to total prostatectomy, the ability to empty the bladder spontaneously has been restored and has been maintained permanently, so that the catheter has been no longer necessary. In these cases there is but little, if any, residual urine, and the quality of the urine has become fairly normal. In a very large proportion of the remaining cases a marked improvement has resulted; the amount of residual urine has decreased, the intensity of the cystitis has diminished, and the frequency of catheterism has been lessened, and the facility of passing the instrument has been increased. As to catheterism we grant that, in many instances, the catheter is well borne for prolonged periods, but even in the cases which are most resistent, cystitis sooner or later develops and chronic prostatism follows. CHOICE OF OPERATION. We still recognize the three distinct types of diseased prostate, i. e., the massive, soft, adenomatous gland; the relatively small contracted hard prostate; and the mixed type. Formerly our judgment as to the character of operation to be selected depended largely upon the type of prostate with which we are dealing. As our understanding of the various pathological conditions becomes more enlightened, we find that the type of prostate is not so reliable a guide as other factors to be enumerated later. Choice of Operation.-Perineal prostatectomy is a more difficult operation and should be performed by one possessing special surgical ability and special training. It, however, entails less post-operative discomfort to the patient, the wounds heal more quickly, and normal urination is established sooner than in the suprapubic operation. It is to be preferred in the vounger patients where a more prolonged operation with the patient lying with his head lower than his body is not dangerous. Suprapubic prostatectomy is indicated in all cases of massive adenomatous hypertrophy of the prostate, irrespective of the age of the patient. It is, by far, the safer and easier operation for a surgeon of less experience. The technical part of the work is more easily accomplished, the prostate is more surely removed in its entirety, and there are fewer chances of wounding adjacent tissues. I believe that with sufficient care. the possibilities of preserving the ejaculatory ducts and preventing impotency are just as feasible here as in the perineal operation. As to the safety of the operation in a given case, the suprapubic operation is as safe as the perineal operation in any case, and can, in some cases, be safely done as a two stage operation, following previous cystotomy, where the perineal operation would unquestionably be fatal. More important, however, than the choice of the type of operation is the preliminary treatment of the patient. Prostatectomy is never an emergency operation and never should be undertaken without due deliberation and careful examination. It is especially important to know the amount, specific gravity, and character of the urine secreted. From this we can judge somewhat of the condition of the kidney and bladder if cystoscopy is not feasible. In my experience cystoscopy, in these cases, is desirable but not absolutely necessary; it may be harmful. The next important factor to know is the amount of residual urine, and the only way of determining that is by passing a catheter, after the patient has passed as much urine as possible immediately preceding the instrumentation. The character and size of the obstructing prostate can best be determined by rectal examination, combined with cystoscopic exploration of the bladder. The surgeon must, at all times, take into consideration the general condition of the patient, his arteries and his heart. The surgeon it. It is dangerous to completely empty a bladder which has been considerably distended for months. It will sometimes be followed by intravesical hemorrhage and considerable shock and prostration, and may defeat the purpose of the instrumentation. Gradually, the bladder is completely emptied, and, after three or four days, a continuous drainage of the bladder may be employed. In the cases of polyuria with a low specific gravity, it will be found that within 24 to 48 hours the amount of urine secreted in a day will materially decrease and its specific gravity correspondingly increase. With the permanent catheter in place, it is a simple matter to test the function of the kidney. We use, preferably, the P. S. T. test, phenol sul Of prime importance is the condition of the patient's kidneys. The enucleation of the prostate may be faultlessly accomplished from a technical point of view and yet death result from uremia, simply because too little attention was given to the condition of the kidneys before the operation. In this we have as our guides, chiefly the amount and specific gravity of the urine and not its albumin content and the various functional renal tests of which the P. S. T. test, i. e., the Phenol Sulphone Phthalein, is the most useful for our purposes. The Pilcher Observation Cystoscope The instrument was constructed for use especially in cases of obstruction or irregularity in the posterior urethra. It was found that a sound often times would pass more easily into a bladder than a cystoscope with a more angulated beak. Therefore, this instrument was constructed, and instead of having an angulated beak, it was constructed with a smooth curve, similar to the sound. It consists of a sheath and removable telescope fitted with a correct vision brilliant lens system, and has proven very satisfactory. The renal function is very considerably influenced by the amount of residual urine present in the bladder, therefore, the first indication is to regularly empty the bladder completely, and keep it empty long enough to allow the kidneys to readjust themselves before the shock of an operaton is added. This is best accomplished by the introduction of a permanent catheter. A catheter of about number 24 of the French scale is inserted until its eye is well within the bladder and fastened in place. A cork or clamp or clamp closes the outer end of the catheter. If there is a large amount of residual urine, the bladder should be partially emptied every two or three hours, or more frequently if the irritability of the bladder demands phone phthalein, and when we find the renal function is sufficiently re-established, we operate. This may take only three. or four days or even three weeks before the proper moment arrives, but it is worth waiting for. There are few of us, I am sure, who have not regretted hasty operations on these patients. The family, attending physician, and patient, are all clamoring for something to be done, and we are often thrown off the balance which our better judgment tells us we should maintain. The early stage of prostatic urinary obstruction in which there is little or no cystitis, a moderately increased frequency of urination, and only three or four ounces of residual urine does not call for any special surgical judgment to handle. A enlargement, and are already suffering from uremic symptoms and suppression of urine. su careful operation, either perineal or prapubic, in the hands of an experienced surgeon, will usually be successful. There are, however, the more advanced and complicated cases, which must be handled very delicately, with the greatest attention to details, lest the entire human fabric be ruined by a sudden undue stress being thrown upon one of its supporting timbers, which have not been braced sufficiently to withstand the shock. Class 1. Patients with a large amount of residual urine, who are passing 70 to over 100 ounces of urine of low specific gravity in twentyfour hours. Their rest at night is disturbed every thirty to forty-five minutes. In the treatment of these cases an indwelling catheter is used to gradually reduce the amount of residual urine, as previously described. When it is not possible to introduce a catheter or evacuator, the patient should be kept as quiet as possible, preferably spending most of his time in bed. The bowels are moved freely by salines, and the amount of liquid given is reduced to a minimum. In this way the amount of urine secreted is considerably diminished. Then, at a favorable moment, a suprapubic cystotomy should be done under local anesthesia, and bladder drainage established. No attempt should be made at this time to remove the prostate. Two weeks of this drainage should usually elapse before it is best to proceed to the removal of the prostate. Class 2. Patients with very frequent urination, or painful dribbling of urine, due to partial retention, complicated by a foul cystitis, with or without a calculus. Such cases, in my estimation, are best handled as in Class 1, by bladder drainage for, at least, one week either by catheter or suprapubic cystotomy, and then, depending on the special training and expertness of the operator, followed by a perineal or suprapubic prostatectomy. In all cases where a previous cystotomy has been done, a suprapubic enucleation can be accomplished most quickly and with the least amount of shock to the patient. I have, personally, removed a large prostate through a previously made cystotomy opening, in two and a half minutes. Class 3. Patients who have suffered a long time from urinary obstruction due to prostatic Some of these are beyond help, while others may be brought safely to operation and recovery. Of the former I have the record of a patient, 97 years of age, whom I called to see in consultation. He was suffering from partial suppression and complete retention of urine, I advised regular catheterism and frequent flushings of the bladder with hot saline solution. He had temporary relief but died, uremic, within a week. It is this class in which we must expect some mortality. If we refused to operate upon them, of course, our 5 or 10% mortality record would be reduced to 2 or 5%. But even in this class, many brilliant results are secured. Here preliminary treatment is absolutely essential and may last three or four weeks before it is safe to operate. Our routine in these cases is: An indwelling catheter and hot irrigations of the bladder for two weeks, or more. A suprapubic cystotomy at the most opportune moment, under local anesthesia, followed in a week or two, by a suprapubic enucleation and free drainage of the bladder. TECHNIC OF THE OPERATION Perineal prostatectomy has been SO carefully described by other surgeons, and Our own modifications in the technic which have been published elsewhere are of such minor importance, that time will not be taken to review this form of operation. Suprapubic cystotomy is performed, usually, under local anesthesia. The operation is started with the bladder empty. After the skin incision has been made, and the recti muscles separated and retracted, the bladder is filled with either sterile fluid or air, through the permanent catheter. As the bladder is seen bulging into the wound, two silverized catgut sutures are inserted to engage and hold the bladder. They mark the high point of the fundus which is to be incised, and serve to steady the bladder while it is being opened. They serve, further, to fasten the drainage. tube in place and close the bladder tightly around it. Our experience has taught us that closure of the sinus is more quickly secured if the opening in the bladder is high up on the fundus. Squire's point* is well taken when he says that "The bladder incision should be made high up on the fundus, close to the peritoneal reflection, for when the patient is in the tube is inserted, with its fenestrated end in the bladder, the bladder wall is snugly closed around it, using the silverized catgut sutures previously inserted, the suprapubic wound is closed around the tube, and, if desired, the tube is connected with a suitable urinal. If a permanent catheter FRY Supra-Pubic Prostatectomy The figure illustrates the removal of the prostrate by the supra-pubic method. The finger has been thrust into the prostatic urethra and enucleation is begun at the point furthest from the bladder. The section shows the finger breaking through the lateral inferior wall of the urethra. At this point it is easier to find the proper line of cleavage between the prostate and its capsule. The finger is swept from side to side, and it will be found that the portion which seems to be above the finger in the illustration, is part of the lateral mass and is easily enucleated with it. After the mass of prostate, including the median enlargement has been freed from its fascia and capsule it is turned out into the bladder and easily removed. The illustration shows how the prostate is supported by a finger in the rectum and pushed up nearer the enucleating finger. upright position, the beginning of the suprapubic sinus is in a less dependent position." Therefore, the tendency to urinary leakage is less marked. If the prostatectomy is not to be completed at this time, a large rubber drainage *Boston Medical and Surgical Journal, Vol. 164, No. 26, p. 911. has been previously inserted, it is allowed to remain in place. Through the suprapubic tube and catheter, the bladder may be treated if deemed necessary, but, as a rule, we find that irrigations after cystotomy are not indicated. The patient is allowed up in a day or two. Suprapubic prostatectomy is a compara moved. The loosened and somewhat torn pieces of mucous membrane which are left behind, fall into the cavity which is left, and, later, undoubtedly help in reforming a normally functionating vesical outlet. tively simple operation. A cystotomy be turned out into the bladder and reis performed as described above. If a suprapubic opening exists as a result of a former cystotomy the enucleation of the prostate is a matter of only a few minutes. Certain points are essential to a rapid, complete and satisfactory operation. The stretched and paralyzed sphincter of the bladder should be left as nearly intact as possible, the plexus of veins surrounding the neck of the bladder, lying beneath the mucous membrane, should be avoided, and the proper line of cleavage between the adenomatous, or fibro-adenomatous tissue, and its confining sheath and capsule should be found. To accomplish this, the enucleation should be started within the prostatic urethra itself, and not by making a puncture through the bladder mucous membrane. Through the suprapubic opening, the finger is passed into the bladder and then is introduced into the prostatic urethra. Squire, who strongly advocates this operation, seeks the line of cleavage through the roof of the prostatic urethra. Personally, I have found it just as satisfactory to enter the tip of the finger anywhere except where the ejaculatory ducts enter; the main point being to have the finger outside the bladder. Aided by a finger in the rectum, the enucleation of the distorted prostatic mass is quickly accomplished and, when loosened up, may After removing the prostate and checking the hemorrhage, if there is any to speak of, the suprapubic opening is closed around a fairly large rubber drainage tube. The permanent catheter still remains in place in the uretha. Both the suprapubic tube and the urethral catheter are connected by rubber tubing with urinals. The bladder may be irrigated through either tube. The suprapubic tube is removed after twenty-four hours and the opening allowed to close if it will. The patient may be allowed up at any time. In review of my own work and that of others, I feel that every surgeon who attempts this work should outline some definite line of attack and perfect himself in that method; not trying this operation and then another, never mastering the really important details of any. Patience, preparation, careful observation, attention to the smallest details, the preliminary drainage of the bladder, clean cut, rapid enucleation, these are the essentials necessary to success in these cases. 145 Gates Ave. DISCUSSION I. D. LOREE, Ann Arbor: I wish to repeat a statement that I made two years ago, at the annual meeting of this society, in which I said: "The choice of operation for senile hypertrophy of the prostate has no influence upon the mortality." In the choice of operation, two things must be considered; viz., the mortality and postoperative complications. Such complications oftenest encountered are permanent fistula and incontenence, either one of which is very disagreeable, not only to the patient, but to the operator. During the last two years, I have performed both the perineal and suprapubic operations, I have had fewer postoperative complications by the latter route, and I think we should be guided in our choice of operation by the one that will give our patient the greatest comfort. There are both good and bad things to be said for each operation. The old idea that you may tear into the bowel, when employing the perineal route, is no more likely than that you should open the general peritoneal cavity when operating from above. If we publish our failures, as |