat of stricture tending to dilate the prostatic urethra. Yet a stricture of some size is present in many cases of enlarged prostate. Other diseases may act as predisposing causes. Among these, Previous Disease 83 arteriosclerosis is prominent in the nosological tables of the French school. Other affections, such as cardiac insufficiency, hepatic cirrhosis, or other diseases which cause congestion of the pelvic organs, should also be considered; but their action is very indirect, and probably a mere coincidence, not an actual cause. REFERENCES (CHAPTER IV) Albarran et Halle": Annal. d. mal. d. org. Gen.-urin., 1898, xvi, 797. Ciechanowski: Annales des Maladies des Organ-Urin., 1901, xix, 536; Anatomical Re- searches on Prostatic Hypertrophy. Translated by Greene, 1903; Mittheil. a. d. Grenzgeb. d. Med. u. Chir., 1900, vii, 183. Conner: Trans. Amer. Surg. Ass., 1893, xi, 210. Crandon: Annals of Surgery, 1902, xxvi, 813. Culver, H., Jour. Amer. Med. Assoc., 1916, Ixvi, 8. Deaver, McFarland and HermSb: The Breast: Its Diseases, Its Anomalies and Their Treatment. P. Blakiston's Son and Co., Phila., Pa., 1917. Dittel: Wien. med. Woch., 1876, xxvi; Nos. 22-25; Dudgeon and Wallace: British Med. Jour., 1904, i, 1744. Freyer, P. J.: Lancet, 1913, i, 1907; 1075. British Med. Jour., 1919, i, 121; Surgical Dis- eases of the Urinary Organs, 1908. Greene and Brooks: Jour. Amer. Med. Ass., 1902, i, 1051. Guyon: Lecons sur les Maladies des Voies Urinaires, Paris, 1903, 46. ed., i, passim. Harrison, Reginald: Ashhurst's Internat. Encycl. of Surgery, New York, 1888, 2d ed., vi, 265. Hitchins, A. P., and Brown, C. P.: The Bacteriology of Chronic Prostatitis. The Ameri- can Jour, of Public Health, 1913, iii, 884. Hodgson: The Prostate Gland and Its Enlargement in Old Age, London, 1856. Humphrey: Old Age and the Changes Incidental to it, Cambridge, 1889, p. 23. Lowsley: Surg., Gyn. and Obstr., 1915, xx, 187. Lydston: Interstate Med. Jour., 1902, ix, 473. MacEwen: Wien. med. Presse, 1897, xxxviii, 769. McGill: Trans. Clin. Soc. London, 1888, xxi, 52, Internat. Centralbl. f. d. Physiol. u. Pathol. d. Harn-u. Sexualorg., 1890, i, 249. McGuire, Hunter: Ashhurst's Internat. Encycl. of Surgery, 1895, vii, 916. Moses: Therapeutische Monatshefte, 1895, ii, 690; 1917. Moullin: Enlargement of the Prostate, London, 1899, 2d ed.; 1904, 3d ed. Mudd: See Belfield: Amer. Jour. Med. Sciences, 1890, c, 439; St. Louis Med. and Surg. Jour., 1883, xlv, 438. Remete: Wiener klin. Rundschau, 1903, xxviii, 3. Rosen, R.: The Bacterial Content of the Prostate and Its Relation to Prostatic Adenoma. Jour. Infect. Diseases, 1919, xxiv, 164. Rovsing: Die Behandlung der Prostatahypertrophie. Arch. f. klin. Chir., 1902, Ixviii, 934. Thompson, Henry: Diseases of the Prostate, London, 1868. Tobin: British Med. Jour., 1902, i, 774. Velpeau: Treatise on Diseases of the Breast. Translation of the Sydenham Soc., London, 1856, p. 287. Wade, Henry: Annals of Surgery, 1914, lix, 321. Wanless: Indian Med. Gazette, 1904, xxxix, 45; 82. White, J. William: Trans. Amer. Surg. Assoc., 1893, xi, 167. Wilson and McGrath: Surg., Gyn. and Obstr., 1911, 647-681. Wishard: N. Y. Med. Jour., 1901; Jour. Cut. and Gen.-Urin. Dis., 1902, xx, 245. Young, Geraghty and Stevens: Johns Hopkins Hospital Reports, 1906, xiii, 125. CHAPTER V PATHOLOGY; GROSS AND MICROSCOPIC It is necessary to describe under the above headings not only the physical characteristics of the enlarged prostate gland but also certain extra-prostatic causes of chronic urinary obstruction. Among the latter conditions are included median bar obstructions and other patho- logical changes which occur in the region of the vesical outlet. Our FIG. 26. HYPERTROPHY OF LATERAL AND MIDDLE LOBES OF PROSTATE. GREAT HYPER- TROPHY OF THE BLADDER. (MacCallum, "A Text-book of Pathology." W. B. Saunders and Co., 1916.) efforts will first be devoted to a description of the gross characteristics of the enlarged prostate gland reserving the extra-prostatic conditions for separate description. 84 Size and Direction of Growth g,- Size and Direction of Growth of the Enlarged Prostate. Any prostate weighing more than twenty-three grams may be considered abnormal. From this size they range up to three hundred and seventy- three grams or over in weight. Freyer has removed one weighing five FIG. 27. VIEW OF AN ENLARGED PROSTATE (No. 1469), MEASURING 2 X 1.5 X i CM. A CATHETER HAS BEEN INTRODUCED THROUGH THE URETHRA. The patient, D. D., aged fifty-eight years, was admitted to (the German, now) the Lank- enau Hospital, May 4, 1903. His bowels were regular; he had used alcohol and tobacco moderately. He complained of a burning sensation after urination. About one month before admission he had evidently suffered from an attack of acute cystitis, being com- pelled to urinate every ten minutes, and passing only 10 to 15 cc. at a time. His urine was highly colored, red, supposed to be bloody. His pain was more marked on moving about. Formerly he was forced to urinate every twenty minutes during the night; of late he has not urinated so often, usually three or four times in a night. The pain starts just above the symphysis pubis and shoots down the penis; there is also a stinging sensa- tion at the end of the penis. The operation of suprapubic prostatectomy was performed, and a vesical calculus removed at the same time. Recovery was prompt, and the patient was discharged, entirely relieved of his urinary symptoms, June 3, 1903. The prostate, No. 1469, which is small and fibrous in character, is shown in the accom- panying figure. 86 Pathology hundred and thirty-five grams. He has also removed prostates weigh- ing three hundred and fifteen, and three hundred and eight grams, respectively, with perfect functional result. The measurements of this last gland were twelve and a half centimetres antero-posteriorly, and eight and a half centimetres transversely. The average weight of prostates removed at operation is probably not over eighty-five grams; and the dimensions rarely exceed five centimetres transversely or seven and a half centimetres in the antero-posterior diameter. The greater the amount of fibrous tissue present, the smaller the organ, other FIG. 28. VIEW OF AN ENLARGED PROSTATE (No. 1555), MEASURING 6 X 4.5 X 3 CM. AND WEIGHING 52 GRAMS. A CATHETER HAS BEEN INTRODUCED THROUGH THE URETHRA. The patient, J. M. C., aged sixty-three years, was admitted to the (German, now) Lankenau, Hospital July 18, 1903. He has used alcohol moderately; tobacco to excess. Six months before admission he first noticed difficulty in starting the stream, especially in the morning. As a rule, he was compelled to urinate only once during the night, and during the day he passed urine about four or five times. He stated that the amount passed was scanty, and that he had slight pain on starting the stream. One week before admission he had his first attack of retention, caused by exposure to cold and rain. He was relieved by catheterization, and has had subsequently to be catheterized twice a day. On admission the amount of residual urine was found to be 60 cc. (2 ounces). Rectal examination revealed a hard mass at the neck of the bladder, about the size of a large hen's egg. Operation (suprapubic prostatectomy) was undertaken a couple of days later. Re- covery was uneventful, and the patient was discharged August 14, 1903, entirely relieved of his urinary symptoms. The prostate, No. 1555, which is shown in the accompanying figure, is a good example of the moderately firm fibrous type of enlargement. Its weight was 52 grams (if ounces). Size and Direction of Growth 87 things being equal, and the greater the relative weight. The average weight of forty adenomatous prostates we find was one hundred and twelve and a half grams; and of ten fibrous prostates the average weight it was sixty grams. Enlargement of the prostate is almost invariably due to the development within the substance of the gland of adenoma-like FIG. 29. VIEW OF AN ENLARGED PROSTATE (No. 1623), MEASURING 7 X 6.5 X 5 CM. AND WEIGHING 122 GRAMS. A CATHETER HAS BEEN INTRODUCED THROUGH THE URETHRA. The patient, T. C., aged seventy-seven years, was admitted to the (German, now) Lankenau, Hospital September 19, 1903. He had been suffering from frequency of urination for years, the calls being more marked at night. Ten days before admission urination became extremely difficult, and three days previously it had become impossible. For two days he had been catheterized by his family physician, but on the third day it became impossible to introduce the catheter. On admission the bladder was found to be greatly distended, reaching to the umbilicus. A prostatic catheter was passed, several strictures being encountered anteriorly; while in the prostatic urethra there was detected a large false passage, leading to the left. The pros- tate was greatly hypertrophied, the size of a small orange. The urine obtained by catheterization was very bloody. After treatment by intermittent catheterization for two days, on September 21, 1903, an English catheter was passed, and permanently retained. Operation (suprapubic prostatectomy) was undertaken September 23, 1903. The patient never rallied, and died from shock and suppression of urine within a few hours. The prostate, No. 1623, which is shown in the accompanying Plates, weighed 122 grams and is a good example of cystic enlargement. 88 Pathology nodules. These nodules which have a spongy appearance, though varying in density, are surrounded by a more or less complete capsule. The latter is composed of dense stroma with an admixture of muscle fibres. Microscopically the nodules are composed of newly formed glands together with an increased stroma although the latter contrib- utes but little to the actual size of the nodule. Enlargement of the prostate due to hyperplasia of the fibrous connective tissue and muscular elements in the absence of glandular increase is not unknown, but it is an extremely rare type of prostatic enlargement. This variety FIG. 30. HYPERTROPHY OF THE MEDIAN LOBE. THE LATERAL LOBES ARE NOT INVOLVED. (Watson.) must be differentiated from the sclerotic prostate due to inflammatory deposits. True myomata of the prostate must be classified among the pathologic curiosities. Whether the nodules comprising an enlarged prostate take origin from the glands of the prostate itself, or, as is claimed by some recent writers, from peri-urethral glands is beside the present discussion. The fact is that encapsulated adenomatous nodules are found in the Size and Direction of Growth 89 portion of the prostate nearest the urethra, and that the enlargement is due to the presence of these nodules and not to any demonstrable hypertrophic change in the stroma. The enlarged prostate has a relatively increased proportion of fibrous connective tissue; indeed the individual specimen may be classified according to the proportional amounts of fibrous tissue and glandular elements, some specimens containing a far greater amount of connective tissue than others. The larger the prostate, the less the relative amount of fibrous tissue FIG. 31. VIEW OF AN ENLARGED PROSTATE (No. iS33) MEASURING 6 X 6 X 4-5 CM. A CATHEIER HAS BEEN INTRODUCED THROUGH THE URETHRA. present, in fact, it is the rule that in the absence of adenomatous nodules the prostate is likely to be either very slightly enlarged or may be normal in size, or even atrophic. Notwithstanding the absence of actual enlargement, the sclerotic prostate frequently causes marked prostatism but for a different reason than applies to the enlarged adenomatous organ. In the case of the latter, the nodules themselves offer an obstructive factor to urination by invading and distorting the lumen of the prostatic urethra and the bladder orifice. The sclerotic 9 o Pathology prostate interferes with urination by causing an actual contraction of these parts and is often complicated by median bar formation at the x X O li z* < n vesical outlet. Obviously the treatment appropriate to these widely differing forms of the disease is by no means the same. In the average case of prostatism occurring in a patient sixty years of age or older, the obstructive factor is easily enucleable; in the exceptional instance Size and Direction of Growth 91 enucleation is almost impossible for the reason that the fibrosis has proceeded to the stage where the entire organ has become transformed into a small, dense, sclerotic mass that has become tightly adherent to FIG. 33. PROSTATE WEIGHING 81^ OUNCES REMOVED JPROM PATIENT AGED 79 YEARS. A. Right Lobe, B. Left Lobe. a'B', outgrowths in the bladder, springing equally from both lobes, the furrow showing the posterior commissure of the prostate. The neck, C, was caused by the grip of the upper margin of the prostatic sheath or rectO'Vesical fascia, and sphincter muscle of the bladder. (Freyer, British Medical Journal, 1919, I, 12.) the surrounding structures. The difficulties of removing a prostate of this type with the finger need no description for one who has attemp- ted it. The operation can be performed but the gland is literally torn away from the pelvic fascia and other structures to which it has become firmly adherent. Between the two extremes of the large, soft, freely movable and 92 Pathology easily enucleable nodules and the small densely adherent mass of scar tissue are types presenting all degrees of variation; indeed it is often- times a matter of great difficulty to classify a given case clinically and as a corollary, to select the appropriate form of treatment. Much useless controversy has been indulged in regarding the origin of the so-called middle lobe of the adenomatous prostate. According to Keyes, Jr., some median enlargement is noted in 81 per cent, of cases but this, no doubt, is meant to include all types of median obstruction. Median projections into the floor of the bladder just posterior to the urethra take origin in the majority of instances from the true middle lobe tubules. These tubules lie beneath the sphincter muscle, and between the ejaculatory ducts and the floor of the prostatic urethra. In well-advanced cases the origin of a middle lobe enlargement may be differentiated, but only with great difficulty, from a pedunculated nodule that has become separated through pressure from one or the other of the hyper trophied lateral lobes. A nodule of this type, after invading the bladder cavity by way of the orifice, may seem to spring from the floor of the urethra. The study in early cases of what would in all probability have proven to be generalized hypertrophy, if development had proceeded, indicates that hyperplasia of the middle lobe tubules is a constant and permanent feature. The process shows a tendency to an earlier and more marked development here than elsewhere, and in the majority of cases the initial obstructive element seems to be a middle lobe hypertrophy. We are not prepared however to accept the teachings of Tandler and Zucker- kandl who believe that so-called generalized hypertrophy of the prostate is confined to the middle lobe. In certain instances the far advanced case of middle lobe hypertrophy presents a more or less movable rounded nodule which effectively serves to obstruct urination by a ball valve action on the vesical outlet. More frequently the nodule projects upward from the floor of the bladder and serves to complete the posterior margin of a collar-like arrangement of the intravesical portion of the hypertrophied lateral lobes, or is situated within a ring formed by these lobes. The evidences of early hypertrophy of the middle lobe tubules are to be looked for within the urethra where a mound will be found pro- jecting upward from the floor of the canal some little distance proximal to the verumontanum. The walls of the urethra covering the projec- tion remain unchanged for some time. Hyperplasia of the middle lobe tubules is easily demonstrable in these specimens. Disease of Albanian's Tubules 93 A second and quite frequent source of obstruction at the vesical outlet is disease, either hyperplastic or inflammatory, of Albarran's tubules: this group of extraprostatic tubules is subcervical in position and therefore ideally situated to embarrass bladder function in the event of their enlargement. Jores was among the first to call attention to the fact that many of the adenomata situated in the region of the bladder orifice have their beginning in accessory prostatic glands. FIG. 34. VIEW OF THE CUT SURFACE OF AN ENLARGED PROSTATE (No. 1542), MEASURING 7 X 6 X 6 CM. AND WEIGHING 120 GRAMS. A CATHETER HAS BEEN INTRO- DUCED THROUGH THE URETHRA. The result of hypertrophic changes in Albarran's tubules is some- times seen in the production of a broad median bar but more often of a rounded nodule which is separated from the lateral lobes of the prostatic gland by deep clefts, one on either side. The lobule itself is grossly tri-lobular, the clefts separating the individual lobules being caused by the pressure exerted by Bell's muscle, bundles of which pass over it from the trigonum above to the urethral floor below. These clefts lend themselves beautifully to cysto-urethroscopic demonstration so that this type of median line obstruction is usually diagnosed with ease. In addition to median obstructions of glandular origin, certain bars composed of fibrous connective tissue occur in the region of the 94 Pathology posterior lip of the vesical orifice. Randall divides these sclerotic bars into two groups : One, the edge of which is narrow and extends from side to side forming an abrupt angle with the sphincteric margin. The trigonum vesicae is foreshortened and the verumontanum is likely to be found lying just beneath the projecting'edge of the bar. The second type of bar is situated higher, so. that the trigonum is affected more than the urethral walls. The verumontanum is not FIG. 35. VIEW OF THE UPPER SURFACE OF AN ENLARGED PROSTATE (No. 1542), MEASURING 7X6X6 CM. AND WEIGHING 1 20 GRAMS. A CATHETER HAS BEEN INTRO- DUCED THROUGH THE URETHRA. displaced and the most apparent effect is a transverse folding of the trigonal mucosa. This variety of bar is less likely to cause serious urinary obstruction than its prototype described above; histologically they are exactly the same, both consisting of sclerotic tissue. The relative frequency of these varieties of median bar is given in the chap- ter on diagnosis. An infrequent though potent cause of prostatism is wide-spread Size and Direction of Growth 95 ft, J 12), MEASURING 7 X 6 X 6 c: rHROUGH THE URETHRA. now) theLankenau Hospital, July if. ed "o g U p Tr "53 "rt a CJ "Z rt 'C u 7" u B . rt c 'C 5 IE in td U 'o V r/; d was present at times. At the bi d c o ed p ^ ft V it t3 a> S- OJ V XI "i V "o _aj si X U "c u 10 C c oj ^ IE c z cd rt a X . h o w < < X 9 <0 rfl < 3 ri ^J j-j CJ if 1 ed a I- 3 8 -g j. cx jq H Z 337- Mallory, M. J.: Acidosis and Renal Insufficiency. Wash. M. Ann., 1917, xvi, n. References 171 Marion, G.: La Cystoscopie dans L'Hypertrophie de la Prostate, Jour. d. Urol., 1912, ii, 2. McGrath: Jour. Amer. Med. Assoc., 1914, Ixiii, 1012. Mosenthal and Lewis: A Comparative Study of Tests of Renal Function. Jour. Amer. Med. Assoc., 1917, Ixvii, 933. Motz: Annal. d. Org. Gen.-Urin., 1907, i, 162. Nicholson, E., and Hainworth, E. M.: Primary Sarcoma of Prostate in Boy. British Med. Jour., 1919, i, 378. Osgood: Trans. Amer. Assn. Genito-Urin. Surg., I9i3,viii, 138. Parmenter: Sarcoma of the Prostate. Surg., Gyn. and Obst., 1917, xxiv, 838. Pauchet: Sarcoma de la Prostate. Jour, d'urol. med. et chir., 1912, ii, 367. Powers: Annals of Surg., 1908, xlvii, 58. Proust and Vion: Sarcome de la Prostate. Ann. d. Mai. d. Org. Gen.-Urin., 1907, i, 721. Remsen: Amer. Chem. Jour., 1884-5, y i> 180. Ibid., xx, 257. Rowntree and Geraghty: Jour. Pharm. and Exper. Therap., 1910, 579; Arch. Int. Med., 1912, ix. Rowntree, Geraghty and Marshall: Surg., Gyn. and Obst., 1914, xviii, 196. Sabawalo: Brit. Med. Jour., 1915, ii, 256. Simons, S.: A Case of Urinary Obstruction Due to Enlargement of the Anterior Lobe of the Prostate. The Jour, of Urol., 1919, iii, 43. Van Fresch: Die Krankheiten der Prostata, 1910. Voelcker and Joseph: Deutsche Med. Wchnschr., 1904, XXX, 536. Walker: Lancet, 1908, i, 1054. Weld, E. H. : The Use of Sodium Bromide in Roentgenography. Jour. Amer. Med. Assoc., 1918, Ixxi, mi; Thesis, University of Minnesota, May, 1919. Wilson and McGrath: Surg., Gyn. and Obst., 1911, xiii, 647. Young: Annals of Surgery, 1909, xlix, 1232. Jour. Amer. Med. Assoc., 1906, xlvi, 699. Cabot's Modern Urology, i, 657-723, The Johns Hopkins Hospital Reports, 1906, xiv; Trans, of the Internat. Assoc. of Urology, London, 1911; Trans. Seventeenth Internal. Congress of Medicine, London, 1913. Young and Frontz: Jour. Amer. Med. Assoc., 1917, Ixviii, 526. CHAPTER IX PROGNOSIS A question of considerable importance and much interest in con- nection with enlargement of the prostate is that of prognosis. In few other diseases is it so necessary for the surgeon to know what may be accomplished by the various methods of treatment, and in probably no other class of cases is he more severely blamed for errors in judg- ment. It is not sufficient, indeed it is neither ethical nor humane, to hope that the patient will die of some intercurrent affection before any necessity arises for instituting active treatment on behalf of his enlarged prostate; and hence every physician or surgeon who has such cases under his charge must give careful thought and attention to each individual patient, and must know whether the expectation of life will be lengthened or decreased by the treatment he proposes, or whether the certainty of a life of considerable discomfort for a rather prolonged period is not less to the patient's ultimate advantage than the immedi- ate risk of life incurred by a somewhat severe and shocking operation, wlu"ch, if successful, will enable the patient to live out his natural term of life in ease and comfort. There are, then, two main questions to be solved in this connection: first, whether the patient's life can be saved, prolonged, or at least not sacrificed by the treatment to be pursued that is to say, the question of mortality; and, second, whether the patient's sufferings will be re- lieved wholly or in part, or whether no change at all can be obtained that is, the question of final functional results. Under medical treatment and catheterism there is practically no possibility of directly terminating the patient's life; with the under- standing that every antiseptic precaution be taken in catheterization, his life may even be prolonged, and in certain cases made very comfort- able. Many a patient who has to pass a catheter only once or twice in the twenty-four hours will live a life of perfect ease, and will round out his days without interruption. But where the catheter has to be passed frequently that is to say, as often as four to six times in the twenty- four hours or where its passage at even longer intervals is attended with pain or difficulty, catheterism must be considered at the present 172 Catheter Life day an insufficient remedy, except in those who are already on the threshold of the grave. The expectation of life, moreover, in patients treated by catheterization, has been shown by Harrison and by Lydston to be, on the average, no more than four or five years; so that it is clear that the life of the average patient is shortened by such treatment. Squier of New York states that 50 per cent, of unoperated patients will die within five years from the time of onset of obstructive symptoms where catheterization is unnecessary. The institution of catheter life, he adds will shorten the expectation of life to two years and eight months on the average and increase the mortality to 62^ per cent, within the shortened period. We have a patient who has carried an in-lying catheter for 9 years. He continues very well. During this time absolutely no urine has been passed, except by catheter, and there is but a mild grade of cystitis. The next mildest form of treatment is drainage of the bladder. By this means may be obtained relief of the cystitis, and consequently of the tenesmus, pain, and general unrest, in a certain number of cases. In our opinion, it is applicable chiefly to those in a very debilitated condi- tion, or to the very old. Drainage by a permanent catheter intro- duced through the urethra can seldom long be endured, and is usually only to be employed in preparing the bladder for a radical operation. The successes of Thompson, McGuire, and others in treating these pa- tients many years ago by means of suprapubic permanent drainage, and of Harrison by means of a perineal tube, should not be forgotten at the present day; and while we recognize the inadequacy of such methods to restore the patient to his normal condition, yet in a limited number of cases they are still useful. Especially is this so in patients with very bad cystitis, and where some immediate relief is imperative. In such cases so radical an operation as prostatectomy will almost surely kill, unless time can be obtained to relieve the cystitis, to get the kidneys into fair condition, and to improve the general health of the patient. In such patients, the two-stage operation is the method of choice. In some few instances it is necessary to form a permanent suprapubic fistula and then drain the bladder for a prolonged period of time before attempting the removal of the prostate. Rarely indeed, do we find it impossible to complete the final stage of the operation with compara- tive safety to the patient after preliminary drainage of the bladder. Primary Mortality. It is the concensus of opinion among surgeons that the primary mortality rate is slightly less following perineal 1 74 Prognosis prostatectomy than that following the suprapubic operation. In this opinion we concur notwithstanding the fact that our collected series of cases fails to confirm this long accepted belief. These statistics are collected from many sources and include the results of operators of both great and small experience. Undoubtedly the primary mortality rate is much or more dependent upon the care with which cases are selected for operation, and upon the thoroughness with which pre- operative treatment is carried out than upon the type of operation selected or the skill of the individual who performs it. Our list includes approximately twenty-five hundred cases but does not include the pub- lished statistics of the recognized leaders in suprapubic and perineal prostatectomy. We have purposely omitted the results of the work of these few men for the reason that we are now attempting to ascertain the average mortality of the operation of prostatectomy as it is per- formed throughout the country. There exist only slight differences in the operative mortality following the two types of operations in the hands of the most experi- enced men. The suprapubic operation is a much safer procedure for the occasional operator than the perineal prostatectomy, as is well illus- trated by the much higher mortality rate for the latter operation as reported by surgeons working in smaller communities. Freyer has recently reported a series of 1550 suprapubic prosta- tectomies with a general mortality of 5.33 per cent. The death rate among the first hundred cases in this series was 10 per cent, while among the last two hundred cases it has been only 3 per cent. Young's mortality rate with the perineal operation is slightly less than 4 per cent. In our collected series of cases the death rate following the perineal operation is 10.9 per cent, in contrast to the 6.9 per cent, mortality succeeding suprapubic prostatectomy. Although fully cognizant of the unreliability of most statistics, we are inclined to believe that these figures express in a general way the relative dangers of the two operations in the hands of the average surgeon. Statistics collected from other sources would undoubtedly yield different results, but we believe that these figures are correct. If the cases operated upon by the more experienced men among the group who were good enough to furnish us the data, i.e., if all series of one hundred or more cases are eliminated from the calculation, the average mortality rate immediately rises to between 20 and 30 per cent. The latter is in keeping with the figures of Page, who reports a mortality rate of 21.5 per cent, for four London hospitals between the years 1906 and 1910. Primary Mortality 175 During this same time sixty-nine suprapubic prostatectomies were performed in St. Thomas's Hospital with a mortality rate of 20.3 per cent. Wade gives the astonishing information that the mortality rate in one of the largest hospitals of Scotland for a ten-year period was 35.4 per cent. SUPRAPUBIC PROSTATECTOMY Operator Number of cases Mortality (per cent.) Gile 2A Tenney and Chase ?o6 o 8 Deaver (collected series) 1724. 6 o Freyer I ceo S-J-2 Dillingham 8<; 2 A. Watson *o 12 O Kelley 7? 2O O Watkin 60 IO O Scherck ico 8 o Denslow 200 6 o Gardner 218 4. 1 Walker 112 . T) .a .5- rt X a *- M 1 A B "S g o "5 a> 1 S _3 H _"' ^-, g J^ fel i h t v^ gg / ^ H i 1 5 c- , U M H . u ^ E I BQ c 03 It N-i 1 a a ~- 1^ s q g' .^ h A 1 i _JJ jjl !. M c y. [AGRA "u "8 e 1 Q 09 2 ~ S -r M >-i i ct > 6 s: fa O ~ It is convenient in these, as well as in curved metallic urethral instru- ments, to have some indicator on the handle to show which way the beak is pointing. So far as we know, there is at present no better way provided of determining this point, in the case of the Mercier catheter, than by recollecting the relation to the beak borne by the printing on 2oo Catheterism the shaft. With the English catheter a similar precaution may be employed, except when it is used with the stylet, when the ring-like extremity of this guide will indicate the direction of the curve. Metallic catheters usually have a curved beak. The original Mercier catheter was silver, but, as already mentioned, it is now usu- ally made of webbing. The normal curve of the subpubic urethra is that of the circumference of a circle whose diameter is 90 mm.; and the length of curve is the arc subtended by a chord of 70 mm. but the curve of the catheter is usually subtended by a chord of only 55mm. (Van Buren and Keyes.) In the urethra altered by prostatic enlargement, however, the curve is considerably increased, having both a greater diameter and a greater length of arc; so that various metallic catheters with "prostatic curves" are found on the market. Probably the largest required curve is one which is one-third of a circle whose diameter is twelve and a half cm. It is important not only to have the curve thus larger, but for the curve to be greater at the tip than elsewhere, thus approaching the instrument of Mercier in type. At the very least, the curve should be continued to the very end of the catheter. The tip of metallic catheters should be solid, to allow no nidus of infec- tion to exist, and it is even more indispensable here than in the case of the webbed catheters for the eye to be made in the mould, and not to be subsequently cut out by a punch. The shaft should be at least twenty cm. in length beyond the beginning of the curved beak, since with an instrument of customary length the bladder might not be reached. Metallic catheters should be plated with nickel, silver, or some other non-corrodible metal; and should be provided with two eyelets at the handle, to serve as indicators of the direction in which the beak is pointing. Or the catheter may be S-shaped, the opposite direction of the two curves effectually indicating the position of the beak. In all these catheters for use in prostatics the eye should be amply large, and should be placed in the concavity of the curve; or one eye may be placed on each side, at different levels, but from ten to twenty- five mm. from the end. It is also best to use an instrument of as large a calibre as the urethra will conveniently take, since there is thus less danger of entering or of producing false passages, and a better chance exists of evacuating pus or blood clots from the bladder. (b) Sterilization of Catheters. Soft-rubber catheters may be boiled. If they are stewed, the elasticity and tone is lost very soon; but if the water is brought to the boiling point before the catheter Catheters 201 is placed in it, the rubber will stand repeated boilings of from three to five minutes without showing material degeneration. Where boiling cannot be employed, as is the case under some circumstances with rubber catheters, and with all catheters made of webbing and coated with shellac, chemical disinfection must be used. Carbolic acid, in the strength of one part to twenty of water, has been much relied upon, the catheters soaking in such a solution for twenty or thirty minutes. This substance has the disadvantage, however, of rendering the catheters so flimsy, even when the solution is cold, as to make them very difficult to use; so that latterly we prefer a loper cent, solution of formalin, which is itself a 40 per cent, solution of formaldehyde gas in water. The well-known hardening effect of formalin preserves the desired form of these catheters admirably. Some surgeons have found the use of formalin so irritating to the mucous membrane of the urethra as to cause great pain to the patient, as well as at times to produce a rather severe urethritis. We have not however, seen any such effects. Wolff advises the use of a one per cent, solu- tion of corrosive sublimate in equal parts of glycerine and water, the catheters being germ-free at the end of six hours. This solution is claimed to possess the threefold merit of sterilizing the catheters, pre- serving their elasticity, and rendering them ready for instant use with- out the intervention of any other lubricant. Metallic catheters are readily sterilized by boiling. The prac- tice of merely igniting alcohol which adheres to their surface is by no means sure as a disinfectant, unless the catheter is already of more than ordinary cleanliness. Where catheters are religiously cleaned and boiled after each time they are used, this method will serve very well as a rapid and efficient manner of sterilization; but if the catheter has been put away with septic blood clots or inspissated pus in its interior, it is idle to expect the momentary application of a flame to its surface to render infection impossible. All catheters should be subjected to the ordinary rules of sur- gical cleanliness immediately after being used. After being washed clean in soap and hot water, and their cavities thoroughly syringed out, and emptied if need be of clots, etc., by means of absorbent cotton mounted on a stylet, they should be returned to the antiseptic solution; or if there will be no need for their use soon again, they may be wrapped in a sterile towel, after being shaken dry in the air. Rubber preserves its elasticity better when kept wet, and it should never be laid away in a dry warm place. 2O2 Catheterism Various types of formalin vapor sterilizers may be purchased from the instrument makers, but personally we have but little faith in the ability of formalin vapor to sterilize instruments, and much prefer to immerse them in a solution of formalin or of carbolic acid. Q tf fc I Q w < 3 i-> z I I w w 5 S !5 ., H O fa Q 8 1 Q ^ 3 M C/D g H H W < H "si r^ O X O M ** S o fc < This applies only to such instruments as will not stand boiling. In fact, if certain precautions are taken, the best grade of modern French woven catheters may be boiled without damage to them. These in- struments are coated with varnish which softens when they are boiled but becomes hard again when the instrument is immersed in cold water. Catheters 203 Nothing must be permitted to touch the instrument when it is heated and it must lie perfectly straight in the sterilizer and no part of it should come into contact with any other object. Bending or grasping the heated catheter with a pair of forceps usually mean the end of use- fulness of that catheter. Where the patient has to catheterize himself, and must care for his catheters in person, it is expedient to render his necessary manipulations as simple as possible. Moullin recommends that he keep in his wardrobe, or wherever else may be most convenient, FIG. 63. ASEPTIC POCKET-CASE FOR CATHETER. NATURAL SIZE. two glass cases, long enough to contain the catheters without bending them; one case should hold a small piece of absorbent cotton moistened with formalin, and the other should be filled with boric acid solution, which should be changed every day. A douche bag filled with a strong solution of green soap should also be provided. The catheters, which should at least equal in number the number of times during twenty-four hours that the patient must catheterize himself, and which are of course flexible or semiflexible, should be rinsed through thoroughly with the soap solution and hot water immediately after use, and then be placed in the boric acid solution. Once each day, or oftener, all the catheters should be boiled, and then stored in the formalin case 204 Catheterism until ready for use. It appears to us that this is rather a complicated process of sterilization for the average prostatic; and we would at any rate suggest that after use and cleansing with the soap and water, the catheter should be placed in the formalin jar, and remain there for six hours at the least. It may then be transferred to the boric acid solution for some time before use, and thus will have been ster- ilized by the formalin, and will have had the irritating qualities of this antiseptic removed, before being brought into contact with the urethra. By this plan also the necessity of boiling is avoided, and however useful this may be for metallic and india-rubber instruments, we cannot but think it destructive to those constructed of webbing and covered with shellac when oft-repeated sterilization by an inexperienced individual is necessary. English catheters should be kept mounted on a stylet of proper curve, and be immersed in the antiseptic solution (formalin or carbolic acid) for a half-hour before they are used; they should then be thor- oughly cleansed and dried. Freyer is quite content if he can accustom his patients to the conscientious use of soap and hot water. The hands, foreskin, glans penis, and the urethra of the patient should be suitably prepared for catheterization, as directed elsewhere. When the patient travels, he must be able to carry his catheter with him in an aseptic and yet not too bulky a form. For this purpose various pocket cases are found in the shops, of which the best are made of metal, so that some formalinized cotton can be kept in them along with the catheter, which is coiled up so as to occupy less space. An ordinary metallic soap-box may be used. (c) Lubricant. For many years olive or castor oil has been employed as a lubricant for catheters. These substances may be sterilized by boiling, but unfortunately they do not remain sterile very long; and the addition of strong antiseptics is very apt to roughen the surface of webbed instruments in time, or else is ineffectual in sterilizing the oil. Yet we are quite satisfied to use carbolized olive oil of the strength of one to twenty. Senn recommended "sterilized vaseline, with the addition of 2\ per cent, carbolic acid or i per cent, of formic aldehyd. " Burckhardt prefers a one per cent, solution of salicylic acid in sterilized olive oil; while, as already mentioned, Wolff lubricates and at the same time sterilizes his catheters in a one per cent, sublimated solution of glycerine and water. An aqueous solution of boroglycerine is another useful lubricant. The preparations on the market consist of Iceland moss in various combinations containing formalin, carbolic acid, oxycyanid of mercury or other antiseptic. Passing the Catheter 20- Dr. E. Wood Ruggles has offered the following formula which is essentially the same and quite as good as the best lubricants sold under trade names. Dissolve i cm. of oxycyanid of mercury in 200 cc. of hot sterile water; add 35 cc. of glycerine and water enough to make 350 cc. After this mixture has cooled add 10-15 g 111 - of gum tragacanth. After standing for several days the lubricant is ready for use. When the patient catheterizes himself, it is far safer as well as more convenient for him to be provided with numerous flasks or sterile collapsible paint tubes each containing ten cubic centimetres of the lubricant, which he then squeezes directly into the urethra, thus mini- mizing the risk of infection. (d) Method of Passing Catheter. The choice of catheters should always be for the soft-rubber first, then for theMercier, then the English, and finally, in rare instances, the metallic instrument. There is prob- ably no department of surgery in which practice, habit, natural aptitude, a light hand, good temper, and patience, are of such paramount importance as in catheterization. It will seem to the patient as if one surgeon rushed at him from the other end of the room with a crow- bar in his hand, prepared to plunge it into the unfortunate man's ure- thra, while another surgeon will gain entrance to the bladder before the patient has really become aware of his maneuvres. And it is next to impossible to inculcate by precept the many tricks which may be required to insinuate a rebellious catheter into an obstructed urethra; only by example and long-continued practice may the uninitiated learn these matters. It is always good to have clean hands, and should be a characteristic of the surgeon; but where a flexible catheter is to be passed ordinary cleanliness will not suffice. As it is necessary always to hold such an instrument close to its point of entrance into the urethra, and as there- fore it must be fingered throughout its whole length during its intro- duction, the surgeon's hands should be sterilized as for a serious operation before he presumes to touch the sterile catheter. The glans penis and the foreskin of the patient should be washed with soap and water, the fatty substances then removed with 70 per cent, alcohol, and finally the glans should be rinsed with corrosive sublimate solution (i to 1000); the anterior urethra should next be flushed out, first, if possible, by directing the patient to pass what urine he is able to, and then by an injection of boric acid solution (2 per cent.). The catheter then being taken in hand, should be thoroughly 206 Catheterism lubricated by being dipped in a sufficient quantity of the lubricant, which is then allowed to run up its whole length; or an injection of the lubricating fluid may be made directly into the urethra. The end of the catheter is then to be carefully inserted into the meatus. We may say here that where there is a prospect of oft-repeated and long-contined use of the catheter, we think it wisest to do a meatotomy at once, when the meatus is not amply large. The Nelaton catheter is so flexible that it must, as already men- tioned, be held close to the penis, and urged forward 25 mm. or less FIG. 64- ASEPTIC CASES FOR CATHETERS. The U-shaped tube has a special flask for the lubricating fluid. at a time. In fact, the urethra should seem rather to swallow the catheter than that the latter was being forced in. It is well to know just how long the catheter is, so that the amount already introduced may be readily gauged from the portion which still remains within the hands. If when the tip of the catheter has reached the prostatic urethra it will not readily pass onwards, the ringer should trace its course through the perineum and from within the anus, and an attempt should be made to direct it on into the bladder. If the catheter feels firmly im- bedded, it should be partly withdrawn, and then again passed forward with a quicker and somewhat rotatory motion, as its tip may have'been engaged in a false passage or entangled in a fold of mucous membrane. At the same time, with the finger in the rectum the catheter's point should be kept against the upper wall of the urethra, out of the usual Passing the Catheter 207 neighborhood of false passages and obstructions. If, finally, no reasonable endeavors will succeed in introducing the soft-rubber catheter into the bladder, this instrument should be withdrawn, and a Mercier elbowed catheter passed. The manner in which this catheter is to be handled does not differ materially from that just described; but it should be the surgeon's care that the elbowed beak follows the roof of the urethra, as it will thus be more likely to glide over the raised internal orifice of this canal. The Mercier catheter also failing, the surgeon should next attempt the English catheter, moulding it to a proper curve before introducing it into the urethra. If it will not pass without the stylet, it should be withdrawn, and then re-introduced with the stylet in place. When the obstruction previously encountered is again met, if slight persistence in pressing the handle well down between the patient's thighs will not cause the beak of the catheter to surmount the ob- struction, the surgeon may by withdrawing the stylet about twelve mm. raise the beak a sufficient distance to enable it to ride over the prominence of the prostate. It is very rarely necessary to employ silver catheters in recent cases that is to say, in cases where the urethra has not been much tampered with by other instruments. Occasionally, however, where there has been long-standing inflammation of the parts about the prostate and the vesical neck, the tissues are so hard and resistant that although no real mechanical obstruction may exist to the passage of a catheter, yet the flexible and semiflexible instruments are not strong enough to press apart the sclerosed structures. In such cases, the use of a metallic catheter may be indispensable; but in em- ploying one it should be constantly borne in mind that even the very minute amount of force that is justifiable here will do an incalculable amount of damage unless the channel of the urethra is strictly adhered to. Hence the surgeon should make it a golden rule to cling close to the roof of the urethra, and never for an instant to use any degree of force, however slight, out of the median line. He will be far more apt to succeed in the object he has in view if he keeps cool and avoids metal instruments. If the first examination of the patient has been conducted in the manner advised in Chapter VII, much valuable information will have been acquired as to the character of the urethra and its obstructions, so that at a later date catheters can be passed with a fair amount of intelligence and certainty. The patient should use the catheter which is most easily passed ; 2o8 Catheterism but he should never be allowed a metallic instrument. The soft-rubber catheter is the most harmless, but so great seems to us the danger of infection from the necessity of handling it so extensively during its introduction an objection which applies also, though in less degree, to the Mercier catheter that we have a strong preference for the English catheter for the patient's use. These catheters are so firm as to be readily introduced by holding their outer end only, as with the metallic catheter, and are at the same time sufficiently flexible to render them safe even in not very skillful hands. Under these circumstances they should, of course, be passed without the stylet. The frequency with which a prostatic should be catheterized depends entirely upon the distress occasioned by the residual urine, provided always that the latter is not increasing in quantity. As a rule, however, it will be found that when a patient has as much as 120 cc. of resid- ual urine he will be so regularly disturbed at night as to require the complete evacuation of his bladder by catheterization once in the twenty-four hours. The most suitable time for this evacuation is just before retiring for the night. It is the least inconvenient time possible for the careful attention to personal and instrumental preparation, and is also a time when the emptying of the bladder will be apt to give the longest relief for the ensuing night. Many a patient, nevertheless, who has this amount or even more of residual urine will not be sufficiently inconvenienced by it to necessi- tate regular catheterization at all. The surgeon should not, on the other hand, dismiss such a patient from his care, but should attentively watch him, and by passing a catheter every three or four months ascer- tain whether the residual urine is increasing. It is in just such quiescent cases as these that the residual urine accumulates, increment by in- crement, until atony of the bladder is well advanced, and overflow from retention occurs; or absolute retention with complete dependence on the catheter makes the remaining days of the patient one long drama of misery. If the residual urine, therefore, is found in the course of weeks or months to be steadily increasing in quantity, the surgeon should not hesitate, even though no compelling symptoms exist, to resort at once to habitual catheterization, as the only preventive of vesical atony. Under either of these circumstances then the presence of symptoms, or the steady increase in residual urine without symptoms the catheter should be used once in the twenty-four hours for 120 cc. or less of residual urine. If 180 cc. are present, use it twice, night and morning; Cystitis 209 and add one more catheterization for each additional 60 cc. of urine up to six times daily. When the required number of catheterizations exceeds this limit, some other form of treatment is urgently demanded, even though catheterism appears to maintain the patient's normal health. 3. Prevention of Complications. The most serious complications which it is our duty to endeavor to prevent are cystitis, retention of urine in all its varieties, calculus, Bright's disease, and uremia. Cystitis. The causes of cystitis in cases of enlargement of the prostate being almost exclusively infection from without through instru- mentation, the paramount importance of aseptic habits in this particular is readily recognized. All that was said as to the means of sterilizing urethra] instruments, the manner of introducing them, and the state of the surgeon's hands and of the patient's urethra, glans penis, and foreskin, should be borne in mind; as far as possible all instrumentation should be avoided; and, moreover, the diet and drugs habitually advised should be such as to prevent vesical congestion or irritability. The state of the urine should be closely watched, and over-acidity or alkalinity strenuously combated. If strictures exist, the prevention of cystitis is even more important, as the bladder will have been in a state of less resistance for some time. Hence the strictures should be systematically dilated, the benefits derived from this treatment when carefully con- ducted far outweighing the dangers of infection. The passage of large- sized steel sounds through the prostatic urethra also will tend to prevent progressive obstruction from the diseased organ, in accordance with the teachings of Reginald Harrison; and by thus maintaining an open channel for the urine, may postpone if not entirely prevent the develop- ment of cystitis. Although the prevention of cystitis is so important a part of treat- ment, it is a sad fact that the treatment of fully developed cystitis constitutes the greatest part of the surgeon's labor in these cases; and this is perhaps so because an uninflamed bladder rarely gives rise to feelings of discomfort on the patient's part or of anxiety on the part of his attendant. But some patients are so subject to urinary fever, that although they may recover from an attack, yet, this complication being ever present in the minds of both surgeon and patient, extraordinary methods are necessary to avoid its recurrence. In these patients more than any others should instrumentation be as limited as possible, and when necessary the most "pedantic precautions" (Senn) against infec- tion should be observed. Quinine or opium, or both, should be adminis- 14 2io Prevention of Complications tered some hours before the catheter is used, and should be repeated at intervals of three or four hours afterwards until all danger of chills and other infective manifestations has passed. As it is probable that both urethral and urinary fevers are occasionally due to the septic condition of the urine itself, and not to any new infection carried in by the instrument, it is well also to give these patients a course of urinary antiseptics, such as salol, urotropin, sodium benzoate, etc. Since, moreover, these manifestations of infection are predisposed to by inter- stitial nephritis, every effort should be made from the beginning of treat- ment to get the kidneys into good working order and to keep them so. Retention of Urine. There are several varieties of retention of urine, which it will be convenient to define at the outset, that we may know the conditions indicated by each term: (i) Acute Complete Retention: where the patient, who was before able to evacuate his urine wholly or in part, becomes unable to do so all the urine is retained, and the condition is acute. (2) Chronic Complete Retention, where the patient depends absolutely upon the catheter as a means of emptying his bladder, being unable, quite as much as in the first variety of retention, to expel a single drop of his own accord all his urine is retained, but the condition is chronic. (3) Chronic Incomplete Retention without Distention of the Bladder, where a certain portion of urine is constantly retained, but where the major portion is evacuated voluntarily a chronic condition, where, without the bladder being overfilled, residual urine exists. (4) Chronic Incomplete Retention with Distention of the Bladder, where so much of the urine is retained that the bladder has reached the limit of its capacity, and overflow from retention results. Guyon mentions still another variety of retention, which he terms acute incomplete retention, and says it is very rare. We ourselves have not observed such a condition, and as M. Guyon leaves its symptoms somewhat to the imagination, we are unable to describe it more fully than by giving its title. Acute Retention. 1. Acute Complete Retention. Chronic Retention. 2. Chronic Complete Retention. 3. Chronic Incomplete Retention without Distention. (Residual Urine.) 4. Chronic Incomplete Retention with Distention. (Retention with Overflow.) The first variety may attack either a patient with no residual urine, Retention of Urine 211 or one in whom the urine has been partly retained for some time. In either case it is almost invariably due to a sudden increase of congestion in the prostatic urethra and the vesical neck. Hence for its prevention all those things should be avoided which have already been mentioned as favoring this state of affairs: Exposure, chilling of the skin, wet feet; retaining the urine an undue time; eating or drinking too freely; lying too long abed. The second variety, chronic complete retention, is almost invari- ably the result of absolute atony of the bladder. It arises probably most frequently as a consequence of the third variety, where the residual urine slowly accumulating ultimately entirely overcomes the power of the bladder to contract and expel any portion of its contents. In some instances it is due to mechanical obstruction from the growing prostate, which prevents, even if the tone of the bladder is preserved, any urine from being expelled. In exceptional cases retention of this kind succeeds immediately upon acute retention, the bladder being then so very much distended that it never regains its contractility. This complication hence is to be prevented by regularly evacuating the residual urine by catheterization, and at times by moulding the prostate as it grows, so as to keep an open water-way from the bladder; also by preventing acute retention. The third variety, that where a varying amount of residual urine is present, is the nearly universal state of prostatics, and is practically unpreventable. In the early stages of enlargement, if no residual urine exists, absence of symptoms is usual, and instrumentation in an attempt to hinder the growth of the prostate by pressure will be more likely to cause cystitis or prostatitis than to prevent the development of a post- prostatic pouch. The fourth variety, retention with overflow, succeeds upon the third when a very small amount of contractile force is still preserved in the bladder, and when the urethra is not absolutely obstructed by the prostatic growth. It rarely occurs where cystitis is present; and is best prevented by regular aseptic catheterization during the earlier stages of the disease. Atony of the Bladder. Atony of the bladder, it is thus seen, is an even more dreaded accompaniment of prostatic obstruction then reten- tion of urine, of whatever variety; for where atony is extreme/it cannot be remedied even by restoration of the urethra and vesical neck to their normal condition. Even though the whole obstructing prostate be removed successfully, and an easy entrance to the bladder be gained 212 Prevention of Complications by catheters, yet the power of contractility lost from prolonged over- distention will in some few cases never be regaineb. Fortunately, however, prognosis is no longer so gloomy as it was only a few years ago. We have learned through the brilliant successes of Freyer and other surgeons that in some instances where for fifteen or twenty years the patients had depended absolutely on the catheter for the evacuation of every drop of urine the complete removal of the enlarged prostate has within a few months or even weeks brought back contractility and good expulsive power to bladders that were thought before operation to be hoplessly diseased. And although, as we say, we can no longer regard atony which is apparently complete as entirely irremediable, we should nevertheless spare no pains to prevent its development. To this end the bladder should never be allowed to become distended. Where the catheter is employed habitually, great pains should be taken to ensure its entrance into the bladder with the evacuation of all the residual urine, not merely drawing off the small amount that may exist in the dilated prostatic urethra, and leaving the true residual urine to accumu- late until either complete chronic retention or retention with overflow has developed. And where the catheter is not habitually employed, nothing should prevent regular periodical examinations to determine the question whether the residual urine is increasing or not. Calculus. The prevention of the formation of calculi in the bladder applies not alone to those means usually employed in patients where no prostatic enlargement exists; for in prostatics we have constantly present a stagnant pool of urine in the bladder, ready at any moment of neglect to crystallize around a blood clot or a plug of mucus or pus. The customary dietetic treatment must be employed; the urine should be carefully watched, and maintained in a dilute and non-irritating condi- tion; and the residual urine should be systematically evacuated. In patients with a family history of calculus, or with a lithemic tendency, the rule of non-interference with quiescent bladders where the amount of residual urine is not increasing, must be abandoned; and on any occurrence of bladder irritability a stone should be carefully searched for. Hemorrhage into the Bladder. This is a complication of extreme gravity. If cystitis does not already exist, infection is practically sure to arise as soon as any amount of blood accumulates in the bladder. Hemorrhage may occur spontaneously, but is usually due to rough or careless instrumentation. The site of the bleeding is frequently the prostatic urethra, whose upper wall may be lined with distended vari- Renal Complications 213 cose veins; but it most often arises from a point on the prostate which is habitually abraded by the introduction of a catheter. Occasionally it follows upon the complete sudden evacuation of a distended bladder from the relief of intravesical pressure, being then in the nature of a general ooze from the mucous membrane. Calculous concretions are at times the exciting cause. In any case, the surest method of preven- tion is the continued use of the utmost gentleness in all manipulations. There is little doubt but that some cases exist where even the most skill- ful and gentle surgeon cannot avoid provoking bleeding; but far more often it is directly due to culpable negligence or ignorance on the part of the person who attempts catheterization. The use of flexible or semi- flexible instruments is, as often before insisted upon, infinitely less harmful; and with their use hemorrhage from traumatism is least likely to occur; in rare cases, however, its recurrence is most readily obviated by recourse to a metal catheter of large calibre and of an eminently fit curve one that has been proved on previous occasions to enter with facility the bladder of this particular patient. The habit of employing metal catheters is, however, a pernicious one, and only a surgeon with the greatest patience, the deftest and lightest hand, should feel himself qualified to introduce one in cases such as this. As mentioned above, hematuria at times supervenes upon the sudden complete withdrawal of intravesical pressure; so that this is a reason against the indiscriminate emptying of chronically distended bladders, in addition to the danger of syncope and renal complications. Orchitis. Orchitis is a complication to which some patients seem peculiarly liable, attacks recurring again and again, oftentimes from no apparent cause. Usually, however, the affection may be traced to infection from instrumentation, and is hence best prevented by limiting instrumentation as much as may be, or by avoiding it altogether, should this be practicable. Vesical and prostatic congestions should also be avoided by the methods already indicated on previous pages. Renal Complications and Uremia. Finally, nephritis, surgical kidneys, and uremia must be prevented if possible from becoming complications of this already sufficiently troublesome disease. Carefully selected food, plenty of fluid, and good bladder drainage are the most important means by which renal complications may be avoided. Increase of renal pressure from damming up of the urine is one of the most unfailing causes of renal insufficiency; and is, of course; best prevented by securing a free outlet of urine from the bladder. For this purpose catheterization will usually suffice; but when kidney 214 Treatment of Complications breakdown is threatened from backward pressure which cannot be otherwise satisfactorily overcome, we think there can be no doubt that permanent drainage of the bladder is indicated. If feasible, this should be procured through a permanently retained catheter; but should such a course not be possible, or should it have failed to avert the impending disaster, no hesitancy should be entertained about opening the bladder suprapubically, and thus establishing an artificial urethra which will at once relieve the kidneys of injurious pressure. The choice between the two operations suprapubic or perineal will be considered when discussing the treatment of complications. By thus relieving the backward pressure on the kidneys, and by preventing the development of cystitis, the renal condition of these patients will be kept as nearly normal as possible; and when this is the case, little fear need be entertained of their being overwhelmed by uremic symptoms; but it is only by the strictest attention to the state of the urine on the one hand, and to that of the circulation on the other, that the kidneys can be maintained in suitable condition. 4. Treatment of Complications. Cystitis. Cystitis is treated both locally and constitutionally. The local treatment may be considered under three headings: first, that by means of drugs acting through the kidneys; second, by means of irrigations and of injections into the bladder; and third, by means of drainage of the bladder. In no cases of cystitis should the constitutional treatment be neglected. If the inflammation is acute, and extremely painful, rest in bed should be enjoined. The diet should be liquid or at most semi- solid. Plenty of water should be taken. Hot sitz-baths may prove beneficial, once or oftener in the course of twenty-four hours. The bowels should be well opened by mild cathartics or an enema. In mild cases these means alone may suffice to effect a cure, with- in one or two days. Where the pain is severe and incessant, an opiate may be required; if morphine is contra-indicated by the state of the kidneys, or other affection, some milder hypnotic and analgesic may be used. The bromides and chloral in combination often act well; hyoscine, chloretone, sulphonal, trional, or even paraldehyde, valerian, or asafcetida, may act benefically. The condition of the urine is an all-important guide to further me- dicinal treatment. Acid urine, as previously mentioned, is best neu- tralized by reducing the amount of sugar ingested, diluting the urine by an increase in the quantity of fluid taken, and by certain of the alka- line waters. Where the urine is alkaline we may resort to the usual Irrigation of the Bladder 215 remedies, such as boric or benzoic acid, sodium benzoate, urotropin, etc. As an exceptionally useful urinary antiseptic we recommend salol. The aseptic and regular employment of the catheter, to remove any residual urine, is frequently enough in itself to restore the bladder to its normal state. Combined with remedies such as the above, where the alkalinity of the urine is not readily overcome, or where there is much pus or blood present, the bladder should be washed out. As a rule, the best solution is the decinormal solution of sodium chloride, which may readily be improvised by adding a teaspoonful of common table salt to a half a litre of sterile water. The proper solution consists of sodium chloride, six gm. sodium bicarbonate, one gm. and sterile water, one litre. The use of drugs in the irrigation fluid is very rarely required; but boric acid solution one half to one gm. to each thirty cc. may at times clear up the urine sooner than the plain salt solution. Silver nitrate should never be employed except in cases of chronic cystitis; it may be com- menced in the strength of 15 mgr. to each 30 cc. and if well borne, and if it appears that anything may be gained by such a course, the strength may run up to one third to two third gr. for each 30 cc. Great care should then be exercised that no part of so strong a solution comes into contact with the urethra, which would probably be much irritated by it; but when acting on the transitional epithelium of a bladder whose walls are further protected by thick layers of mucus, and perhaps incrusted with salts, it does not seem probable that any harm can arise. Potassium permanganate, in the strength of i to 4,000 is at times a useful drug. The temperature of any solution employed should be between 90 and 100 F.; and it should not negligently be permitted to cool unduly during the process of irrigation. The position of the patient should usually be supine; but where the post-prostatic pouch is large and diffi- cult to drain, the pelvis may advantageously be raised six or eight inches. The manner in which the bladder irrigations are given is important. It is very much better and more comfortable to the patient for them to be given through a soft-rubber or even a Mercier or English catheter; but where these cannot be introduced into the bladder, a metal catheter may readily be utilized by attaching a rubber tube to its outer extrem- ity. Two methods of injection are used: the first by means of a syringe, holding at most 30 cc., whose tip is carefully placed in the outer end of the catheter, which should be funnel-shaped for its recep- tion; the other method consists in attaching by means of glass and 2i6 Treatment of Complications rubber tubing, a small funnel, holding about 30 cc. of water, into which the solution is poured, and from which it is allowed to run into the bladder by the force of gravity. Where a syringe is used for the injection no force whatever should be used in pushing the piston home; indeed, it will usually be found that when the syringe is held ver- tically the piston sinks upon the contained fluid by its own weight. When the tubing and funnel apparatus is employed (and it is the more convenient when available), the funnel should never be raised to a height of more than two feet above the patient's bladder; usually the fluid will run easily at a height of a few inches. Whichever apparatus is used, not more than 120 cc. at the outside should be thrown into the bladder at any one time; when this quantity, or' less if pain be caused, has been injected, it should be allowed to remain for ten or fifteen seconds, and then let out; nor should the abdomen of the patient be kneaded too vigorously in an effort to hurry the process. It is a form of treatment that requires patience and time, and nothing is to be gained by haste. The bladder should not be refilled more than four or five times at the same sitting, and the operation should not be repeated, except in offensive cases, oftener than once in twenty-four hours. Contrary to the general rule above stated : to the eff ect.that not more than 1 20 cc. of fluid should be injected into the bladder at once, which rule, however, we invariably adopt at the first irrigation, we believe that much good may accrue from the passive but very gradual distention of chronically inflamed and contracted bladders. Thus we have seen patients who at the first sitting could not bear to have more than 30 cc. thrown into their bladder at one time, in the course of a few weeks, regain lost bladder capacity so that instead of 30 cc., three or four finally six or eight times the amount could readily be retained; the patient meanwhile experiencing a corresponding de- crease in the frequency of urination. But the most gradual distention in the world should be practised : we are quite satisfied if we can estab- lish a tolerance for a few cc. additional at each sitting. In the practice of irrigating the bladder the attendant, and the patient as well, will often lose heart from the apparent slowness of progress in the relief of the cystitis; and many a time the surgeon will feel tempted to throw a large quantity of fluid into the bladder rapidly and with considerable force, in the effort to clear its cavity of accumulat- ing mucus and blood clots by a process analogous to hydraulic mining; but let him beware that he does not adopt such a practice ! The sudden changes in form to which such methods would subject the bladder would Irrigation of the Bladder 217 but augment the inflammation, and might possibly cause the rupture of some of the vessels in its walls, burst some thin-walled sacculi, or carry infection into the ureters and on the way to the kidneys. The bladder itself might even be ruptured. It should be remembered that there is no expectation of mechanically ridding the bladder of the products of inflammation and hemorrhages; we are not even operating by a variety of litholapaxy; and however pleased we may be when a quantity of debris is spontaneously evacuated through the catheter, we must not forget, that our object is rather to prevent the persistence or extension of the inflammation than to remove its products we hope that these may dissolve and be passed by the urethra in the natural course of events. But in some cases these means do not suffice to arrest the cystitis; the introduction of a catheter is painful, difficult, or even impossible; the bladder irrigations give no relief; renal and uremic complications impend, and urinary fever has already set in. Under these circum- stances no further delay should be tolerated, but as soon as it is evident that ground is being lost the bladder should be drained. Of course, the simplest way by which this may be accomplished is by permanently retaining a catheter, so that its eye projects just within the vesical cavity, and the urine is collected and discharged drop by drop, just as it is received from the ureters. It is important to have the catheter neither too far in, nor yet too far out of the bladder: in the former case its tip will cause great irritation of the vesical trigone, while in the latter the drainage will be very imperfect. To ensure its being in the correct situation, the catheter should first be fully introduced into the bladder until the urine flows in a steady stream; then it is to be slowly withdrawn until the urine stops running entirely, which it does when the eye enters the urethra; and then, finally, the catheter is to be pushed back again about ten to twelve mm. until the urine escapes through it by drops. But it is an exceedingly difficult matter to keep a catheter perma- nently in the correct place. Many forms of self-retaining catheters have been invented, but in our opinion there is not one of them which is practically useful. The Nelaton catheter should, if possible, be that selected for the purpose, as being perfectly flexible it is less apt to cause irritation. Some degree of urethritis is nearly unavoidable, but with in flexible instruments not only is urethritis more likely but every change inposition of the patient is liable to wound the prostate, or the bladder; besides which it is very difficult to secure such a catheter in place. 2l8 Treatment of Complications For rubber catheters the appliance shown in Figs. 65 and 66 may be used, when it is at hand. This consists of a caoutchouc bridle attached at one end to the catheter at its point of entrance into the urethra, and fastening at the other around the body of the patient's penis. Where this is not available the catheter should be transfixed with a double ligature, through the loops of which, tied fairly close to the catheter on each side, strips of adhesive plaster are to be adjusted and fastened in a spiral FIG. 65. CATHETER RETAINER. (CAPLES) Surgery, Gynecology and Obstetrics. and interlacing manner around the body of the penis. If a ligature cannot be procured in an emergency, the catheter may be transfixed with a safety-pin, and the adhesive plaster tied to that. Care should be FIG. 66. CATHETER RETAINER. (CAPLES) Surgery, Gynecology and Obstetrics. taken that the attachment of the plaster to the catheter, in any case, is close to its point of entrance into the urethra, thus preventing the catheter from slipping too far in, as well as keeping it from falling out. Watson has suggested an ingenious method by which a piece of rubber Cystostomy 219 drainage tube, ten to twelve cm. and of slightly less calibre than the catheter'employed (so as to grip it firmly), is passed over this latter, the_drainage tube being split longitudinally into two halves up to with- in twenty-five mm. of its outer extremity, and these lateral halves then being attached to the penis by adhesive plaster in the usual manner. Mercier and English catheters may be fastened in by means of a ligature or safety-pin as already described; while a metal instrument is best secured by passing the middle tails of a double T-bandage through the rings on each side of its shaft. The period during which the same catheter can be safely retained without changing varies much in different cases, and depends largely on the state of the urine; in some patients the catheter will within forty- eight hours become so incrusted with salts as to make its removal difficult. It appears that instruments made of webbing are more liable to the deposit of salts than the soft-rubber catheter, and this constitutes another objection to their use for such purposes. Even when no such trouble arises, the irritation to the urethra or bladder, or the pain experienced by the patient may render the removal of the catheter imperative within a comparatively short time. As a rule, one should not be left longer in place without changing than a week or ten days, unless surety exists that no crusts are forming. This question is best determined by previous experience with the same patient, although the condition of the urine may serve as a fairly reliable guide. When changed at suitable intervals permanent drainage by a catheter may be continued almost indefinitely. Thus Bazy kept a Nelaton catheter in. the bladder for eighteen months, the patient not being confined to bed. In some patients a catheter will not stay in place; it seems to work its way out either spontaneously, or slips from the urethra every time the patient changes his position in bed; while in others a catheter will stay securely in the bladder even when the patients are up and about, and leading a fairly active life. When from any cause the catheter cannot be retained in the urethra and drainage of the bladder still continues to be indicated, cystostomy must be done. In a certain proportion of cases immediate incisional drainage of the bladder is indicated, not however to relieve cystitis alone, but to insure against continued back-pressure on the kidneys. Cystostomy has indeed become, in recent years, a preliminary step in the operation of suprapubic prostatectomy, but we still cling to the belief that the two-stage operation is indicated in only a certain proportion of 22O Treatment of Complications cases and that the proper use of the in-dwelling catheter will reduce the proportion of such cases considerably. The two-stage operation is really a development of the idea which was first expressed by Reginald Harrison of treating suppurative nephritis by means of perineal cystostomy. Cabot, of Boston, later proposed the treatment of patients with surgical kidneys by means of drainage of the bladder. Encouraging results were obtained by this method, and it soon became evident not only that obstructive lesions of the lower urinary tract caused grave disturbances in kidney function, but also that the relief of back-pressure by treatment preliminary to the removal of the obstructive factor permitted the restoration of kidney function to a degree that made the subsequent prostatectomy a much safer procedure. In certain cases the necessity for long-continued preliminary treatment, first perhaps by intermittent catheterization, later by in-dwelling catheter or by suprapubic cystostomy, is evident, but in a not inconsiderable number of patients whose disease is in the early stage, where the obstructive factor is not pronounced, and has given rise to little or no deleterious alteration in bladder or kidney function, we cannot see the rationale of subjecting the individual to a long series of treatments designed for the relief of something he does not suffer from. The two- stage operation should, in our judgment, be used only in selected cases. Cystostomy is a very much safer procedure than tapping the bladder and allowing the cannula to remain in plcae; and besides being safer, affords the surgeon the additional advantage of digital or even visual examination of the interior of the bladder and the prostate, as well as enabling him to proceed to the formation of an artificial urethra, should such an operation be indicated at that time. As*a rule, suprapubic drainage is to be preferred; but in certain cases the perineal route is the better. Perineal drainage, so commonly employed in the early days of pros- tatic surgery, is now reserved for those fortunately rare cases of inter- stitial cystitis with great thickening of the bladder walls, and marked by diminished bladder capacity. These cases are extremely difficult ones to treat and the results obtained are, to say the least, not brilliant. The suprapubic operation either for simple drainage or with the purpose in view, of some operative procedure on the vesical neck, is unsatisfactory on account of the great thickness of the bladder walls and the diminished bladder capacity. Many forms of operative treatment have been suggested for this class of cases and, doubtless in certain instances, the Young punch Acute Urinary Retention 221 or Chetwood's galvano-cautery may be used with gratifying results. Our preference, however, is for perineal drainage with or without prostatectomy, as circumstances indicate. In many of these cases the rigidity of the vesical neck is secondary to the chronic cystitis. The prostate is usually the seat of a chronic interstitial, inflammatory process, and is oftentimes small in size and very indurated; it may or may not be a contributing factor to the obstructive lesion at the vesical neck. Operation should not be attempted in these cases until every effort has been made to bring some measure of relief by urethral dilatta : on, lavage of the bladder, etc.; but having failed in these attempts it behooves the surgeon to try some form of operative treatment. It is our practise in operating upon these individuals to open the perineum, and if conditions warrant it, to remove the prostate gland; otherwise, the vesical neck is merely dilated and a drainage tube of large calibre is inserted. This procedure insures temporary relief, the duration of which is almost in direct ratio with the length of time that the drainage is con- tinued, and the care with which the post-operative treatment is carried out. Perineal drainage as a preliminary step to the operation of prostatec- tomy is no longer employed; in the presence of violent intractable cystitis, with the exception just noted, the two-stage operation of supra- pubic prostatectomy is indicated. Retention of Urine. (a) Acute Complete Retention of Urine. This variety of urinary retention in prostatics is quite as serious an affection as strangulated hernia, and requires quite as prompt and efficacious treatment. The bladder may be very greatly distended by a small quantity of urine since it may have been chronically con- tracted and inflamed for a long time. The pain is indescribably terrible, and instantly grows worse; not only is rupture threatened every moment, but the damming up of the urine into the ureters and kidneys renders urinary fever and uremia likely: and even if rupture of the bladder does not occur, peritonitis by contiguity may soon develop. Since, moreover, the most usual cause of this form of retention is a mechanical obstruction caused by congestion of the prostatic urethra or the vesical neck, which congestion grows worse every moment the reten- tion is not relieved, it is evident how idle it is to resort to those remedies, such as opium and the hot bath, which are so successful at times in the treatment of acute urinary retention due to spasmodic or even to organic 222 Treatment of Complications stricture. In 'patients of the latter class the retention is rarely absolute usually a few drops trickle through the strictures now and again ; and the bladder, moreover, is apt to be in a less unhealthy state than where prostatic disease has existed for a long time. Hence the only rational treatment for this serious complication is immediate relief by the catheter. It is very rarely indeed that a cathe- ter cannot be introduced, provided no false passages have been made in careless and forcible attempts to gain entrance to the bladder before the case is seen. The patient himself, in his agony of pain and impera- tive desire for relief, may have produced false passages which even the most skillful catheterization will be unable to elude; or another practi- tioner with greater zeal than dexterity may likewise have rendered the urethra impassable. But in virgin urethras, which have not before had a catheter passed, and where no strictures are present, a little persistence, and a good deal of patience and gentleness, will almost invariably accomplish the desired result. The soft-rubber catheter is to be tried first; this failing, the Mercier should be introduced, and its elbowed beak made to follow closely the roof of the urethra; should this also be met by an insuperable obstruction, the English webbed catheter, moulded to a proper prostatic curve, may be tried, first alone, and then with its stylet. If passed with the stylet in its interior, the beak of the English catheter may usually be lifted over the raised vesical orifice of the urethra by partially withdrawing the stylet, as already described. When efforts thus con- scientiously made also fail, metallic instruments may be tried; but we believe that a skillful surgeon will rarely succeed with these where he has failed with the English catheter mounted on the stylet. A hasty and impatient surgeon will no doubt often succeed in introducing by force, perhaps by tunnelling the prostate, a metallic instrument into the bladder, where a little more dexterity and less force would have brought the same result to pass by means of a semiflexible instrument and without injury to the bladder, prostate, or urethra. Where strictures render the urethra difficult to catheterize, the usual manipulations employed in such cases should be employed. These it is not necessary to describe in the present work. It seems scarcely requisite to add that wherever in genito-urinary surgery a catheter has been introduced only with the greatest difficulty, it should be allowed to remain permanently in the bladder until all acute symp- toms have subsided. If, finally, no judicious efforts succeed in gaining entrance to the Chronic Urinary Retention 223 bladder through the urethra, the bladder must be tapped. The time during which urethral instrumentation should be persisted in will, of course, vary somewhat with different cases; but, as a rule, we do not think such attempts should be prolonged more than a half hour or forty-five minutes. Even this length of time will be injudicious where the retention has lasted for more than a few hours at most. While we recommend tapping of the bladder as the next step, we recognize that it must be only a temporary expedient; since it is very exceptional for the power of voluntary micturition through a urethra so much wounded and inflamed as these usually are, to return within any reasonable time; indeed, as already pointed out, where this acute retention is allowed to exist for any length of time, it is not impossible, indeed scarcely unusual, for chronic complete retention to follow from atony of the bladder; so that where a competent surgeon is in attendance, and the surroundings make it suitable, it is best to do a suprapubic cystostomy at once; or if the bladder is very small and the abdominal walls thick, perinea! drainage may be established, as indicated in the last section. But where no facilities for such operations exist, the bladder may be safely punctured suprapubically, and immediate danger averted, and the patient's pain temporarily relieved. This procedure may be repeated a number of times without evil consequences, but, as long ago pointed out by Dittel, such treatment is really only a pastime for the surgeon, and is one which should be tolerated only until proper arrange- ments for cystostomy can be made. When the resort to cystostomy must be delayed, it may appear better to retain the cannula in the punc- ture than to reintroduce it every few hours. In cases of acute retention it is absolutely unjustifiable to extend the palliative operation of cystostomy to the radical removal of the prostate. (6) Chronic Complete Retention of Urine. If atony of the bladder exists in cases of this variety, as can readily be determined by the degree of force with which the urine is expelled through a catheter, it will be proper to make use of drainage of the bladder by a permanent catheter, in the hope that the chronic retention may be due to the atony alone, and not to mechanical obstruction by the enlarged prostate. By this method the bladder walls may in the course of a few weeks recover their contractility, as evidenced by increasing force in any stream (whether of urine or irrigation fluid) expelled through the catheter. If the atony is thus relieved, it still remains to determine whether 224 Treatment of Complications the mechanical prostatic obstruction is too great to be overcome by the restored bladder contractility. This question is readily answered in the affirmative if, on discontinuing the permanent drainage, the retention persists. In some exceptional cases it will have been found at the very outset that no atony of the bladder existed. Under either of these circumstances, then, whether vesical atony never existed, or whether it be easily recovered from after relief of intravesical pressure by permanent drainage, it is evident that the retention is due to mechanical prostatic obstruction. Hence the indication is to remove this by radical operation. If atony did exist, and was not relieved after permanent drainage, we are confronted with another problem: Will removal of the pros- tate be any more apt to relieve the vesical atony than was the drainage of the bladder through the catheter? We think this question may fairly be answered in the affirmative; although we would hesitate to recommend radical treatment to a feeble patient whose catheter life was satisfactory to him. For there would still remain the risk that the radical operation would leave him no less dependent on the catheter than he previously was; but if his catheterism is painful, difficult, or unduly frequent, and the patient himself is not too old and feeble for any operation, we would be inclined to advise him to take the risk. (c) Chronic Incomplete Retention of Urine without Distenlion oj the Bladder. Much of what has been said in the early part of this chapter under the general heading of catheterism. applies to this complication. It is a nearly invariable accompaniment of every case of enlargement of the prostate. (d) Chronic Incomplete Retention of Urine with Distention of the Bladder. For these patients the indications are first to restore the full measure of vesical contractility, and then to remove, if necessary, the obstructing prostate. The proper treatment to be advised for prostatics with overflow from retention, is to remove only a few- 120 to 180 cc. of urine at a time, repeating this procedure every four or five hours as may be required, and thus gradually to empty the distended blad- der in the course of two or three days. Or, if desired, more urine may be withdrawn, and partially replaced with saline or boric acid solution. The above plan of treatment presupposes that the urethra is freely open to catheterization. But this may not be the case, the urethra Calculus 225 being obstructed by strictures or false passages. If a catheter can be introduced, but only with difficulty, the surgeon may try to clamp it, and leave it in situ, allowing a few cc. to run off by removing the clamp every couple of hours. But if no catheter of any kind can be introduced, a filiform bougie should be tried, as in the case of stricture unaccompanied by prostatic enlargement; when success attends these efforts, the filiform should be left in place, as the urine will satisfactorily and not too rapidly drain off along its track. If no kind of instrument can be introduced, we believe the proper course for the surgeon to pursue is to perform suprapubic cystostomy, evacuate the urine, staunch bleeding from the mucous membrane of the bladder by the hot douche; and take the usual constitutional precautions against the development of surgical kidney and uremia. Aspiration or tapping of the bladder may be thought by some a preferable course, only a few cc. being removed each time, and the operation being repeated innumerable times; but such a plan of treat- ment admits of no hope to the patient save the classical "meditation upon death;" for it is the most improbable thing in the world that the urethra will again become open to instrumentation before the " medita- tion" of the patient has passed into the reality. Suprapubic cystot- omy under local anesthesia is the method of choice in the treatment of these cases, not only because it is the safest and best method of relieving the acute retention when catheterization is impossible, but also because it offers the best means of decompressing the kidneys. Cystostomy under these circumstances constitutes the first stage of the two stage prostatectomy. In rare instances, however, the condi- tion of the patient following the operation will not improve sufficiently to justify removal of the prostate; he can then be provided with a cannula to be worn permanently in the fistula. Calculus. The most generally accepted plan of treatment for calculus complicating enlargement of the prostate is suprapubic litho- tomy. In suitable cases the prostate may be removed at the same time, but it is generally advisable to drain the bladder for a time before attempting prostatectomy. The latter operation should not be under- taken until the kidney and other vital functions have been restored to as near the normal as possible. Preliminary drainage of the bladder not only aids in such restoration of function, but serves also to relieve the cystitis which usually accompanies stone, and thus minimizes the dangers of sepsis and hemorrhage after prostatectomy. It is sometimes stated that patients with enlarged prostates corn- is 226 Treatment of Complications plicated by stone bear operation better than those in which stone is not a complicating factor; this view is erroneous in our experience and we can find no statistical confirmation of it. Not a few successes have been reported from operation by lithola- paxy but the operation is not to be employed in patients with marked intravesical projection of the prostate. We have long since abandoned the operation of litholapaxy yet this procedure with or without a Young punch operation may possibly have a place in the treatment of small stones complicating median bar formation or sclerosis of the vesical neck. An alternative method of treatment in cases of this kind is that of median perineal lithotomy followed by galvano-cauterization of the vesical neck. (Chetwood.) Orchitis is to be treated as when arising from other causes. Instru- mentation should also be discontinued. Hemorrhage into the bladder is best treated by hot irrigations, and permanent drainage, which may be instituted by means of a suprapubic wound if necessary. Renal Complications and Uremia. For these complications the treatment in patients with enlargement of the prostate does not differ materially from that habitually employed in other cases. Good bladder drainage is imperative. The permanently retained catheter, or supra- public or perineal drainage, may be employed, according to the principles already laid down. If polyuria is a distressing feature it may be partially relieved by reducing the amount of fluid ingested, and by promoting perspiration. Care should be exercised that atony of the bladder from overdistention does not arise. In the later stages of renal affections, when the urine becomes scanty or suppressed, the usual increase in ingested fluid should be prescribed; and great advantage may be derived from the use of saline solution by the bowel. A half litre is readily absorbed from the colon in the course of an hour or so; the temperature should be over 100 F. In sudden emergencies intravenous infusion of the decinormal salt solution may be employed, it being rarely advisable to give more than one or two litres at once by this method. This fluid is probably absorbed nearly as rapidly from the bowel as when given intravenously, and certainly more rapidly than when administered by hypodermocylsis. The steam bath should be employed in case of uremia, or when it is not available, pilocarpine should be given hypodermatically. The tendency which this drug is said to possess of producing or at any rate Acidosis 227 favoring edema of the lungs is against it; but in so great an emergency as uremic coma this risk may be taken. The hydrochlorate is the best salt, and is prescribed in doses ten to fifteen mgms. Digitalis is of use in increasing the action of the kidneys and heart. Sparteine is also an efficient diuretic. Sparteine and caffeine given together are at times beneficial. The sulphate is employed in doses of 30 to 1 20 mgms. Dry cups applied over the loins may sometimes be of service. Acidosis. The exact symptoms which an uncompensated acidosis produces in any given individual are difficult, if not impossible, to define; for acidosis is present only in connection with, or as a result of, more or less grave conditions. It can be expected, however, from results of experimental procedures on controlled isolated phenomena, that the condition will be productive of unfavorable symptomatology. As a result of studies on large numbers of operative cases with due allowances for differences in individuals, in pathology, and in operative procedures, it seems fair to postulate that excessive nausea and vomiting, gas pains, restlessness, and similar symptoms, are often accompanied by uncompensated acidosis. The type of patient presenting an enlarged prostate is one in which it is very likely to occur. The individuals are older, have usually been ill for a considerable time; many, if not most, have some form of nephritis varying in grade, together with arterioscle- rosis, and a damaged myocardium. The mechanism by which an anes- thetic, ether for example, changes the carbon dioxide of the blood has been studied in some detail. In the management of this condition, prevention, as in so many other cases, is far more important than cure. A general . scheme which has given satisfaction is as follows : At the same time that blood is secured for the determination of blood urea and other substances, enough is taken with proper precautions to determine the carbon dioxide combining power of the plasma. The danger point is 50 cc. of carbon dioxide per 100 cc. of plasma. Below this, uncompensated acidosis is said to exist. The decrease in the carbon dioxide combining power due to anesthesia and operation has been found to be from 5 cc. to 15 cc. To assure that the safe level is main- tained, it is well to give alkali, e.g. sodium bicarbonate, to those indi- viduals showing an original carbon dioxide combining power of 60 cc. carbon dioxide, or less. The necessary dose can be calculated by the use of a formula: i gm. of sodium bicarbonate when neutralized will yield 267 cc. of carbon dioxide. 228 Treatment of Complications For every kilo of body weight, there are approximately 700 gm. of fluid. Consequently, the amount i gm. of sodium bicarbonate will increase the carbon dioxide of the plasma of an individual weighing i kilo per 267 100 cc., will be 38? Consequently, x will equal > where x stands for the desired increase per 100 cc. of plasma, g the number of grams of sodium bicarb- onate, and w the weight of the individual in kilos. If, therefore, preliminary analysis has shown the carbon dioxide capacity of the plasma to be 55 cc. carbon dioxide per 100 cc., and it is desired to increase to 70 cc. in an individual weighing 75 kilos, the amount of sodium bicarbonate necessary will be xw 15X75 g = ^8~ : ~^8~ = 3 gm> The maximum effect of a single dose by mouth is reached in about two hours; but it can be given in hourly doses ending about two hours before operation. Rectal administration may be used after operation either inter- mittently or constantly in 4 per cent, solution. With these precautions, trouble from- acidosis per se, may be entirely avoided. If doubt is present at any time, determinations can easily and quickly be made. Attention is here also called to too much alkali, and while alkalosis has not received the same amount of consideration accorded to acidosis, it perhaps is as well not to administer too much, i.e., the carbon dioxide carrying power of the plasma should never be above 75 cc. carbon dioxide per 100 cc. REFERENCES (CHAPTER X) Bazy: Presse M6d., Paris, 1897, i, 251; Surgical Disorders of the Urinary Organs, London 1887, p. 417. Cabot: Boston Med. and Surg. Jour., 1903, ii, 559. Caples, B. H. : Catheter Retainer, Surg., Gynec. and Obstet., 1920, xxx, 521. Chetwood: Annals of Surgery, 1905, Ixi, 497. Cullen, G. E. and Van Slyke, D. D.:.A Method for the Determination of Carbon Dioxide and Carbonates in Solution. Jour. Biol. Chem., 1917, xxx, 347. Dittel: Wien. med. Woch., 1876, 26; Nos. 22-25. Freyer: Stricture of the Urethra and Hypertrophy of the Prostate, 2d ed., London, 1902. Guyon: Lecons sur les Maladies des Voies Urinaires, Paris, 1903, 46. ed. i. Harrison: The Prevention of Stricture and of Prostatic Obstruction, London, 1881; Surgical Disorders of the Urinary Organs, London, 1887, p. 417. References (Chapter X) 229 Moullin: Enlargement of the Prostate, London, 1899. Palmer, W. W. and Van Slyke, D. D.: Relationship between Alkali Retention and Akali Reserve in Normal and Pathological Individuals. Jour. Bid. Chem., 1917, xxxii, 499. Reimann, S. P.: The Acid-Base Regulatory Mechanism in Anesthesia. Am. Jour. Surg., 2. Suppl. Anesth., 1919, xxxii, 86. Reimann, S. P., and Bloom, G. H.: The Decreased Plasma Bicarbonate during Anesthesia and Its Cause. Jour. Biol. Chem., 1918, xxxvi, 211. Ruggles: Quoted by Keyes: Urology, 1917, p. 29. Senn: Practical Surgery, Phila., 1902. Socin and Burckhardt: Die Verletzungeh u. Krankheiten der Prostata, Stuttgart, 1902. Van Slyke, D. D., and Cullen, G. E.: The Bicarbonate Concentration of the Blood Plasma, etc. Jour. Biol. Chem., 1917, xxx, 289. Watson: Boston Med. and Surg. Jour., 1895, ii, 154. Wolff: Deutsche med. Woch., 1899. Young: Jour. Amer. Med. Ass., 1913, lx, 253. CHAPTER XI PALLIATIVE OPERATIONS INCLUDING CYSTOSTOMY, YOUNG'S PUNCH OPERATION, CHETWOOD'S OPERATION, AND FULGURATION The history of the development of the operations of suprapubic and perineal cystostomy by simple puncture has been dealt with elsewhere. Perineal puncture has been universally abandoned, while tapping the bladder suprapubically is merely a palliative measure for use in cases in which the urethra is impassable, and where other means of relieving the retention are not available. Lower, of Cleveland, has suggested the use of the trocar and cannula to take the place of the more formal cystostomy, not only for the purpose of providing suprapubic drainage in inoperable cases, but also as the initial step in the two-stage operation of prostatectomy in certain circumstances that preclude a more radical procedure. The simplicity of this method and the satisfactory results that follow its use should make it, according to Lower, the method of choice in selected cases. The Trocar and Cannula Method of Lower. Lower has recently called FIG. 67. TROCAR AND CANNULA WITH METAL CULLAR. (Lower, Urol. and Cutan. Rev., 1914, xviii, 6.) attention to a method of draining the bladder by means of the trocar and cannula which undoubtedly has many advantages over simple puncture. The senior author used this same method many years ago before the operation of cystostomy was fully perfected; he believes that it has a place in the treatment of certain desperate cases of enlarged 230 Gibson's Operation 231 prostate with acute retention in which almost any operative interference would be attended with grave danger. The method provides not only for relief in cases in which relief is urgently demanded, but provides in addition for permanent drainage of the bladder. It may be used as a substitute for the ordinary cystostomy and has the advantage over simple puncture in that it practically eliminates the danger of urinary infiltration in the abdominal parietes. Lower states that the trocar and cannula method often proves to be a more comfortable way of providing bladder drainage as a preliminary to prostatectomy than the use of the catheter per urethram. We cannot see the advantage of this method over formal cystostomy except in cases of acute urinary retention in which catheterization is impossible, and in which even so slight an operation as cystostomy under local anesthesia would be attended by grave danger. The uncertainty of the location of the opening in the bladder, the small size of the fistula which pre- vents digital exploration of the bladder, the fact that it provides in- adequate drainage and renders the subsequent removal of the prostate difficult, are the great disadvantages of the trocar and cannula method. This method may be used to advantage, however, in establishing a urinary fistula for the treatment of certain inoperable cases. Technique. The trocar and cannula are forced into the bladder a ta point sufficiently distant from the pubis to avoid puncture of the plexus of veins which lies just behind the pubic bone. A local anesthetic may be used but is ot essnential. The bladder must be sufficiently distended to displace the peritoneum out of harm's way. The trocar is withdrawn leaving the cannula in place and through the latter a sterile, No. 14 (F.), soft rubber catheter is inserted into the bladder cavity. The cannula is then withdrawn over the catheter which is allowed to remain in the bladder. FIG. 8. LOWER'S TROCAR AND CANNULA METHOD. Step i. Trocar introduced into Bladder. (W. E. Lower, UroUglcal and Cutaneous Review. ~) 232 Palliative Operations The after-treatment is essentially the same as with other forms of suprapubic drainage operations. In the subsequent removal of the prostate it is necessary greatly to enlarge the opening and in so doing it must be remembered that the original opening is located at a point more distant from the summit of the bladder than is the case with the ordinary cystostomy wound. FIG. 69. LOWER'S TROCAR AND CANNUXA METHOD. Step 2. Catheter Introduced into bladder through the Cannula. (Uro- logical and Cutaneous Review.) FIG. 70. LOWER'S TROCAR AND CANNULA METHOD. Step 3. Cannula withdrawn leaving Catheter in Bladder. (Urological and Cutaneous Review.) In cases in which prostatectomy is contraindicated, and in which permanent drainage is necessary, the fistulous tract may be fitted with a metal cannula with urinal attachment, or the cannula may be fitted with a cork which can be removed when the desire to uri- nate is felt. Gibson's Operation. The formation of a bladder valve, as devised by Gibson, for the treatment of inoperable carcinoma of the bladder and prostate is likewise useful in a very limited group of patients with benign prostatic hypertrophy. This group includes only those cases in which the absolute impossibility of subsequent removal of the prostate can be predetermined. This is a necessarily limited group, Gibson's Operation 233 because one can rarely be sure, however desperate the condition of the patient may be before drainage of the bladder is provided, that the vital functions will not be sufficiently restored as the result of such drainage to justify the attempt to remove the prostate at some later time. The Gibson operation is applicable only to patients with a reasonably large bladder capacity. The operation is performed as follows : The bladder is exposed suprapubically in the usual manner. An incision large enough to admit a catheter, No. 30 French scale, is then made into the bladder at its mid- point. A No. 30 soft rubber catheter is inserted through the incisional opening into the bladder and anchored to the margins of the incision which is then closed above and below the catheter. Two Lembert sutures are now passed through the bladder wall above and below the catheter, these sutures being so placed that an infolding of the bladder wall will occur when they are tied; the por- tion of the bladder wall between these sutures is thus invaginated into the bladder cavity, carrying the catheter with it. FIG. 71. LOWER'S TROCAR AND CANNULA METHOD. Step 4. Catheter fixed in position. (Urological and Cutaneous Review.) Additional Lembert sutures are inserted and tied so that further invagination of the bladder wall is produced with the result that a valve-like fold is formed. The suture material recommended is No. 2 chromic catgut. The abdominal wound is closed with through and through sutures of silkworm gut. The steps in the opera- tion are clearly shown in the accompanying illustrations. The after-treatment consists in the removal of the catheter as soon as absorption of the retention sutures has occurred, usually at the end of the first week, with the substitution of a No. 23, soft rubber catheter. This is replaced about the end of the second week by a No. 20 catheter; with the contraction of the fistula to this size the bladder valve becomes retentive. The subsequent care of the fistula is simply a matter of cleanliness 234 Palliative Operations FIG. 72. GIBSON'S OPERATION. Step i. (Ramon Guiteras, A Text-book of Urology, D. Appldon and Co.} FIG. 73. GIBSON'S OPERATION. Step 2. (Ramon Guiteras, A Text-book of Urology, D. Appleton and Co.) Gibson's Operation 235 except if it shows a tendency to close in which event dilatation is neces- sary. The Oberlander dilator is recommended for this purpose athough straight, olivary tipped urethral bougies of the woven variety may be used with equal satisfaction. FIG. 74. GIBSON'S OPERATION. Step 3. (Ramon Guiteras, A Text-book of Urology, D. Appleton and Co). The bladder valve permits the easy removal of residual urine per catheter. Leakage of urine does not occur, and the patient can void normally if the urethra is patulous. If, for any reason, the use of the normal channel is undesirable the bladder may be emptied at regular intervals by simply inserting a soft rubber catheter through the valvular opening. The Gibson operation is, as we have already stated, rarely indicated in cases of benign prostatic hypertrophy, but it is enimently suited to that small group of cases in which prostatectomy is contra-indicated and in which a false urethra must be provided. It is not to be employed as a substitute for catheterism, but only in cases where the latter has been tried unsuccessfully, where prostatectomy is out of the question, and where the valve operation seems to be superior to the ordinary suprapubic operation of cystostomy as a means of providing the neces- sary false channel for evacuating the urine. 236 Palliative Operation INTRA-URETHRAL OPERATIONS FOR THE RELIEF OF OBSTRUCTIONS AT THE VESICAL OUTLET The development of urethral instruments and the technique of their employment for the relief of obstructions at the vesical outlet are discussed at some length in Chapter I. There will be found descrip- tions of some of the instruments and methods that are now employed, in a modified form it is true, but still the same in principle, for the removal, or destruction of various obstructing factors in this locality. Much confusion characterizes the attempts made to separate these conditions into pathological entities separate and distinct from diseases of the prostate gland; clinically they give rise to a syndrome that is identical with that arising from true prostatic hypertrophy. The expert cystoscopist can form a rather precise idea of the nature of the lesion in any given case, and of the method of treat- ment particularly adapted to its removal; the average surgeon, however, must rest content with FIG. 75. GIBSON'S OPERATION. Diagram showing the Infolded Bladder Wall forming a Valve. the knowledge that an obstructive lesion exists which is organic but not neoplastic in nature, and probably not of prostatic origin, or at least not associated with generalized benign hypertrophy of the prostate gland. He will realize also that prostatectomy may or may not be necessary to remove the obstruction. The diagnosis and pathological description of the conditions to which we now refer are given elsewhere, suffice it to say here that they are variously known under the terms, "contracture of the vesical neck, median bar formation, submucous fibrosis, atrophy of the prostate, prostatism sans prostate, hypertrophy of the subcervical (Albarran's) glands, hypertrophy of the subtrigonal glands, isolated fibro-adenomata of the prostate gland, median lobe enlargements, etc." Practically all of the modern instruments used in the treatment of the aforementioned conditions are, in principle, quite similiar to others Intra-Urethral Operations 237 which have long been discarded. Thus the punch devised by Young is very similar to Mercier's prostatectome, a picture of which is shown in Chapter I. Mercier's instrument was introduced into surgery in 1839 but was soon forgotten. This antedated the modern cystoscope by many years and doubtless the improper selection of cases explained in part the failure of Mercier's method, which enjoyed but a brief popularity. Chetwood's galvano-cautery is in principle the same as the galvano- cauterization of Bottini, to which however it is vastly superior. Finally, the high-frequency spark operation introduced by Bugbee is a refinement of the method advocated by Wossidlo; the latter attempted, but without much success, to combine in one instrument the cystoscope with the galvano-caustic incisior, and to this instrument he gave the name of " Incision Skystoskop. " The trend of modern surgery in the treatment of these cases is undoubtedly toward suprapubic operation notwithstanding the claims made by the advocates of the palliative forms of treatment. We believe that the prostate should not be disturbed in cases where it in no way contributes to the existing obstruction at the vesical outlet. But we believe also that in the hands of the average surgeon, and this includes the great majority of specialists, better results will be obtained by opening the bladder suprapubically and removing the obstructing element with the knife or rongeur than with from any form of intra- urethral operation. In certain cases we have performed perineal prostatectomy but the results were not entirely satisfactory; this applies especially to those cases in which there is a widespread fibrosis in the region of the vesical neck associated perhaps with interstitial Cystitis. In the treatment of these and other cases in which we formerly used the Bottini incisor, we now prefer the suprapubic operation with removal of the obstructive elements by means of the rongeur forceps, scalpel, or scissors. The choice of the method to be employed is made after the bladder is opened, and in many instances the final judgment is for prostatectomy in cases in which simple excision of a median bar or other extra-prostatic lesion seemed to be indicated by cystoscopic examination. It is not good surgery, in our judgment, to do a punch operation for the purpose of providing temporary relief from a condition that will later demand a radical operation. The punch operation may be used to advantage in cases in which under more favorable circumstances prostatectomy would be indicated and, judging from the results of this operation as 238 Palliative Operations reported by Young and others, a great deal of good may be accomplished, even though a complete cure is not obtained. We prefer, as previously mentioned, the suprapubic operation with excision of the obstructing element and would limit the use of intra- urethral operations to those cases in which the more radical form of treatment is for any reason contra-indicated. Electric Cauterization of Obstructions at the Vesical Outlet by means of the high frequency current has been given some prominence lately by Bugbee and his followers. Originally this method was said to be applicable to the same class of cases as the Young punch operation. More recently, however, Bugbee has expressed the view that the high- frequency spark is inferior to the Young punch since it is difficult to burn deeply into the products of inflammation surrounding the outlet of the bladder. The fulgurating or high-frequency current may perhaps be useful as a palliative if not curative method of treatment in the early stages of subcervical glandular hyperplasia. It may also prove to be an efficient means of relieving chronic congestive states of the mucosa in this region, but little can be hoped for in the treatment of true pros ta tic hypertrophy or submucous fibrosis. The high-frequency spark was suggested by Bugbee for the destruction of prostatic nodules remaining about the vesical neck after incomplete prostatectomy, and it is stated that partial relief was obtained by fulguration in these cases. An incomplete prostatectomy which fails to relieve the patient's sufferings is in our judgement a very definite indication for re-operation, provided the condition is not a malignant one. In the cases of this kind that we have re-operated, the condition of the tissues in the region of the outlet of the bladder was such that radical operation was obviously necessary. Cases have been reported, however, in which remaining nodules of prostatic tissue and obstructing folds of mucous membrane were successfully removed with the Young punch. Technique. The nature and location of the obstructive lesion is determined in preliminary cystoscopic studies, for which the cysto- urethroscope is the most satisfactory instrument both for examination and treatment. . Having decided upon the nature of the lesion and the location of the areas where the cauterization is to be applied, the cystoscope is introduced into the bladder cavity, With the beak of the instrument in the partly distended bladder, the electric wire is introduced until it appears in the field and is then further advanced until at least one half inch projects from the window of the cystoscope. The irrigating Young's Punch Operation 239 fluid is then permitted to flow slowly into the bladder and at the same time the cystoscope and the electric wire are slowly withdrawn until the area to be treated appears within the field of vision. If this is on the floor of the sphincteric margin, the instrument is held against the roof of the urethra by depressing its ocular end, and a similar procedure will aid in bringing other areas more clearly into view. When the obstructive lesion has appeared in the field, the instrument is further withdrawn, but only for a very short distance, and the deflector is turned, whereupon the tip of the wire will be seen to touch the diseased area. Some cystoscopists advise that the lesion be located before the wire is made to emerge from the sheath of the cystoscope, but we have found it much easier to place the wire in the proper position with the technique just described. The Oudin (unipolar), or the d'Arsonval (bipolar), current is used and the spark is applied for variable periods of time, usually one minute, depending upon the strength of the current and the depth of the tissues to be destroyed. Several weeks are required for the sloughs to separate. The frequency of the treatments must be guided by the tolerance of the individual patient to instrumentation. As a rule, it is unwise to repeat the cauterization until the slough caused by the first treatment has come away and the ulceration has begun to heal. Repeated cau- terizations are usually necessary before definite improvement is noted. Young's Punch Operation. Under the title "A New Procedure (Punch Operation) for Small Prostatic Bars and Contractures of the Prostatic Orifice," Young of Baltimore, in 1913, presented to the profession a new method of treatment for the particular groups of cases now under discussion. This method is, in principle, that described many years ago by Mercier, but it remained for Young not only to perfect the instrument, but to clearly define the group of patients suffering from obstructions at the vesical neck to which the punch operation is applicable. He further subdivided these cases into groups, showing the method of applying the punch in each group and the results that might be expected to follow. The punch operation has met with more general acceptance than any of the other intra-urethral methods of treatment, if we may judge from the reports in the literature, although it has by no means met with the enthusiastic support of the large majority of surgeons. We have had no experience with the method, prefering instead the 240 Palliative Operations suprapubic operation in those cases in which the punch operation might be thought to be appropriate. The following remarks are based entirely on data contained in the literature. At the time of the first report (1913), Young had performed the operation in approximately one hundred cases, which number has been considerably increased since then. The first group of cases were classified as follows: (a) Median bar obstruction 51 (b) Prostatic bar or contracture with diverticulae 5 (c) Prostatic bar or contracture with calculus 1 1 (d) Prostatectomy cases with incomplete results 20 (e) Median bar with trigonal elevation and obstruction 3 (/) Spinal cases with large amounts of residual urine (associated with median bar) 3 (g) Obstruction associated with carcinoma (vesical or prostatic) . . 9 Results. Class (a) 51 cases. The results were entirely satisfactory, there were no fatalities and the only immediate post-operative complica- tion was hemorrhage. This was never alarming however and never necessitated opening the bladder to control it. The end-results were likewise satisfactory. Class (6) 5 cases. Young's experience in this group of patients led him to remark that simple removal of the obstruction either by prostatectomy, or by the punch operation relieved the patient and that excision of the diverticulum is unnecessery except when the ureter is interfered with. In our experience the removal of the obstruction does not greatly benefit the patient with a large diverticulum. If such patients can be kept in comparative comfort by palliative means it is better, in our judgment, to withhold operation even though the ureter is drawn into the sac of the diverticulum. Class (c) ii cases. Young is particularly enthusiastic over the results of the punch operation in cases of median bar complicated by stone. The stone is crushed and removed, and following the litholapaxy the median bar is punched out thus removing the cause of stone for- mation in this particular group. All of the patients were cured and none had a recurrence of the stones. Class (d) 20 cases. This most interesting group of cases, the details of which are described in the "Transactions" of the Section on Genito- urinary Diseases of the American Medical Association, 1912, were operated upon with the "punch" and with most gratifying results. The type of obstruction and its location with reference to the various segments in the circumference of the vesical outlet was by no means Young's Punch Operation 241 constant. In some instances the cystoscopic rongeur was employed to remove pedimculated or rounded nodules followed by the removal of the base of such lobe or nodule with the punch. Class (e) 3 cases. This group is of interest in that attention is drawn for the first time to trigonal elevation as a cause of urinary obstruc- tion. Class (/) 3 cases. In only one of these cases was the removal of an obstructing median bar followed by a restoration of bladder function. Class (g) 9 cases. The punch operation is advised only as a pallia- tive measure, the purpose of which is to remove a median bar obstruc- tion complicating an otherwise inoperable carcinoma of the prostate. Since the publication of this preliminary report the punch has been used more extensively in this class of patients and with good results. It should not be used, however, to the exclusion of radium and other mea- sures that may hold the disease in check. Since the appearance of Young's report the punch operation has been used by many surgeons and the reports are on the whole encourag- ing, although no one seems to have had extensive experience with the method except its originator. Post-operative bleeding has been observed and in some instances this necessitated suprapubic cystostomy. Cun- ningham suggests the use of a dePezzer catheter after the punch operation. He claims that the button-like end of the catheter will exert sufficient pressure on the wound to control all dangerous bleeding. Cunningham states that he found it necessary on several occasions, before adopting the retention catheter, to do an external urethrotomy to control the bleeding. The introduction of a larger catheter through the perineal wound than could be introduced per urtthram effectually controlled the hemorrhage. Young originally advocated the use of a two-way catheter intro- duced through the urethra with continuous irrigation of the bladder after the punch operation, but in a more recent article he states that the hemorrhage can be controlled by the introduction of a single catheter the end of which is coated with cephalin, a hemostatic agent described by Howell. Notwithstanding the interest in this subject that Young's work has stimulated, the literature contains comparatively few references to the punch operation. In practically all instances such references as are available refer to only a few cases. Young seems not to have changed his opinion regarding the merits of the operation, and it is interesting to review the later reports from his clinic. Among these may be quoted 16 242 Palliative Operations that of H. C. Cecil, who gave a resume of the results of Young's opera- tions before the Philadelphia Academy of Surgery in 1917. This report includes the late results in 128 cases, tabulated as follows: 70 patients Cured 13 patients 90 per cent, improved 16 patients 75 per cent, improved 13 patients 50 per cent, improved 3 patients 25 per cent, improved 13 patients Not improved In the thirteen cases in which no improvement was noted after the punch operation, the symptoms were due to a contracted bladder. All of these cases showed median bars on cystoscopic examination, but the associated pathology in the bladder wall was such that the punch opera- tion failed to effect a cure. FIG. 76. YOUNG'S URETHROSCOPIC MEDIAN BAR EXCISOR. In a detailed description of a very remarkable case, Young shows the possibilities of treatment with the combined use of radium, fulgura- tion, and the punch in desperate cases of enlarged prostate. This report is interesting in that it shows how much can be done to relieve the sufferings of certain individuals in whom prostatectomy is absolutely contraindicated on account of cardiac or other organic defects. Technique. The instrument consists of two tubes which fit one with- in the other, and an obturator. The inner tube is hollow and has a sharp edge which serves as a knife to punch out any tissue that may appear through the fenestrum of the outer tube or sheath. The latter is pro- vided with an opening on its convexity near the inner or bladder extremity. The latter end is curved like a coude catheter. The outer end of the sheath is provided with a light-carrying attachment similar to that of the Young urethroscope. Young's Median, Bar Excision 243 The use of the urethroscopic light is unnecessary for locating the part to be removed; this should be done by cystoscopic examination before the operation is attempted. The exact position of the part to be operated upon being known, it is a simple matter to engage it in the fenestrum of the sheath by pushing the instrument into the bladder cavity whereupon urine will escape; by withdrawing the instrument until the flow of urine suddenly stops the bar is brought into the fenes- FIG. 77. Median bar excisor or punch instrument introduced into the bladder; cutting inner tube withdrawn allowing fluid to escape, showing that the instrument is in the bladder. (HughH. Young, Annals of Surgery, 1917, Ixxv, i.) trum and it is then a simple matter to insert the inner tube and punch out the desired amount of tissue. The procedure may have to be repeated several times before all of the obstructing tissue is removed. This procedure calls for familiarity with urethral instrumentation, but if the operator is possessed of sufficient skill to enable him to locate and recognize the bar and to bring it into the fenestrum under the guidance of the eye aided by reflected light, he is equally capable of accomplish- ing this by the manipulations just described. The operation is performed with local anesthesia and with the bladder filled with a mild antiseptic solution. When the bar is engaged in the instrument, the inner tube is pushed home, thus excising in one piece the tissues contained within the window of the tube. The inner tube contains the piece of tissue, which is removed with forceps. Young advises the removal of several additional segments of tissue at the lateral extremities of the bar. 244 Palliative Operations The tissues to be excised may occupy the anterior or lateral portions of the vesical outlet and the position of the instrument must be varied accordingly. The after-treatment consists of drainage of the bladder by a catheter of large calibre and lavage of the bladder to remove blood clots. As previously stated, Young recommends that the end of the catheter be coated with cephalin. This substance is dissolved in a small quantity of ether and the solution is slowly poured over the end of the catheter so that the ether will evaporate leaving a coating of cephalin on the instrument. FIG. 78. INSTRUMENT WITHDRAWN UNTIL THE MEDIAN BAR is ENTRAPPED IN THE FENESTRA WHEN THE INNER CUTTING TUBE is QUICKLY PUSHED INWARD TO EXCISE THE BAR. (Hugh H. Young, Annals of Surgery.) If blood clots collect in the bladder cavity they must be re- moved by aspiration with a Valentine or other suitable syringe. The catheter may be removed within twenty-four hours if the bleeding has ceased. Subsequent dilatation of the urethra is unnecessary. Caulk has recently introduced a modified Young's punch in which a cautery blade takes the place of the cutting edge of the inner sheath of the Young instrument. The originator of this instrument reports a series of fifty cases in which the obstruction was relieved by electro- coagulation, with uniformly good results. The danger of hemorrhage after electro-coagulation are said to be nil. Chetwood's Galvano-Prostatomy 245 Perineal Gahano-prostatomy (Chetwood). Galvano-cauterization of the vesical neck through a perineal urethrotomy wound (Chetwood's operation) is a modification of the Bottini operation, the latter being FIG. 79. CUTTING TUBE HALF WAY THROUGH THE BAR. (Hugh H. Young, Annals of Surgery.) also a galvano-prostatomy but is performed through the urethra without a perineal incision. Both operations have been abandoned by the majority of operators FIG. 80. CUTTING TUBE PUSHED HOME, COMPLETELY EXCISING THE BAR. (Hugh H. Young, Annals of Surgery.) and especially is this true of the Bottini method. Chetwood and a limited number of other surgeons hold to the opinion that galvano- cauterization offers the best means of treating contractures or strict- 246 Palliative Operations ures of the vesical neck, which conditions may or may not be a part of, or arise subsequent to, primary disease in the prostate gland. The pathology of this condition, according to Chetwood, is not that of fibrosis alone, but one associated with what he terms circular or concentric hypertrophy of glandular prostatic elements which normally lie in juxtaposition with the sphincteric area of the bladder outlet. Whether or not this is a true conception of the pathological change, the fact remains that there is a considerable group of cases in which an obstruction to urination exists at the bladder outlet which cannot FIG. 81. THE EXCISED BAR GRASPED IN TUBE WITH INTRAURETHRAL FORCEPS PREVIOUS TO REMOVAL. (Hugh H. Young, Annals of Surgery.} be relieved satisfactorily by removal of the prostate. To this group Chetwood believes the operation of galvano-cauterization is eminently suited. It will suffice to remind the reader at this time that we ad- vocate suprapubic exploration of the bladder in this group of cases, with radical removal of the prostate if necessary, or with simple excision of a median bar, or isolated nodule of glandular tissue if these are found to be the cause of the obstruction to urination. It should likewise be noted that the Young punch operation was primarily intended for the treatment of the same type of patients. Technique. The following description of galvano-prostatomy is taken from Chetwood's text-book of Urology. The instrument is composed of a handle and sheath and several sizes of cautery blades. The handle of the instrument is graduated so that the dimensions of the cut may be determined. The sliding of the knife is effected by traction instead of the rotation of a wheel, so that Chetwood's Galvano-Prostatomy 247 the operator readily appreciates the progress of the blade and the density of the tissues during cauterization. One hand is required to operate the instrument and the index finger of the other hand is free to be intro- duced into the rectum. No cooling device is attached to the instrument. The circulation during the operation of a cold sterilized solution through the urethra and out through the perineal wound is required to keep the handle of the instrument cool without affecting the blade. The current is supplied by a storage battery or preferably from the street current with the aid of a motor transformer and rheostat. About 50 amperes are required to heat the knife to a white heat which is cooled to a certain extent as it passes through the tissues. The patient is placed in the lithotomy position, the bladder having been previously washed with boric acid solution. The preliminary step of external perineal urethrotomy is performed. The bladder having been reached, the staff is removed and the finger introduced through the perineal opening. In cases of marked contracture, whether or not accompanied by hypertrophy, the vesical orifice may be too tight to admit the examining finger. This opening is not forced and torn by the finger, but is enlarged by the first incision of the cautery knife. The instrument having been previously tested, is introduced through the perineal opening: the index finger of the left hand feels the beak through the rectum, and irrigation through the urethra is commenced. The operator now gives the signal to turn on the current; ten seconds are allowed to heat the knife after which it is slowly unsheathed by drawing outward. From one-half to three-quarters of a minute is generally allowed to complete an incision of moderate length (1-2 cm.) and return the knife to its sheath. A longer period is required for an incision of greater length. After returning the knife to the sheath irrigation is forced through the perineal incision before withdrawing the heated instrument. The finger of the operator is now introduced into the bladder and a careful exploration made. In cases of simple contracture a single in- cision of one cm. is generally sufficient to complete the operation. In cases of wide, collar-like intravesical hypertrophy, a double incision may be necessary, one on either side, or a second incision to deepen the first, the aim being to render the neck of the bladder readily accessible to the examining finger. Care should be taken not to draw the knife too far outward into the prostatic urethra or so deep through the contracted tissue as to completely sever the internal sphincter beyond. 248 Palliative Operations Following the galvano-cautery incision, a perineal drainage tube is introduced and the after-treatment is the same as after external perineal urethrotomy, the perineal tube being usually left in place one or two days according to the condition of the bladder. Daily washing of the bladder is required through the perineal tube, and after its removal, by means of a catheter introduced through the perineal opening and later through the urethra. Cystostomy. The establishment of a urinary fistula in the treat- ment of prostatic hypertrophy is merely palliative; it is a remedy to be employed only when absolute centra-indications to prostatectomy exist, or in cases in which prolonged drainage of the bladder is a neces- sary step in the operation of prostatectomy. FIG. 82. RESULT AFTER EXCISION OF BAR. (Hugh H. Young, Annals of Surgery.} The aim of treatment differs under these different circumstances and the technique of the operation likewise differs. In performing a cystostomy which is merely preliminary to prostatectomy, our object is to provide free drainage of the bladder, but to provide it in such manner that the prostate can be removed easily at some future time through the fistulous tract, enlarged by incision if necessary, and with the assurance that the fistula will close promptly after the removal of the prostate. In establishing a urinary fistula for the purpose of permanent drainage of the bladder our aim is, on the contrary, to provide the patient with a false urethra through which the urine may be evacuated at regular intervals, either voluntarily, or by means of the catheter. The ideal is attained when the canal shows little if any tendency to Suprapubic Cystostomy 249 close and at the same time prevents the constant leakage of urine. For the treatment of cases in which prostatectomy is inadvisable and in which relief per urethram is impossible, our preference is for suprapubic cystostomy with the establishment of an artificial urethra by the method of McGuire. The reasons already given for this pref- erence may be reiterated and enlarged upon in the present chapter. In the first place, the results to the patient are more satisfactory than when a perineal fistula is established. When the artificial urethra remains as a permanent thing, the convenience and comfort of the patient are matters of considerable importance. Incontinence is rarely a sequel of the suprapubic operation; and when it does occur, is very readily obviated by the use of an obturator in the new chan- nel. Where the artificial urethra is in the perineum incontinence is more likely, and when it does exist no obturator will keep urine from dribbling out; and the wearing of a urinal becomes necessary, with the retention of a tube in the perineal fistula to conduct the urine to its receptacle; since without the tube the urine would trickle down the thighs. Urination moreover, is usually more convenient through a supra- pubic than through a perineal fistula. In the former case, if the patient is not able to expel his urine in a parabolic stream, much as in the normal state, a soft-rubber catheter is very readily dropped into the bladder, and with a slight primary contraction the remainder of the urine is evacuated by syphonage. Patients with perineal fistulae are very seldom satisfied with their method of urinating; we have heard them compare it to that of a cow. fj)_By the suprapubic route the inflamed vesical neck is not injured, either at the time of operation, or in the subsequent treatment of the patient. Better opportunity is afforded for examination of the interior of the bladder, and for the evacuation of calculi, pus, mucus, and blood clots. The route for drainage of the bladder and for post-operative irriga- tion is more direct; larger tubes are used for drainage, and as a conse- quence the drainage is better, the tubes are less likely to become obstructed or kinked; and convalescence is pleasanter for the patient. The prostate is usually so large as to make access to the bladder from the perineum difficult, and to render drainage of the post- prostatic pouch by this route ineffectual. The bladder is usually dilated and carried well above the symphysis, so that it is much more readily reached by the high operation. 250 Palliative Operations But there are certain cases, few in number we acknowledge, but still worthy of consideration, where bladder drainage is indicated, where it cannot be obtained satisfactorily through the urethra, and yet where the bladder is small, thick, contracted, and very difficult of access by the hypogastric route. In these patients, as a rule, the prostate is small and sclerosed, and does not obstruct urination so much by its size, as FIG. 83. SUPRAPUBIC FISTULA ESTABLISHED BY McGuiRE's METHOD, SHOWING THE OBTURATOR. by rendering the neck of the bladder immobile. In such cases the advan- tages possessed by the perineal route are obvious. It appears to us, then, that cystostomy for enlargement of the prostate is a very valuable operation, not lightly to be discarded. It is a step between catheterism and prostatectomy; and while it should, Suprapubic Cystostomy 251 on the one hand, never be undertaken without the hope of being able to cure the patient at a later time by the radical operation, yet it should always be done in such manner that, if further interference should subsequently seem inadvisable, the patient will nevertheless recover with an artificial urethra worthy of the name. When employed only in selected cases the operation of forming an artificial urethra is attended by a very slight mortality. We are not aware that statistics of the perineal operation have been published, but the following table gives the results of McGuire's operation (in cases presumably selected) in the hands of various operators : MORTALITY, OPERATOR CASES DEATHS PER CENT. Wiesinger 24 o o . oo Bjorn Hodernus 20 o o.oo Lagoutte 21 4 19 . oo Poncet and Delore 39 2 5.12 McGuire 39 2 5.12 Horwitz 33 o o.oo Total 176 8 4.54 Poncet and Delore called attention to the very much greater mortality which obtains among patients whose bladders are already seriously infected. Others they term the mechanical; but among the infected cases these authors record forty-two patients treated in this manner by Lagoutte, of whom fifteen died, a mortality of 35.7 per cent. ; while of seventy-five such operations in their own hands, no less than twenty-nine terminated fatally, a mortality of 38.7 per cent. Watson published the results of 146 drainage operations by various surgeons, not classed as suprapubic or perineal, but probably including examples of both operations; of these, forty-nine terminated fatally, a mortality of 33.5 per cent. This high death-rate is probably to be explained in the same way as that which attends the infected cases of Poncet and Delore: because in these cases the operation is undertaken as a last resort, some of the patients being even moribund at the time, and the surgeon adopting this form of treatment as a forlorn hope, or as a means of producing euthanasia. Technique of the Establishment of an Artificial Urethra by Suprapubic Cystostomy. This operation may readily be performed under local anesthesia with novocaine, if desired; but where the condition of the patient does not contraindicate a general anesthetic, we prefer to use ether. The bladder should contain from 90 to 180 cc. Where the urethra is impassable the bladder will be distended by its retained urine. 252 Palliative Operation The surgeon standing on the patient's right side, an incision about five cm. long is made just above the pubis, to one side or the other of the linea alba, separating the fibres of the rectus muscle longitudinally. This lateral position of the incision decreases the chance of subsequent incontinence, as the muscular fibres keep the wound closed except when separated by the introduction of a tube. The lower end of the incision should touch the symphysis pubis, and at the upper end the incision should grow progressively shorter as it is deepened through the abdominal walls. No vessels or nerves FIG. j. i. Stevenson's suprapubic tube. 2. Senn's sigmoid tube for a suprapubic fistula. large enough to be named are divided, and hemorrhage is insignificant. The space of Retzius is now opened. The fat and cellular tissue which fill it should be carefully separated in the same line as the abdominal incision, deviating neither to the right nor left. Any large veins should be avoided. If cut, however, they will cease to bleed when the bladder is opened, but can be ligated if necessary. It is usually more expeditious, as well as productive of less disturbance to the parts, to dissect through this tissue with blunt-pointed scissors. Tearing it apart with the handle of the scalpel or the fingers contuses it so that it is more liable to infection from the urine. Suprapubic Cystostomy 253 The bladder is readily recognized by its bluish appearance and its consistency. The reflection of peritoneum is seldom seen at all. If in the way, it is readily separated from the bladder by blunt dissection. When the bladder is reached, a silk or silkworm-gut suture should be passed through the outer layers of its wall about eight mm. on each side of the line of the incision. These are to be used as tractors, and may be looped, or caught with hemostatic forceps. They are not designed to remain after the operation, nor to secure the bladder to the abdominal wall. Where the belly wall is thick, and the introduction of these sutures difficult, a single suture will suffice ; this may then be placed in the line of the incision, at its upper limit; or a tenaculum may be used to steady the bladder, as originally recommended by McGuire. The bladder being thus secured it should be opened at a point not above the upper margin of the pubis, the edge of the knife being turned downwards. The incision in its wall should be longitudinal, and amply large to admit the surgeon's index finger. Some of these bladders have very tough and thick walls, and the opening does not dilate as the finger is introduced. The finger should follow the knife into the bladder before much of the intravesical fluid has escaped, as it will thus be able to gain a much more accurate idea of the interior of the bladder. Whereas in providing drainage preliminary to prostatectomy the open- ing into the bladder is made as near its summit as is possible, the opening in the bladder of a permanent fistula is placed close to the vesical outlet. Prompt closure of the fistula occurs after removal of the prostate when the opening is situated near to the summit of the bladder while the permanency and efficiency of a fistula are in direct proportion to the proximity of the bladder opening to the vesical outlet, and to the obliquity of the fistulous tract in its course through the abdominal wall. Unless the prostate has been injured previously or during the operation, hemorrhage from the interior of the bladder is not apt to be severe. It is usually easily controlled by douching the bladder with hot water or with salt solution. In extreme cases the cavity of the bladder may be packed with iodoform gauze, which may be pressed firmly against any bleeding point that can be discovered. Any calculi present should then be removed, and blood clots, inspissated mucus, etc., washed out. For such purposes it may become necessary to enlarge the wound in the wall of the bladder; but it is well to avoid this when possible. A good-sized rubber catheter about number 35 to 40 of the 254 Palliative Operations FIG. 85. STEVENSON'S SUPRAPUBIC TUBE IN PLACE WITH URINAL ATTACHED. (After DaCosla.) Suprapubic Cystostomy 255 French scale or a drainage tube, should then be inserted into the bladder, down to but not touching the post-prostatic pouch. A double tube is necessary only when vesical catarrh is pronounced. If the tube is carried down too far, its end may become hermetically sealed by the bladder contracting on it. It is therefore well to have a tube with a lateral opening, as well as to avoid inserting it too far. The retention sutures may then be removed, and the bladder in sinking back into the pelvis will carry the vesical opening of the new urethra even lower than before. The tube may have to be inserted more deeply at this stage of the operation. The lower angle of the incision in the anterior sheath of the rectus should then be approximated with a couple oi interrupted sutures of chromicized catgut or silk; and both angles of the skin wound sutured, so as, however, to allow the catheter to emerge higher than the middle of the original incision. In his later operations McGuire employed no sutures at all, relying on careful placing of the tube to secure an artificial urethra of the desired obliquity. If the wound in the bladder has been enlarged beyond that requisite to admit the finger, it will of course be proper to apply a couple of sutures in that position. This may best be done so as to invert the bladder wall into the cavity of this viscus, thus producing a wound which is least likely to result in sub- sequent incontinence of urine. The tube should be sutured to the skin on one side, to prevent it slipping in or out. A copious dressing of sterile gauze and absorbent cotton is then applied; and the tube connected by rubber tubing with a urinal beside the bed. The urine should be kept scrupulously acid, both before and after the operation. The patient may be allowed to sit up in bed as soon after the operation as he feels able; and may be out of bed, as a rule, on the fourth or fifth day. If the drainage tube causes much annoyance, it may be safely removed within six or eight hours after the operation; by which time the wound will have become thoroughly "glazed." The tree dis- charge of urine through the suprapubic opening may be relied upon to keep the wound from closing; but it is better to leave the tube in the bladder for at least forty-eight hours after the operation. If however, it has been removed earlier to relieve the patient, it can usually be replaced after the first day or two, if necessary without producing renewed irritation. Palliative Operations FIG. 86. SENN'S SIGMOID CATHETER IN PLACE WITH TUBE ATTACHED FOR CONSTANT DRAINAGE INTO URINAL. (After DaCosta.) Continuous Drainage Tubes 257 If the urethral obstruction is marked there is no likelihood of the artificial urethra closing; but where this tendency is observed, a good- sized tube should be constantly worn in the wound. Where continuous drainage, as in cases of bad cystitis, is desired, one of the many forms of tubes with urinals attached may be employed, so that the patient will not be confined to bed. If the vesical irritability is great, and the prostate encroaches much on the cavity of the bladder, FIG. 87. i. Owen's perineal tube. 2. Watson's perineal tube. Senn's sigmoid drainage tube is probably the best variety. Stevenson's tube is another convenient form. Where constant drainage is not required, but where the bladder is able to retain a certain quantity of urine and needs only occasional evacuation, McGuire's obturator may be worn in the wound; although in some cases no involuntary leakage will occur even without this appliance, except when the level of the urine within the bladder becomes higher than the external opening of the artificial urethra, or when the patient assumes the supine position. On removing the obturator the patient may be able to empty the bladder by voluntary contraction; but where the vesical atony is extreme the introduction of a catheter through the suprapubic wound will be necessary. 17 258 Palliative Operation REFERENCES (CHAPTER XI) Bugbee: Internal. Abstr. of Surg., 1915, xxi, 581-593; Boston Med. and Surg. Jour., 1920, clxxxiii, 41; 80. Caulk, J. R.: A New Method of Removing the Median Bar Type of Prostatic Obstruction. The Jour, of the Missouri State Medical Assoc., 1921, xviii, 191. Chetwood: Annals of Surgery, 1905, Ixi, 497; Surg., Gyn. and Obst., 1915, xxi, 202. Gibson: in Guiteras' Urology, ii, p. 306. Jacobs, P. C.: The Diagnosis and Treatment of Glandular Obstruction at the Neck of the Bladder. California State Jour. Med., 1919, xvii, 56. Lower: Trocar and Cannula for Suprapubic Drainage of the Bladder. Urol. and Cut. Rev. 1914, xviii, 6. Luys, G.: "Fovage de la Prostate" in Treatment of Prostatic Hypertrophy. Jour, of Urol., 1919, iii, 17. McGuire: Trans. Amer. Surg. Assoc., 1886,349.; Ashhurst's Internat. Encycl. of Surgery, 1895, vii, 916. Poncet and Delore: Traite d. la Cystostomie sus-Pubienne chez les Prostatiques, Paris, 1899. Watson: Boston Med. and Surg. Jour., 1895, u *S4- Wossidlo: Centrabl. f. d. Krankheiten d. Harn-u-Sexualorg., 1900, xi, 113. Young: Jour. Amer. Med. Ass., 1913, lx, 253. CHAPTER XII INDICATIONS FOR RADICAL TREATMENT BY SUPRAPUBIC AND BY PERINEAL PROSTATECTOMY The palliative treatment of prostatics,- which formerly engaged the attention of surgeons in almost equal degree with the radical forms of treatment, is now reserved for cases who either refuse operation, or on whom operation seems for any reason unsuited. In this disease, as indeed in the history of many surgical conditions, operative treatment has become gradually perfected to the point where radicalism has proved itself safer than any method of palliation. In a former edition of this work the reader was told that "when palliative treatment fails, then a radical operation is indicated." So far has surgery advanced since then that we can now say, and, in so saying express a universal surgical opinion, that in the vast majority of cases palliation should be employed only as a means of preparing the patient for prostatectomy. It is needless to recount the develop- mental steps in operative technique which have made prostatectomy a comparatively safe procedure; safe enough to justify it as a substitute for the former necessary evils of catheterism. Those of us who have lived through this developmental period in the surgery of the prostate derive the keenest pleasure in advising operation in patients for whom previously we would have hesitated at the threshold of radicalism, and fearing to enter through its portals of uncertainty, would have condemned the individual to a life that is brief on the average, and certainly a miserable one, at least in part, as is the inexorable fate of these individuals. The most recent development in the surgery of the prostate, namely the two-stage operation, is believed by some to meet the requirements of a routine procedure but to this we take exception believing that this method of treatment should be selected only in a certain class of cases. For practical purposes of treatment we divide all operable cases into three groups as follows: Group I comprises all patients in the initial stages of prostatism who present no complications necessitating pre- 259 260 Indications for Radical Treatment liminary treatment. An individual belonging to this group presents himself with the history characteristic of a beginning adenomatous enlargement of the prostate. His symptoms are mild in type; he is suffering only slightly but realizes that something is mechanically wrong with his urinary apparatus. Patients of this type usually belong to the better classes, and the more intelligent will most likely attribute the nocturia and associated symptoms from which they suffer to a dis- turbance in the prostate gland. Examination of the prostate per rectum usually reveals a moderate degree of enlargement although in many instances little or no palpable change in the organ can be felt. Having carefully examined the cardiovascular system and ascer- tained the kidney function, the patient is given a urinary antiseptic for a period of several days at the expiration of which time he is prepared for a cystoscopic examination and the determination of the amount of residual urine. If we are able to demonstrate a small quan- tity of residual urine in the absence of marked distention, inflammation or atony of the bladder wall; if the cystoscopic examination demonstrates sufficient prostatic obstruction at the vesical outlet to explain the presence of the residual urine; if the patient's vital organs are in good condition; if his kidney function is approximately normal, we deem it not only safe but wise to proceed at once with the operation of prostatectomy. Unfortunately this group of cases is now small, but the number of prostatics who apply for operative treatment in the incipiency of their disease is increasing. The mortality among this group of patients should be almost nil. Group II, which comprises the great majority of patients with pros- tatic hypertrophy, includes all cases in which some form of preparatory treatment is necessary if the operation is to be undertaken with safety. Cases in this group are always moderately advanced in prostatism; the effects of urinary obstruction are evident, primarily in the bladder and the upper urinary tract and secondarily, in the general effects of urinary stasis and in the systemic effects consequent upon a distress- ing affliction. There is the history of suffering beginning as did that of the patients in Group I, but gradually increasing and often made worse by the instru- mental attempts to relieve them. Almost all of the patients are familiar with catheterism and its effects; the majority of them have infected bladders; a considerable degree of organic change haks taen place in Operable Cases 261 the bladder walls; and the kidney function is diminished sometimes to a very low ebb. The amount of residual urine present varies but is usually consider- able. In this group of patients the treatment has been either that of neglect or of the palliative form including regular catheterization, in either instance with results that have prompted the patient to seek operative relief. Included also in this group are cases of acute retention of urine which is easily relieved by the catheter. To attempt prostatectomy immediately in patients belonging to this group is to invite disaster. In the great majority of instances catheterism, either intermittent or continuous, together with the treat- ment appropriate to the complications present will result in an improve- ment sufficient in degree to permit of prostatectomy being attempted with every chance of success. The operation may be performed some- times in one stage; more often it should be done in two stages. Some few patients who at first sight belong apparently to Group II must be transferred to Group III which includes those in whom for any reason palliative treatment is contraindicated and in whom imme- diate relief of urinary obstruction is a necessity. This group therefore includes all patients whose condition demands removal of the prostate gland but in whom instrumentation is impossible and for this reason palliative treatment cannot be carried out and preliminary cystostomy is therefore urgently demanded. The alternative method to cystostomy under these circumstances is tapping the bladder suprapubically, a procedure that has a very limited field of usefulness. It is indicated when the circumstances are such that an immediate suprapubic cystostomy cannot be done. After determining the advisability of prostatectomy in any given case we must next carry out the preliminary treatment designed to get the patient in the best possible condition for operation. Having succeeded in this, we choose the method of operation best suited to the needs of the individual case. We have before us a choice of two routes of access to the prostate gland, the suprapubic and the perineal; and a number of variations in the operative procedure by either route. To determine which of these many different methods is applicable to any given case, is the task at present before us. The technique of the operations will be described in the next chapter. Those surgeons who would confine their operative technique to either the suprapubic or the perineal route alone, and who do not admit that in some cases one route may justly be preferred to the other, so that each 262 Indications for Radical Treatment is occasionally employed, appear to us to be very narrow-minded, and to be looking at the subject with prejudiced eyes. There is no more reason for one method of operating on the prostate being exclusively applicable to every case, than there is for one incision or one avenue of approach being always the only one possible in other condi- tions. For cleaning out the sphenoid cells, for example, it will some- times be better to approach them from above, through the frontal sinuses, while at other times entrance will be more safely gained through the middle meatus of the nose. For draining the lesser peritoneal cavity it will at times be more advantageous to open through the left loin, while at other times the transabdominal route will be proper. For the operation of hysterectomy an abdominal operation will usually be preferred; but there are times when a vaginal excision will give better results. So with the operation of prostatectomy the suprapubic operation is in certain cases (we think in the majority) in every way pref- erable to that through the perineum. No doubt a skillful surgeon will in time become able technically to remove all, or nearly all, enlarged prostates by one or the other route exclusively; but this does not prove that in a certain few cases a resort to the neglected route would not result in an easier operation, and recovery be more assured, as well. Mr. Freyer, who is inclined to the opinion that all enlarged prostates are best removed by means of the suprapubic operation which bears his name, nevertheless met with one case (Brit. Med. Journ., 1902, ii, 248; ibid., 1903, i, 901) in which he was unable to remove the prostate by this route; and the patient died of heart failure, a couple of days after the unsuccessful operation, the bladder at autopsy being found to be full of clots. Now, this result is very far from proving that the prostate in this individual patient could have been satisfactorily removed by a perineal operation, but it certainly shows that no one method can be exclusively employed, if we aim to secure the best results. And since Mr. Freyer may be supposed to possess more skill in the performance of his operation, as he certainly has had more experience than any one else, it is but reasonable to conclude that where he has failed, others will fail as well. We once saw a distinguished surgeon in a neighboring city operate by perineal prostatectomy, and although he finally did succeed in extracting the diseased organ, yet he sweat blood throughout the operation, and there was for some time grave anxiety as to the life of the patient. This surgeon was one of those who advocate the perineal operation for every case; and, as in the parallel case of Mr. Freyer. it may reasonably be supposed that those surgeons who employ Choice of Operation 263 one operation exclusively will be more apt to make it succeed in diffi- cult cases than will those who have no objection to resorting to a different method when they think the one they usually prefer will fail. There may be, indeed we have little doubt that there are, prostates which can be removed neither by one route nor the other; but there can, we think, be no question that the surgeon will do best for his patients, as well as for his own reputation, who is competent to resort to either method of treatment, as may seem indicated to him. Speaking in favor of suprapubic prostatectomy, and referring to Watson's statement that the perineal distance is scr great in one-third of the cases as to prevent the completion of the operation by the perineal route, McGill said "it is unwise to commence an operation with the probability of failing in one-third of the cases;" and "it is not advisable to limit the ability to perform an operation to gentlemen with preterna- turally long fingers;" while Moore asserts that the operator's fingers grow longer as he grows in experience in the perineal operation. Both these statements, while epigrammatic, are no doubt true; but they do not invalidate the principle, already laid down, that the ability to operate by both routes is a prerequisite for the most successful treatment. This being accepted as an axiom, it will be the surgeon's next duty to determine which cases are suited to each method of operation. It will be recollected that enlargement of the prostate occurs in two main varie- ties one variety, the glandular or adenomatous overgrowth, constitut- ing the majority of cases; while the fibrous enlargement constitutes the minority, and even at times approaches more nearly in type to prostatic atrophy, or to sclerosis of the neck of the bladder, or is at least conspicious by the relatively slight enlargement compared to the magnitude of the symptoms produced. In the former variety, as has already been pointed out, the prostate attains a greater size, and at the same time the bladder is more often dilated than contracted. In the latter variety, which seems rather intimately connected with inflammatory changes, the bladder is usually small and thickened. Hence at the onset we have the general law laid down that the hard, small fibrous prostate will usually be very difficult of access by the suprapubic route, while the adenomatous organ will at times be so bulky as to absolutely prevent its removal through the perineum, except by fragmentation. It was in a case .of the former variety that Mr. Freyer found himself unable to complete his suprapubic operation, for although the gland could be satisfactorily reached, yet it could not be 264 Indications for Radical Treatment removed because of its intimate adherence to the surrounding structures. As has been frequently insisted upon by Mr. Freyer, the adenomatous glands gradually "shake themselves loose" from the surrounding struc- tures, tend to resume their bi-lobed condition, and are easily enucleated by the ringer. But where the organ is fibrous, and where periprostatitis (which usually has accompanied the development of this variety) has existed, the adhesions between the prostatic capsule and its sheath are very dense, no natural line of cleavage exists, and enucelation is there- fore difficult or impossible. Where prostates which approach the fibrous type (for a number are intermediate in character) are removed by enucleation, portions of the sheath, or even of the levator ani muscle, are frequently found adhering to the outer surface of the organ, it having been impossible to separate the capsule from the sheath on all sides. Yet in the fibrous prostates no subsequent increase in size is to be apprehended, and the removal of the floor of the urethra, together with as much of the lateral lobes as may be requisite, will result in sufficient lowering of the vesical outlet to accomplish the desired result; whereas a similar operation a partial prostatectomy in the case of an adenomatous prostate still increasing in size, would indeed give temporary relief , but might, on the other hand, be followed by continued growth in the remaining portions of the prostate, which would eventually cause renewed urinary obstruction. For such cases, therefore, complete enucleation is preferable, and that this may be more readily and satis- factorily accomplished by the suprapubic route we will presently endeavor to show. But it is proper at this place to sound a note of conservatism. Many surgeons are rolling up long lists of successful (or unsuccessful) operations by either the suprapubic or the perineal route. But it appears to us that some such operators may be a little hasty in resort- ing to operative interference; and while one death from neglect to oper- ate at the proper time is more reproach to a surgeon than several deaths which a timely operation merely failed to prevent, even though the former death never appears in his statistics; yet one death clearly caused or hastened by an ill-judged resort to operative treatment will demand an immense number of successes to blot out its remembrance. And we cannot but think that some surgeons are displaying more enthusiasm in adding many operations every year to their tale of cases, than they are in seeking the best interests of their patients. And in connection with these thoughts, we would like to insist upon the propriety of not doing too much at any one operation. If we open Choice of Operation 265 the bladder to drain it for cystitis, let us be satisfied, except in rare instances, if we secure the desired drainage, and let us not attempt to remove the prostate at the same time. If we open the bladder prepared to do a prostatectomy, and find a pedunculated outgrowth acting as a ball-valve against the vesical orifice of the urethra, let us be satisfied to remove it, and leave the remainder of the prostateal one. We do not think we can justly be accused of timidity, but we are free to confess that we are afraid to do too much to some of these decrepit old men: their tenure on life is slight, and pressing our manipulations too far may at any moment loose the silver cord, and instead of curing the patient by a brilliant operation, we shall have killed him by meddlesome, injudicious surgery. We know quite well that in a certain number of cases removal of a pedunculated outgrowth has not prevented a return of symptoms; but, on the other hand, we are perfectly familiar with several instances where the most radical, dangerous, brilliant, and remarkable operation in the world could have had no more successful result than the simple snipping off of such a ball- valve, with scarcely more present danger to the patient than that of the anesthetic. And although Mr. Freyer has made somewhat caustic remark's upon the futility of employing anything else than total enucleation in any such cases, we have had too many cases of this kind with satisfactory results following this simple procedure to allow ourselves to be influenced even b)' Mr. Freyer for whose judgment and experience we have nevertheless the deepest respect. The following case history well illustrates a cure by this procedure. J. S., aged sixty-nine years, had been forced for seven or eight years to rise during the night to urinate. The desire was imperative, and sometimes recurred ten or twelve times during the same night. There was difficulty in starting the stream, and only a small quantity was passed at any one time. Vesical tenesmus occurred at frequent intervals, both day and night. On admission to the Lankenau Hospital, the patient was found to be plethoric; his color was sallow; his arteries were somewhat atheromatous, and their tension increased. His heart-sounds were muffled, and the second cardiac sound was accentuated throughout. His lungs were emphysematous. There was tenderness in the pubic region, and combined intravesical and rectal examination demonstrated an enlarged "median lobe" of the prostate. There were 60 cc. of residual urine. The pedunculated "median lobe" was removed by suprapubic cystostomy, by means of large forceps. Bleeding was free, but easily controlled. A rubber 266 Indications for Radical Treatment tube was inserted through the suprapubic wound, which was not sutured. The patient was discharged, well, in two weeks. We have heard from him frequently since, and on recent inquiry, four years after operation, ascertained that his urination was normal in every respect. Other similar cases are to be found in prostatic literature, but they seem to have passed from the memory of many in the profession. Burckhardt recorded the case of a patient who had suffered from urinary symptoms for five and a half years; and who for one year had had frequent attacks of retention of urine. By removal of a projecting "middle lobe" by suprapubic cystostomy, all the symptoms were re- lieved; and when last seen, four and a half years after the operation, the patient was in good health, and his urinary functions were normally performed. Prof. Ashhurst reported a case of similar nature, as long ago as 1882. The patient for five years had been absolutely dependent on the catheter. Finally the end of his catheter broke off and remained in the bladder. After suffering for seven weeks from this added dis- comfort, he applied for treatment. The foreign body was removed by median perineal cystostomy, and a pedunculated "median lobe" of the prostate was removed at the same time. On recovery the patient found to his great delight that he could pass his urine in the normal manner, and had no further use for the catheter. Harrison reported another such recovery. To these few instances others might be added, but those given are sufficient to emphasize our point. The preferable route for total enucleation of the prostate is the suprapubic. The prostate lies upon the triangular ligament, and above the aponeurosis of Denonvilliers; neither of these structures, so impor- tant in completing the floor of the pelvis, is divided when the prostate is lifted off them, and delivered into the cavity of the bladder. And when the prostate is adenomatous in character its enucleation is accom- plished with surprising ease. Whether the prostatic urethra is removed or not, apparently makes no difference in the functional result. In many of the older perineal operations it is sacrificed in a similar manner. Indeed, Goodfellow's procedure appeared to be precisely the same as Mr. Freyer's, except that the former removed the prostate through a perineal incision. The approach to the prostate by the suprapubic route is through structures which are less vascular, and less liable to permanent injury from the necessary manipulations. They are, moreover, not required for the function of urination. It is customary to cast in the teeth of the Choice of Operation 267 suprapubic operator the fact that he makes two incisions in the bladder wall, one on its superior surface, to enter its cavity, and another in its floor to reach the prostate ; and it is pointed out by perineal operators that the organ whose removal we are attempting lies entirely outside the bladder, and that by the perineal approach the bladder wall is not divided. But those surgeons who, like Goodfellow, insisted upon the propriety of entering the enucleating finger into the bladder cavity before beginning the enucleation, surely divided the floor of this viscus during their maneuvers; while those who, like Proust and Young, approach the prostate from its lower side, employ an extensive dissection separating the rectum from the anterior structures, and dividing the base, or working around the lower margin of the triangular ligament, and thus in either case form a wound which, as their results show, is more apt to result in a permanent fistula, while it affords no better drainage than is procured by the suprapubic operation. As was pointed out by McGill and W. G. Richardson, drainage is really better by the supra- pubic wound; for it is a iact that where the bladder is drained both ways simultaneously almost all the urine escapes by the suprapubic tube, and that when both tubes are removed, the perineal tract closes first. This is, of course, where the perineal wound is a simple median urethrotomy, since, as has already been said, the wound left after a suprapubic cystostomy closes more rapidly than that resulting from the extensive perineal operations. As to the objection that the prostate is an e'xtravesical organ, it may be replied that it is so to the same extent as, but scarcely more so than the appendix is an extraperitoneal structure; for the enlarged prostate (and it is only that form that we are discussing now) almost invariably becomes chiefly intravesical in character, and it is therefore no more unsurgical to traverse the bladder to reach it than it is to attack the appendix by a transperitoneal route; and yet we all know that an inflamed appendix may readily, if circumstances require it, be stripped out from its peritoneal covering, leaving this in place like the empty finger of a glove, much as the perineal operators advocate scoop- ing out submucous prostatic outgrowths from beneath the floor of the bladder without opening this organ; but nevertheless no one will prefer an extraperitoneal approach to the appendix. The enlarged prostate, in fact, is covered only by mucous membrane, or at most by attenuated muscular tissue which is as much prostatic capsule as it is bladder wall. The mortality of Freyer's operation is higher than that shown by the statistics of the modern perineal operations; but of the cases that 268 Indications for Radical Treatment recover, those that are classed as good results form a somewhat larger, and those with perfect cures a considerably larger proportion. These facts which were originally established by statistics collected during the earlier years of the radical operation of prostatectomy have been confirmed many times by subsequent writers. The statistics which we have collected from the more recent litera- ture and from personal communications with confreres as well as our own experience confirms the validity of the statement that the primary mortality is slightly greater following the suprapubic opera- tion than it is after perineal prostatectomy, but this disad- vantage is more than offset by the far better results obtained in cases which recover after the suprapubic operation than after perineal prostatectomy. This subject is discussed at some length in the chapter on prognosis to which the reader is referred. We at one time also advocated the perineal as the preferable opera- tion, because of the difficulties and dangers attendent upon McGill's suprapubic method; but when after seeing Mr. Freyer's excellent results, and appreciating the force of his arguments, we were emboldened to attempt a similar operation, and were greatly surprised at the simpli- city of the technique, and at the pleasant convalescence of the patient. This ease of performance is another argument in favor of the supra- pubic route. For although mere facility of execution by the surgeon is of itself no valid argument in favor of one operation rather than another, provided this other would secure better results and entail less danger to the patient, yet in Freyer's operation the ease consists not alone in mechanical execution, but in rapidity of performance, less distortion of neighboring parts, and less likelihood of post-operative complications; all of which are factors of much importance in old prostatics. The perineal operation, as we have already stated, we think, is best confined to those cases where the prostate is small, fibrous, and scler- osed; where the removal of the floor of the prostatic urethra and the main part of the lateral lobes of the prostate will lower the vesical orifice sufficiently to make a clear water-way; and where there is little chance of the only portion of the prostate left (the superior commissure) subsequently enlarging and causing renewed obstruction. Where the prostate is of the character described it is usually impossible, or at all events extremely difficult, to enucleate it from within its sheath; and a more or less exact dissection is required. To accomplish this Suprapubic Prostatectomy 269 through a suprapubic wound is nearly impossible, since the prostate is at such a distance from the surface; but when it is well drawn down into the perineum by tractors of some variety, such a dissection may usually be accomplished. As to the preservation of the ejaculatory ducts, we regard this as entirely unnecessary. As shown in a former chapter, it is extremely improbable that semen without the admixture of prostatic fluid is fertile; and the destruction of these ducts need not of itself cause impo- tence. Impotence often exists before the operation; and although it has been stated that removal of the prostate may restore sexual potency, yet of this we are not very sanguine. It will be seen from the preceding paragraphs that we prefer supra- pubic prostatectomy as the radical treatment for the majority of patients. Indeed, since first adopting this method we have seen few cases in which it did not seem preferable to the perineal operation; but we recognize the fact that there are cases where the perineal is to be preferred, and when we encounter such, we do not hesitate to adopt the latter procedure. We do not employ the various endo-urethral forms of opera- tive treatment for the removal of median bars or the relief of contractures of the vesical neck and kindred conditions. It has always seemed to us to be the part of better judgment to open the bladder suprapubically in this class of patients and remove the obstruc- tion under the guidance of the eye, preferably with the aid of the rongeur forceps, sometimes with the knife by a procedure similar to that recently described by Buerger, and rarely with the cautery. Occa- sionally a case is met with in which the prostate has been removed by the suprapubic route but in which a tab of mucosa attached to the margin of the prostatic bed is so situated as to obstruct the urethra and interfere with the emptying of the bladder. After accurate cysto- scopic localization of an obstructive factor of this type it may in certain instances be removed with ease with the Young punch. Usually how- ever we prefer to re-open the bladder in these cases, which are fortunately rare. Indeed, additional operative procedures are rarely necessary to complete the cure after a total suprapubic prostatectomy. REFERENCES (CHAPTER XII) Ashhurst: Principles and Practice of Surgery, Phila., 1893, 6th ed., p. 1026. Buerger: Jour. Amer. Med. Ass., 1919, Ixxiii, 1677. Goodfellow:^Jour. Amer. Med. Ass., 1904, ii, 194. 270 Palliative Operation Harrison: British Med. Jour., 1902, ii, 1499. McGill: Trans. Clin. Soc., London, 1888, xxi, 52. Moore: Trans. Amer. Surg. Ass., 1902, xx, 59. Proust: Manuel de la Prostatectomie Perineale pour Hypertrophie, Paris, 1903. Richardson: Development and Anatomy of the Prostate Gland, -London, 1904. Socin and Burckhardt: Die Verletzungen und Krankheiten der Prostata, Stuttgart, 1902. Watson: Annals of Surgery, 1889, ix, i. Young: Jour. Amer. Med. Ass., 1903, ii, 999. CHAPTER XIII TECHNIQUE OF OPERATIONS, INCLUDING THE PREPARA- TION OF THE PATIENT, WITH THE AFTER-TREATMENT Preparation of the Patient. The preparation of the patient is essentially the same no matter by which route suprapubic or perineal the prostate is to be removed. These are not emergency operations, and the patient should be under preparation for the operation for a time sufficient to restore the vital organs to their maximum functional power. In the case of many patients the surgeon will have been in attendance for weeks or months; but even such patients require further preparation than mere surgical attention. This preparation should be both general and local As to constitutional treatment, it is well to pay special attention to the condition of the kidneys, the heart, and the lungs. As regards the details of pre-operative treatment both local and general these have been described in the discussion of renal functional tests and the palliative treatment of prostatic obstruction. We wish merely to recall to the reader's mind the urgent necessity for pre-opera- tive treatment in all cases of prostatic hypertrophy. Treatment of the kidneys is governed by the state of renal function which is almost invariably impaired when the patients come under observation for the first time. Such treatment must differ necessarily in different cases since no two individuals present exactly the same alterations in kidney function. In one group of cases, a simple dietary and hygienic regimen is the only pre-operative treatment necessary; at the other extreme is a group in which impending uremia necessitates prolonged treatment which may or may not include preliminary cystostomy. Selection of the time for prostatectomy even in cases in which preliminary cystostomy has been done is quite as perplexing a problem as the selection of the proper form of pre-operative treatment. Indeed, in no other surgical condition is the necessity for wide surgical exper- ience and fine judgment greater; the most consummate technical skill is powerless to offset the evils of ill-advised surgery, and the patient whose time for" operation has been chosen scientifically has a better chance for recovery in the hands of a veritable tyro in surgery than the 271 272 Technique of Operations patient who is operated upon by a master technician before the kidney function has been restored. For the heart it is usually well to prescribe a course of strychnine or digitalis, even if the cardiac action is not noticeably abnormal. The shock of the operation is a strain even on a well-preserved heart; but it may be much lessened by getting the heart into training previous to the operation. In our hospital experience we have found that resident physicians are only too apt to overdose the patient with strychnine after the operation, while omitting it in the preparation. The lungs should of course be free from acute disease, such as bronchitis; and where a more or less chronic or subacute bronchitis, hypostatic congestion, asthma, or emphysema is present, special care should be exercised in the administration of the anesthetic, as well as in the prevention of chilling or exposure. For such patients we prefer nitrous-oxide oxygen to ether. Drugs directed to the condition of the lungs are usually of little use, but if the heart is treated the lungs may be benefitted indirectly. It is not usually advisable to confine the patient to bed even on the day immediately preceding the operation, unless he is already bed- ridden: it is sufficient for him to regulate his life with the utmost care, confining himself to the house, and taking special precaution to break no well-established habits of life. On the morning of the operation he should, of course, remain in bed. It is well to have the services of a trained nurse for at least twenty-four hours before the operation. The alimentary canal should be well cleaned out by a brisk cathartic given in the afternoon before the operation, and the rectum should be emptied by enema on the morning of the operation. Should the afternoon cathartic not act, it is to be repeated early in the evening or on the following morning, before the operation. If, as has been advised, the patient has been in the habit of taking a cathartic about once in a week or ten days, no difficulty will be experienced in thoroughly emptying the intestinal tract without the use of drastic purges. In- deed, the routine administration of cathartics to patients as practised in some hospitals in preparation for operation is debilitating in the ex- treme; the patient being in no fit condition to undergo a serious opera- tion after a sleepless and frequently disturbed night. We think that one good free movement, which may, as a rule, be procured by one dose (15 cc.) of epsom salts or of castor oil, together with an enema on the morning of operation, will evacuate the intestinal tract quite Preparing the Patient 273 sufficiently; and we can see no sense in repeatedly purging patients until exhaustion is produced. The diet for the few days preceding the operation should be light; and the supper the evening before may best be confined to fluids (milk, broth, gruel, milk-toast, etc.), and perhaps a soft-boiled or poached egg, with a little stale bread. If the laxative is taken before supper, such a meal will leave comparatively little resi.due, and this may be removed by an enema in the morning. Plenty of fluid may be taken up to within about six hours of the operation. This will flush out the kidneys, and help to refill the vascular system, which is always somewhat depleted if a saline purge is employed. If the operation is not to take place until afternoon, a light breakfast (broth or gruel) should be allowed, but this should be omitted when the operation is to be in the morning. The extent of local preparation will vary somewhat with the patient. The lower class patient had best be given a warm tub bath, in the afternoon of the day before the operation; but in a patient who is in the habit of bathing himself, such active cleansing will not be required. Some patients will not become decently clean until the bath has been repeated on several successive days, and will re-acquire dirt at the least opportunity. When the demands of ordinary clean- liness are satisfied, the patient may rest until morning, when he should be shaved. It is always well to prepare for both suprapubic and peri- neal wounds, as some unforeseen complication may make it advisable to open in a place not anticipated. Hence the pubic and perineal hair both should be shaved; the skin of the abdomen, the groins, the genitals, the perineum, and the anterior and inner surfaces of the thighs, should all be thoroughly washed with green soap and hot water, then with seventy per cent, alcohol, and finally with corrosive sublimate solution (i: 1000). A dry sterile dressing should then be applied to the abdomen and perineum, and should remain in place until removed on the operating table. Proust laid especial emphasis on the propriety of preparing the urethra of every patient who is about to undergo a prostatectomy. He thought it extremely important to dilate the canal by the passage of sounds for some days before the operation, so as to insure the earliest possible restoration of urethral urination. But while we have no hesi- tation in dilating any strictures that may exist, yet we think that the routine dilatation of urethras which are apparently normal except for the prostatic obstruction is an unnecessary and therefore an undesirable performance. 18 274 Technique of Operations We may then summarize the preparation for a prostatectomy as follows: Preliminary treatment following the principles already stated and continued for a time sufficient to restore the vital organs to their maximum functional capacity. FIG. 88. SupRAPtTBic OPERATION. Skin incision exposing the sheath of the right rectus muscle close to the median line. On the day before the operation give a bath in the afternoon: give a cathartic before supper; for supper give only semisolid food; the bowels should be opened during the late afternoon or early evening; a good night's rest should follow. Fluid may be taken as desired until six hours before the operation. On the morning of the operation an enema is to be given. Then Preparing the Patient 275 shave and surgically cleanse the abdomen, perineum, etc. Apply the dressing, and wait for the operation. Nitrous-oxide oxygen or ether is to be preferred. Chloroform is sometimes administered to patients with advanced pulmonary lesions but with relatively sound cardio-vascular systems. Anesthesia in aged individuals will often tax the skill and ability of the most expert anesthetist; this is especially true of prostatics. We never trust these cases to the relatively inexperienced Resident-Surgeon who is neces- sarily lacking in the skill and judgment which are so important for the successful and safe administration of anesthetics, and especially of nitrous-oxide. We use spinal anesthesia in selected cases. In using this agent, however, it is very important not to give it where there is low blood pressure. Suprapubic Prostatectomy. The patient, being well covered with blankets and sterile sheets, is to have a soft-rubber catheter passed into his bladder. If such a catheter cannot be introduced the surgeon should select that instrument which from his previous experience with that patient he regards as most likely to succeed in passing the obstruction. Through this catheter the bladder is to be evacuated, and rinsed out with hot boric acid, saline solution (over 100 F.) or oxycyanid of mercury solution i : 10,000 two or three times, or until the fluid returns clear. About 120 cc. of this fluid should remain in the bladder, the catheter being clamped to prevent its regurgitation. The disadvantages of distention with air have already been referred to. If a preliminary cystostomy has been done the bladder is irrigated through the drainage tube which is then removed. All of these prelimi- nary procedures are completed before the anesthesia is begun especially if nitrous-oxide oxygen anesthesia is to be given. The patient is then raised into a moderate Trendelenburg position about thirty degrees and the suprapubic region uncovered. The surgeon, standing on the right of the patient, then makes his suprapubic incision, which in thin patients need not exceed six cm. in length; but must be increased up to a limit of perhaps ten to twelve cm. where the abdominal wall is extremely fat. This incision, which we make to one side or other of the linea alba, usually to the right side, exposes the sheath of the rectus muscle. Its lower end should be at the symphysis pubis, neither above nor below. If annoying bleeding occurs from veins or arterioles, these should be clamped; the hemostatic forceps may usually be re- moved as soon as the bladder is exposed, and will therefore not be in the way in the subsequent steps of the operation. Vessels of any size, 276 Technique of Operations which are rarely met with near the middle line of the abdomen, had best be ligated at once. The sheath of the rectus muscle is then opened, and its fibres sepa- rated, longitudinally with the handle of the scalpel, from their pubic attachment below, up to but not quite as far as the skin incision extends. We regard this lateral incision as of distinct'advantage in decreasing FIG. 89. SUPRAPUBIC OPERATION. Separation of the fibres of the rectus muscle with the handle of the scalpel. the chances of the formation of a permanent fistula. The wound thus made tends to close spontaneously as soon as the drainage-tube is removed; and although post-operative hernia in this situation is unusual, it is by no means unknown. The transversalis fascia and preperitoneal fat are then divided with the scissors in the line of the skin incision; any decrease in the length Suprapubic Prostatectomy 277 of the incision should be made at the expense of the upper end of the wound; that is to say, the surgeon should aim to work down on the anterior wall of the bladder, not up towards its peritoneal surface. The layer of vesical fat will next be exposed, lying below the prevesical reflection of the peritoneum. The surgeon may then either pass the FIG. 90. SUPRAPUBIC OPERATION. The bladder has been exposed, below the prevesical fold of peritoneum, which can be seen across the upper angle of the wound. A tenaculum steadies the bladder, preparatory to its being opened. fingers of his left hand down behind the pubis to the pubo-prostatic ligaments, and draw this layer of fat bodily up towards the abdominal end of the wound, or snip through it in the line of the original incision, with his blunt-pointed scissors. We prefer the latter course. Retractors may be applied to each side of the wound, and aid in keeping the struc- tures to be divided fairly taut. Any hemostatic forceps which were 278 Technique of Operations used to clamp bleeding points in the abdominal wall may now be removed, since it will be found that such vessels have ceased to bleed. The large veins in the prevesical fat should be avoided if possible. If the surgeon divides any, it is well to ligate them at once. If possible, they should be ligated in two places before being cut, the division between two ligatures maintaining the wound dry, and enabling the surgeon to see clearly the field of operation. The edges of the wound having been retracted, a small piece of moist gauze is placed above the bladder and with a third retractor the peritoneum is pulled upward thus making exposure of the bladder, divi- sion of the prevesical fat, and opening the bladder a simpler procedure. The prevesical fold of peritoneum may not be seen in these opera- tions, the Trendelenburg position, even without the distention of the bladder, allowing it to recede above the upper limits of the wound. If it is seen, it is, as a rule, easily recognized, both by the typical appear- ance of peritoneum seen elsewhere, and by the fact of its being a trans- verse fold; and it is easily detached from the bladder by blunt dissection. Should it unfortunately be opened, it should at once be sutured. The bladder is recognized by its blue appearance and its consist- ency. If any doubt exists as to its identity, it will be sufficiently mani- fested by injecting more fluid through the catheter. There are often large and turgid veins on its surface. When the bladder is thus exposed, two retention sutures may be passed through its outer coats, about twelve to eighteen mm. apart, equidistant from the proposed line of incision, and in its upper third. We formerly passed these sutures through the whole thickness of the abdominal walls as well, and let them remain at the conclu- sion of the operation, thinking thus to lessen the danger of extravasa- tion into the space of Retzius ; but we think the likelihood of this danger is overestimated, and we have had more fear of causing an injurious ante- flexion of the bladder; so that we no longer intend these for permanent sutures, but merely to act as guys during the enucleation of the prostate. If it is difficult to pass these sutures, on account of the depth of the wound, one may be made to suffice by placing it in the line of the incision, at the upper angle of the wound. Indeed, we now find it quite suffi- cient to steady the bladder with a tenaculum until the finger reaches the prostate and then to remove the tenaculum and let the bladder fall back into the pelvis during the enucleation. The bladder, being thus securely fixed in the wound, is to be opened by an incision made towards the pubic symphysis, and extending below Suprapubic Prostatectomy 279 it. This incision in the bladder walls should never be made upwards, as not only might the peritoneum be opened, but a coil of intestine wounded as well. It is inadvisable to make an incision of more than 25 to 40 mm. in length in the bladder wall, and the left index finger of the surgeon should follow the knife in, so as to palpate the inner surface of the bladder, the prostate, and the urethra, before all the fluid has escaped. A much more accurate idea of the relations of the various parts is attained when the bladder is distended. The table may now be replaced in the horizontal position. The finger should first seek to recognize the position of the urethra with its contained catheter. The outlines of the prostate can next be determined, the presence of calculi detected, and plans made for the further continuance of the operation. Any calculi present should first be removed, with forceps or scoop. If no guy sutures have been retained in the bladder it is best not to remove the finger from its interior until the completion of the operation, as its re-introduction may be difficult if the abdominal wound is deep. If a large calculus is found, the inci- sion in the vesical wall may need to be enlarged before the stone can be safely removed; but with skill even large stones may be removed through an incision of little more than 25 mm. In very many cases retractors must be employed to draw apart the sides of the abdominal wound and the bladder wall before the prostate can be satisfactorily exposed. At times two other retractors may be used to advantage, increasing the field of operation in its longitudinal diameter. If a pedunculated prostatic outgrowth acting as a ball-valve against the vesical orifice of the urethra is found, it should be twisted off with the fingers, or its pedicle should be cut through with scissors or bladder forceps. If no other urethral obstruction exists, a fact which can readily be determined by partially withdrawing and re-inserting the catheter, the operation may now be terminated, and the bulk of the prostate be left untouched. Often, however, there will be found similar prostatic tumors projecting into and obstructing the urethra, which are not evident from the cavity of the bladder; hence the great importance of making sure of thepatulous condition of the urethra before de- ciding to conclude the operation by a partial prostatectomy. This is a point which was much insisted upon by Belfield, and is probably the explanation of the failure of so many of the early suprapubic prostatec- tomies to effect a permanent cure. At the present time but few operators would be content to remove a pedunculated nodule or lobe. and leave the prostate undisturbed. But 280 Technique of Operations we insist, there are some few cases in which this condition exists, in which a cure can be effected without removal of the prostate. Doubt- less some of these tumors arise from the sub cervical group of glands and are, therefore extra-prostatic in origin, which fact explains the success following their removal. We are in the habit of making a careful bimanual examination of the prostate in these cases, with the index FIG. 91. SUPRAPUBIC OPERATION. The bladder has been opened, and by the use of retractors the field of operation is exposed sufficiently to show the enlarged prostate with the end of the catheter projecting from the vesical orifice of the urethra. An incision has been made in the vesical mucous membrane over the right lobe of the prostate, down to its capsuls. finger of one hand in the prostatic urethra and the index finger of the other hand in the rectum. By this means any irregularities in the shape or increase in size of the gland may be demonstrated, and if a beginning hypertrophy, however early, is found, the prostate is removed. If no such pedunculated growth exists, or if a complete prosta- Suprapubic Prostatectomy 281 tectomy is indicated, the enucleation of the prostate is begun. This may be accomplished in one of several ways; no one method is appli- cable to every case. In the majority of instances we find the intra- urethral, or as it is sometimes called, extravesical method, preferable. Squier, who first advocated this procedure, recommends that the roof of the urethra be broken through and that the enlarged lateral lobes be removed separately through this single opening. We have found it advantageous to begin the enucleation by breaking through the mucosa on the side wall of the urethra usually over the most prominent part of the prostate and on a plane posterior to the colliculus. With the manipulation necessary to free the lateral lobe this tear in the mucous membrane is enlarged, but it usually extends circum- ferentially and proximal to the colliculus so that the anterior portion of the prostatic urethra, including the colliculus and the terminals of the ejaculatory ducts, is not destroyed. Nature aids us in preserving these structures, as Squier has shown, because they are but loosely attached to the prostate. If the finger is now made to cross behind the urethra to reach the opposite lobe after freeing its fellow, there is little danger of injury to the floor of the urethra especially when the lateral lobes are easily enucleable, and the enucleation of these lobes is done separately. This is often unavoidable, however, because of the presence of nodules beneath the urethra. These may take origin from the middle lobe tubules or from the lateral lobes; in either event destruction of the proximal part of the urethra occurs during their removal. Care should be taken to remove only that part of the urethra proximal to the colliculus. In cases where there is bilateral and symmetrical enlargement of the lateral lobes in the absence of nodules beneath the floor of the urethra, the hypertrophied lobes may be removed separately through a tear in the mucosa of the roof of the urethra after the method of Squier. Ordinarily the details of the enucleation as practised in our clinic are as follows: the index finger is introduced into the prostatic urethra which is thus dilated; care being taken not to overstretch the parts. One or two fingers of the opposite hand are inserted into the rectum for the purpose of steadying the prostate. The mucous membrane on the lateral wall of the urethra covering the most prominent part of the en- larged prostate is torn through on a plane posterior to the colliculus. The finger soon finds the line of cleavage and this is followed upward and forward thus freeing the apex of the lobe. Next the finger is 282 Technique of Operations swung around the upper and outer surfaces. Having completed this the finger is again passed forward and an attempt is made to free, or, as Squier expresses it, "hook back" the lobe into the bladder. Succeeding in this, it only remains to free it from its attachment to the vesical mucosa; this is usually not difficult. The finger is re-inserted into the urethra and into the cavity whence the lobe came; it is then passed across the roof of the urethra, if we may be permitted to so express it, and the remaining lateral lobe is enucleated in exactly the same manner. In many cases it is found after freeing the first lobe that a sub- urethral portion of it, or in some instances, an attached median lobe enlargement prevents the delivery of the otherwise freed portion into the bladder cavity. It is better in these circumstances to remove the gland en masse at the same time making every attempt to] spare the floor of the urethra. Having failed to deliver the lateral lobe into the bladder cavity, the finger is swung around and behind the median portion. This brings us to the posterior surface of the opposite lateral lobe. This is dissected free, exactly as was its fellow on the opposite side, except that the steps of the procedure are reversed the posterior and outer sur- faces being freed first. The gland may then be hooked back into the bladder cavity not as separate lobes but as a single trilobed body. The final step in its removal is completed when adhesions to the vesical mucous membrane are divided. With proper care, the anterior part of the prostatic urethra need not be destroyed. In enucleating the prostate from the vesical side, an incision long enough to admit the end of the index finger, should be made over the more prominent of the two lateral lobes. This incision should run parallel with the urethra, and is usually most conveniently made with a pair of scissors; we have, however, on numerous occasions, simply scratched through the vesical mucous membrane with the finger-nail. The surgeon then introduces the middle and index fingers of his right hand, gloved, into the patient's rectum, passing his arm beneath the flexed thigh; and placing his thumb against the perineum, makes counterpressure on the prostate, and raises it up towards the enucleating finger. The larger and more adenomatous the prostate, the easier it is for the surgeon to find the natural line of cleavage which exists between the prostatic capsule and its sheath. It is not safe to go too wide of the Suprapubic Prostatectomy 283 prostate in the endeavor to remove it all. All of it will be removed, except perhaps here and there a flake off the outer surf ace of its capsule, by clinging close to the adenomatous organ rather than by going off on voyages of discovery into the sheath. In other words, the prostate is to be removed from its sheath, not the sheath from the prostate. The finger should first pass to the outer side of the lateral lobe first attacked. In this situation the attachment of the prostate to its sheath is least dense. Then the finger should cautiously but not timidly work down and under the lateral lobe, towards the neighbor- hood of the posterior commissure and the ejaculatory ducts. Next the posterior and inferior surfaces are separated from the sheath; and, finally, when the lobe is pretty well outlined, the finger may pass along the lateral and inferior surfaces to the apex, and free it from the triangular ligament. At times the lateral lobe first attacked may come away alone, leaving the urethra still attached to the other lateral lobe. More often in our experience the original incision through the vesical mucous membrane has torn larger during this enucleation, and the vesical orifice of the urethra has become entirely detached by the extension of the tear across the trigone of the bladder. Then the enucleating finger will pass across to the second lobe, often as it does so tearing loose the ejaculatory ducts from their union with the urethra, and finally, having completed the enucleation of this second lobe, will find the prostate fully detached from all its surrounding structures except where the urethra annexes it to the triangular ligament. At this stage of the operation either one of two things happens the urethra slips out from the centre of the prostate, remaining still attached to the triangular ligament, and hanging loose like the empty finger of a glove (with its end cut off) in the cavity from which the prostate has been enucleated; or, which we think is more frequently the case, the urethra tears off at the triangular ligament, and its prostatic portion is removed entire in the centre of the prostate. We do not see how it is possible, and know it has never been so for us, to leave the prostatic urethra, with the attached ejaculatory ducts in place, annexed at both ends anteriorly to the triangular ligament, posteriorly to the bladder wall. We have been able to remove the entire prostate, including of course its urethra, through the one .original incision made through the vesical mucous membrane; but where the organ is very large this cannot be satisfactorily done, and a second incision, compar- able to the first, must be made over the other lateral lobe. If the 284 Technique of Operations anterior commissure of the gland gives way during these manipulations it is theoretically possible to swing the whole prostate (which is then merely an organ with the urethra lying in a groove on its upper surface) across beneath the urethra, and to deliver it entire through one or other of the incisions in the mucous membrane of the bladder; but even thus, we cannot see how the attachment of the ejaculatory ducts can be preserved, in the Freyer operation, though it is theoretically possible for the prostatic urethra to remain intact, traversing the cavity from Q c (8 jr. Suprapubic Prostatectomy 285 which the prostate has been removed, much as a resistant artery traverses a phthisical cavity. The condition of the parts which is probably the most usual is shown in Figure 93 taken from one of Freyer's patients who died two hours after the operation. Here two tongue-like processes can be seen, representing the remains of the urethra, extending down- wards from the vesical mucous membrane, and upward from the triangular ligament; while between and below these can be seen the ejaculatory ducts, torn loose from all connection with the urethral floor. The technique of enucleating the prostate just described is essen- tially that of Freyer; it is the method which we have employed for many years but which has lately been discarded largely for the intra-urethral method of Squier. The latter is described on page 300 et seq. Our technique isotherwise as just described. When the prostate has thus been delivered into the interior of the bladder, the tissues left between the rectal and vesical hands are felt to be very thin, and no trace of remaining prostatic substance can be detected. The hand is then withdrawn from the rectum, the glove removed, and the prostate extracted from the bladder with the fingers or with suitable forceps. The more adenomatous the postrate, the more compressible it will be, and the vesical incision should not be enlarged until attempts to remove the prostate have failed. The cavity from which the prostate was enucleated will now be found to have become amazingly reduced in size, both by active con- traction, and by pressure from the surrounding structures. Bleeding may be free, but is usually only moderate in amount, and readily con- trolled by the hot douche, which is to be freely applied through the suprapubic wound. Should this fail to control the hemorrhage another plan must be tried. Often by gauze pressure well directed against the oozing area the bleeding may be checked. But if the hemorrhage persists, or in case of secondary hemorrhage, continuous pressure must be applied. It has been advised to apply this in the following way: a number of layers of gauze, of suitable size, are stitched together at their centre; the end of the suture is left long, and is attached to the intravesical end of the catheter which has been lying in the urethra throughout the operation, or which is to be introduced if not already in place. By with- drawing this catheter, the thread will follow, and will press the attached gauze firmly against the vesical orifice of the urethra. Care should be taken that this gauze does not occlude the ureteral orifices. 286 Technique of Operations This method of hemostasis has always seemed to us to be objection- able. When the gauze becomes soaked through with urine there is risk of its acting merely as a sponge, and thus allowing the blood to ooze through its meshes. A safer plan, we think, is to pack with gauze the cavity from which the prostate has been enucleated, and then to suture FIG. 93. APPEARANCE OF PARTS AFTER THE COMPLETION OF FREYER'S OPERA- TION, SHOWING THE REMNANTS OF THE PROSTATIC URETHRA, ATTACHED BELOW TO THE TRIANGULAR LIGAMENT AND ABOVE TO THE BLADDER. BETWEEN THE DIVIDED ENDS OF THE URETHRA ARE SEEN THE REMAINS OF THE EJACULATORY DUCTS. (Walker.) over the packing the mucous membrane forming the roof of the cavity from which the prostate has been removed, of course leaving an end of the gauze long, to come out through the suprapubic wound, and facili- tate its removal. The suture material should be catgut, and the pack- Hemostasis 287 ing may remain in place until it became loosened by the absorption of the catgut usually in from four to five days. Of course, if this method were adopted for the control of secondary hemorrhage, the patient would have to be anesthetized and the suprapubic wound en- larged. For secondary oozing which is not marked irrigation with hot water will usually be found an efficient hemostatic; or a solution of adrenalin chloride (i : 10,000) may be used. It is certainly well to try the effect of milder measures first, and not resort to packing injudi- ciously. Of recent years it has been our practise to place a purse- string suture of catgut in the torn edge of the vesical mucosa. With this suture in place the prostatic bed is packed with gauze in the manner just described. The suture is then tied, thus drawing the edges of the mucosa together over the packing and holding it securely in place. This has proved a most efficient method of controlling bleeding after prostatectomy. Since adopting the intra-urethral method of enucleating the prostate we have had less troublesome bleeding. In the cases where packing has become necessary the enucleation of the prostate has been beset with difficulties. These have been cases with small fibrotic prostates during the removal of which lacerations of the mucosa in the region of the vesical outlet have occurred. Packing after the manner just described is particularly applicable to these cases. When the urethral mucosa remains practically intact the arrest of hemorrhage, which is rarely called for in these circumstances, can be accomplished by packing gauze into the remaining funnel of mucous membrane in quite the same manner as one might fill the finger of a glove. The pressure thus exerted on the cavities whence the lobes of the prostate came, is sufficient to stop all dangerous bleeding; sutures are unnecessary. Of the many methods proposed for controlling hemorrhage after suprapubic prostatectomy in addition to the one just described, two alone are worthy of consideration. One of these, advocated by Judd, entails careful hemostasis by suture and ligature with primary closure of the bladder. This method was advocated, and practised for a time, by the late John B. Murphy of Chicago but was later discarded by him. We likewise discarded this method after experiencing the necessity of re-operation to evacuate a bladder filled with blood clots. The advantages in time and comfort for the patient to be gained by primary closure of the bladder are more than offset, in our judgment, by the dangers attending this procedure. 288 Technique of Operations Hagner is sponsor for the other method, namely, the control of bleeding by pressure exerted through the medium of a distensible rubber bag. The Hagner bag has been modified by Pilcher to the extent that a catheter attachment is provided. This method is especially applicable to cases in which the two-stage operation has been performed, and in which, for any reason, haste is vitally necessary for the control of bleeding after the removal of the prostate. We do not advocate this method for cases in which it is per- missible to enlarge the wound and control the bleeding by gauze pressure and suture. As soon as the prostate is extracted from the interior of the bladder, the urethral catheter, if not previously withdrawn, is to be removed; and a long rubber tube of large calibre eight to ten mm. passed in to the bladder through the suprapubic wound. This tube should be open not only at the end, but should be provided with large eyes on its sides near the vesical end; since, should the bladder wall come in contact with the distal opening, all drainage would be effectually prevented. To further obviate the likelihood of any such obstruction We do not pass the tube to the bottom of the post-prostatic pouch, nor do we, in any circumstances, dismiss the patient from the table until it is evident that the tube is clear of all clots and other obstructions, and the urine or intravesical fluid can be seen distilling from its further end drop by drop. The tube should project from the bladder cavity for a distance of several centimetres; it should be fitted with an elbowed glass tube, to which in turn is attached rubber tubing leading to a urinal which is at- tached to the side of the bed. The anesthetic may be stopped as soon as the irrigation of the bladder is commenced; and by the time the patient is in his bed he should be fairly conscious of his surroundings. The suprapubic tube is held in place by a stitch through the skin; and the angles of the wound, when this is large, may be sutured, but if the urine is foul no sutures at all should be employed; but as the parietal peritoneum has a tendency at times to prolapse into the upper angle of the wound, one suture in this situation may be necessary. Separate catgut sutures should be used for the sheath of the rectus muscle and for the skin. The dressing, of sterile gauze, cut so as to fit around the tube, and each piece overlying that beneath in an imbricated manner, should be copious, and may be reinforced with absorbent cotton. Thus what- Hemostasis 289 ever urine is not carried off by the tube, but leaks out along its sides, will be quickly absorbed in the dressings, and will not trickle over the patient's buttocks and clothing. The further end of the tube must be connected with a suitable receptacle below the level of the patient's bladder, so that the syphonage FIG. 94. SUPRAPUBIC OPERATION. In case of persistent hemorrhage the cavity from which the prostate has been enucleat- ed is packed with gauze, and the margins of the vesical mucous membrane sutured over the packing with catgut. may be continuous. If this detail is attended to there will be no necessity for the employment of a vacuum pump, as described by W. G. Richardson or the more recently described vacuum bottle of E. G. Davis. The urinal into which this suprapubic tube drains should be partly filled with some antiseptic or deodorant solution, sufficient in depth to cover 19 290 Technique of Operations the end of the tube; and in calculating the amount of urine excreted the quantity of fluid already in the urinal must be subtracted. The suprapubic dressing may be renewed as often as it becomes saturated. As a rule, twice daily is quite frequently enough. Should there be much shock after the operation, suitable stimulation must be administered; but it is of more importance to prevent shock, and for this purpose nothing is so efficacious as external heat. The patient may be surrounded with hot-water bags throughout the opera- tion in many cases with the greatest advantage, or, better still, be placed on a hot-water bed. On the day following the operation, and once each subsequent day, the bladder may be douched through the suprapubic wound. This should not be done routinely however; if the drainage is perfectly satisfactory and the bladder cavity is free from large blood clots there are no indications for douching in the average case. Bladder irriga- tions are useful, however, in patients with foul cystitis. We do not retain a catheter in the urethra, nor do we pass one to irrigate the bladder after the operation until this can no longer be accomplished through the suprapubic wound. But if an ammoniacal state of the urine develops we think great advantage is to be derived from douching the bladder through the urethra, the fluid draining off by the suprapubic wound. For the purpose of intravesical douching in these cases it is usually quite sufficient to introduce the nozzle of the syringe into the urinary meatus, there being no necessity to pass a catheter into the bladder, since the passive resistance of the urethra can readily be overcome by fluid pressure. The suprapubic tube may usually be removed on the second day after the operation, and the patient encouraged to pass his urine in the natural way; but there is no objection to leaving the tube in place for five or six days if such a course should seem desirable. Voluntary micturition commonly returns early after this operation; and, as there is no fear of a sinus persisting the patient may be propped up in bed on the fourth or fifth day, and be allowed to sit in a chair at the end of a week or ten days if his general health permits. Indeed, as soon as the patient feels able to be out of bed, no matter how few days have elapsed since the operation, we think he should be allowed to be up. Unless something should indicate the existence of urethral obstruc- tion, we are not in the habit of passing instruments by this route so long as the suprapubic wound remains available for the daily irrigation of the bladder. Should, however, this fail to show any signs enclosing Post-operative Treatment 291 FIG. 95. SUPRAPUBIC OPERATION. Pramage-tube and dressing in placet 29 2 Technique of Operations in the second week, we think it proper to sound the urethra, so as to ensure against the formation of strictures. We do not regard it as at all impossible for strictures to form as a result of the removal of the prostatic urethra; but we think the injudicious resort to instrumen- tation might very well render their formation more probable. When, however, the suprapubic wound has closed, which it commonly does in the third or fourth week, we consider it safe to irrigate the bladder through the urethra; and this, we think, should be done at least once a week for some months after the operation, unless the urine sooner becomes normal. In any case, the regular passage of a full-sized sound once a week for some months after the operation can be productive of no harm, and should, we think, be advocated in most cases, especially where a tampon has been employed for the control of hemorrhage. Some surgeons have found that the suprapubic wound is apt to re-open once or twice before finally healing; but this has not been our experience except in the rarest instances. Secondary hemorrhage and the means of controlling it have already been referred to; but we think it important to call attention to looseness of the bowels as a cause of this complication. Every time the bowels are opened the granulating wound is disturbed, and the liability to bleeding increased. Hence diarrhea should be avoided, and where slight oozing persists it may be well to try the effect of opium or pare- goric before more strenuous measures are resorted to. Secondary hemorrhage has been known to occur after the passage of the rectal tube. Care must be taken, therefore, in giving enteroclysis lest the insertion of the tube cause injury to the prostatic bed. The patient's usual diet and mode of life may be resumed as rapidly as his convalescence will permit; but he should pay particular attention to the state of his kidneys and urine for many months after the operation. He should be encouraged to drink all the water possible from the instant his stomach becomes retentive after recovery from the anesthetic; this is the surest method of preventing uremic conditions. The appear- ance of hiccough and nausea following the recovery from anesthesia, particularly if a small amount of urine is being excreted, is indicative of a mild degree of uremia, and should be promptly met by medical measures. It is not our practice to resort at once to agents such as calomel, sparteine, caffeine, etc., after operation, but to immediately wash out the stomach with the stomach-tube, this being a far more effective remedy for hiccough than any antispasmodic drug; we then introduce into the stomach 45 to 60 cc. of Glauber's salt in concentrated Two-Stage Prostatectomy 293 solution. Where the stomach is empty the solution soon finds its way into the small intestine, and in a short time bowel action is obtained. We have found this of more service than any other agent. Should further treatment be required, however, rectal, subcutaneous, or intravenous infusions of decinormal saline solution should be employed, and other appropriate treatment should be instituted, as already indicated. SUPRAPUBIC PROSTATECTOMY THE TWO-STAGE OPERA- TION In speaking of the methods of choice in the treatment of the several groups into which prostatics may be more or less definitely separated on pathological grounds, we defined very clearly our belief regarding the two-stage operation. This discussion needs no reiteration and we will proceed therefore, with descriptions of the most satisfactory methods of performing cys- tostomy preliminary to removal of the prostate. In performing a cystostomy for preliminary drainage of the bladder the technique which we employ differs but little from that followed in opening the bladder in the one-stage operation, except insofar as the length of the incision is concerned, and the degree of exposure of the space of Retzius and of the anterior bladder wall. Our aim in doing a preliminary cystostomy is to open the bladder as near to its summit as possible, to make the opening of sufficient size to permit of digital exploration of the bladder cavity and of the removal of any calculi that may be present, to provide adequate drainage, and, finally, to perform the operation in such manner that the tissues surrounding the incision will be disturbed as little as is consistent with the proper performance of the operation. To determine the proper position for the drainage tube it is advisable to locate the line of reflection of the peritoneum from the bladder wall. In some cases it will be found necessary after opening into the bladder cavity either to enlarge the opening in an upward direction or to make an entirely new opening at a higher level so that the drainage tube emerges from the bladder near its summit. A cystostomy opening for permanent drainage is placed near the bladder outlet; here our pur- pose is quite the contrary since the more distant the opening is from the neck of the bladder the more quickly will the fistula close after the removal of the prostate. 294 Technique of Operations For preliminary drainage we prefer a tube of large diameter, as large as, or even larger than the one used for drainage after prostatec- tomy. In some few cases a small dePezzer catheter after the method of Pilcher is desirable. This is done especially in cases of acute retention with enormously distended bladders. If immediate operation becomes necessary owing to the impossibility of catheterization, the introduction of a dePezzer catheter into the bladder through a suprapubic wound under local anesthesia is a matter of commendable simplicity. The operation may be performed quickly; it provides adequate drainage to relieve the dangerous back pressure on the kidneys, and it provides an easy and efficient means of intermittent relief of the abnormally high intravesical pressure. This method we believe is superior to the trocar and cannula method of Lower which suggests itself as particu- larly applicable to this group of cases. The after-results, however, leave something to be desired as far as the ease of subsequent removal of the prostate is concerned. FIRST STAGE PRELIMINARY CYSTOSTOMY The average patient who is subjected to the two-stage operation in our clinic is a poor operative risk; this is true certainly at the time of the preliminary drainage operation. For this reason it is advisable to use local anesthesia in many instances. We prefer, however, nitrous oxide, oxygen or ether anesthesia when there are no special contra- indications to their use. We have practically discarded spinal analgesia. For local anesthesia we use novocaine in solutions of Hoo or Hoo strength, the stronger solution being used in the skin and bladder wall. In the absence of very definite centra-indications to their adminis- tration, morphine sulphate gr. ^ and atropine sulphate gr. Hoo are given hypodermatically one-half hour before operation. Scopolamin g r - Moo an d morphine gr. Y may be given before operation with gratify- ing results. We have seen no harm result from the judicious use of these drugs in combination. The patient is prepared for operation in the usual manner, a catheter is introduced into the bladder and the latter distended with a solution of warm boric acid, oxycanid of mercury (1-10,000) or other antiseptic. The technique is essentially the same whether the cystostomy is per- formed under local or general anesthesia except as regards the intro- duction of the local anesthetic into the tissues. We will describe the use of local anesthesia in some detail. Preliminary Suprapubic Cystostomy 295 The instrument tray should contain, in addition to the usual instru- ments, a number of syringes, fitted with sharp needles of small calibre and filled with novocain solution of the desired strength. The injection of novocain solution (Koo) is begun at a point about ten centimetres distant from the symphysis pubis and about one cm. to midline. Beginning at this point the injections are continued in a straight line downward to the top of the pubic bone. The skin and subcutaneous tissues are included in this primary line of analgesia. An incison is then made down to the rectus sheath. The latter is infiltrated and is then incised in line with the skin incision. The muscle tissues and underlying transversalis fascia are injected with a weaker solution of novocain, the muscle fibres are then separated and the fascia is incised. The prevesical tissues are now exposed. These are sepa- rated by blunt dissection, and only insofar as is necessary to expose the line of peritoneal reflection from the bladder, and enough of the latter to permit cystostomy. The cystostomy opening is made of sufficient size to admit the introduction of the drainage tube. The space of Retzius is exposed during these manipulations but its contents are but little disturbed. No difficulty is experienced in recognizing the bladder wall which is easily distinguished from other tissues and structures by the large and tortuous veins coursing over its surface, for the most part in an upward and downward direction. Having located the summit of the bladder, a small quantity of the novocain solution is injected near to the line of the peritoneal reflection- and at this point the bladder wall is grasped by tenaculum forceps. Gentle traction is exerted in an upward direction, using the tenaculum to steady the bladder wall, and the anesthetic solution is injected in a line extending downwards for a distance of approximately five cm. The bladder cavity is then opened, the size of the opening being made sufficient to admit only the index finger. This is accomplished by intro- ducing the knife, with its cutting edge turned towards the pubic bone, into the bladder cavity at a point just below where the bladder wall is grasped by the forceps. The finger is immediately introduced into the bladder cavity acd acts as a plug to prevent the escape of urine, the examination of the interior of the bladder being more easily and satisfactorily made when the viscus is distended. It must first be determined whether the open- ing is properly placed in relation with the summit of the bladder. If placed too low, the peritoneum must be carefully dissected away and the incision enlarged upward, or in some instances an entirely new 296 Technique of Operations opening must be made. Digital examination of the interior of the bladder is made before enlarging the opening. The post-prostatic pouch is searched for calculi and if the cystoscopic examination revealed the presence of diverticula the attempt is made to explore their cavities ; the characteristics of the intravesical portion of the prostate next engage our attention. If calculi are found the bladder incision is enlarged to the required dimensions and they are then removed; otherwise the incision is enlarged only to a size sufficient to admit a large Freyer, or a Marion Calf) etc r . FIG. 96. THE DEPEZZER CATHETER IN THE PROPER POSITION FOR PRELIMINARY DRAIN- AGE. (Pikher, Cabot's Urology.) drainage tube. The latter is anchored by a single suture of chromic catgut to the incisional margin and the opening is closed tightly around the tube. The latter is made to emerge from the upper angle of the incision. We attach considerable importance to the level at which the end of the drainage tube is placed in relation to the bottom of the postprostatic pouch. It should almost touch the bladder wall to insure complete siphonage of its contents. The bladder wifeh the drainage tube in position is permitted to fall back into the pelvic cavity and the incision is closed by continuous catgut suture of the rectus sheath and through and through sutures of Preliminary Suprapubic Cystostomy 297 silkworm gut. It is our practise to anchor the badder to the rectus muscle by a catgut stitch in many cases. The position of the drainage tube in its relations with the abdominal wall is determined after the bladder has been allowed to fall back into the pelvic cavity, when if the tube is moderately rigid, it will naturally assume the proper position. The space of Retzius need not be drained if care be taken not to lacerate its fibro-fatty contents. But carrying a piece of rubber drain down to the space can do no harm. We prefer a drainage tube of very large caliber, 25 mm. in diameter, for routine use. In certain cases, as previously mentioned, in which it is desirable to establish drainage in the shortest possible time and in which prolonged drainage will, in all likelihood, be necessary, we sometimes use a dePezzer catheter, or the Pilcher modification of this instrument. This technique as devised by Pilcher who advises it for routine use in the two-stage operation, will be described in detail later; suffice it to mention here a few details in its use which we have found advanta- geous in cases of acute retention. Under local anesthesia the greatly distended bladder is exposed by as limited a dissection as is possible. In these cases there is little or no danger of wounding the peritoneum and there is likewise little danger of placing the bladder incision too low. Having exposed the bladder wall, the button-like end of the dePezzer catheter is folded and grasped in the jaws of a pair of small dressing forceps and its distal end plugged. The scalpel with its cutting edge turned downwards is then quickly plunged through the bladder wall and immediately the dressing forceps carrying the catheter are intro- duced through the opening into the bladder cavity. The forceps are opened, thus releasing the catheter, and are then removed. The button- like end of the catheter is drawn tightly against the bladder wall, thus effectually plugging the opening so that practically no urine escapes. If the incision is not too large, it is unnecessary to use sutures except to anchor the tube to the bladder wall. The wound is then closed in the usual manner. The bladder is gradually emptied by removing the plug from the catheter from time to time. If the patient's condition is good he may be lifted out of bed on to a chair the following day. This not only minimizes the dangers of pulmonary congestion and senile pneumonia, but the patient is impressed with the apparent innocuousness of the 298 Technique of Operations operation so that he will undergo the second stage without fear and in full confidence of his ability to "get well." The bladder drainage may be continued for a month or more without leakage of urine and under circumstances that are ideal for repeated functional kidney studies, and if subsequent removal of the prostate is contra-indicated, the dePezzer catheter may be removed and a silver cannula substituted for it as a means of permanent drainage. SECOND STAGE REMOVAL OF THE PROSTATE GLAND Having determined the fitness of the individual for prostatectomy he is again prepared for operation in the usual manner. The bladder is thoroughly irrigated through the tube with a warm solution of oxy- cyanid of mercury (1-10,000), before the patient is brought to the operating room. For anesthesia we choose either nitrous-oxide oxygen or ether. If the second stage succeeds the cystostomy operation within a period of ten days the sutures above the drainage tube are not removed. If a longer period of time has elapsed the stitches will have been removed and the wound is firmly healed. It will then be necessary to enlarge the wound downward; this is especially true if a dePezzer catheter has been employed for drainage. In cases in which a very large tube has been used, digital dilatation of the opening usually gives ample room for the enucleation of the prostate although some difficulty may be experienced in delivering the freed prostate from the bladder cavity, indeed, it is necessary in some instances either to enlarge the opening or to section an unusually big prostate before it can be brought out of the bladder cavity. Having removed the drainage tube and provided an opening of sufficient size, the removal of the prostate is effected according to the principles already described. The second stage of a two-stage prostatectomy differs only in minor details from the one-stage operation, except as concerns the enlarge- ment of the wound and in the treatment of complications of which hemorrhage is the most important. Hemorrhage is one of the com- monest causes of death after prostatectomy and in the vast majority of cases it is controllable. Patients rarely die as the result of the loss of blood during the operation; it is the bleeding that occurs after the patient is returned to the ward or recovery room that proves fatal. The time to control this bleeding is at the time of operation, not after several hours of waiting to see whether it will stop spontaneously. It is absolutely unjustifiable to send a patient from the operating table who Secondary Prostatectomy 299 is bleeding; prostatic surgery offers no exception to this surgical principle. Serious bleeding is less likely to follow prostatectomy in cases which have had preliminary drainage because of the relief of congestion incident to such drainage. It does occur, however, and active measures must sometimes be taken to arrest it. Our technique does not differ in this respect from that employed in the ordinary prostatectomy; the wound is opened widely, the bleeding area is exposed, and if possible the bleeding vessel or vessels are ligated. Failing in this the prostatic bed is packed with a strip of gauze, one end of which is brought out through the suprapubic opening. The gauze is held securely in place by a purse string suture in the mucosa surrounding the vesical side of the prostatic bed. This procedure is attended with some difficulties in patients who have had preliminary drainage, but we much prefer it to any of the other methods proposed. Some surgeons prefer not to enlarge the opening and are willing to trust to the pressure of a Hagner or Pilcher bag for the control of bleeding. The descriptions of the latter methods together with certain other variations in technique, are given elsewhere. The after-care of patients operated upon in two stages differs not at all in our clinic from that practised after a one-stage prostatectomy. Suprapubic Prostatectomy Modifications in Techniqu e . The tech- nique of enucleation of the prostate gland has undergone many modifica- tions especially in respect to the manner of beginning the enucleation. It will be recalled that Freyer recommended that an incision be made parallel with the urethra through the vesical mucosa covering the most prominent part of the intravesical projection and beginning the enu- cleation at this point. Attention was called to the fact that this por- tion of the prostate is covered merely by mucous membrane beneath which lies, what Freyer believes to be, the true capsule of the gland. Fuller of New York had previously recommended that a cut be made through the median lobe or bar with scissors, and that this incision ex- tend from the lower margin of the internal vesical opening of the urethra backward for an inch to an inch and a half. Through an incision of this kind he did what was undoubtedly the first complete prostatectomy. Freyer however, popularized the operation and modified it to the ex- tent that the incision was placed over the most prominent part of the intravesical projection. He also recommended that the finger nail instead of the scissors be used for cutting through the vesical mucosa. We soon adopted the technique as described by Freyer but found it ad- 300 Technique of Operations vantageous to make a second incision over the other lateral lobe when there was considerable intravesical projection. Other modifications in the technique for the most part of minor importance were evolved. Perhaps the most important of these, certainly the one that has caused most discussion, was our advocacy of simple extirpation of pedunculated median lobes leaving the bulk of the prostate untouched. This of course was the principle of the McGuire operation. As we have ex- plained, it is rarely indicated for the reason that isolated prostatic nodules giving rise to urethral obstruction seldom occur ; when they do occur and the prostate is not hypertrophied throughout, the latter, we repeat should not be disturbed. FIG. 97. INTRA-URETHRAL ENUCLEATION OF THE PROSTATE. Step i. (/. Bentley Squier, Surgery, Gynecology and Obstetrics, 1912, xv, 599.) After meeting with certain cases in which folds or tabs of mucous membrane caused obstruction to urination after prostatectomy it was proposed that an incision be made through the vesical mucosa covering the intravesical portion of the prostate in an encircling manner; to this the fanciful name of circumcision of the vesical outlet was given. The technique of the subsequent enucleation of the prostate differed to some extent with individual operators but the fundamental principles Modifications 301 were quite the same as those enumerated by Fuller and Freyer. These we have already described. The fact that the so-called hypertrophied prostate really consists of a group of adenomata or rather, adenomatous masses, more or less firmly bound together and originating within the prostate gland, must be borne in mind during the enucleation. If our conception of the pathology of the condition is correct, these nodules have formed a false capsule as the result of pressure. This capsule consists of compressed prostatic tissue which has not participated in the neo-formation, and of the peripheral fibromuscular stroma or true capsule. Within the en- velope and more or less loosely attached to it lies the part of the prostate that will be removed. Outside of the envelope and almost inseparably bound to it is the sheath of the prostate which is merely a visceral pro- longation of the pelvic fascia. FIG. 98. INTRA-URETHRAL ENUCLEATION OP THE PROSTATE. Step 2. (/. Bentley Squier, Surgery, Gynecology and Obstetrics. This sheath is deficient in the region of the vesical outlet and through this hiatus the enlarging prostate enters the bladder. The major pressure on the true capsule and on the compressed, but otherwise nor- mal prostatic tissue, is exerted here, and it is reasonable to suppose that these tissues undergo partial if not complete atrophy, so that the tumor itself comes to be directly beneath the vesical mucosa. 302 Technique of Operations This fact explains also why the line of cleavage between the false capsule and the tumor mass, which it surrounds, is sometimes found with difficulty when the enucleation is begun from the vesical side. The sphincter muscle is not directly attached to the tumor but is separated from the latter by such parts of the false capsule as exist in this area. FIG. 99. INTRA-URETHRAL ENUCLEATION OF THE PROSTATE. Step 3. (/. Bentley Squier, Surgery, Gynecology and Obsetrics.) If we accept the views of Tandler and Zuckerkandl, namely, that the great majority of cases of prostatic hypertrophy begin in the middle lobe tubules and remain localized to this structure, and that the lateral posterior lobes suffer pressure atrophy, we must materially change our technique relative to the steps in the enucleation. It has been established beyond dispute largely, as the result of Lowsley's investigations, that the posterior lobe tubules which lie posterior to the ejaculatory ducts, rarely, if ever, take part in benign hypertrophy. The ejaculatory ducts traverse the prostate gland on a plane lying between the posterior lobe tubules behind and the middle and lateral lobe tubules in front. If, as is generally believed, the Squier's Technique 303 latter structures alone are involved in the hypertrophic processes, it follows that the ejaculatory ducts will be displaced posteriorly and will not be disturbed by prostatectomy, provided that part of the floor of the urethra anterior to and including the verumontanum is preserved. These ducts open into the sides of the anterior declivity of the verumontanum. In the light of our present knowledge this then is the ideal to be attained, namely, to remove the prostate or rather to remove the adeno- FIG. too INTRA-URETHRAL ENUCLEATION OF THE PROSTATE. Step 4. (/. Bentley Squier, Surgery, Gynecology and Obstetrics.} ma-like masses originating in the prostate without destroying the ejacu- latory ducts or that portion of the floor of the urethra into which they open. That this is always possible, we much question; that it is the result to be aimed at is undoubted. In describing the enucleation of the prostate by the Freyer method some lines were devoted to an argumentative consideration of the possi- bility or impossibility of sparing the ejaculatory ducts. We believe it is impossible to remove the prostate according to the Freyer technique without destroying the prostatic urethra in practically every instance. 304 Technique of Operations To Squier of New York is due the credit for having evolved a tech- nique of suprapubic removal of the prostate which theoretically and probably actually in the majority of instances, allows of preservation of the ejaculatory ducts. His method isf ounded on careful studies of the normal anatomy of the parts and the changes to which they are sub- jected as the result of prostatic disease. He takes into careful con- sideration also the bearing of the pathogenesis of the disease on the surgical problems of enucleation. FIG. ioi. INTRA- URETHRAL ENUCLEATION OF THE PROSTATE. Step 5. (/. Bentley Squier, Surgery, Cynecology and Obstetrics.) In addition to less important considerations, Squier calls attention to the backward displacement of the ejaculatory ducts in hypertrophic states of the prostate. He likewise points out the importance of the fact that "the urethra anterior to the colliculus is practically free from the prostate, but posterior is quite intimately attached." Since the ejaculatory ducts are out of harm's way posteriorly, it follows that if the colliculus and adjacent urethral floor can be spared, the terminals of these ducts will likewise be spared. This is not a diffi- cult matter if the prostate is easily enucleable and if the urethral mucosa is divided primarily on a plane posterior to the colliculus; the anterior portion being but slightly attached will have little tendency to adhere to the prostate. Squier's Technique 305 The preservation of this part of the urethra with the ejaculatory ducts while undoubtedly of importance in the preservation of the sexual function, is really of minor importance in comparison with the greater facility and safety to the sphincter mechanism of the bladder when the prostate is removed by the Squier method. We are in the habit of begin- ning the enucleation by tearing through the mucous membrane cover- ing the most prominent portion of the growth in the urethra; this almost invariably lies posterior to the colliculus but on the side wall of the urethra. In some few instances it facilitates matters to begin the enucleation on the floor of the urethra. Squier's Operation. Squier's operation is described by its origina- tor as follows: "We will presume that all operative preliminaries are completed even to the filling of the bladder, the arrangement of the towels, etc., and the surgeon is ready to operate before the anesthetic is commenced. At the moment of relaxation, the abdominal incision is made and the bladder exposed. The bladder is opened by an incision large enough to admit two or three fingers, high up on the fundus and close to the peritoneal attachment. This may seem to be a trivial matter, yet it has a direct bearing upon the time required for the healing of the suprapubic sinus. "The next step in the operation, namely, enucleation of the prostate is necessarily the most important one. "We have been taught to remove the prostate from its sheath through an opening into the bladder mucous membrane over its most prominent lobe. Such an enucleation is, therefore, started intravesically. The finger dissects forward, meets with the fibres of the internal sphincter and external longitudinal muscles where they encircle the prostate at the line of demarcation between intra- and extra- vesical portions, and the tendency is for the finger to pass outside the muscular covering of the prostate and thus remove the prostate as a whole rather than the lobes separately. This so-called removal en masse is characteristic of Freyer's operation, in which no effort is made to save the prostatic urethra but a removal of the prostate with its encircling muscle fibres is aimed at. "The method of enucleation which I prefer varies from this descrip- tion in that enucleation is begun extravesically. It is recommended because it materially reduces the length of the time of operation, on account of the rapidity by which the prostate can be shelled out, as well as by lessening the chance of damaging the ejaculatory ducts. 20 306 Technique of Operations "The procedure is to insert the finger into the internal meatus and break through the roof of the prostatic urethra. Access is at once given to the proper line of cleavage between the lobes, since at this point they lie in close opposition, being separated only by the capsule. Pi Ic'K ep .button drainage tube FIG. 102. FIG. 103. THE PILCHER HEMOSTATIC BAG. "The enucleation is begun by pushing the finger upward and forward, freeing the apex of the lobe from its attachment to the urethra and triangular ligament. It is then swept around the surface, and the lobe be For inflating bag Opeqiube Ihrougtj FIG. 104. SAGITTAL SECTION OF THE PILCHER BAG. (Pitcher, Cabot's Urology.) is hooked back into the bladder with its apex pointing upward, then a little separation from the bladder mucous membrane completes its removal. A similar procedure is repeated on the other side and the enucleation is complete. The moment the prostate has been delivered the anesthetic is stopped. Pilcher's Technique 307 "With a little care there is no danger of injury to the rectum. An assistant steadies the prostate through the rectum during enucleation. The operator should not do so as it interferes with the immediate completion of the operation because of the necessity of resterilization of the hands and changing of gloves. "Carried out in this way, a suprapubic prostatectomy can be accomplished in four or five minutes in most cases, and the patient need be subjected to complete anesthesia but two or three. "Therefore a prostate without median outgrowth may be enucleated with practically no damage being done to the floor of the prostatic urethra. In cases where a median outgrowth exists, a part of the floor of the prostatic urethra, namely, that portion which is posterior to the colliculus, will come away with the prostate on account of its intimate attachment through the prostatic ducts. FIG. 105. THE HAGNER HEMOSTATIC BAG. "Whether or not this portion of the urethra is removed is of no great moment. It is, however desirable to preserve the integrity of the prostatic urethra anterior to the colliculus, as here are situated the openings of the ejaculatory ducts. Fortunately nature aids us in so doing, as the part of this urethra is not intimately attached to the prostate and, therefore, remains. "The operation just described is not only applicable to prostates in which hypertrophy is of the glandular type. It has been the most efficient means of removing the small, hard, fibrous prostate whose growth is practically extravesical. " Pilcher's Operation. Pilcher recommends that the principles of anoci-association be employed whenever possible in operating upon prostatics. Local anesthesia is employed for preliminary cystostomy. The night before operation the patient is given thirty grains of sodium bromide and this is repeated on the morning of the operation. Morphine, grain Y combined with atropine, gr. ^ 50 is given by hypo- dermic one half hour before the operation in many cases. The local application of the principles of anoci-association both during the cystos- 3 o8 Technique of Operations tomy and later in enucleating the prostate as recommended by Lower are followed. I. An hour before the operation the patient is given a hypodermic injection of morphine and scopolamine, the size of the dose depending upon the age of the patient. II. Immediately before the operation the bladder is irrigated and 60 to 99 cc. of a five per cent, solution of alypin is injected through the catheter. The catheter is clamped and both catheter and solution are allowed to remain. III. The bladder is approached in the usual way except that the skin incision and every division of tissue is preceded by a thorough infiltration with novocain in ^oo solution. Sutures FIG. 106. HEMOSTATIC BAG IN PLACE. The inflating tube is passed up through the large drainage tube. In two or three hours the bag is allowed to deflate and the pressure is relaxed. If bleeding recommences, the bag is re-inflated and pressure re-established. The bag is removed in twenty-four hours. (Pilcher, Cabot's Urology.) IV. When the bladder is exposed it is elevated with curved hooks and thoroughly infiltrated with novocain solution. Technique of Suprapubic Cystostomy. (Pilcher.) The bladder is exposed through a mid-line incision in the usual manner. It is then well filled with sterile water through a catheter introduced by the urethra. The finger is introduced into the wound until the under surface of the symphysis pubis is reached; then the finger covered with gauze is Flicker's Technique 309 slowly swept upward, gradually lifting the tissues away from the anterior surface of the bladder at the same time forcing the peritoneal fold upward. Great care must be exercised in pushing back the peritoneum for it is easily torn. The bladder having been properly exposed, retractors are intro- duced, two lateral ones to hold back the muscles and one in the upper angle of the wound to hold back the peritoneum. Two retaining sutures are then introduced into the blader wall about an inch apart on either side of the point where the bladder is to be incised. This incision is made as near to the peritoneal fold as possible. The fluid is then allowed to flow out of the bladder through the urethral catheter. Then the bladder is opened at the point chosen. Digital exploration of the bladder cavity follows. With this completed the button drainage tube is inserted and fixed in place either by a purse- string suture of chromic gut or silk, or by tying the stay sutures around the tube. Pilcher lays much emphasis on the importance of placing the drain- age tube in the proper position. He recommends that a second opening be made if the primary opening in the bladder wall is found placed too low. Closure of the prevesical space by catgut suture is also advocated. The wound is carefully closed by interrupted chromic gut sutures. Interrupted silk sutures are used to close the skin incision and the drain- age tube is fixed to the skin by means of an adhesive strip. Wound infection seldom occurs. General anesthesia is rarely necessary in performing cystostomy, according to Pilcher; spinal anesthesia is not employed. The Convalescent Period. Drainage of the bladder is begun as soon as the patient reaches his room. This may be continous if there has been only a small amount of residual urine. Otherwise continuous drainage should be avoided for some days, the bladder being emptied intermittently. Irrigation of the bladder is not advised during the first three or four days. Pilcher states that primary union of the wound is secured with complete control of the urine ; further that the prevesical and perivesical spaces have been eliminated from the surgical problem and half of the operation of transvesical prostatectomy has been completed without the employment of general anesthesia and with freedom from surgical shock. 3io Technique of Operations Enucleation of the Prostate. Ether by the drop method is recom- mended. The application of the principles of anoci-association as outlined by Lower is given in detail. This embodies the hypodermic infiltration of the prostate gland and its capsule with novocain solution. The needle of the syringe containing the novocain solution is introduced into the prostate through the suprapubic opening using the finger as a guide. If two weeks or less have elapsed since the cystostomy operation it is unnecessary to use instruments to enlarge the drainage opening; the silk sutures should not be disturbed. If the sutures have cut through it is sometimes advan- tageous to re-insert heavy silk sutures to prevent the wound from tearing open during the enuclea- tion of the prostate. In cases in which a long time elapses between the two stages of the operation it will probably be necessary to enlarge the opening. Pilcher speaks of this merely as being of advantage, but we have found it absolutely necessary in cases in which a button drainage tube has been used. To enlarge the suprapubic opening Pilcher suggests making three radiating incisions one inch in length, extending on each side of and FIG. 107. METHOD OF downward from the opening. These incisions ATTACHING CATHETER TUBE are carried to the rectus sheath. The latter may OF PILCHER BAG TO THE LEG be incised when necessary and to gain additional BY MEANS OF ADHESIVE .-, , . j- .-i room the subcutaneous fat surrounding the PLASTER TO KEEP UP INTRA- > VESICAL PRESSURE ON THE wound may be excised. The wound should not PROSTATIC BED. (Pilcher, be enlarged upward on account of the danger of Bloody GO*'* Urology.) in j ury to ^ per itoneum. Having provided the necessary opening the enucleation of the prostate is begun. The technique advocated by Pilcher is in no wise different from the usual intra-urethral enucleation. For cases in which median lobe enlargement is lacking but with great enlargement of the lateral lobes, Pilcher recommends that the enucleation be begun on the vesical side after the method of Freyer. Attention is called to the importance of thoroughly cleansing the bladder after the removal of the prostate. This includes the removal Plicher's Technique of blood clots, loose pieces of tissue, and of small prostatic calculi that may have become dislodged during the manipulations. Cleansing of the bladder is best accomplished by wiping the debris away with small gauze sponges. The use of the button catheter for suprapubic drainage and the method of controlling hemorrhage after removal of the prostate are among the characteristic features of the Pilcher operation. The FIG. 108. "ENLARGING THE SUPRAPUBIC OPENING AFTER CYSTOSTOMY WHEN A NEARER APPROACH TO THE PROSTATE is DESIRED. THE WOUND is NOT ENLARGED UPWARD BECAUSE OF THE DANGER OF OPENING THE PERITONEAL CAVITY." (Pilcher, Cabot's Urology.) latter he accomplishes by means of the bag hemostat, an instrument originally suggested by Hagner but used in an improved form by Pilcher. To place the bag in the prostatic bed, a silver prostatic catheter is passed through the urethra into the bladder after the removal of the prostate; its tip is caused to emerge through the suprapubic wound and the rubber tube which is attached to the bag is fitted over the end of the catheter to which it is firmly tied; the end of the catheter is then withdrawn carrying with it, through the urethra, the rubber tube. The bag is then inflated and the tube clamped off. 312 Technique of Operations The desired pressure on the prostatic bed may be obtained by exerting traction on the tube. The latter is attached to the leg by means of adhesive straps, thus completely controlling the degree of pressure exerted at the vesical neck. Pilcher's modifications of the Hagner bag consist of the addition of a catheter arrangement and of a second tube which is used to inflate the bag. The latter is brought out through the suprapubic wound. The urethral tube passes through the bag and serves the purpose of a catheter. FIG. 109. TIP OF THE FINGER INTRODUCED INTO VESICAL PORTION OF THE URETHRA. (Pitcher, Cabot's Urology.) Removal of the bag is easily accomplished. If the suprapubic drainage tube is of large diameter the deflated bag may be removed through its lumen without disturbing the tube. The Hagner bag is provided with a silk ligature which, like the tube of the Pilcher bag, is brought out through the drainage tube. The silk ligature serves for the removal of the bag. It is generally desirable to remove the drainage tube and the bag at the same time. Pilcher recommends that air be used to distend the bag; we have employed hot water with gratifying results; it has also been suggested that metallic mercury be used for the same purpose. In Pilcher's opinion every case should be drained after prostatec- tomy; with this we thoroughly agree. He recommends the use of a large drainage tube which should not extend more than a half inch Pilcher's Technique 313 within the bladder cavity. This is in addition to the drainage by the catheter per urethram. After-Treatment. A considerable degree of pressure is exerted on the prostatic bed for the first hour after prostatectomy. The adhesive strips attached to the leg are then cut and the bag is deflated but is left in situ lest secondary bleeding should occur. It is FIG. no. SEPARATION or THE SPHINCTER MUSCLE FROM THE PROSTATE. (Pilcher, Cabot's Urology?) removed in from twenty-four to forty-eight hours. Should an excessive amount of blood appear in the drainage fluid the bag is again inflated and traction exerted on the urethral tube, as before. In the absence of complications, the patient is allowed to sit up in a chair the day following operation. If the bag gives rise to discomfort it may be removed together with the suprapubic drainage tube, at the end of twenty-four hours; otherwise they are not disturbed until the end of the forty-eight hour period. To remove the bag it is merely necessary to deflate it to cleanse the distal end of the urethral tube and apply to it a sterile lubricant, and to cut the suture holding the suprapubic drainage tube; the latter, together with the bag may now be withdrawn through the suprapubic wound. 314 Technique of Operations The patient will not suffer any pain if the bag is withdrawn slowly and with gentleness. The deflated bag may be removed without disturbing the supra- pubic drain if the latter is wide enough to permit its passage. FIG. in. "AFTER FREEING THE INTERNAL SPHINCTER, THE FINGER is FORECD THROUGH THE PROSTATIC URETHRA TO ITS UTMOST DlSTAL POINT AND HERE THE REAL ENUCLEATION OF THE GLAND is BEGUN. WITH ONE FINGER IN THE RECTUM, AND ONE FINGER IN THE BLADDER THE GLAND CAN BE ALMOST ENTIRELY CONTROLLED. IF ENUCLEA- TION WITH ONE FINGER is DIFFICULT, IT WILL BE FOUND THAT BY USING THE FIRST AND SECOND FINGERS ENUCLEATION is FACILITATED." (Pilcher, Cabot's Urology.) We prefer not to remove the drainage tube, but Pilcher recommends the early substitution for it of a button-catheter introduced into the bladder immediately after the drainage tube is removed, using as a guide for the purpose, a long narrow retractor. The enlarged end of the button-catheter is grasped with a pair of dressing forceps which are made to follow along the groove of the narrow retractor into the cavity of the bladder. The catheter is then released and the forceps and retractor are withdrawn. According to Pilcher, Judd's Technique the bladder wall contracts immediately and holds the catheter in place. It serves he says to completely drain the urine away in most cases so that the patient is kept dry. The button catheter is not removed until the patient has begun to pass the urine per urethram. If success attends this first effort the patient will have little trouble in regaining the normal function of his bladder. FIG. 112. ENUCLEATED PROSTATE TURNED OUT INTO THE BLADDER. (Pilcher, Cabot's Urology.} Most of the patients will not need the drainage tube after the tenth or eleventh day, and when it is removed there is very little leakage of urine through the sinus which quickly closes. Judd's Operation. This differs in some respects from the operation of suprapubic prostatectomy as it is ordinarily performed, especially in the manner of controlling hemorrhage. ]udd also advocates pri- mary closure of the suprapubic wound in Delected cases, depending entirely upon a catheter per prethram for drainage. A wide exposure of the prostatic area is provided through a supra- pubic opening of generous dimensions. Self-retaining retractors aid in the exposure of the operative field. The prostatic mass is grasped with forceps, if this is practicable, 316 Technique of Operations and is lifted up and steadied while the enucleation is proceeded with. The latter is begun much after the method of Freyer, the gland being separated first from the sphincter muscle and bladder walls. After the prostate has been freed and removed from the bladder, the cavity whence it came is carefully inspected. Spurting vessels are clamped and tied with catgut. The torn edges of the vesical mucous membrane are caught with clamps and a few sutures of chromic catgut are inserted. These are placed so as to include the bladder wall and the adjacent sides of the prostatic bed; when they are tied all bleeding from the vesical mucosa is controlled. The area is again examined carefully and if all bleeding is controlled a catheter is passed per urethram for drainage and the suprapubic wound is tightly closed. Perineal Prostatectomy. So many variations and modifications of this operation have been suggested that a minute description of each in a work of this kind would be impracticable. All of the methods employed, however, may be classed in either one of two categories those in which the gland is removed from within the urethra through a straight perineal incision, and the extra-urethral perineal prostatectomy, as seen in the technique of the French School developed by Proust and popularized, in a modified form, by Young in this country. Perineal removal of the prostate or of parts of it through a small perineal incision is rarely if ever practised at the present time, although this was the perineal operation advocated by many American surgeons before the elaborate dissections of the perineum characteristic of the Proust and Young operations came into popular favor. Likewise with the perfection of the latter, the intra-urethral perineal operations have gradually fallen into disuse. Intra-urethral Perineal Prostatectomy. The credit for the develop- ment of the intra-urethral method of perineal prostatectomy is due to Goodfellow who, in collaboration with Wishard, introduced it to the profession in 1891. The first of the modern operations of extra-urethral perineal prostatectomy that of Zuckerkandl antedated this by several years. It should not be forgotten that Goodfellow's operation antedated the transvesical or suprapubic operation of Fuller and Freyer. Dr. Goodfellow's own description of his operation is as follows: "The usual pre-operative procedures are carried out. . . . With the patient in the ordinary lithotomy position, the legs held by assist- ants, the bladder being empty or full as the case may be, a lithotomy Perineal Prostatectomys 3*7 staff is introduced, the legs then elevated somewhat, a median incision from the base of the scrotum to the margin of the anus is made, and carried to the membranous urethra, which is entered with a straight lithotomy knife and the opening extended into the bladder. The finger is then introduced into the bladder, the staff removed, and the moderate flexion of the legs and thighs on the abdomen and the thorax increased to as great an extent as possible; then with the opposing hand over the hypogastrium the bladder is depressed, and the enucleation, beginning FIG. 113. THE DEPEZZER CATHETER IN PLACE AT HIGH POINT OF BLADDER. (Pitcher, Cabot's Urology.) at the beak of the prostate below and working upward next to the bladder, or from above on either side downward, is carried on, the time consumed for complete enucleation rarely being over five or ten minutes, the resulting haemorrhage being virtually nothing. The gland may be removed entire or lobe by lobe. . . . What becomes of the prostatic urethra? has been asked. The answer is that part or all is removed with the gland, an incident that in no manner seems to affect the restora- tion or the continuity of the urethra, nor the power of the bladder to regain and control its functions; nor is stricture or occlusion caused. The seminal ducts are not ligated, for this seems to me an irrational refinement, especially as many of my patients have (so they say) to a greater or less extent regained sexual vigor. " "The points to be expressly emphasized are the position and the 318 Technique of Operations incision into the bladder. ... I do not find it necessary now to use the knife to enter the urethra and bladder. After cutting to the FIG. 114. PROUST'S INVERTED PERINEAL POSITION FOR PERINEAL PROSTATECTOMY. urethra I am able with the finger to open it and get into the bladder by a boring movement. - Then not having a cut through the commissure, I enucleate from above instead of from below as formerly." Perineal Prostatectomy 319 American surgeons, among whom may be mentioned Alexander, Syms, Ferguson, Murphy, Watson, Cabot, Guiteras, Cunningham and Bryson, were enthusiastic in their support of the Goodfellow operation. Certain modifications and improvements in technique were FIG. 115. PERINEAL PROSTATECTOMY. (Proust.) The transverse perineal incision. soon suggested and various instruments were designed to facilitate the removal of the gland. Difficulties in bringing the prostate within the reach of the finger were encountered and the pressure of an assistant's hand over the bladder, as advised by Goodfellow for the purpose, was 320 Technique of Operations found insufficient. This led Nicoll and others to open the bladder above the pubis, introduce the hand or fingers into the bladder cavity and make direct counter pressure on the prostate during the enucleation. To obviate the necessity for opening the bladder, Bryson, Guiteras, and others merely opened into the space of Retzius and, with the hand in this extravesical position, made the desired counter-pressure on the prostate. Partly owing to the unsatisfactory results with the aforementioned methods, and doubtless also because of the introduction of practical prostatic tractors, the suprapubic incision was discarded. Among the tractors that met with more or less favor may be men- tioned those of Delbet, Albarran, dePezzer, Syms, Ferguson, and Guiteras. Various other instruments were introduced whose purpose it was to pull down the prostate; prominent among the latter were Murphy's hooks. The development of the intra-urethral perineal operation had made considerable progress and many operators had expressed great, if not complete, satisfaction with the results attained, when Proust described his method of extra-urethral removal of the prostate through the perineum. The Proust technique embodies the basic principles of perineal prosta- tectomy as it is now performed. What popular favor the operation now enjoys in this country, however, is due to the work of Young who modi- fied the Proust technique and brought it to a high state of perfection. With the introduction of extra-urethral prostatectomy the opera- tions of Goodfellow and his followers fell more and more into disuse. Among the more prominent urologists who clung to the intra-urethral technique may be mentioned Watson whose method differed but slightly from that of Goodfellow. Within recent years the intra-urethral operation has been practi- cally abandoned, although A. J. Ochsner still advocates it but in a modified form. He employs a lateral perineal lithotomy incision through which the membranous and prostatic urethras are cut poste- riorly. Having thus opened the urethra, the finger is introduced into the bladder and the prostate is enucleated in exactly the same manner as with Freyer's technique. The freed prostate is then grasped with Young's forceps and removed. The left index finger is then introduced into the bladder and under its guidance the edges of the prostatic capsule are caught with fine tooth forceps and drawn downward. Two rubber drainage tubes, one within the other, are next introduced; the longer Perineal Prostatectomy 321 inner one, whose diameter is one cm. drains the bladder cavity, the shorter outer tube, which fits snugly over the other, reaches only to the prostatic cavity. Ferguson retractors are then applied and gauze is packed into capsules around the drainage tubes. The outer tube is fixed to the margins of the incision by means of a silk worm gut suture, and the wound is closed in the usual manner. In the event that a hard prostate is encountered, Ochsner advises its removal by means of Ferguson rongeur forceps. Extra-urethral Perineal Prostatectomy. This term is used to signify an enucleation of the prostate by a perineal dissection is carried out either entirely, or in part, outside of the urethra. The prin- ciples upon which the operation is founded were first outlined and given to the profession by Proust and Albarran of the French school in about 1900. At this same time Young, of Johns Hopkins University, was engaged in the development of a technique for perineal prostatectomy, the details of which were described in the Journal of the American Medical Association, October 24, 1903. Young states that his operation "was developed quite independ- ently and without knowledge of the work of the French school to which however it bore resemblance, but only superficially." If one reads very carefully the original descriptions of the Proust and Young operations he is impressed with the parallelism of the two procedures up to a certain point. True the skin incisions differ, and in certain instances, Proust advised lateral incision of the levator ani muscles, but until the actual beginning of the enucleation, the two operations are strikingly similiar. In each the urethra is exposed behind the triangular ligament; the dePezzer tractor which Proust employed to depress the prostate is very similiar to the Young tractor, but the methods of employing the two instruments were quite dissimilar. Having inserted the dePezzer tractor and spread its blades over the vesical surface of the prostate, the instrument was used by Proust merely to steady the organ while freeing it from all of its attachments save where it was adherent to the urethra and ejaculatory ducts. The enucleation was begun through an incision made in the sheath of the prostate where it covers the rectal surface of the gland. This incision was made parallel with the urethra but apparently did not, as do the incisions recommended by Young, go deeply into the compressed prostatic tissue (false capsule) which lies superficial to the hypertrophied lobes. 21 322 Technique of Operations Having made an incision in the sheath, Proust advised that the finger be introduced into the space thus created and that the gland be freed by careful dissection on all surfaces, with the exceptions just no ted. The retractor was then removed and the floor of the prostatic urethra incised. The finger was then introduced into the urethra and the remaining attachments of the prostate freed, care being taken to preserve the major portion of the urethral walls. The ejaculatory ducts were ligated routinely. Evidently from this description, the Proust method of enucleation differed widely from that described by Young whose operation provides for separate removal of the lateral lobes through incisions placed lateral to, but parallel with the urethra. It becomes evident from Proust's description of his operation that he failed to comprehend the essential points in the gross pathology of prostatic hypertrophy, or else he would not have commenced the enuclea- tion between the sheath and the gland. Had he recognized the exist- ence of a false capsule, as did Young, and deepened the incision on the posterior surface of the prostate so as to reach the line of cleavage be- tween the hypertrophic portion and the false capsule, the entire enuclea- tion could have been completed without incision into the floor of the urethra. Undoubtedly the prostatectomy of Proust insured a thorough and complete removal of the gland, but the virtues that this might seem to hold are wanting since it is not only unnecessary but materially adds to the gravity of the operation. Proust's operation is no longer advocated even by the French school of urologists. The Young operation is superior to any other perineal prostatectomy thus far proposed; rarely do we follow the perineal route in operation on the prostate, but when circumstances indicate this as the preferable procedure the method of Young is chosen. Perineal Prostatectomy Technique of Young. The operation of Young is an extra-urethral operation in the true sense of the word, since the enucleation of the prostate is done entirely from the outside and not in part from the urethral side, as recommended by Proust. The method is called "conservative" perineal prostatectomy, its special feature being the preservation of the connection between the ejaculatory ducts and the urethra. The position he advises may be characterized as the "exaggerated lithotomy position," the patient's thighs being fully flexed on the abdomen, so as to bring the perineum more nearly parallel with the floor. Before elevating the thighs, a sound, which is to be used subse- Young r s Permeal Prostatectomy 323 quently as a guide for the urethrotomy, is inserted into the posterior urethra. The incision is shaped like an inverted V, the apex of which is placed over the posterior position of the bulb about five cm. distant from the anus. The arms of the incision are made parallel with the ischio- FIG. 116. YOUNG'S SOUND GUIDE. FIG. 117. YOUNG'S DISSECTOR, SHARP AND BLUNT. FIG. 118. YOUNG'S BOOMERANG NEEDLE HOLDER. FIG. 119. YOUNG'S BIFID RETRACTOR. pubic rami, each one being about five cm. in length. The scalpel is carried to the level of the deep fascia after which the necessary exposure is obtained largely by blunt dissection. The index finger is pushed through the soft cellular tissue to either side of the central tendon of the perineum, thus opening up a space which is bounded in front by the transverse muscles of the perineum and laterally by the levator ani muscles. With the displacement of these muscles a large cavity is exposed to either side of the central tendon into which the blades of a bifid retractor are placed. The purpose of the retractor is to enable the operator to put the central tendon and associated muscles on the stretch in order that they 324 Technique of Operations may be severed close to the bulb without danger of injury to the latter structure. At this stage of the dissection there is only slight danger of wounding the rectum. But having freed the musculo-tendonous structures from the bulb, the rectum is in great danger of injury if the knife or scissors are used recklessly, since it not infrequently is drawn forward in front of the membranous urethra by the recto-urethralis muscle. This muscle lies between the levator ani muscles and covers, and is attached to the membranous urethra anteriorly, and to the anterior wall of the rectum posteriorly. To properly expose the recto-urethralis muscle and thus avoid injuring the rectum when the muscle is divided, it is well to heed the advice of Young and pull the bulb forward with a suitable retractor before any attempt is made to divide the muscle. Indeed, the secrets of success in this operation are adequate skill in dissection to expose, and the anatomical knowledge necessary to recognize each individual structure. It is never permissible to incise a tissue until its identity and limitations have been determined. The greatest danger in the operation, injury to the rectum arises during the division of the recto-urethralis muscle; there is, however, little likelihood of this occurring if the central tendon has been properly divided, the bulb displaced forward, and the division of the muscle made close to the urethra. Having divided the recto-urethralis muscle, the rectum may be pushed backward thus exposing a space in which all of the subsequent steps of the operation will be carried out. This space is bounded pos- teriorly by the rectum, anteriorly by the prostate, the membranous urethra and deep perineal interspace within the confines of the trian- gular ligament, and laterally by the levator ani muscles. By pulling the bulb forward a good view of the urethra between the triangular ligament and apex of the prostate is obtained. Posterior and lateral retractors aid in providing the necessary free exposure of the parts. The next step in the operation is to incise the urethra in its long axis over the sound, at a point just distal to the apex of the prostate; this, which is in reality a part of the membranous urethra, comes into view only when the triangular ligament and its contained structures are displaced forward along with the bulb of the urethra. The urethral incision should be no longer than is necessary to admit of the introduction of Young's prostatic tractor. Before removing Young's Perineal Prostatectomy 325 the sound from the urethra the edges of the urethral incision are caught up on either side with clamps or ligature, care being taken to include the mucous membrane. Failure to make a clean cut and especially to include the urethral mucosa in the clamps may be followed by the great- est difficulty in attempting to insert the tractor. Having opened the urethra, and with the clamps properly and securely placed on the margins of the incision, the sound may be removed. To facilitate the introduction of the tractor, the prostatic urethra is dilated with sounds introduced through the opening in the urethra. The insertion of the tractor is not always easy, especially in cases in which obstructing nodes of prostatic tissue have deformed the urethral lumen, but by rotating the instrument, turning its beak from side to side, etc., it can generally be made to enter the bladder cavity. After assuring himself that the beak of the instrument has entered the bladder, the operator separates the blades and fixes them in position, a set screw being provided for the purpose. The prostate is now drawn downward and forward by pulling on the tractor and turning it upward and backward over the symphysis pubis, the anterior retractor having been removed in the meantime. The prostate is, as it were, pried out of its normal position, the tractor acting as a lever with the pubic symphysis playing the role of a fulcrum. This description is figurative rather than real, since great traction is usually unnecessary to bring the prostate to the proper level, but it serves at least to illustrate the principles involved. But one structure alone remains to be divided before full exposure of the prostate is obtained; this is the posterior layer of the fascia of Denonvillier which covers the rectal surface of the gland. A transverse incision is made through this fascial layer near to the apex of the prostate and the finger is then made to seek, and easily finds a space between it and the latter organ "Tespace decollable retroprostatique." The anterior layer of Denonvilliers' fascia, which is inseparably bound to the prostatic sheath, is thus brought into view. By enlarging this incision the rectum is freely mobilized and not only the prostate but the seminal vesicles as well, are brought into view. The rectum may now be held with a retractor in such manner that it will not intrude itself upon the operative field. This completes the preliminary stages of the operation, the most important part of which, namely, the enucleation of the gland, follows. If the dissection up to this point has been done properly and with the various retractors held properly in position by assistants, an excel- 326 Technique of Operations^ lent exposure of the posterior, or rectal surface of the prostate is FIG. 120. YOUNG'S SPOON TRACTOR. FIG. 1 21. YOUNG'S LATERAL RETRACTOR FIG. 122. YOUNG'S RETRACTOR BULB FIG. 123. YOUNG'S PROSTATIC TRACTOR. obtained; indeed, in many instances, the gland may be brought, almost if not actually, to the surface of the perineum. The capsule is incised on either side of the median line. These incisions are made about 1.5 cm. in depth and extend almost the entire length of the posterior surface of the prostate. They diverge slightly from before, backwards, being about 1.8 cm. distant behind and 1.5 cm. distant in front. Young's Perineal Prostatectomy 327 Young explains that the advantage of deep incisions lies in the ease with which the finger can be made to find the line of separation between the hypertrophied lobes and the urethral wall. Deep incisions likewise permit the operator easily to find the line of cleavage between the cap- sule and the posterior and lateral surfaces of the hypertrophied lobes. In fact, Young advises that the enucleation be begun on the posterior surface and that this surface and the lateral surface be separated from the capsule by means of a blunt dissector before an attempt is made to free the remaining surfaces. It is well, in this connection to recall, that the posterior lobe tubules of the prostate rarely if ever share in the hypertrophic process, but become compressed as the result of the growth of the hypertrophic lateral lobes. Thus they come to contribute to the formation of the false capsule, hence the deep incision necessary to reach the line of cleavage. Having freed the- posterior and lateral surfaces of the prostate on either side, the urethral surface is freed in a similiar manner, care being taken to inflict the minimal amount of injury to the urethral walls. Firm adhesions will be found binding the apex of each lateral lobe to the capsule and it is necessary to use the scissors at this point. After freeing the apices of the lateral lobes, the enucleation is completed by carrying the finger along the anterior surface of each lobe until the bladder surface is reached, which alone remains to be separated. The enucleation is facilitated by exerting traction on the lobes, a special forceps being provided for this purpose. As a rule, the hypertrophied lateral lobes can be removed without tearing into either the urethral or the vesical mucosa, but should this occur, it is not of great importance and it is not necessary to make any attempt to repair the damage. No one method of enucleation is applicable to all cases, and instead of the orderly sequence of events just described, the removal of an adherent fibrous prostate oftentimes proves a difficult task and one in which morcellement must be practised, removing the organ piece- meal. In fact, we frequently fall far short of the ideal in these exceed- ingly difficult cases in which it becomes necessary at times, not only to destroy the ejaculatory ducts but a portion of the urethra as well, in our efforts to remove the obstructing organ. In the ordinary case of benign prostatic hypertrophy, however, the procedure just described sufficies completely to remove the obstruction at the vesical outlet without endangering the integrity of the ejacula- tory ducts. 328 Technique of Operations The presence of isolated median lobe enlargements or median bar formations at the posterior lip of the vesical outlet necessitates addi- tional dissection. Their removal is best accomplished by delivering them into one or other of the cavities left after removal of the lateral lobes. Whether the remaining obstruction is in the nature of a lobe or median bar its relation to the ejaculatory ducts is exactly the same; both lie beneath the floor of the urethra primarily, and in front of the ducts. The enlarged median lobe can be delivered more easily into one of the lateral cavities, the delivery being accomplished by means of the tractor blades or with the ringer pressing on the lobe through the walls of the cavity on the opposite side. Young advises that the tractor be removed from the bladder before attempting the removal of a transverse or median bar. The latter is picked up with a sharp hook through one of the lateral cavities; it is then dissected free from the ejaculatory ducts behind and the urethra in front, either by blunt dissection or with the aid of the scissors. After the removal of the bar, the finger can be passed through the space whence it came,. from one lateral cavity to the other. Rarely is the urethral wall intact at the conclusion of a perineal prostatectomy, and advantage may be taken of the rents in the mucous membrane for digital exploration of the interior of the bladder. Most important in this connection is the condition of the vesical outlet; are there any remaining lobules of prostatic tissue is the sphincteric area infiltrated with a constricting ring of fibrous tissue which demands dilatation does the bladder contain calculi? These are the important factors which must be searched for and if found, corrected, before the operation can be said to be completed. Calculi may be removed through an incision on the lateral wall of the urethra. This incision may be carried through the sphincteric area if the calculi are too large to be delivered through the vesical outlet. These tissues must be brought together with sutures after the removal of the stones. We have never had occasion to remove large stones from the bladder during the course of a perineal prostatectomy although Young states that a stone five cm. in diameter can be removed in the manner just described. In our judgment the presence of stones, especially large ones, complicating hypertrophy of the prostate, is a very definite indica- tion for the suprapubic operation; we should certainly hesitate before enlarging an urethral incision through the sphincteric area After-Treatment 329 into the bladder, for the purpose of removing a large stone, on ac- count of the danger of permanent incontinence of urine following this procedure. Wide dilatation of the internal vesical sphincter, while not attended with the same danger of incontinence as division of the muscle, is nevertheless, dangerous. There can be, it seems to us, no question of the superiority of the suprapubic operation when stones are a complicat- ing factor. It now remains properly to drain and to close the wound. For the former purpose a catheter of large calibre is used. Through this the bladder is thoroughly cleansed of blood clots and debris by irrigations of hot saline solution. The lateral cavities are packed with strips of gauze, the ends of which are brought out along with the drainage tube. Young advises as a final step in the operation, careful digital explora- tion of the rectum in search for injuries which, if present, must be sutured. The levator ani muscles are drawn together in front of the rectum by a single suture of catgut. The skin incision is closed with interrupted sutures leaving a space near the apex through which the gauze packing and the drainage tube emerge. After -Treatment. The general systemic treatment for the purpose of restoring the normal, function of the vital organs, combating shock, etc., does not differ from that usually employed. Hypodermoclysis is given routinely. Before the patient is removed to his room the drainage tube must be anchored in the proper position and the bladder irrigated with hot saline solution to remove any blood clots that may have accumulated. Subsequent irrigations of the bladder are unnecessary unless the tube becomes obstructed. In this event the obstruction, which is usually caused by a blood clot, should be removed by flushing the tube with saline solution. In the absence of bleeding the gauze packing is removed early, within twenty-four hours after operation, and is not renewed. The tube is retained until the following day when, in the absence of bleeding, it also is removed. The subsequent treatment is quite the same as that following the suprapubic operation. The patient should be gotten up on a chair within forty-eight hours after operation, if conditions warrant it. Instru- 330 Technique of Operations mentation to prevent stricture formation of the urethra is unnecessary. A complicating cystitis may necessitate local treatment. FIG. 124. PERINEAL PROSTATECTOMY. (Proust.) After dividing the skin, and separating the insertion of the sphincter ani from the perineal centre (which is raised by forceps in the right hand of an assistant), the recto- urethral muscle is exposed, and is now being divided with scissors, close to the membranous urethra. Perineal Prostatectomy. Technique of Proust. Perineal prosta- tectomy as practised by Proust requires a special operating table, and special retractors. The patient is placed in the "inverse lithotomy position," so that the perineum is in the horizontal plane, its surface Proust's Perineal Operation 33 1 looking upward. To secure this the patient's lumbar spine and sacrum are placed upon an inclined plane of forty-five degrees, and his legs are held by special stirrups high in the air, with the thighs fully flexed and horizontal. By means of this position it is claimed that a very much FIG. 125. PERINEAL PROSTATECTOMY. (Proust.) The recto-urethral muscle has been divided, allowing the rectum to fall away from the anterior structures, and opening the "espace decollable retro prostatique." larger operative field in the perineum is exposed, since, after division of the recto-urethral muscle, and opening of the aponeurosis of Denon- villiers, as will be presently described, the rectum and anus can be drawn 332 Technique of Operations upward against the coccyx and the lower bones of the sacrum, making a yawning wound. For this purpose a self-retaining retractor is employed, and the aid of an assistant may be dispensed with. FIG. 126. PERINEAL PROSTATECTOMY. (Proust.) The two index fingers of the operator are introduced between the two layers of the apon- eurosis of Denonvilliers, and enlarge the "espace decollate retroprostatique." With the patient in the position above described, his bladder being empty, and a metal guide or catheter in the urethra being held close beneath the pubic arch, so as to draw the bulb of the urethra well up out of the operative field, a transverse incision is made in front of the Proust's Perineal Operation 333 anus, with its convexity forwards, from one ischiac tuberosity to the other. The attachment of the external sphincter ani to the perinea 1 centre is then divided, and the dissection continued posterior to the FIG. 127. PERINEAL PROSTATECTOMY. (Proust.) The sheath of the prostate (the anterior layer of the aponeurosis of Denonvilliers) has been opened, and the surgeon's finger now detaches the sheath from the prostate by blunt dissection. The prostatic tractor sometimes employed by Proust is not shown in this illustration. transverse perineal muscles. By drawing the anus backward, that is, towards the operator, the recto-urethral muscle is put upon the stretch. 22 334 Technique of Operations This is a somewhat indefinite structure which consists of muscular and fibrous tissue passing from between the layers of the triangular ligament backwards to the rectum, by their insertion into which is produced the acute flexure of this canal just within the anus. FIG. 128. PERINEAL PROSTATECTOMY. (Proust.) Hemisection of the prostate along the floor of the urethra. The recto-urethral muscle must next be divided. This is done with a pair of scissors, snipping through these fibres close to the membranous urethra. If great care is not exercised to keep close to the membranous urethra, but without opening it, the dissection will be made below the posterior layer of the aponeurosis of Denonvilliers, Proust's Perineal Operation 335 between it and the rectum, instead of between the two layers of this structure, where is found the " espace decollable retroprostatique." As soon as the recto-urethral muscle has been divided in the required place, the rectum will fall away from the anterior structures, and the FIG. 129. PERINEAL PROSTATECTOMY. (Proust.) Each lobe of the prostate in turn is dissected free from the sides of the prostatic urethra. two layers of the aponeurosis of Denonvilliers may be readily separated with the two index fingers. The rectum will now appear like a loop of intestine floating free in the peritoneal cavity, being covered by the posterior layer of this aponeurosis, while the anterior layer still conceals the prostate and seminal vesicles from view. It is to be recalled that 336 Technique of Operations of Denonvilliers is really an obliterated sac of the aponeurosis peritoneum. When the "espace decollable retroprostatique" is thus widely opened, the special retractor is inserted, and screwed up so as to hold the rectum and anus against the sacrum and coccyx. FIG. 130. PERINEAL PROSTATECTOMY. (Proust.) The ejaculatory ducts have been ligated, and the urethra is now being sutured. Beyond the anterior layer of the aponeurosis of Denonvilliers the prostate can now be indistinctly felt, floating away as soon as it is touched. Proust now opens the urethra, at the apex of the prostate, posterior to the triangular ligament, not between its layers; and after withdrawing the guide, inserts into the bladder through the urethral Proust's Perineal Operation 337 incision a special tractor dePezzer's which is very similar to that employed by Young. The prostate being thus steadied by spreading the blades of this tractor over its vesical surface, the sheath of the prostate (the anterior layer of the aponeurosis of Denonvilliers) is to be opened, with scissors, I FIG. 131. SKIN INCISIONS FOR PERINEAL PROSTATECTOMY. parallel to the urethra. The finger of the surgeon is then inserted between this layer of fascia and the capsule of the prostate, which is thus exposed on its rectal aspect; and the surgeon proceeds to detach the prostate from its sheath by the finger. He detaches it first along the side of one lateral lobe, then below, and from the vesical aspect, and 22 338 Technique of Operations finally in front, above, and close to the pubis. This enucleation should be done deliberately, and with the most painstaking thoroughness. FIG. 132. YOUNG'S PROSTATIC TRACTOR. Proust says that time apparently lost at this stage of the operation will at a later stage be found to accelerate matters considerably. When the prostate is thus freed of all its attachments, except those to the Proust's Perineal Operation 339 urethra, and to the ejaculatory ducts, the operation may proceed, but not before. The prostatic tractor is then removed. The wound in the urethra is now enlarged. This is accomplished by splitting its floor from the apex of the prostate to but not FIG. 133. Young's prostatic tractor in place, seen from within the bladder. FIG. 134. PERINEAL PROSTATECTOMY. (Young.) Diagram to show parts removed in operating according to Young's technique: in the centre a catheter is seen in the prostatic urethra; below are shown the ejaculatory ducts and uterus masculinus in the posterior commissure of the prostate. into the neck of the bladder. This cut hemisects the prostate as well; and each lobe in turn is then dissected off the lateral and upper aspects of the prostatic urethra by means of scissors, the index finger of the left hand being placed on the mucous surface of the prostatic urethra, 340 Technique of Operations FIG. 135. PERINEAL PROSTATECTOMY. (Young.) Incisions on each side of posterior commissure down to the prostatic urethra, prostatic tractor has been introduced through the opening in the membranous urethra, and draws the prostate well down into the perineum. Proust's Perineal Operation if necessary, as a guide. Proust ligates the ejaculatory ducts, thinking that by this means orchitis is less apt to occur. He removes each lateral lobe entire, advising against morcellement, which he considers neces- FIG. 136. Ferguson's prostatic depressor. sary only when the gland is extremely friable- and comes away in pieces of its own accord. He follows Albarran in the practice of resecting the FIG. 137. Syms's prostatic tractor, collapsed, and ready for introduction through an opening in the membranous urethra. floor of the prostatic urethra when this part of the canal is unduly dilated. When an intravesical projection, more or less pedunculated, is FIG. 138. Syms's prostatic tractor, distended, as it is after its introduction into the bladder. present, he delivers this through the prostatic urethra, and accomplishes its removal just as though working through a suprapubic wound; or if the pedicle is too short or too broad to allow of its delivery in this manner, he works up from the lower surface of the bladder, and enucleates the mass without opening the vesical mucous membrane. 342 Technique of Operations The operation is completed by passing a rubber tube or catheter through the penis into the bladder, and another catheter to the bladder FIG. 139. SYMS'S PROSTATIC TRACTOR IN USE. Its bulbous extremity has been expanded within the bladder, and by traction on the stem the prostate is drawn down into the perineum. through the perineal wound. Ordinarily the calibre of the prostatic urethra is such that it will easily accommodate both these tubes; should Proust's Perineal Operation 343 such, however, not be the case, that through the penile urethra is to be omitted. The prostatic urethra is sutured around the perineal tube with interrupted stitches of catgut, except where the tube emerges, at the triangular ligament. Three wicks of gauze are required to drain the perineal wound, which is partially closed by a few buried sutures, and by two deep (not buried) sutures at each of its angles. A firm gauze FIG. 140. MURPHY'S HOOKS, FOR USE IN PERINEAL PROSTATECTOMY. pad is placed between the coccyx and the anus, so as to hold the rectum forward, its normal anterior support having been destroyed by the division of the recto-urethral muscle. The usual superficial dressings are applied; and the patient when returned to bed is so arranged that the bladder shall be higher than the outer end of the perineal tube. This is best accomplished by using a perforated mattress, and having the tube drain into a urinal beneath the bed. If this plan cannot be carried out, Proust advises placing a board across the bed beneath the 344 Technique of Operations mattress, where the patient's buttocks will rest upon it, and thus be effectually prevented from making a depression in the bed lower than the outer end of the tube, which would then have to drain up-hill. As a substitute for this plan, the patient's buttocks may be made to rest FIG. 141. SKIN INCISIONS FOR PERINEAL PROSTATECTOMY. The dotted line shows Dittel's incision. The unbroken line shows the incision employed in the technique illustrated in Plates. upon a firm pad or pillow, placed above the mattress. Some such device Proust insists is essential to ensure the proper drainage of the bladder. The penile catheter is plugged, and all urine passes by way of the perineal tube. After-Treatment 345 In the after-treatment, the bowels are kept locked for eight days; for the first week the bladder is irrigated twice daily by injecting small quantities of fluid through the penile catheter, and allowing it to escape by the perineal tube. The dressing is first removed at the end of forty- eight hours, and subsequently renewed once every day. He removes the perineal tube on the eighth day, and lets the urine then drain by the penile catheter. This should be changed frequently to prevent concre- tions forming on it; and in doing so the upper wall of the urethra should be sedulously followed. Proust employs catheters of the general form of Mercier's, but having an extra eyelet on the convexity of the angle; before withdrawing one he passes a straight flexible guide along its interior until the guide projects through this extra eyelet into the bladder; the catheter is then withdrawn over the guide, which remains in the urethra, and serves as a conductor for the insertion of the new catheter. He prefers to keep the penile catheter in place, changing it frequently, for from three to five weeks, that is, until the perineal wound has closed. Complete healing of the perineal wound is generally assured in from five to seven weeks. REFERENCES (CHAPTER XIII) Albarran: Presse 'Medicale, 1902, No. 42, 17-24. Alexander: N. Y. Med. Jour., 1896, Ixiii, 171; Tran<*. N. Y. Acad. of Med., Dec. 15, 1898. Belfield: Amer. Jour. Med. Sciences, 1890, cii, 439. Bryson: St. Louis Med. Rev., 1899, xxxix, 246. Cabot: Surg., Gyn. and Obstet. 1913, xvii, 213. Crowell, A. J.: A New Prostatic Tractor. Jour. Amer. Med. Ass., 1918, btxi, 2057. Davis: Jour. Amer. Med. Ass., 1916, Ixvi, 1680. Dittel: Wien. klin. Woch., 1890, No. 8, 339. Ferguson: Trans. South. Surg. and Gyn. Congress, 1901, xiv, 147. Freyer: British Med. Jour., 1901, ii, 125. Fuller: Annals of Surgery, 1905, Ixi; Jour. Cutan. and Gen.-Urin. Diseases, 1895, ii, 239 Gardner, J. A.: The Silent Prostate. Jour. Amer. Med. Ass., 1918, Ixxi, 1636. Goodfellow: Jour. Amer. Med. Ass., 1904, ii, 194. Gouley: Surg. of Gen.-Urin. Organs, 1907. Guiteras: Jour. Amer. Med. Ass., 1901, ii, 1157. Urology, 1913, ii, p. 288; Trans. Third Pan-American Med. Congress, Phila. Med. Jour., April 20, 1901. Hagner: Surg., Gyn. and Obst., 1913, xviii, no. Judd: Journal Lancet, 1915, xxxv, 380; Collected Paper, Mayo Clinic, 1914, vi, 295. Murphy: Jour. Amer. Med. Ass., March 29, 1902. Nicholl: Lancet, 1894, i, 926. Ochsner: Surg., Gyn. and Obstr., 1919, xxix, 84. Pilcher: Cabot's Modern Urology, i; Surg., Gyn. and Obst., 1917, xxiv, 162; Annals of Surgery, 1914, lix, 500. Proust: Manuel de la Prostatectomic Perineale pour Hypertrophie, Paris, 1903. Senn: Jour. Amer. Med. Ass., 1903, ii, 414 346 Technique of Operations Soresi, A. L.: N. Y. Med. Jour., 1919, ex, 51. Squier: Surg., Gyn. and Obst., 1911, xiii, 254. Syms: Annals of Surgery, 1902, i, 468. TandlerandZuckerkandl: Folia Urologica, 1912, vi, 635. Watson and Cunningham: Diseases and Surgery of the Genito-Urinary System, Phila., 1908, i. Wishard: New York Med. Jour., Aug. 17, 1901. Jour. Cut. and Gen.-Urin. Diseases, 1902 xx, 245. Young: Jour. Amer. Med. Ass., 1903, ii, 999. Zuckerkandl: Wien. med. Presse, 1889, xxx, 857, 902. INDEX OF AUTHORS Abel, 162 Achard, 159 Adams, 68 Albarran, 12, 74, 145, 320, 321 Alexander, 13, 319 Amussat, 5 Anderson, 36, 64, 67 Anger, 107, 109 Annandale, 12 Ashhurst, 12, 266 Astruc, 2 Atkinson, 10 Bangs, 6 Baudet, 12 Bazy, 219 Belfield, 6, 279 Bier, 14 Billroth, 2 Blizzard, Sir William, 5 Boeckmann, 14 Bormann, 36 Bottini, 6 Bouffleur, 6 Boyd, W. H., 40 Braasch, 167 Braun, 9 Brodie, 2 Brown, Bucks tone, 10 Bryson, 12, 13, 319 Buerger, 269 Bugbee, 237, 238 Burckhardt, 112, 191, 204, 266 Cabot, n8, 220, 296, 319 Camus, 69 Caples, 218 Castaigne, 159 Caulk, 244 Cecil, 242 Chase, 175, 177 Cheron, 9 Chetwood, 6, 144, 226, 245 Chopart, 2 Ciechanowski, 26, 73, 81 347 Civiale, 5 Conner, 76 Covillard, 5 Cruveilhicr, 3, 108 Cullen, 9 Cunningham, 241, 319 Da Costa, 254 Davis, E. G., 289 Delbet, 320 Delore, 8, 251 Dennis, 168 Denslow, 175 de Pezzer, 13, 320 Derjuschinsky, 14 Desault, 5 Dillingham, 175 Dittel, 8, 12, 78, 223 Dorsey, 7 Eckhard, 36, 66 Edwards, Swinford, 8 Evatt, 21 Fenwick, 35 Fergusson, Sir William, 5, 12, 319, 320 Finger, 65, 105 Folin, 1 68 Freudenberg, 6 Freyer, 10, 59, 72, 85, 91, 103, I42,"i45, 175, 183, 212, 262, 263, 299 Fuller, 10, n, 299 Furbinger, 68 Galen, 2 Gardner, 175 Gebele, 145 Geraghty, J. T., 40, 162, 164, 168 Gerish, 52 Gilson, 232 Gile, 175 Gley, 69 Goodfellow, 12, 266, 316 Gouley, 5, 9 Griffiths, 14, 19, 22, 26, 69 348 Index of Authors Guiteras, n, 13, 101, 234, 319 Guthrie, 5 Guyon, 75, 198, 210 Hagner, 288 Halle, 145 Harrison, Reginald, 4, 9, 75, 80, 113, 173, 209, 220, 266 Heidenhain, 159 Heine, 9 Henderson, 77 Herophilus, 2 Hey, 7 Hodernus, 251 Hodgson, 8 1 Home, Sir Everard, i, 15, 21 Horwitz, Orville, 6, 251 Ho well, 241 Humphrey, 78 Hunter, John, 2, 14, 21, 26 Iversen, 9 Iwanoff, 68 Jones, 93 Jores, 21 Joseph, 159 Judd, 145, 179, 187, 189. 287, 315 Kelley, 175 Keyes, 8, 10, 74, 105, 166, 199 Keyes, Jr., 6, 92 Knorr, 152 Kolischer, 28, 6 1 Kolliker, 68 Konig, 14 Kiimmel, 10, 145 Kuzuitzky, 39 Lafaye, 2 Lagoutte, 251 Langenbeck, 9 Langley, 36, 64, 67 Launois, 14, 30, 75 Legueu, 175 Leroy, 3, 5, 15 Lewis, 156, 169 Loeb, 36, 67 Loumeau, 27 Lower, 230, 308 Lowsley, 18, 22, 27, 37, 61, 79, 302 Lydston, 80, 173 MacCallum, 84 MacEwen, 81 Macht, 68 Mark, 156 Marshall, 67 Massa, Nicolo, 2 Mayo, 1 68 McDonald, 183 McFarland, 73 McGill, 10, 77, 263, 267 McGrath, 74, 79, 145 McGuire, Hunter, 8, 78, 173, 249, 253 300 Mears, 14 Mercier, 3, 5, n, 239 Myers, Willy, 6, 14 Moore, 12, 263 Moreau-Wolf, 9 Morgagni, 21 Morris, 8, 12 Mosenthal, 169 Moses, 81 Moullin, 14, 23, 26, 77, 103, 113, 125, 193, 203 Mudd, 77 Miiller, 66 Murphy, John B., 12, 13, 287, 319 Nicoll, 13, 320 Nuslowsky, 36 Ochsner, A. J., 320 Oesnos, 87 Oppenheim, 65 Owen, 23, 25, 26 Page, 174, 182 Paget, 126 Pallin, 20 Par6s, 68 Parrish, 7 Pauchet, 178 Petit, 12 Physick, 2 Piersol, 18, 61 Pilcher, 74, 113, 288, 294, 296 Poncet, 8, 251 Porosz, 30 Powers, 147 Proust, 12, 13, 49, 147, 267, 273, 316, 320 321 Index of Authors 349 Ramm, 13 Randall, 94 Remete, 81 Remsen, 162 Richardson, W. G., 19, 23, 267, 289 Riolanus, 2, n Roberts, n Rossetus, 7 Rovsing, 74 Rowntree, 162 Ruggle, 205 Schafer, 26 Scherck, 175 Schmidt, Benno, 10 Schultz, 76 Senn, 12, 204, 209 Serrallach, 68 Socin, 30, 112, 191 Spalteholz, 47 Squier, 173, 281, 285, 300, 304 Ssnitzin, 14 Steinach, 68 Strieker, 23 Swinburne, 140 Syms, 12, 319 Tandler, 22, 40, 92, 302 Taylor, n Tenney, 175,177 Thomas, 167 Thompson, Sir Henry, 5, 8, 22, 77, 173 Tobin, 80 Trendelenburg, 10 Tupper, 14 Van Buren, 199 Velpeau, 75 Vignard, in Vion, 147 Voelcker, 159 von Zeissl, 65 Wade, 74, 175, 182, 187 Waldeyer, 45, 6 1 Walker, n, 28, 44, 145, 175, 286 Wallace, 10, 44 Wanless, 76, 80 Watkin, 175 Watson, 6, 12, 88, 115, 175, 218, 251, 263, 3i9> 320 Weski, 44 White, J. William, 13, 80 Whitehead, 9 Whiteside, 175, 185 Wiesinger, 251 Wilson, 74, 79, 145 Wishard, 6, 77, 316 Wistar, 8 Wolff, 146, 2OI, 2O4 Wossidlo, 237 Young, 6, 12, 24, 41. 59, 61,74, i45> 147, IS5> !7S, 187, 188, 238, 239, 267, 316. 321 Zuckerkandl, 12, 22, 40, 92, 302, 316 INDEX OF SUBJECTS Abdomen, sagittal section, 32 Abscess, prostate, 143 Accessory glands, 40 pudic artery, 35 Acidosis, 227 Adeno-carcinoma prostate, 144 Adenoma, 87 Adenomyomata, 102 Aero-urethroscope, 157 Age in etiology, 77 incidence table, 79 Albarran's tubules, 21, 41 hypertrophy, 93 Alimentary canal, pre-operative care, 272 Alkalosis, 228 Allantois, 17 t Ambard's constant, 169 Anal fascia, 33 Anatomy, 17 applied, 48 comparative, 23 gross, 27 microscopic, 37 relational, 48 Anesthesia, local, 295 Anesthetics, 275 Anterior lobe, 38 Aponeurosis of Denonvilliers, 23, 34, 44, 49 development, 22 Applied anatomy, 48 Arteries, prostatic, 35 Artery, accessory pudic, 35 internal pudic, 35 prostatic, 35 vesico-prostatic, 35 Artificial urethra, 249 Atony of bladder, 139, 211 Atrophy, prostate, 144 Axis, prostatic, 31 Bar at neck of bladder, 114 Bell's muscle, 93 Bi-coude catheter, 198 Bladder, atony, 116, 139 Bladder, prevention, 211 bar at neck, 114 blood supply, 64 calcareous deposits, 117 changes in, 112 diverticula, 117 embryology, 17 hemorrhage, 212 irrigation, 215 ligaments, anterior, 49 lymphatics, 65 muscles, 62 neck, carnosities, i excrescences, i nerves, 64 peritoneum, 52 polypoid growths, 142 post-prostatic pouch, 112 structure, 61 tabetic paralysis, 141 tapping in retention, 223 tuberculosis, 142 urethral outlet, 113 Blizzard's operation, 5 Blood urea, 168 Bottcher's crystals, 70 Bottini's operation, 6 "Bouchon vaginal," 70 Bougie, Harrison's, 4 olivary, 4 Bryson's operation, 13 Bursa, prostatic, 22 Calcareous deposits in bladder 1 1 7 Calculus, 1 1 8, 141 prevention, 212 removal, 279 treatment, 225 Capsule prostate, 28 Caput gallinaginis, 28, 41 Carcinoma, prostate, 144 frequency, 145 Cardiac dilatation, 135 Carnosities, bladder, i Castration, 13 352 Index of Subjects Catheter, 196 bi-coude, 198 coude, 197 elbowed, 7, 197 English, 197 in diagnosis, 131 Leroy's, 197 lubricant, 204 Mercier's, 197 elbowed, 7 metallic, 200 Nelaton,"i96 passing, 205 permanent, 217 pocket-case, 203 prostatic curve 199 retainer, 218 retention, .202 soft-rubber, 196 sterilization, 200 woven, 197 Catheterism, 172, 195 Catheterization, frequency, 208 Catheterizing, 131 Caulk's punch, 244 "Cervix uteri" enlargement, 112, 114 Chetwood's galvano-cautery, 237 galvano-prostatomy, 245 incisor, 6 Chopart's operation, 2 Chromo-ureteroscopy, 155 Coccyx, excision, 12 Colliculus seminalis, 28 Comparative anatomy, 23 Complications, acidosis, 227 alkalosis, 228 calculus, 212 treatment, 225 hemorrhage, 212 treatment, 226 nephritis, 213 orchitis, 213 treatment, 226 prevention, 209 renal, 213 treatment, 226 surgical kidney, 213 treatment, 214 uremia, 213 treatment, 226 Compressor urethra muscle, 63 Concretions, prostatic, 70 Constipation, 128 Constitutional treatment, 190 Contracture of vesical neck, 144, 236 Corpora amylacea, 70 Coud6 catheter, 197 Cryoscopy, 169 Cystitis, 141 chronic, urine, 120 cystostomy, 219 encrusted, 120 irrigation, 215 perineal drainage, 220 post-operative, 184 prevention, 209 treatment, 214 Cystoscopic diagnosis, 148 differential, 157 Cystoscopy, 148 dangers, 148 technique, 150 Cystostomy, 248, 293 for cystitis, 219 Pilcher's, 308 suprapubic in history, 7 Cysto-urethroscope, 157 Density, 100 Denvillier, aponeurosis, 23, 34, 44, 49 de Pezzer's tractor, 13 Diagnosis, 136 catheter, 131 cystoscopic, 148 differential, 157 differential, 139 Diet preceding operation, 273 Dietetic treatment, 192 Differential diagnosis, 139 Dilatation, cardiac, 135 Dissector, Young's, 323 Dittel's incision, 12, 344 Diverticula, bladder, 117 Dog, prostate, 26 Dorsal vein of penis, 34 Drainage in suprapubic prostatectomy, 288 perineal in cystitis, 220 permanent, 8 Drug treatment, 193 Duct, ejaculate ry, 42 Ducts, Mullerian, 17 Duck-mole, genitalia, 26 Ejaculation, physiology, 66 Ejaculatory ducts, 24 Index of Subjects 353 Elbowed catheter, 7, 197 Electric cauterization, 238 Embryology, 17 Emission of semen, 67 English catheter, 197 Enucleation, prostate, 281 Epididymitis, post-operative, 183 "fispace decollable retroprostatique," 49 Etiology, 72 age, 77 arteriosclerosis, 83 gonorrhoea, 82 occupation, 80 predetermining factors, 76 previous diseases, 82 race, 76 sexual excitement, 76 intercourse, 80 social habits, 80 stricture, 82 testicles, 81 Examination, cystoscopic, 148 rectal, 132 Excrescences, bladder, i Fascia, anal, 33 obturator, 32, 45 pelvic, 32 recto-vesical, 33, 45 Ferguson's depressor, 341 Fistula, perineal, history, 9 post-operative, 186 urinary, 248 history, 7 vesico-rectal, 187 Frequency of urination, 123 Freyer's operation, 10, 275 Galvano-cautery, Chetwood's, 237 Galvano-prostatomy, perineal, 245 Genitalia, duck-mole, 26 goat's, 24 hyena, 25 ornithorhyncus, 26 Genito-urinary tract, development, 20 Gibson's operation, 232 Glands, accessory, 40 " Glandulae prostatae," 23 Goat, genitalia,. 24 prostate, 24 Gonorrhoea in etiology, 82 Goodfellow's operation, 316 Guthrie's operation, 5 Hagner hemostatic bag, 288, 307 Harrison's bougie, 4 operation, 9 Heart, pre-operative care, 272 Hedgehog, prostate, 26 Hematuria, 127 Hemorrhage, control of, 285 into bladder, 212 post-operative, 184 secondary, 292 Hemorrhoids, 121 Hemostatic bag, Hagner's, 307 Pilcher's, 306 Histology, prostate, 37 History, i Homologue uterus, 42 Hyena, genitalia, 25 Hygienic treatment, 190 Hypogastric nerves, 36 tumor, 129 Iliac artery, ligation, 14 Incision, Dittel's, 12, 344 for perineal prostatectomy, 337 Murphy's, 12 Proust's, 319 transverse perineal, 319 "Incision skystoskop," 237 Incisor, Chetwood's, 6 galvano-caustic, 6 Incontinence of urine, 127 post-operative, 187 tabetic, 141 Indigo-carmine test, 155, 159 Insects, prostate, 23 Instrumentation, post-operative, 292 Intermittent urination, 126 Internal pudic artery, 35 Involuntary dribbling, 125 Irrigation, bladder, 215 Judd's operation, 315 Keyes-Ult?mann syringe, 151 Kidney, changes in, 117 function, indigo-carmine test, 155 phthalein test, 163 tests, 158 Lataste, 70 Lateral lobe, 39 Leroy's catheter, 197 "1'Espace decollable r6troprostatique," 325 354 Index of Subjects Levator prostatae of Santorini, 34 Ligaments, bladder, anterior, 49 pubo-prostatic, 34, 44, 49 triangular perineum, 34 Ligation, iliac artery, 14 Litholapaxy, 226 Lobe, anterior, 38 lateral, 39 middle, 21, 39 hypertrophy, 40 posterior, 39 hypertrophy, 40 ventral, 39 Lobes, 38 Local anesthesia, 295 Lower's trocar and cannula, 230 Lubricant for catheters, 204 Ruggle's, 205 Lymphatics, bladder, 65 prostate, 37, 46 Mammals, prostate, 23 McGill's operation, 10 McGuire's artificial urethra, 249 obturator, 257 operation, 8 Mears's vasectomy, 14 Median bar, electric cauterization, 238 excisor, 242 formation, 93, 236 Mercier's catheter, 197 Metallic catheters, 200 Microscopic anatomy, 37 Micturition, post-operative, 290 stammering, 120 Middle lobe, 21, 39 enlargement, 40, 92 Moles, prostate, 26 Mortality, operative, primary, 173 table, 175 Miillerian ducts, 17 Murphy's hooks, 320, 343 incision, 12 Muscle, Bell's, 93 compressor urethras, 63 pubo-prostatic, 49 pubo-vesical, 62 recto- vesical, 62 Muscles, bladder, 62 urethral, 63 Myomata of prostate, 88 Nausea, post-operative, 292 Needle holder, Young's, 323 Nelaton catheter, 196 Nephritis, prevention, 213 Nerves, bladder, 64 hypogastric, 36 prostatic, 36 Nervi erigentes, 36 Nocturia, 123 post-operative, 188 Obturator fascia, 32, 45 McGuire's, 257 Occupation in etiology, 80 Ochsner's operation, 320 Olivary bougie, 4 Operation, Blizzard's, 5 Bottini's, 6 Bryson's, 13 Chopart's, 2 combined, history, 13 cystostomy, 248, 293 Pilcher's, 308 first stage, 294 Freyer's, 10, 275 galvano-prostatomy, 245 Gibson's, 232 Goodfellow's, 316 Guthrie's, 5 Harrison's, 9 intra-urethral, 236 Judd's, 315 local preparation, 273 McGill's, 10 McGuire's, 8 Ochsner's, 320 Paget's, 8 palliative, 230 Physick's, 2 Pilcher's, 307 preparation of patient, 271 prostatectomy, perineal, 316 extra-urethral, 321 suprapubic, 275 Proust's, 320, 330 Rossetus's, 7 second stage, 298 Squier's, 305 suprapubic, 274 Syms's, 13 technique, 271 Index of Subjects 355 Operation, trocar and cannula, 230 two-stage, 293 Young's, 322 punch, 239 Orchitis, prevention, 213 Organ of Weber, 18 Ornithorhyncus, genitalia, 26 Overflow from retention, 126 treatment, 224 Owen's perineal tube, 257 Paget's operation, 8 Pathology, 84 clinical, 105 Pelvic fascia, 32 Pelvis, coronal section, 47 from behind, 47 sagittal section, 32 side view, 50 transverse section, 33 Penis, dorsal vein, 34 reflex pain, 36 Perineal drainage in cystitis, 220 fistula history, 9 galvano-prostatomy, 245 prostatectomy, 316 extra-urethral, 321 history, 12 indications, 268 prostatotomy, 9 tube, Owen's, 257 Watson's, 257 Perineum, dissection, 53 triangular ligament, 34 Peritoneum, bladder, 52 Permanent catheter, 217 drainage, 8 Phenolsulphonphthalein test, 159, 162 Phlebitis, post-operative, 183 Phleboliths, prostatic, 121 Phthalein test, interpretation, 165 technique, 163 Physical characters, 100 examination, 129 Physick's operation, 2 Physiology, 61 ejaculation, 66 prostate, 67 urination, 65 Pilcher's cystostomy, 308 operation, 307 Pilcher's cystostomy, hemostatic bag, 306 tube, 306 Plexus, prostatic, 34 Polypus, bladder, 142 Polyuria, treatment, 226 Posterior lobe, 39 hypertrophy, 40 Post-operative nausea, 292 Post-prostatic pouch, 112 Predetermining factors, 76 Pre-operative care, 272 Preparation for operation, local, 273 of patient, 271 Prognosis, 172 primary mortality, 173 Prolapsus ani, 121 " Prostatse cirsoides," 2 " Prostatae glandulosae," 2 Prostate, abscess, 143 adeno-carcinoma, 144 adenoma, 87 adenomyoma, 102 arteries, 35 atrophy, 144 axis, 31 capsule, 28 carcinoma, 144 "cervix uteri" enlargement, 112 discovery, 2 dog, 26 embryology, 18 enucleation, 281 f octal, 21 goat, 24 hedgehog, 26 histology, 37 insects, 23 internal secretion, 68 lymphatics, 37, 46 malignant disease, 144 mammals, 23 moles, 26 myomata, 88 nerves, 36 physiology, 67 sarcoma, 147 secretion, 68 sheath, 31 size, 27 tubules, 37 tunneling, 3 356 Index of Subjects Prostatectome ; Mercier's, 4 Prostatectomy, choice of operation, 263 complications, 181 indications, 259 morbidity, 186 mortality, 173 age, 1 80 causes, 176 predetermining factors, 180 tables, 175 perineal, 316 after-treatment, 329 conservative, 322 extra-urethral, 321 history, 12 incision, 337 indications, 268 intra-urethral, 316 Proust's, 330 Young's, 322 preferable route, 266 suprapubic, 275 advantages, 266 drainage, 288 hemorrhage, 285 modifications, 299 post-operative care, 290 Young's, 322 Prostatic artery, 35 bursa, 22 concretions, 70 depressor, Ferguson's, 341 fluid, 67 hooks, Murphy's, 343 plexus, 34 phleboliths, 121 secretion, 69 tractor, Sym's, 341 Young's, 326, 338 tumors, 102 urethra, 28, 46 capacity, no utricle, 29 Prostatism, post-operative, 188 sans prostate, 236 Prostatitis, chronic, 143 Prostatotome, Mercier's, 4 Prostatotomy, perineal, 9 Proust's incision, 319 operation, 320, 330 Pubo-prostatic ligament, 34, 44, 49 Pubo-prostatic ligament, muscle,j49 Pubo-vesical muscle, 62 Pudic artery, accessory, 35 internal, 35 Punch operation, 239 Young's, 237 Pyelitis, 128 Pyelonephritis, post-operative, 184 Pyonephrosis, post-operative, 184 Race in etiology, 76 Rate of growth, 100 Rectal examination, 132 Recto-vesical fascia, 33, 45 muscle, 62 Rectum, effects on, 121 Relational anatomy, 48 Renal complications, 213 treatment, 226 failure, 128 Residual urine, 118, 131 Retention of urine, 126, 210 acute complete, treatment, 221 chronic complete, treatment, 223 overflow, 126 treatment, 224 post-operative, 188 varieties, 210 Retractor, Young's, 323 Rossetus's operation, 7 Ruggle's lubricant, 205 Santorini, venous plexus, 35 Sarcoma, prostate, 147 Sclerosis neck of bladder, 144 Secretion, prostatic, 69 Semen, emission, 67 Senn's sigmoid tube, 252 Sexual orgasm, 66 power, post-operative, 188 Sheath, prostatic, 31, 44 Shock, prevention, 290 Sinus pocularis, 18, 29 urogenital, 17 Size, 85 Social habits in etiology, 80 Soft-rubber catheter, 196 Sound guide of Young, 323 Sphincter, vesical, external, 63 internal, 62 Squier's operation, 305 Index of Subjects 357 Stammering in micturition, 120 "Stammering with urinary organs," 126 Steam bath in uremia, 226 Sterility, post-operative, 188 Sterilization of catheters, 200 Stevenson's suprapubic tube, 252 Stricture, urethra, 140 Subtrigonal tubules, 41 Suprapubic operation, 274 prostatectomy, 275 Surgical kidney, prevention, 213 Symptoms, cardiac, 128 catheterizing, 13.1 constipation, 128 cystitis, 127 frequency of urination, 123 hematuria, 127 incontinence, 127 intermittent urination, 126 nocturia, 123 objective, 129 pyelitis, 128 renal failure, 128 retention, 126 sexual powers, 128 subjective, 123 uremia, 128 Syms's operation, 13 tractor, 341 Tabes dorsalis, 141 Tabetic paralysis bladder, 141 Tapping bladder, 223 Testicles in etiology, 81 Tractor, de Pezzer's, 13 Sym's, 341 Treatment, 190 catheter, 195 constitutional, 190 dietetic, 192 drug, 193 hygienic, 190 pre-operative, 271 Trocar and cannula, Lower's, 230 Tube, perineal, 257 suprapubic, 252 Tuberculosis, bladder, 142 Tubules of Albarran, 41 hypertrophy, 93 prostate, 37 subtrigonal, 41 Tunneling prostate, 3 Two-stage operation, 293 Uremia, 1*28 post-operative, 185 treatment, 226 Ureter, changes in, 118 dilatation, 118, 124 embryology, 17 Urethra, artificial, 249 changes in, 105 direction, no from above, 43 length, 105 muscles, 63 musculature, 63 normal, 46 pre-operative care, 273 prostatic, 28, 46 capacity, no stricture, 140 Urethral crest, 28 Urinary fistula, 248 history, 7 Urination, dribbling, 125 effects on, 120 frequency, 123 intermittent, 126 obstructive factor, 89 physiology, 65 post-operative, 290 Urine, incontinence, 127 residual, 118, 131 retention, 126 Urogenital sinus, 17 Uterus, homologue, 42 masculinus, 18, 29, 41 Utricle, prostatic, 29 Utriculus, 18 Vacuum bottle, 289 pump, 289 Vasa deferentia, embryology, 18 Vasectomy, 14 Venous plexus of Santorini, 35 Ventral lobe, 39 Verumontanum, 28, 41 Vesical calculus, 118, 141 removal, 279 neck, contracture, 144 358 Index of Subjects Vesical calculus, outlet, obstruction, 93 Young's dissector, 323 sphincter, external, 63 median bar excisor, 242 internal, 62 needle holder, 323 Vesico-prostatic artery, 35 operation, 322 after-treatment, 329 Watson's perineal tube, 257 punch, 237 Weight, 86 operation, 239 White's treatment, 13 retractor, 323 Wolffian bodies, 17 sound guide, 323 Woven catheter, 197 tractor, 326, 338 University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. PRINTED IN U.S.A. CAT. NO. 24 1 61 522389 WJ759 D285e D ^ver, John B. 1922 of the prostate WJ759 D285e 1922 Deaver, John B.. Enlergement of the prostate MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664