again. Cystitis added to the symptoms caused by the contraction. Towards the latter part of December the supra-pubic wound gave way again with considerable sluffing of surrounding tissues. All urine then passed through this opening. On January, 4, 1902, I again went to McKinney to operate on the boy. Besides Dr. Wiley, I had the assistance of Drs. Kirkpatrick and Largent, of McKinney, and Dr. Calaway, of Midland, Texas. Patient was given chloroform, and although completely anesthetized we could not irrigate bladder with receptacle seven feet high. No fluid would pass through the contraction. It was necessary to pass a small, stiff catheter for the irrigation. After bladder was thoroughly washed a No. 28 grooved staff was with some difficulty passed. Perineal section was then made and on introducing finger the membranous urethra was found normal in size, as well as anterior portion of prostatic urethra. At posterior portion of prostatic urethra the tip of finger came in contact with a tight circular contraction. No little force was required to introduce finger to depth of nail. After permitting each assistant to examine the constriction, the left index finger was again passed with much force as far as first joint. The circular fibers were cut on floor and finger passed into bladder. Not feeling that the contraction was thoroughly relieved, a shallow cut was made on roof of canal. After fibers were cut, the canal felt normal. There seemed no hypertrophy of these circular bands, and the prostate from rectal touch was found normal. As described by Dr. Fuller, the urethra in front of contraction was pouched. Perineal drainage was kept up for several days with daily irrigation of bladder. The boy recovered rapidly from the operation. A recent letter from Dr. Wiley states that the result of operation was all that could be desired. The urine is clear and the patient is entirely free of all his old symptoms. A No. 30 F. sound is passed with ease. I have every reason to believe that the cure will be permanent.

DISCUSSION.

DR. KEILLER: In a paper in the British Medical Journal I came across a number of cases similar to the one just reported, in all of which it was claimed that complete relief was obtained by operation.

DR. J. E. THOMPSON:

This is the first time I have heard of such a condition as that just described, but I may quote an analagous case. I recollect on one occasion seeing a patient who had chronic rectal trouble. He thought it necessary to keep his bowels moving two or three times a day. He came to me with symptoms pointing to stricture. I found that the sphincter muscle was chronically contracted. There were no cicatricial lesions. Of course the cause was undoubted-too much use of the sphincter muscle. In the present case the age of the boy and the absence of gonorrhea, as well as of any other history accounting for the condition, makes the case peculiar.

DR. CANTRELL: I have never had any experience along this line, but I have been interested in the paper, and in future will be more careful to look out for conditions of the kind referred to.

DR. H. A. WEST: I do not know anything about the particular subject dealt with, but the reading of the paper has reminded me of an interesting case that lately came under my observation showing the interchangeable symptomatology of affections of the rectum and bladder. Nothing I could use had any effect. The patient, a woman, suffered from constant vesical irritation. At last I found a small urethral caruncle. I proceeded to remove it, and she was better for a few days, when the bladder irritation returned. At last she said something about piles, to which my attention had not been previously drawn. Finding a mass of inflamed and ulcerating hemorrhoids, I proceeded to remove them, and her vesical trouble was immediately relieved. In other words, treatment of the rectal disease completely cured the bladder trouble.

DR. S. E. MILLIKEN: The subject is a very interesting one. I believe the condition is due to the contracted state of the muscles.

DR. SHELMIRE: Contraction of the muscles is not an analagous condition. No operation on the membranous urethra would have had any effect. The growth was in the posterior part, and was a hard structural ring. As to the cause we could not find anything. I am sorry I had not as accurate a history of the case as I would have liked. The only thing that could have acted as a cause was that the boy masturbated moderately. Still, I believe if that were the cause such conditions would be more frequent.

THE SURGICAL TREATMENT OF ENLARGED

PROSTATE.

BACON SAUNDERS, M. D.,

FORT WORTH, TEXAS.

If a reason were sought for the recent great activity in the development of the surgical treatment of enlarged prostate, it could easily be found in the following conditions. Practically all men, or at least a very large number of men, over sixty years of age have more or less of the distress and disability that follow in the train of symptoms due to prostatic hypertrophy. It has been truthfully said, too, that it is the man ripe in years, mature in judgment, and full of honors and usefulness and whose presence and valuable counsels can least be spared from the circle in which he lives, that is the victim of this disease. Under accepted methods of treatment up to within the immediate past, the possessor of a prostate that prevented the complete emptying of his bladder, was condemned by force of circumstances of the prevalent treatment to a lingering death of agonizing pain, except the fortunate few who were able by leading "a catheter life" to postpone the inevitable until in the kindness of fate some other malady or infirmity took them off.

Hitherto, the results of radical surgical methods aimed at the removal of the cause of the distressing condition of prostatism had not been such as to justify in the minds of surgeons generally its adoption except in the most favorable cases under the most exceptionally promising circumstances. Consequently, after the usual fruitless efforts at relief by medication, these most worthy and influential citizens were given a catheter, instructed in its use, aided by an occasional antiseptic bladder irrigation, and were told when they could no longer procure comfort from its use there was nothing left but to resort to opiates and wait with what composure they can the coming of certain doom.

Happily, meanwhile, a few surgeons more aggressive than the

rest were continually asking the question, "Why these things should be," and cut short the useful lives of the choicest men of the land.

In the evolution of the surgical treatment of urinary obstruction due to enlarged prostate, as worked out by these restless spirits, seeking for a ray of hope for these unfortunates, we have by common consent reached that point in the development of operative technique that offers a cure by methods entirely within the limit of surgical safety.

It is not the intention to discuss at this time the steps by which this conclusion is reached any more than it is to deal with the complex problem of hypertrophied prostate from an anatomical or pathological point of view. Enlarged prostates with all their train of disastrous consequences, men have had, do have, and will probably continue to have. Let others of more philosophical turn of mind attempt to answer why. It is enough for this inquiry to know that with the present method of operative treatment men should not, must not, be allowed to die from prostatic obstruction without an effort to save them. There are reasons to believe that in the immediate future, as a result of still better technique and early operations, enlarged prostate will cease to be the bête noire of surgery and the constant menace to the lives of old men.

The proper surgical treatment of enlarged prostate depends upon two things: the general condition of the patient, and the size, situation and condition of the gland itself.

To state the case a little dogmatically, perhaps, if the patient's condition is not too reduced from age, cystitis, pyelitis and exhaustion to stand a somewhat prolonged operation, and sometimes a rather bloody one, and if the prostate is a large one, the gland should be removed by prostatectomy, either through a supra-pubic or perineal incision. Sometimes neither of these methods is easy to do, and both are often difficult and bloody. The choice of route will depend upon the skill of the individual operator, the thickness of the abdominal wall, the depth of the pelvis and the size of the gland to be removed. In most cases of large middle lobe projecting up into the bladder the tumor can be more easily reached through the bladder, as, indeed, can all or most all very large

21-Trans.

glands. Small, soft enlargements can be attacked better by the perineal incision aided by special retractors and hooks to draw down the capsule and with it the gland or part of gland to be removed. If there has been no adhesive inflammation between the gland and its capsule, the glandular tissue can be "peeled out" without any great difficulty, but in cases ordinarily coming to operation there will nearly always have been adhesion enough between the gland and capsule to make the "peeling out" much easier to read about than to do.

In cases clearly unsuitable for prostatectomy prostatomy by the Bottini method may be done. The method is applicable to a limited number of cases, and is only partially successful in them. The operation is not the simple and easy one to do that some of its advocates would have us believe, and has its dangers as well as limitations. The mortality after prostatomy is undeniably less than after prostatectomy, but so also are the chances of a cure after it unquestionably much less. So that it will probably be better and safer surgery in cases too far gone for prostatectomy to offer a reasonable hope to trust for temporary relief from pain, distress and sepsis to supra-pubic drainage, unsatisfactory as it generally is to both operator and patient.

It now appears to be a reasonable conclusion that the surgical treatment for enlarged prostate has approached that stage in its history to justify its claim to general recognition, as not only admissible, but urgently demanded as giving strong grounds for hope in a class of cases that are of all men the most miserable and that are otherwise "without hope in the world.”

But the surgeon cannot save any respectable number of cases of enlarged prostate by this or any other plan of treatment as long as they are only sent to him reeking with sepsis and completely exhausted by "hope deferred" as a result of the "catheter life" or other worse than temporizing methods of treatment.

Let us hope the future has in store for these old men better things than their predecessors even dreamed of as possible. If this hope. is to be realized it will be largely along the lines of better development of individual skill and technique, and especially from the