troops ten medical officers are considered necessary something of the magnitude of our task may be realized. Are we alive to the vital importance of fulfilling our obligation to our country?

Nothing need be said of the personal sacrifice involved in the performance of this duty, the sacrifice to be made by family and patients. Neither is it necessary to speak at length of the emoluments, the attractions of military life the companionship with fine red-blooded men who are doing things is in itself a stimulus. It shakes off the dust of a medical practice, awakes all that is best in a man, and furthermore, it gives a man that feeling that all like to have but not all like to struggle and work for, that you are doing something worthy, a feeling that you will carry with you to your grave.

I wish only to remind you of the present need, to appeal to your patriotism and sense of duty, and to make the earnest plea that we wait not to be forced into this service, but that every ablebodied, earnest man get into the service, gets in with all his heart, takes the three months' intensive training, and proves that the medical profession is still in the vanguard of everything that is fine and loyal. This thing that you will do will be the greatest thing you have ever done; the feeling of righteousness it will bring. to you will be the finest you have ever known.

A LONG-DISTANCE VIEW OF PROSTATECTOMY HORACE PACKARD, M.D., F.A.C.S., Professor of Surgery, Boston University School of Medicine

This communication is presented in answer to a query recently propounded as to the remote and final results of removal of the prostate. This view of the subject seems timely because most of the literature which has appeared since this has become an established surgical procedure has dealt with the indications for operation, the technic and the immediate results. This is a somewhat difficult phase to treat in extenso because the subjects of this operation are all far past the middle period of life when other causes quite apart from the operation itself or the local results therefrom may bring life to an end. In examining my records of prostate cases of the past fourteen years I find that a very large percentage were over seventy years of age and many of them were in a very wretched condition because the operation was invoked far past the time of election for the best results. A case which has drifted on and permanently into catheter life with consequent cystitis and concentric hypertrophy of the bladder wall or dilatation and atony and long existing back pressure with diverticula, cannot anticipate a cure of these conditions even though the prostate be successfully

removed. He may recover from the immediate effects of the operation and be regarded as a success from a surgical point of view but the damage from procrastination will never be effaced. Obviously cases of this kind do not present a fair reflection of what the remote results of prostatectomy are in cases which seek operation early, before irreparable damage has occurred.

The following case history would probably be accepted as a surgical success by all, both professional and lay. At least the patient considers himself a shining example of modern surgical science. At the present writing he is 80 years old and it is 10 years and 8 months since the operation:

C. J., a professional man, age 70, had been unable to empty the bladder voluntarily for two years. He had become thoroughly established in the catheter habit for 18 months. In addition to the daily use of the catheter, repeated instrumentation of the bladder had been practised by an electrical specialist. All this resulted in infection of the bladder to the end that the urine was at all times heavily loaded with pus. A suprapubic cystotomy was made for temporary drainage and flushing of the bladder, with marked improvement both in his general condition and locally. Suprapubic prostatectomy was then effected with final healing and restoration of voluntary urination. He was cured as far as restoration of voluntary evacuation of the bladder was concerned, but mark the sequel - he has never fully recovered from the cystitis; notwithstanding repeated and faithful irrigations of the bladder and the use of autogenous vaccins, the urine constantly shows the presence of bacteria and he has periodic exacerbations characterized by bladder irritation and systemic toxæmia.

In contrast to the abc ve is the following case (a physician) reported in the patient's own words. He had never used the catheter, had no cystitis, his residual urine was but two ounces, the integrity of his bladder wall was practically unchanged, he had no back pressure symptoms. He is now 81 years of age (10 years since the operation). He writes:

"So far as my control of the sphincter vesicæ goes this is practically perfect now, though for some time after the operation it remained fitful and imperfect sudden escapes occurring unexpectedly during the day. At night, which was the trying time, it soon became automatic, sleep not being disturbed and the voiding of urine was complete. Now at very rare instances under sudden mental stress, there is a very slight escape quickly controlled by effort of will.

"The frequent wakening at night, the urging to frequent urination during the day, the delay in starting the urinary flow have entirely disappeared. Often in travelling or at inconvenient times I am able with comfort to retain the urine eight or even ten hours when a little careful of the amount of liquid consumed beforehand or during the need of restraining the action of the kidneys. These and the old undue sensitiveness of the bladder are things of the past.

"The result is a marked improvement not only in my sleep but in my general health and enjoyment of life. With the approach of my eightieth year I have found it expedient to abandon practice, but still find myself interested in professional questions although shrinking from the drudgery and physical effort."

These two cases are quoted at the outset of this paper and the reader is asked to analyze them critically since they represent the two great classes of cases which the surgeon is called upon to treat. The class represented by the first case are poor surgical risks for the reason of irreparable damage which has come about from pro

crastination. Such cases are, to be sure, likely to go through the operation safely, but the pitfalls of sepsis, anorexia and malassimilation, heart failure and hypostatic pneumonia are likely to make the weeks following the operation full of anxiety and life a short shift. It is true that by the adoption of modern methods of preparatory treatment, constitutional and local, such cases may pull through and be greatly relieved and live for years as in the case cited, but in the sum total of that class of cases there are sure to be chronic bladder infections which linger on through the patient's life; a contracted bladder still imperiously calling the patient. up many times a night; or a fistulous opening may persist at the site of the wound, keeping the patient moist and uncomfortable. These, even though the patient recover from the immediate results of the operation, are a drag and a drain upon him and tend to shorten the span of life which an earlier operation might have afforded.

Obviously, such unfavorable post-operative sequelæ should not be scored up against the surgeon, nor against the operation, but against the procrastination- the fear, or the repugnance of the patient to any operation at all.

Indeed it is with many misgivings that the conscientious surgeon operates on these derelicts for he well knows that an appreciable mortality awaits upon his best efforts, and this with the disappointing annoying sequelæ above referred to bring to an otherwise great and beneficent surgical procedure unmerited condemnation.

Of the class of cases represented by the second case-history little need be said. The clear-cut and positive testimony given in the patient's own words supplemented by the groups of cases which are to follow answers in the most eloquent way the query which suggested the preparation of this paper.

The successive groups of cases whose personal testimony is herewith appended are mostly cases which came to the writer au naturel, i.e., they had not been materially injured by procrastination, instrumentation of the bladder, or back pressure. They came early while in good physical condition because their alert family physician wisely advised and urged them to do so. A very serious responsibility rests upon the family doctor in these cases, for he who aids or abets in the establishment of the catheter habit or complacently views the insidious symptoms of prostatic obstruction without fully warning his unfortunate patient of the impending catastrophe and urging to the only sane course, viz., early prostatectomy, is failing in his full duty as a wise and faithful physician.

A GROUP OF CASES WHICH LIVED SIX YEARS OR MORE AFTER
THE OPERATION OR WERE STILL ALIVE AT THE EXPIRATION
OF THE SIX-YEAR PERIOD:

A Ten Year case reported by his son.

Was operated on (suprapubic prostatectomy) in his 54th year and lived ten years and three months.

"Dear Dr. Packard:

"In reply to yours of Sept. 4th will say that father died on the 26th of July last (interstitial nephritis). From the time he left Boston after the operation until his death he had perfect control of urination. On entering the hospital he weighed 150 lbs., having suffered a great deal for three years. One year later he weighed 180 lbs. and continued the same, not varying more than two or three pounds until Sept., 1915, when he began to show symptoms of nephritis. But during his sickness he often remarked that he had enjoyed ten years of comfortable life, in fact never would have known that he had been a victim of prostatic trouble. Father never suffered one inconvenience from the operation. He was apparently normal in bladder control. Would go to bed and sleep all night and not the least inconvenienced during the day.

"I am very glad, Doctor, to comply with your request and if there is any further information would be very glad to give it.

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'Very sincerely,”

Eleven Year Case, 73 years old, operated in 1906, reported by his physician.

"Dear Dr. Packard:

Replying to yours of the 4th inst., just received, I have called up and Mr. states first, I am very much alive'; in fact, he is actively engaged in a carpentering jobbing business, conducting it and sometimes taking an active hand himself; second, I regained perfect control of urination and retained it up to the present time'; third, I was not only restored to a comfortable condition but I was greatly improved in general health.'

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'Sincerely and cordially yours,"

Ten Year Case, now 82 years old, reported by his physician. "Dear Dr. Packard:

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In reply to your questions which reached me recently I am delighted to say that Mr. J. R. made a magnificent recovery and has been in excellent health ever since his operation. It was a decided success from every standpoint. He is still living and has very good health for one of his years. On account of high blood pressure his nervous system has suffered and during the past year he has felt and seemed old.

"Very truly,"

Twelve Year Case, 76 years old, reported by his physician. My dear Dr. Packard:

In regard to Mr., whom you operated on twelve years ago, he is in very good health, has no dribbling of urine, can void very nicely although rather more frequently than in his younger days; he is now 76 years old.

Yours very truly,"

Ten Year Case. This was complicated with a very bad cystitis caused by repeated instrumentation of the bladder over a long period prior to operation. A preliminary suprapubic drainage was made. Reported by the patient.

My dear Doctor:

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I am glad to report that the operation performed ten years ago this spring was entirely successful. I have had no trouble in passing or controlling the pas

sage of urine. I pass water every three or four hours during the day, and from three to four times at night, according to the soundness of my sleep, but have no trouble in retaining it for longer periods if desirable. An examination of urine made within six months found it practically normal.

"Yours very truly,"

Three Cases Respectively Eleven, Seven, and Six Years since Operation. Reported by their physician.

"Dear Dr. Packard:

"I hope my delay in answering your letter has not caused you inconvenience. I have only today been able to see Mr. W. and Mr. I. Both say, and I may include myself in their category, that since their operations their bladder functions have been practically perfect; that their general health and comfort has greatly improved so that they have nothing to complain of. They wish me to give you their kindest regards and heartfelt thanks for the great relief you have given them and I also wish to join them in these sentiments.

"Very sincerely yours,"

Group of Cases Seven Years after Operation. A case, now 83 years, reported by his physician.

"C. F.S. Operated upon in 1911, is now living and enjoying most excellent health. He has practically perfect control. Age 83, and this past summer attended the Knights Templars Conclave at Los Angeles, Cal., making a trip of something over 12 000 miles, never missing a day or a meal."

Case, now 70 Years of Age, Living and Well. My dear Dr. Packard :

"In reply to your question which reached me recently, I am delighted to say that Mr. E. made a magnificent recovery and has been in excellent health ever since. I have rarely seen a man who more deeply appreciates what was done for him in the way of relieving him from serious suffering. I hear from him only at long intervals because he is so well he needs no medical attention. I look upon his case as a most satisfactory one.

"Sincerely,"

Case, now 73, Six Years after Operation. Reported by his physician.

My dear Dr. Packard:—

I had a talk with Mrs. G. this afternoon. She tells me Mr. G. is quite well, that he urinates two or three times at night, and has no trouble otherwise with the bladder. She considers him a healthy man for 72 years of age.

Sincerely,"

Case, now 76 Years old, Six Years after Operation. Reported by patient's physician.

"My dear Dr. Packard:

"Your letter of Sept. 11 relative to Mr. F. came duly to hand. He is still living and as he says is very much alive.' As you will recall he was some length of time in healing at the abdomen - due, as you may now know, to disregard of advice against a too speedy return to business; his temperament rather than fault with the wound was responsible for the tardiness in closing.

He had control of urinating long before the wound entirely healed, and has continued to have to now. He has been very comfortable since the trouble was removed; and so far as troublesome urinating was a factor in his general condition of health, it has long since ceased to exist.

"He is daily present at his place of business, which you will remember is blacksmithing, horse-shoeing and wagon-making and repairing.

He is no longer active in the manual end of it, though if the occasion demands he gets into it for a brief period - his heart won't permit him to continue long at it.

"Yours most cordially,"