struction had to reach a certain point before the stoppage occurred, and once reached it was immediate and absolute. The specimens will show that no portion of the prostatic urethra has been removed. The three lobes weigh three ounces. Lilienthal has carefully examined for mucous membrane in the prostates he has removed, but has never found any, so that the danger of injuring the prostatic urethra by this route must be very slight. The same can not be said of the perineal route.

I put in a syphon drain and a permanent catheter. The patient, though his arteries were very atheromatous, took his chloroform well. There was no shock and practically no fever. Twice his temperature reached 100°. His pulse never was above 70°. The ease with which the prostate was removed surprised me. I required no counter pressure from the rectum. The blood left the urine in ten days. I removed the catheter on the eighteenth day, and he returned home on the twenty-fourth day with a slight leak still from the suprapubic fistula.

The interesting features in the case are: The long freedom from obstruction with a very large prostate, and the otherwise healthy bladder, so that we can judge of the operation itself and its effect in an absolutely uncompiicated case; the lack of reaction or any symptoms of shock; the complete control of his urine as soon as the catheter was removed on the eighteenth day. I ordered him to pass his water at first every two hours, and he informed me that he saw no difference in his micturition from his former healthy functioning. I believe in this case I could have left the left lobe and perhaps done better by my patient in helping the neck of the bladder hold its shape, and I shall certainly follow out this procedure should I get another opportunity to do the operation.

In these two cases I have noticed a very free flow through the syphon drain, rarely less than fifty ounces a

day, and often sixty or sixty-five ounces. Even with the catheter a demeuse I have noticed a freer flow than ordinary. It has occurred to me that the opening of the bladder with the constant drain must have a strong diuretic action on the kidneys, and independently of any diabetic condition which may have been caused by the operation. Some sugar was found in my third case, but I can not say whether this was due to the operation or existed before. A cystotomy with drainage might tide a patient over a dangerous anuria occurring during an acute infection or in the course of acute or chronic rephritis. I give the suggestion for what it may be worth. I should be inclined to try the experiment in a desperate

case.

I may state my conclusions briefly as follows:

The suprapublic route is preferable in the majority of cases; the operation is simpler, can be done more quickly, cuts fewer tissues, much less chance of injuring the rectum or prostatic urethra, and with it the sexual function; and this route is even better when the patient's condition demands two stages for the opera

tion.

Finally, I believe the profession is gradually coming tɔ view the suprapubic route as the better of the two in the majority of cases.

DISCUSSION ON DR. CORSON'S PAPER.

Dr. Jabez Jones: We have employed a method of getting to the prostate through the perineum by introducing a sound down to the prostate and then following this sound as a guide, cutting with a pair of blunt scissors, down to the prostate. By this means we do not have to bother with the anatomical relations and also prevents going into the rectum.

IRRITABLE AND HYPERTROPHIED SPHINCTER ANI-CAUSES AND TREATMENT.

BY J. L. FARMER, M.D., SAVANNAH.

A diseased or irritable and hypertrophied sphincter ani is not in many cases, if any, an original pathological condition, but an indication or symptom of some other pathological process which involves the nerve fibers of the muscle. This involvement of the nerve fiber is the true cause of the irritability, and in time hypertrophy, if the original disease is not eradicated. Irritable sphincter and hypertrophied sphincter are comparatively synonymous terms and differ only in the acuteness or chronicity of the process responsible for this condition. As in the first stages of some disease which induces the trouble you will find more or less irritable and tightly contracted sphincter with no hypertrophy, while in the more chronic cases you will often find a more thickened, hardened and contracted muscle with reflexes hardly noticeable. There is, of course, a subacute inflammation or irritability in these cases, or the muscle would return to its normal healthy

state.

Examination of Sphincter Muscle-To determine the exact condition of the muscle, whether healthy or diseased, an examination of the parts is necessary in each and every case. Have the patient lay on left side, thighs flexed upon abdomen; then by placing the thumbs on either side of the anus and forcing the buttocks apart the muscle will easily relax, and the anal or mucocutaneous tissue brought into view if the muscle is healthy and patulous. If, on the other hand, the muscle is irritable

and contracted, it will be a hard matter to separate the edges of the anus or bring this tissue into view, as the tendency of the muscle is to contract rather than relax when handled or interfered with in any way when in an irritable and hypertrophied state.

Anoint the index finger of the right hand well with vaseline and place against the anus, and with steady pressure and a boring motion it can be readily introduced into the rectum in most instances, though introduction of the finger is very painful in some instances. If acute irritability exists you will find a tight cord-like muscle with no thickening of the fibers, with clonic or continuous contraction, causing more or less pain as you press the hand against the anus and attempt to sweep the finger round the rectal walls, and there will be a constant effort of the muscles to expel the finger. The same is true of the chronic or hypertrophied stage; exhibiting possibly less pain and a thickened, hard, and contracted muscle.

The

It must be remembered that the sphincters are much broader and heavier in some people than in others, and it is necessary to distinguish between a pathologically hypertrophied, and the broad healthy muscle. healthy muscle is soft and patulous, rather dilating under examination with the finger in the rectum than contracting, and there is no special effort at expelling the finger after the first few moments.

External Sphincter Muscle-The external sphincter being one of the most important muscles of the body from its office of opening and closing the anus and preventing incontinence of the feces, and controlling to some extent peristaltic action of the bowels, it is important that we prevent, if possible, impairment or destruction of its functions by disease or from operations upon it and adjacent organs.

Diseases Causing Irritability and Hypertrophy of Sphincter-The diseases most prominent in causing irritability and hypertrophy of the sphincter are: Acute or chronic posterior urethritis, prostatitis, urethral stricture, cystitis, displacement of the uterus, external infiammatory or thrombotic hemorrhoids, internal hemorrhoids, anal fissures, acute prostitis, anal or rectal abscess, fistula in ano, and fissure in ano or irritable ulcer of the rectum.

I shall not attempt to give the etiology and pathology of these different diseases causing irritability and hypertrophy of the sphincter; as either of them fully considered, would make a sufficiently lengthy paper, will only go briefly into symptoms and treatment.

Urethritis, Prostatitis and Cystitis-Acute posterior urethritis, prostatitis and cystitis, either singly or collectively, will from the reflexes and extension of inflammation cause congestion, irritability and hypertrophy of the sphincter. The subacute and chronic stages of these diseases will also induce a corresponding condition of the sphincter. The irritation about the sphincter will be present in a corresponding ratio, to the extent of inflammation existing in these organs.

As these diseases are cured, so will the sphincter return to a normal state. For treatment of the above diseases I would refer you to works on genito-urinary diseases. In some instances stretching or divulsion of the sphincter may be necessary, and I wish to say here that there is no treatment which relieves so readily and positively in irritable sphincter, as a thorough divulsion correctly done. In the milder cases of irritable sphincter, gradual divulsion every second or third day, with a bivalve speculum, may be practiced to the comfort of the patient and relief of the muscle. For a moderate amount of rapid or gradual dilation without anesthesia local or general. I have found Bodenhamer's bivalve solid blade