or extreme general disability. Drainage can be readily established and bladder tolerance secured by trocar and canula, leaving the canula in the suprapubic position for several days. All other conditions of the enlarged obstructive prostate are attacked from the perineum.

In our earlier perineal operations we made the transverse horseshoe incision, later the inverted Y. While these incisions give much space for manipulation, there was always some hemorrhage at the time and considerable oozing afterward. The earlier steps of the operation seemed needlessly severe for the simple enlargements by reason of the extensive exposure of the arterial supply and the venous plexus about the capsule. Although it is without question the better plan for the surgeon without experience in this operation to gain it through the Y or transverse curved opening until the anatomy of the region becomes familiar. The ordinary methods of opening the capsule by a transverse or two vertical incisions preserved the urethra for a short time only, to open it later in the operation. We now make a short median incision within a half inch of the anus and, after exposing the bulb, a dry separation is made to the membranous urethra, which is opened on a sound and the finger inserted into the bladder. This outlines the growth and, with the finger still in place, a short hook knife, not unlike a pruning knife, is passed beside the finger and the urethra opened into the prostate posteriorly on either side from the bladder out, incising the capsule, next the membranous urethra, slightly, as it is withdrawn. With the finger still in place two more incisions are made on both sides of the prostatic urethra, with the cutting surface directed parallel with this portion of the passage. The last incisions are at right angles with the first and separate the urethral walls from the gland. The two lobes are now shelled out of the prostatic capsule with the finger and left in situ, hanging from the bladder attachment. The finger also separates the urethra from each lateral lobe through the vertical incisions. A three-tined hook catspaw retractor is inserted, or the spoon blade stone forceps employed, and one lobe will be drawn down with one or the

other of the lateral. A very hot wet sponge of gauze is pushed into the capsule and left for a few minutes to check oozing, and a short rubber tube drain inserted into the bladder, with which it is now irrigated. The perineal wound. is closed by a couple of sutures, and the bladder drain is removed on the third or fourth day. If there is much bladder tenesmus a Jacobs' self-retaining catheter is inserted through the perineal incision. The patient should be on the back during the operation, with the legs flexed and forcibly compressed against the abdomen. This very materially shortens the perineal distance and produces some intra-abdominal pressure in a favorable direction. The plan of operation practically is similar to the principle advocated by Goodfellow of San Francisco, who probably made the first deliberate attack on the prostate through the perineum in 1891. From Jan. 1, 1903, to June 15, 1903, at St. Mary's Hospital, Rochester, Minn., we have removed seventeen prostates through the perineum; three of these cases were complicated by stone, the removal of which was easy through the small incision. The ages were between 55 and 82. Two cases were operated for stone by suprapubic incision, one being too debilitated for prostatic removal at the time and is to return for a perineal removal of the gland, the other was a paralytic. One case was drained by suprapubic trocar and canula left in place for a week, when the prostate was removed.

One prostate proved to be carcinoma. All of these cases have recovered from the operation and are relieved of their suffering. The carcinoma case has been done five months, but will undoubtedly recur later. One far advanced case of cancer of the prostate was not operated. A temporary epididymitis occurs in a small percentage of cases, but the inflammation is of short duration, as a rule.

DISCUSSION.

DR. J. E. MOORE-I think this is too important a paper and subject to let go by without discussion, even at this late hour. Dr. Mayo and I crossed swords a little before the time he mentioned a year ago last June, when I had the pleasure of reading a paper before the

Surgical Section of the American Medical Association. He speaks of the danger of the catheter, but the real danger begins when he begins to use the catheter, and it has cost more lives than it has saved. It carries them along with a false sense of security, and they wait until the bladder and kidneys are affected before they come to us. We have learned some things in our experience in the past few years. No matter what his age is, if his kidneys are not going well they should receive attention. The technic of the operation is not so difficult, and a surgeon can perform a prostatectomy in a few minutes in the average case. We have learned that the dangers are not so great as we used to think they were when we did it through the suprapubic site and they bled to death. We learned that the dangers were diminished as our knowledge of the technic progressed. We have learned that good results can be obtained from this operation. The time is not far distant when we can say to the patient that we can offer him sure and certain relief, and the whole profession as well as the laity will be so taught that they will allow us to operate early enough to achieve the desired result. We have not learned how to have control of the bladder in every case, we have not learned how to prevent diseases of the prostate, we have not learned to prevent attacks of epididymitis, although in one case the removal of the epididymis relieved the patient's suffering.

DR. F. A. DUNSMOOR-I was fortunate in hearing the paper read before the Surgical Association in Chicago. I had an experience like the Doctor, and I began with suprapubic work. My first operation was done with the idea of removing the prostate, and until the reading in which the Doctor described the operation I had never attempted one from below. The last patient had complete retention for thirty-six hours and was 76 years old, and I feel very much complimented to say that he came from as near Rochester as he did from Minneapolis, and he is alive and well. This much as to the method. I believe it makes very little difference so far as the external wound is concerned. As to the cutting into the bladder. I can not help feeling that the chances for drainage are not so good. There must be a portion of the urethra injured if we remove the prostate gland. I think the people are afraid of infection. The incision may be made through the integument. If we aim to get at the capsule, slit that as wide as possible and keep the finger nail inside, the same as we would do in taking out a pus tube, you will find how readily you can turn it down if at the same time you attempt to make enucleation between that portion of the urethra attached to the upper and middle portion of the prostate. One measure to prevent infection was, as soon as the capsule was reached and we had an opportunity to open on the urethra, to smear the parts with vaseline to help to shut off the ureter over the edge of the wound without allowing it to be absorbed.

SOME COMPLICATIONS OF STRANGULATED HERNIA, WITH CASES.

ARTHUR T. MANN, M. D., MINNEAPOLIS, MINN.

This paper is written for the purpose of dealing with a few phases of strangulated hernia, illustrated by some of the cases which have fallen to the experience of the writer. First, apparent reduction of a strangulation. This may occur when sufficient force is used, by reduction of the sac still containing its hernia and without relief of the constriction at its neck, or by forcing the contents into another portion of the same sac or through a tear in its neck. It is a grave accident. It gives one a sense of security. Valuable time is lost and a fatal issue made more sure. The following is a case in point.

Six months ago the writer was asked to see Wm G., a strong, well-developed Swede, aged forty years, previously perfectly well. His bowels had moved last five days before. Nausea had developed the second day; occasional vomiting and retching the third, fourth and fifth days. When seen the patient was in no pain; his face was flushed and anxious; his pupils were dilated; perspiration was standing on his forehead. The abdomen was moderately distended, bulging more in its upper third, and for the most part tympanitic. There was dullness in the hypogastrium and right iliac region. A small inguinal hernia presented on the right which seemed easily reducible, which the patient had had for some time, and which was not tender. There was no noticeable abdominal tenderness. thartics and enemas had given no result. The pulse was slightly rapid and rather small; the temperature was normal. The writer made a diagnosis of intestinal obstruction from some cause not yet clear, and advised operation. The advice was not accepted.

Ca

Three movements of the bowels were obtained later in the day from high enemas, but the symptoms slowly increased in

severity. Two days later the vomitus was stercoraceous, thin and yellow, with a slight pinkish tinge.

Operation was now demanded as a last resort and was performed by another hand, on this same day, the seventh day of the symptoms. Through a median incision the small intestines, congested and distended, were turned out of the abdomen. The large bowel was empty and collapsed. A knuckle of the small bowel, just enough to close the lumen, was found strangulated in its sac at the right internal ring. The patient required repeated stimulation during the operation and vomited constantly. During the act of replacing the bowels, a copious outpouring of a fluid, stercoraceous vomitus occurred, the patient became asphyxiated, drowned in his own vomitus, and expired in spite of rapid resort to artificial respiration.

This case brings up several points of interest. It shows that we can not exclude a strangulated hernia because of a lack of pain and localized tenderness. The hernia was found and was handled. It shows, further, that it does not require great force in the reduction of a strangulated hernia to produce a reduction en masse, with the sac still grasping the bowel, and in this case leading to a fatal issue. It forces home to us again the fact that time is of supreme importance when dealing with intestinal obstruction and intestinal strangulation. Within a year the writer has seen five cases of intestinal obstruction lost because of delay and temporizing after the symptoms clearly indicated the need of operative relief. The following is an example:

A woman sixty-four years of age had had symptoms for four days, beginning with pain over an old, right, femoral hernia and radiating over the abdomen, with obstruction of the bowels, with general depression, and with nausea which led to vomiting by the next morning. Her family physician was called and he was anxious and faithful in his attendance during the succeeding three days. He made repeated attempts to reduce the strangulation by taxis and by cold applications. Meantime the symptoms increased, vomiting became more frequent, and on the fourth day was faintly fecal in odor. At