pocket in the prostatic urethra in which the tip of the soft catheter would catch. His bladder was over distended, and he had incontinence with overflow. A large-sized sound and a silver catheter with a prostatic curve easily entered the bladder. Rest in bed with a retention catheter made him more comfortable, but did not enable him to urinate even after several days of drainage. At the end of a week a perineal section opened a prostatic abscess containing fully one and one-half ounces of thick pus. At the end of four days he still could not urinate, so the perineal incision was carried into the bladder, two other small abscesses were opened, and most of a moderately enlarged prostate was enucleated, and the bladder was drained with a soft rubber tube. This man has recovered from the operation, but too recently to determine the ultimate results.

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Most prostatics come to operation as the result of bladder infection. They have usually been through with the ordinary palliative course of treatment, and have reached the so-called break-down of "catheter life." What these unfortunate old men need more than anything else is perfect drainage. The Bottini operation occasionally gives this result. The suprapubic operation seldom gives it. The combined, and the perineal operation always gives it, because the perineal section provides a direct down-hill outlet for the urine.

Each of these operations has its legitimate field, but the present conclusion of those surgeons who have tried them all, is, that the great majority of cases needing any operation, are best relieved by perineal prostatectomy.

Suprapubic prostatectomy is a little more dangerous than the perineal operation:

First, on account of the greater danger from hemorrhage from the prostatic plexus of veins.

Second, because of the liability of infection of the space of Retzius from the septic bladder, and the difficulty of draining this portion of the wound.

It is true that one can see the prostate, and make out the variety of deformity through a suprapubic opening, but

once the enucleation is started the surgeon must rely almost entirely upon the sense of touch; it is not necessary to see the prostate. Bimanual palpation is the most valuable method of examination in these cases, and the diagnosis of hypertrophy of the prostate can frequently be made by this method alone. At the time of operation a finger passed into the bladder through a perineal section will demonstrate at once the character of the hypertrophy, whether it be an enlargement of the middle or of one or both lateral lobes.

In the operation of perineal prostatectomy a median perineal section is the first step, taking care to avoid the rectum, which has been opened by several of our best surgeons. When the apex of the prostate is reached, a cystotomy on a staff will allow of the exploration of the inside of the bladder, and the recognition of the particular form of prostatic deformity. The capsule of the prostate can now be divided on either side and the hypertrophied prostate or the fibro-adenomatous tumors enucleated. Young's tractor is at times a help, but ordinarily the finger alone is sufficient.

In November, 1903, Geo. M. Phillips published a small hand book giving the experience of 40 American surgeons in prostatic surgery. Of this number Senn, Murphy, Horwitz, McGowan, Ferguson, Ochsner, C. H. Mayo, Martin, Haynes, and Guiteras report 199 perineal prostatectomies with 21 deaths, with the following after-results or complications:

In 13 prostatectomies which I have done there has been one operative death. This man was suffering from a sup

puration of both testicles and an acute cystitis; he was profoundly septic, and in bad physical condition. He was drained and irrigated for several days before his operation. He died on the third day and at the post mortem he was found to be suffering from a double pyelonephritis. This man ought not to have been operated upon for radical removal; possibly a Bottini would have helped to make him more comfortable and to have prolonged his life.

One man died nine months after his operation from a cancer of the pelvis. This case was not known to be malignant until after the prostate was exposed. Then the entire -neck and base of the bladder was removed. In spite of this fact the man had good control of his urine until his death.

One man had total incontinence; in his case the prostatic urethra was removed with a hard inflamed prostate. When last heard from he was wearing a urinal, but said he would not go back to his former condition with his constant suffering under any consideration.

The other patients are all living and well, passing urine not oftener than once at night and five times during the day.

The oldest man was 82, at the time of his operation; the youngest 46; the average age was 64. In five of these cases there were stones in the bladder as a result of the prostatic obstruction. In three there has been a secondary stone formation after the operation necessitating a secondary removal. In two of these cases the stones have been easily removed by lithotrity; in one it seemed wiser to make a perineal section.

A continuation of the cystitis seems to have been the cause of the re-formation of the phosphatic stones, and argues in favor of longer drainage. I have been accustomed to remove the perineal soft rubber drainage tube in 10 days' time. In the future I shall be inclined to leave the drain in a few days longer in all cystitis or stone cases. In one case where two stones were found in the bladder at the time of the prostatectomy, a stone was later found in the right kidney, and removed.

One of my patients has had considerable inconvenience from a urethral fistula, which makes it necessary to sit down to urinate; otherwise he is perfectly, well.

These II living patients are the most satisfactory and the most grateful of any class of surgical patients that I have ever met. The relief which they have received from their constant sufferings, and the delight which they take in being again able to urinate normally, is a great satisfaction to see.

OBSERVATIONS DRAWN FROM AN EXPERIENCE OF ELEVEN THOUSAND ANESTHESIAS

ALICE MAGAW

Rochester

In a rather recent article by Dr. E. J. Mellish the field of general anesthesia has been so thoroughly covered that there is little left to be said. As the call is becoming greater for skilled anesthetists, not only from the surgeons but the laity, it is important to become as proficient as possible in the best methods of administering all anesthetics.

I doubt if the ideal anesthetic and ideal method will ever be found, since, after experimenting for about sixty years with methods and drugs, we still have to cling to the first one, ether, as being chief. It is needless to say that ether is, and has been, our preference at St. Mary's Hospital. In 1902 out of 1,852 anesthesias, 1,51I were ether, and in 1903 we gave 2,091 anesthesias, and 1,771 were ether, out of which number 1,234 were given by the writer. Out of the 11,000 anesthesias, I have never been so unfortunate as to have a death directly from the anesthetic, neither have there been many "scares," for in six consecutive years artificial respiration was not resorted to. True, we have had some that I will remain with us forever. To the conscientious anesthetist, the profession is a hard one, indeed, as there is but one view, and that is that the administrator of any anesthetic is responsible for the narcosis.

We mean to be exceedingly careful in our selection of an anesthetic with different cases. An acute cold is a contraindication to any anesthetic, more especially ether. The cold invariably becomes worse, and pneumonia during certain seasons of the year is not infrequent; while chronic bronchitis is often improved by an anesthetic. Our pulmonary tubercular cases undergo ether well, as a rule. As Mellish