RC^Hq n. Columbia (Hnitiem'tj) intlieCttpotlfttigork College of ^fjpsficiang an& ^urgeonfi ilibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/studiesonhypertrOOyoun THE JOHNS HOPKINS HOSPITAL REPORTS THE Johns Hopkins Hospital Reports STUDIES ON HYPERTROPHY AND CANCER OF THE PROSTATE VOLUME XIV BALTIMORE The Johns Hopkins Press 1906 '?? /'/ Copyright, 1906, by THE JOHNS HOPKINS PRESS BALTIMORE, MD., U. S. A. CONTENTS I. The Treatment of Prostatic Hypertrophy by Conservative Peri- neal Prostatectomy. An Analysis of Cases and Results based on a Detailed Report of 145 Cases. By Hugh H. Youxg, M. D. . 1 II. Recto-Urethral Fistulge. Description of New Procedures for their Prevention and Cure. By HroH H. Young, M. D 477 III. The Early Diagnosis and Radical Cure of Carcinoma of the Pros- tate. Being a Study of 40 Cases and Presentation of a Radical Operation which was Carried Out in Four Cases, and an Appendix, Compiled Later, Containing the Complete Histories of 64 Cases. By Hugh H. Yovsg, M. D 485 ILLUSTRATIONS 1. Large intravesical median lobe removed by suprapubic route (Fig. 1) 7 2. Instrument completed (Figs. 2 and 3) 10 3. Longitudinal section of normal prostate (Fig. 4) 11 4. Cross-section of normal prostate (Fig. 5) 12 5. Longitudinal section of a prostate, with great hypertrophy of the median and lateral lobes (Fig. 6) 13 6. Six cross-sections of the same prostate at different levels, as in Fig. 5 (Fig. 7) 14 7. Side view of hypertrophied prostate, showing low entrance of ducts on posterior surface (Fig. 8) 15 8. The inverted V cutaneous incision (Fig. 9) 16 9. Exposure of bulb, central tendon, and levatores ani (Fig. 10) ... . 17 10. Bifid retractor (Fig. 11) 18 11. Bifid retractor. Side view (Fig. 12) 18 12. Showing bifid retractor, exposing and making tension on the cen- tral tendon (Fig. 13) 19 13. Opening of urethra on sound, preparatory to introduction of tractor (Fig. 14) 20 14. Tractor introduced ( Fig. 15 ) 21 15. Showing position of blades in interior of bladder in case of median and bilateral hypertrophy (Fig. 16) 22 16. Posterior retractor (Fig. 17) 23 17. One of the lateral retractors (Fig. 18) 23 18. Blunt dissectors or enucleators (Fig. 19) 23 19. External enucleation begun (Fig. 20) 24 20. Lobe forceps (Fig. 21) 25 21. Enucleation of lobes. Forceps in position (Fig. 22) 26 22. Two lobes removed by perineal prostatectomy (Fig. 22a) 26 23. Schematic cross-section after enucleation of lateral lobes, show- ing ducts and median bridge of tissue (Fig. 23) 27 24. The blade rotated so as to engage middle lobe (Fig. 24) 27 25. Showing technique of delivery of middle lobe into cavity of left lateral lobe (Fig. 25) 28 26. Photograph of a pedunculated median lobe which was removed through the cavity left by left lateral lobe without tearing urethral or vesical mucosa (Fig. 2oa) 29 27. Photograph of prostate in which the left and median lobes were enucleated in one piece (Fig. 26) 30 viii Illustrations. 28. Longitudinal section after enucleation of median lobe through a lateral cavity ( Fig. 27 ) 30 29. Cross-section at level of cavity left by median lobe (Fig. 28).... 30 30. Blade engaging anterior lobe (Fig. 29) 31 31. The use of index finger to deliver a small median lobe into lateral cavity (Fig. 30) 32 32. Showing suburethral method of enucleating median bar (Fig. 31) 34 33. Schematic longitudinal section of the urethra, showing the me- dian enlargement enucleated beneath the urethra (Fig. 32) . . 34 34. Photograph, natural size, of a small median bar (Fig. 33) 35 35. Division of lateral wall of urethra to allow extraction of large calculus through left lateral cavity (Fig. 34) 36 36. Exact size of calculus removed through perineal incision (Fig. 35) 37 37. Showing how the tractor may slip beneath prominent lateral lobes (Fig. 36) 38 38. Scheme of continuous irrigation apparatus (Fig. 37) 39 39. Approximation of levator ani muscles with single suture of cat- gut (Fig. 38) 40 40. Final closure (Fig. 39) 42 41. Gimlet curette (Fig. 39') 101 42. A picture commonly seen in the glandular form of hypertrophy (Fig. A) 126 43. Epithelial activity in one of the acini shown, has resulted in the formation of capillary loops (Fig. B) 127 44. A very glandular form of hypertrophy (Fig. C) 128 45. A high magnification of portion of the field shown in C (Fig. D) . 129 46. In the center is seen a rather extensive degree of cystic dilata- tion of numerous acini (Fig. E) 130 47. A section from the periphery of a hypertrophied lobule showing the condensation of the tissue and the flattened and elongated acini (Fig. F) 131 48. Represents a fibro-muscular form of hypertrophy (Fig. G) 132 49. A cross-section of a prostate which represents an early stage of hypertrophy (Fig. H) 135 50. A cross-section of a hypertrophy somewhat more advanced than that seen in Fig. H (Fig. I) 135 51. The hypertrophy here is advanced still further than that seen in Figs. H and I (Fig. J) 136 52. A myomatous nodule (Fig. K) 137 53. Single-bladed tractor (Fig. 39a) 143 54. Lateral lobes, median bar, and floor of urethra removed in one piece (Fig. 40) 143 55. Single-blade prostatic tractor (Fig. 40a) 150 56. Large lateral and median lobes (Fig. 41) 170 Illustrations. ix 57. Lateral lobes, moderate median bar, small pedunculated sub- cervical median lobe (Fig. 42) 200 58. Long pedunculated median lobe, moderate lateral lobes (Fig. 43) . 269 59. Case 64 (Fig. 44) 287 60. Large lateral lobes, each with a portion of median lobe attached (Fig. 45) 289 6L Case 74 (Fig. 46) 309 62. Median bar, oral suburethral lobe, two lateral lobes (Fig. 47).. 312 63. Case 104 (Fig. 48) 375 64. Large coalescent median and lateral lobes (Fig. 49) 388 65. Case 121 (Fig. 50) 416 66. Large median and lateral lobes (Fig. 51) 420 67. Very small median and lateral lobes, causing complete retention of urine (Fig. 52) 426 68. Case 126 (Fig. 53) 428 69. Case 127 (Fig. 54) 432 70. Case 137 (Fig. 55) 454 71. Small median and lateral lobes from man, age 37 (Fig. 56) 455 72. Large globular median lobe, moderate-sized lateral lobes (Fig. 57) 468 73. To show levator muscles (Fig. 1) 481 74. After transverse section of urethra (Fig. 1) 499 75. Exposure of the seminal vesicles (Fig. 2) 500 76. Incision into bladder just above prostate (Fig. 3) 501 77. Exposure and division of trigone (Fig. 4) 502 78. Final separation of seminal vesicles and division of vasa (Fig. 5) 503 79. Photograph of specimen, side view (Fig. 6) 504 80. Photograph of posterior view of specimen (Fig. 7) 504 81. The anastomosis of anterior wall of bladder to urethra has been made. The rest of vesical opening is being closed (Fig. 8) . 505 82. Diagram showing plan of vesico-urethral anastomosis (Fig. 9).. 506 83. Lateral view of specimen from Case VIII. Case 11, side view prostate and vesicle (Fig. 10) 513 84. Anterior view, showing trigone, urethral orifice, the vasa, and prostate ( Fig. 11 ) 515 85. Schirrous form of adenocarcinoma. Case 13a (Fig. 12) 528 86. A medullary form of carcinoma in which there is very little stroma and the cancer cells varying in size and shape are loosely arranged. Case 64 (Fig. 13) 529 87. A tubular form of carcinoma in which solid strands of epithelial cells are seen growing into the lumina of the tubules and by their union forming irregular open spaces. Case 10 (Fig. 14) 530 88. Nests of cancer cells lying in between dense bundles of muscle. Case 10 (Fig. 15) 531 X Illustrations. 89. A small carcinoma nodule about 2 mm. in diameter in an other- wise benign prostate. Some of the normal acini still persist in the cancerous area. Case 9 (Fig. 16) 532 90. Shows an acinus partly lined by cancer cells and partly by normal epithelium. Case 14 (Fig. 17) 533 91. Cystoscopic chart before operation. Case 10 (Fig. 18) 560 92. Cystoscopy one year after perineal prostatectomy. Case 10 (Fig. 19) 562 93. Prostate and region of seminal vesicles (Fig. 20) 604 94. Outlines of induration in region of prostate, seminal vesicles, and intervesicular space. Case 53 (Fig. 21) 613 95. Shape of the prostate and indurated vesicle. Case 56 (Fig. 22) . . 617 96. Rectal chart with outlines of prostate, vesicles, lymphatics, and pelvic glands shown in comparison with normal (in dotted lines). Case 60 (Fig. 23) ^T6 97. Cystoscopic chart showing irregular tumor growth around pros- tate orifice. Case 61 (Fig. 24) 625 STUDIES ON HYPERTROPHY AND CANCER OF THE PROSTATE BY HUGH H. YOUNG Associate Professor of Genito-Urinary Surgery, The Johns Hopkins University THE TREATMENT OP PROSTATIC HYPERTROPHY BY CONSERVATIVE PERINEAL PROSTATECTOMY. AN ANALYSIS OF CASES AND RESULTS BASED ON A DETAILED REPORT OF 145 CASES. By HUGH H. YOUNG, M. D. CONTENTS. I. Peeface: Misleading Statements and Statistics in the Liter- ature 2 II. The Operation of Conservative Perineal Prostatectomy 6 III. An Analysis of 145 Cases of Perineal Prostatectomy 43 a. Onset of the disease 47 b. Status prsesens 54 Symptoms 54 Sexual powers 58 Catheter life 58 Condition of patient 61 Character of prostatic enlargement 64 Cystoscopic findings 71 c. Preliminary treatment 77 d. The operation 81 Character of technique 81 Shock of operation; spinal anaesthesia 85-86 Characteristics of lobes removed 87 Operation in the presence of vesical calculi 92 e. The convalescence 93 Complications 95 Length of time in hospital 98 f. Immediate result. Condition on discharge 101 g. Condition after leaving hospital 108 h. Contracture of bladder before and after operation 110 i. Ultimate results 113 Mortality 113 The removal of obstruction 116 Perineal fistulse 118 Frequency of urination due to vesical contracture .... 118 Cases now suggesting presence of calculi 118 Cases with peculiar symptoms 119 Hugh H. Young. Recto-urethral fistulse 120 Incontinence of urine 120 Pain 121 Preservation of sexual powers 122 j. The pathology, as shown by a study of 120 cases 124 fc. Conclusions 140 PREFACE. I. Misleading Statements and Statistics in the Literature. The following paper is the result of numerous articles which have appeared recently, demanding more detailed information as to the pre- and post-operative condition of patients on whom perineal prostatec- tomy has been performed. The promulgation of successful methods of removing hypertrophied prostates, and the assertion of their benignity has been followed by their wholesale employment by men unprepared to do these operations, and as a result a considerable mortality has been produced and many of the operative results have been imsatisf actory. Many physicians without special operative training, doing a surgical operation only now and then, without the requisite knowledge of the rather intricate anatomy of the perineum, and the pathology and mechanics of the prostatic obstructions, have boldly essayed to operate these cases and as a result a frightful mortality and a horrible record as to results and complications has been recorded against a benign and thoroughly successful procedure. It is not surprising then that Whiteside finds a mortality of 20% in 36 cases reported by nine operators, and absolutely good results in only 30% of the cases, and that Belfield and Pedersen after making similar studies shoidd send out " timely " warnings against prostatec- tomy as a routine procedure, and that we should hear of " a return to conservative methods,^' non-operative treatment, the catheter life (with all its horrors!), and the "selection of cases" which are suitable for operation. If the reaction against operation which has been aroused (for the pendulum once started backward must continue its swing) results in discouraging men imprepared to do good work in this line, men who cannot use and decry the using of the cystoscope and ignorantly neg- lect to take advantage of its often great assistance, and who rush in study of 145 Cases of 'Perineal Prostatectomy. 3 blindly without knowing, seeing or apparently caring what they are doing, much will be gained. But if the medical profession is unduly alarmed and, returning to the old so-called conservative methods rele- gates such patients to miserable catheter lives, and refuses them the splendid results obtainable by accurate methods, much will be lost. Such is the history of all advances in surgery — first the demonstra- tion of valuable new procedures, then a horde of bungled operations, then a discovery of miserable results and a startling mortality, then a reaction against the procedure, and finally, but after the loss of many valuable years, a return to the truth. When one has had during the past year 50 consecutive operations, with but one immediate or remote death (and this patient in extremis at time of operation), with no complications of the slightest moment, and no bad results it is not wonderful that he feels outraged by the presentation of a mortality of 30% and successful results in only 30% in 36 cases operated on by nine surgeons ! There have also been those of experience and knowledge, but cham- pions of the suprapubic route, who have savagely attacked perineal, prostatectomy (without having tried the procedure). For example, in the Transactions of the Medical Society of London for May 8, 1905 (Vol. XXVIII), in a discussion on "The Perineal and Suprapubic Methods of Prostatectomy," one of the members is reported to have thus delivered himself: " Mr. P. J. Freyer remarked that he had not come either to read a paper or to make a speech on the subject, as his views with reference to removal of the prostate had already been placed before the Profession in numerous lectures and papers which had been published in the journals during the last four years. He congratulated the Society that it had awakened from what appeared to be a lethargy with regard to the great subject of removal of the prostate. It seemed extraordinary that during the past four years, when the subject had been so much discussed, the oldest medical society in London should not have hitherto invited discussion upon it. He thanked his old friend and colleague, Mr. Harrison, for the full-hearted eulogium which he had been good enough to pronounce upon his (Mr. Freyer 's) operation, which was all the more gratifying as Mr. Harrison's views in that respect had been a plant of slow growth. When first introduced to the Profession the operation was not fully grasped by Mr. Harrison, who did not believe in its efficacy. With reference to the subject of perineal and suprapubic prostatectomy, he remarked that there was no comparison whatever capable of being introduced between the two operations, because they did not deal with the same subject. It was 6 Hugh H. Young. In this report I have not given the details of five cases in which perineal prostatectomy was performed thinking that the prostate was benign when subsequent examination showed that it was malignant, six cases which were under my care but were turned over to assistants (the operation being partly performed by me), three cases of perineal prostatectomy done without the tractor, and four cases of perineal prostatectomy for chronic prostatitis. Most of these cases will be found reported in more or less complete detail in other portions of this volume, in the articles on carcinoma and prostatitis. There were no cases of rectal fistula, or other bad results among them so that nothing is being concealed. The present study of cases is intended to include only those operated by a special technique and of a benign hypertrophic character. II. The Operation of Conservative Perineal Prostatectomy. In several publications which have appeared at intervals during the past four years, I have described a so-called method of conservative perineal prostatectomy and reported lists of cases. The development of the operation and the reasons for the various improvements were described as follows in my first publication in the Journal of the American Medical Association,^ October 24, 1903. The literature of the prostate and its operative treatment has be- come so vast that I vsdll not attempt to discuss the many valuable articles which bear on this subject, but will simply present a resume of my own work and the problems which have presented themselves. My first prostatectomy was in 1S98, a patient on whom a supra- pubic opening had been made for drainage. At this operation a tre- ^ The use of a new tractor for perineal prostatectomy was first described in a discussion at a meeting of ttie Southern Surgical and Gynecological Association, on November 12, 1902; a second report was made and a perfected technique by which the ejaculatory ducts were preserved, de- scribed at a meeting of the Medical and Chirurgical Faculty of Maryland in April, 1903. A more complete report was made before the American Association of Genito-Urinary Surgeons, May 12, 1903, and was published in the Journal of the American Medical Association, October 24, 1903. Since then additional reports have been made in the Monatsberichte fiir Urologie, Bd. IX, Heft 5 u. 6, 1904. Journal of the American Medical Association, October 4, 1903. The Annals of Surgery, April, 1905, and the Journal of the American Medical Association, 1905. study of IJj-o Cases of Perineal Prostatectomy. 7 mendous intravesical outgrovrth of the middle lobe "^as found, and as there was Terr little enlargement of the lateral lobes, I enucleat-ed the mass through the suprapubic -wound, with the assistance of a finger in the rectum (Fig. 1), a method which has also been employed by Guiteras, and described bv him in 1900. Y^> 9^ Fig. 1. — A large intravesical median lobe removed by suprapubic route. Actual size. The next three cases presented no median enlargements, the hyper- trophy being confined to the lateral lobes. Following the advice of Alexander, I used the combined method, removing the lobes through the perineal wound with the assistance of a suprapubic incision, illthough the operation was tedious and extensive, these patients did well, and in a paper on the subject I said that Alexanders was the operation of choice, except for middle lobe cases. 8 Hugh H. Young. My next four cases were characterized by considerable middle lobe enlargements, and I therefore used the suprapubic route, and was sur- prised to find that with the assistance of the finger in the rectum I could easily enucleate very large lateral lobes in one piece with the median without destroying the urethra. The operation was also very much quicker — it frequently being possible to complete the enucleation in five to six minutes, whereas the combined operation would fre- quently take nearly an hour. The principal objection to the perineal route was the necessity of the suprapubic incision to push the prostate down into the perineum where it could be enucleated, and I then thought of having an instru- ment made with two blades which could be inserted closed through a perineal urethrotomy, separated when in the bladder, and then used as a tractor to drag the prostate toward the perineum. This was in 1899, but I never had the instrument constructed, but continued to do all prostatectomies suprapubically. The results obtained were excellent, the greatest objection being the considerable hemorrhage following the operation, the great duration of the convalescence and the occa- sional development of suprapubic hernia afterward. In 1899 several patients came to me who were so old and so weak that I was afraid to even administer a general anesthetic, much less to do so severe an operation as a suprapubic prostatectomy. One patient being unable to use a catheter, caused me to purchase a Bot- tini incisor, and the results which I obtained on extremely old and feeble men, under local cocaine ansesthesia, were indeed so marvellous that I adopted the Bottini operation as the method of choice in cases past 65 years of age, who were not in a prime surgical condition. Using my instrument with interchangeable blades of different size I was able to operate safely and radically on prostates of any size. I found it possible also to successfully attack large middle lobes by making an oblique incision with the cautery blade on each side of the pedicle, thus dropping it back out of the way, where it would after- ward atrophy. In two years I operated thus on 40 cases, with two deaths, only one of which was due to the operation. Of these 15 were over 70 and three over 80, with no deaths, and with cures in all these cases but one. I feel sure that many of these patients would have succumbed had a suprapubic or a combined prostatectomy under general anaesthesia been done, with the subsequent prolonged recumbent posture. The study of Ho Cases of 'Perineal Prostatectomy. 9 use of cocaine, the little shock and hemorrhage produced by the Bot- tini, and the rapidity of the convalescence — out of bed on the second or third day — ^were the factors which contributed to save them. Since then I have used the cautery incisions on many more cases, some just as old and as desperate as those described above, with similar gratifying results. The publications of S}Tns, Murphy, Ferguson, Bryson, and others within the past two years, caused me to turn my attention again to the perineal route. In studying the methods that have been proposed, the intravesical balloon, which Syms used to draw the prostate into the perineal wound, seemed to me to be much better suited to over- come the great objection to perineal prostatectomy, the depth of the wound with the consequent difficulty of reaching the lobes to enucle- ate them, than MurpM^s hooks, Ferguson's capsular retractors, or Bryson's suprapubic prevesical incision. The rubber balloon did not, however, appear to me to be quite per- fect in that it did not seem to furnish sufficient strength for the great traction which is necessary, and the fact that S}Tns had acknowledged that he found a metal instrument devised by Gouley, which was passed like a sound into the bladder, of great assistance in pushing down the prostate, confirmed me in my opinion that while the idea of making traction by means of an instrument which could be introduced into the bladder through a perineal urethrotomy wound was correct, the method adopted by Syms — the rubber balloon and the tube— could be improved on. I therefore set to work to construct an instrument of metal for this purpose. After several months of experiment, during which I en- deavored to discover and correct the faults of each model ^ by operative use, the instrument was completed, as shown in Illustrations 2 and 3. It consists of two fenestrated blades attached to shafts, one of which revolves around the other. When the two handles near the outer end which regulate the rotation are brought together the blades are approximated and in position for insertion into the bladder through the opening in the membranous urethra (Fig. 2). Once intro- duced above the intravesical limits of the prostatic lobes the blades may be separated by rotating the handles away from each other (Fig. 3), A ^ See Appendix, Case 1, p. 143, for description of first instrument used and p. 150 for the second modification. 10 Hugh H. Young. when it is ready for whatever traction on its shaft may be necessary to draw the prostate well into the perineal wound. Before discussing the use of this instrument, however, I wish to discuss some problems of technic and conservatism which have been met. The ejaculatory ducts. — The fact that many of the cases requiring prostatectomy are vigorous men in the fifties, with sexual powers well preserved, renders it important to do nothing to injure their manly vigor. Fig. 2. — The prostatic " tractor " closed, ready for introduction. Fig. 3. — The prostatic tractor opened out. In a recent report. Petit ^ furnishes the results of a careful study of Albarran's cases of perineal prostatectomy. He was able to fol- low six cases who had had normal sexual powers before the operation. Of these, two, both under 60 years of age, have never been able to have erections since the operation. In two cases the erections are much en- feebled; two cases are as strong sexually as before operation. The operation is performed by Albarran without respect to the ejaculatory ducts, the prostatic urethra being opened widely in the median line, and the lobes enucleated through this incision. It would seem that the ejaculatory ducts are almost certain to be injured or removed in this procedure. ^ Petit: De la Prostatectomie Perineale, Paris, 1902. study of 145 Cases of ■Perineal Prostatectomy. 11 Petit mentions the work of other operators and concludes : " It seems to be shown that perineal prostatectomy diminishes if it does not suppress erections in some cases. But it is a curious fact that some cases operated on can still ejaculate." Another evidence of in- Jury done to the ejaculatory ducts is that Petit reports that 12 cases in 30 suffered with epididymitis after the operation. I know of no other statistics on these points. The three cases on whom I performed perineal prostatectomy by Alexander's method five years ago I have been unable to follow, and the twelve perineal prostatectomies which I have done in the past five months are too recent to draw final deductions from. Although the question needs further study, it is nevertheless evident that due attention should be paid, in performing the operation, to the importance of the prostate as a sexual organ. Fig. 4. — Longitudinal section of normal prostate. A, Prespermatic group of glands. In order to determine the relation of the ejaculatory ducts to the urethra and the prostatic lobes, I have made transverse and longi- tudinal sections in the specimens both of normal and of hypertrophied prostate. The accompanying illustrations show very graphically the course of the ejaculatory ducts in the normal state (Figs. 4 and 5). As seen here, if we trace them backward from their urethral orifices we find that they rapidly approach the posterior capsule of the prostate; that the tissue separating them from the urethra gradually increases, and that the point of junction of the seminal vesicle and vas is reached considerably in front of the junction of the prostate with the bladder. Stained sections of the posterior portion show a considerable agglom- eration of the glandular tissue surrounded by encircling muscular and connective-tissue fibers which separate it more or less markedly from the glandular tissue of the adjoining lateral lobes. This mass of 12 Eugli H. Young. glands has been called by Albarran ' the prespermatic group, and this it is which is most concerned in the production of median lobe en- S ^ Fig. 5. — Cross section of normal prostate. A, At a point just in fronr of opening of ducts and utricle; B, at opening of utricle and ducts; C and 1) 5-10 mm. back; E, at entrance into bladder; G, at the junction of seminal vesicles and ampullae; E, the seminal vesicles and ampullae separated. largements. If this mass of glands (Fig. 6, A) is only slightly hyper- trophied a median bar may be produced, which may be continuous with 'Albarran and Motz: Annales d. Mai. d. Organes Genito-Ur., July, 1902. study of 145 Cases of 'Perineal Prostatectomy. 13 the lateral enlargements on each side, the whole forming a collar around the prostatic orifice. If, however, this group takes on con- siderable hypertrophy a sessile or pedunculated intravesical median lobe, sometimes of huge dimensions, results. In these latter varieties another group of glands which lie just beneath the mucosa where the trigone joins the urethra, and which Albarran has called the sub- cervical group, may take part in the hypertrophy. All these median enlargements grow upward, away from the ejaculatory ducts, from which they are separated by considerable tissue, including their en- capsulating fibers. Fig, 6. — Longitudinal section of a prostate, with great hypertrophy of the median and lateral lobes. Urethra very wide and thin. Note low in- sertion of ducts. In the hypertrophied prostate the position of the ejaculatory ducts and vesicles depends considerably on the character, size, and disposition of the enlargements. If the hypertrophy is great, and especially if a considerable median lobe is present, the vesical neck is generally found elevated far above the level of the ducts and vesicles, as shown in Fig. 6, which is a longitudinal section of a prostate in which the lateral and median lobes are all three greatly hypertrophied. The ducts enter so low down on the posterior surface of the prostate that the median lobe is not in relation to them at all, and is separated from the vesicles by the prostatic capsule. It would, therefore, be easy to enucleate this lobe without injuring the ducts at all if properly done. Note here also the great width of the urethra, the proximity of its 14 Hugh H. Young. floor, and the sharp bend which it makes in front of the middle lobe. Cross-section A (Fig. 7) is taken where the utricle and one duct enter the urethra ; B is taken a little further back and shows the ducts (^) ^^) Fig. 7.— Six cross sections of the same prostate at different levels, as in Fig. .5. The ducts rapidly approach the posterior capsule and in D are already outside of it. A shows the beginning of the median lobe, and F just before the entrance of the urethra into the bladder. study of IJfO Cases of 'Perineal Prostatectomy. 15 midway between the posterior capsule and the urethra. Xote the inverted Y urethra produced by the verumontanum below and the pressure of the lateral lobes against each other in front, and the slit- like character of the urethra. In G the ducts lie very close to the capsule. Section D, which has been taken through about the middle of the prostatic mass, shows the junction of the vesicle and vas just outside the prostatic capsule. ISTote the greater distance of the urethral floor from the capsule. This is shown in still greater amount in C, and the vesicles and ampuUge are here seen to be separated from the median mass by the prostatic capsule. In F, which is taken about 5 mm. in front of the vesicle orifice of the prostate, the further elevation of the median lobe is sho"^Ti. The full extent of the median lobe is shown in the median section (Fig. 6). Fig. 8. — Side view of hypertrophied prostate, showing low entrance of ducts on posterior surface. Figure 8 is a side view of another specimen in which the vesicles and vasa join the prostate low down on the posterior surface. In cases of little or no median lobe enlargement the hypertrophied lateral lobes seem also to carry the vesical neck upward and leave the vasa behind, so that they are often found entering the capsule well down on its posterior surface, as depicted in Fig. 8, the side view of a specimen of considerable hypertrophy of the right lateral lobe. The aponeurosis of Denonvilliers, which is firmly attached to the posterior surface of the seminal vesicles and of the prostate below their en- trance, and which binds the two together closely, may be responsible for the upward growth of the hypertrophied prostate and the result- ant low insertion of the ducts into the posterior surface. The results of this study of the course of the ejaculatory ducts may be thus summarized : 16 Hugh H. Young. In the normal prostate the ejaculatory ducts lie for the most part just beneath the posterior capsule, considerably below the level of the vesical neck, and are separated from it by the prespermatic group of glands. In the hypertrophied prostate the same statements are true, the only difference being that the ducts enter relatively lower down, and the vesical neck is separated from them by much more tissue, especi- ally if the prespermatic group of glands have taken on growth with Fig. 9. — iThe inverted V cutaneous incision. the resulting median lobe enlargement, in which case the vesical orifice is lifted high up above the level of the ducts. The prostatic tissue im- mediately adjacent to the ducts is beneath the urethra and plays no part in the obstruction, which is caused entirely by the lateral and median enlargements, both of which are well above the ejaculatory duets. The measures which I have adopted to preserve the integrity of the ejaculatory ducts and sexual puissance of the patient I will take up a little later. study of lJf5 Cases of Perineal Prostatectomy. 17 TECHXIC OP THE OPEEATION. Position of the patient. — The exaggerated dorsal lithotomy position is the most satisfactory. The perineal board of the Halsted table is admirably suited for this purpose. The perineum should be so ele- vated that it is almost parallel with the floor. Before placing the patient on the table a No. 24F sound, to be used as a guide for sub- sequent urethrotomy, should be placed in the urethra, as it is difl&cult to introduce it after the thighs have been flexed. Cutaneous incision. — I generally use an inverted Y-shaped incision, as shown in Fig. 9. The ap-^ix is taken just over the posterior part of the bulb, and the two branches are each 5 cm. long, the posterior limits Fig. 10. — Exposure of bulb, central tendon and levatores ani. being about midway between the anus and ischial tuberosities. This incision is carried through the skin fat and superficial fascia. The handle of the scalpel is then used on each side of the central tendon to open up the space back of the bulb and in front of the levator ani muscles as shown in Fig. 10. This blunt dissection should be car- ried well down behind the triangular ligament on each side, before sectioning any muscular structures. It is easily accomplished and a good exposure simplifies the next step in the operation. Exposure of the mernbranous urethra. — After exposure of the cen- tral tendon by blunt dissection, the bifid retractor (Figs. 11 and 12) is inserted as shown in Fig. 13. Traction upon this instrument gives an excellent exposure of the narrow band of central muscle and greatly facilitates its division close to the bulb. Great care should be taken not to puncture the bulb — an accident which leads to inconvenient Vol. XIV.— 2. 18 Hugh H. Young. hemorrhage. After the central tendon has been completely divided a retractor may be placed beneath the bulb, thus affording a better view of the recto-urethralis muscle, which lies beneath the two branches of Fig. 11. — Bifid retractor. Fig. 12. — Bifid retractor. Side view. the levator ani and covers the membranous urethra and the apex of the prostate in the median line.* The special retractor shown in Fig. 16a is well adapted for this purpose. The concavity in the middle * The recto-urethralis is a short muscle with rather indefinite margins, which, as its name indicates, joins the rectum with the urethra. It is apparently responsible for the acute anterior flexure of the rectum which lies so close to the apex of the prostate and membranous urethra and which one finds in rectal examinations. In order to reach the membranous urethra and the apex of the prostate, it is necessary to divide this muscle, as shown in Fig. 13. This at once exposes the " espace decollable retro- prostatique " which has been so well described by Proust, who has shown that unless this muscle is divided the operator is apt to tear into the rectum, which is drawn forward by it. Division of this muscle allows the rectum to drop back, and leads at once into the space surrounding the posterior surface of the prostate. study of 1J/.5 Cases of 'Perineal Prostatectomy. 19 allows it to partly encircle the urethra and catch the triangular liga- ment. At this stage it is generally best to remove the " bifid retractor " and to insert a narrow-bladed retractor about two inches in depth, by which the rectum can be pushed back and the muscular fibers sur- rounding the membranous urethra — the recto-urethralis — put upon tension. They are then divided by a transverse incision close up to the triangular ligament and the membranous urethra exposed by blunt dissection. Fig. 13. — Showing bifid retractor, exposing and making tension on the central tendon. Uretlirotomy and insertion of tractor. — After the membranous urethra has been exposed by division of the recto-urethralis muscle a retractor is inserted and the apex of the prostate brought into view, as shown in Fig. 14. The membranous urethra is then opened on a sound (which was inserted in the urethra before the patient was put in the lithotomy position), and the edges of the urethral wound caught up by silk sutures or preferably by Halsted clamps. A 20 Hugli H. Young. sound of moderate size is then passed through the incision into the prostatic urethra and bladder, and the sphincters dilated by a to-and- fro motion of this instrument. The prostatic tractor, closed (Fig. 2), is then passed into the bladder, the edges of the urethral wound being held open by the silk sutures to facilitate its introduction.' As soon as the beak is free in the vesical cavity the thumb-screw Fig. 14. — Opening of urethra on sound, preparatory to introduction of tractor. which fixes the blades in position is loosened, the blades rotated 180 degrees by means of the external blades, and then fixed by tightening the thumb-screw (Fig. 3). ^ Carelessness in this part of the operation may lead to considerable trouble. If the membranous urethra is not carefully exposed and thor- oughly opened, difficulty may be experienced in picking up the edges of the mucosa of the urethra on each side. If the edges of the mucosa are not carefully secured with clamps and held apart, they may be inverted by the introduction of the tractor and the operation delayed until they can be picked up again. study of 145 Cases of Perineal Prostatectomy. 21 The instrument is now ready for whatever traction may be neces- sary to draw the prostate well down into the perineal wound, as shown in Fig. 15. Fig. 16 shows the position of the blades in the interior Fig. 15. — Tractor introduced; blades separated, traction made, exposing posterior surface of prostate. Incisions in capsule on each, side of ejacu- latory ducts. of the bladder, each blade projecting laterally so as to engage the intravesical surface of the lateral lobe. 22 Hugh H. Young. Exposure of prostate and incision of capsule. — Lateral retractors are so placed that with the posterior retractor (Fig. 17) drawing the rectum hack^^'ard, and the prostatic tractor drawing the gland out- ward, a splendid exposure of the entire posterior surface of the pros- tate is obtained." These retractors should be especially made to suit the diameters of the space, as shown in Figs. 17 and 18. An incision is then made on each side of the median line for almost the entire length of the posterior surface of the prostate and about 1.5 cm. deep. The two lines are Fig. 16. — Showing position of blades in interior of bladder in case of median and bilateral hypertrophy. divergent, as shown in Fig. 15, being about 1.8 cm. behind and 1.5 cm. apart in front. The bridge of tissue which lies between them ^ Even after the insertion of the tractor care must be taken in the further separation of the prostate and rectum, which is sometimes closely adherent along the entire posterior surface of the prostate. After the apex of the prostate has been thoroughly exposed so that the white capsule is plainly visible, the rest of the posterior surface of the prostate is freed by gradually pushing back the rectum with the handle of a scalpel, and dividing any muscular bands or fibrous adhesions which hinder the process of separation, but being careful to work against the prostate and not to- wards the rectum. The finger is particularly dangerous and nearly all the cases of rectal tear to which my attention has been called, have been pro- duced by the finger in attempting to rapidly push back the rectum. study of lJf5 Cases of ■Perineal Prostatectomy. 23 contains the ejaculatory ducts, and its preservation is of importance, if the integrity of these non-obstructive structures is to be left unin- jured. It is for this purpose that I make the initial capsular incision 1.5 cm. deep on each side, and these define at once, and correctly, the Fig. 16a. — Anterior retractor for drawing forward bulb and transverse perineal muscles to expose the membranous urethra. Fig. 17. — Posterior retractor Fig. 18. — One of the lateral retractors. Fig. 19. — Blunt dissector or enucleator. width of the "ejaculatory bridge," and prevent its being torn, as might happen if we depended on blunt dissection. Another advan- tage is that these incisions bring us at once to the side of the urethra where the internal enucleation (urethra from inner surface of lobe) can be easily accomplished later on. 34 Hugh H. Young. Enucleation of lateral lubes. — We are now ready to begin the ex- ternal enucleation, the separation of the capsule from the lateral lobes, which is best done with the blunt dissector, as shown in Figs, 19 and 20. Capsules are of varying thiclmess, and contain several layers of cleavage. It is important to start the separation in the right layer, not too deep as you may be led into the substance of the lobe, and not so superficially as to be outside of the most of the capsule. After the 'I u^9^^ ^^^r^ ^ * *l #1^^ ^ ^ 1 ■ / ^S^fe-"*"^"™ f /. Fig. 20. — External enucleation begun. stripping up process has been started correctly it is easily continued by blunt dissectors until first the lateral and then the anterior surface of the lateral lobes have been freed from the capsule. The internal enucleation should be taken up after the external, as it is a much more delicate procedure and often requires considerable care to prevent tearing into the urethra. As remarked above, the primary incision is made with the scalpel until pa,st the level of the urethra after which the blunt dissector is used. During this procedure the shaft of the prostatic tractor is grasped firmly in the operator's study of H5 Cases of Perineal Prostatectomy. 25 left hand (Fig. 15) and serves not only to draw the prostate so well down into the cutaneous wound that every procedure is done in plain view, but to steady the prostate and to mark out the course of the urethra so that it can be avoided. At the apex of each lateral lobe firm adhesions to the capsule, usually requiring divisions with scissors, are nearly always present. When the enucleation of a lateral lobe has progressed fairly well on each side, it is advantageous to have traction made on the lobe itself in order to facilitate the separation of the deeper portion, I tried various instruments — vulsellum forceps, pedicle forceps, and hook Fig. 21. — Lobe forceps. retractors — for this purpose, but I found that all toothed instru- ments quickly tore through the friable tissue whenever traction suffi- cient to be of any assistance in drawing out the lobe was used. It, therefore, seemed advisable to have fenestrated forceps which could grasp the entire lobe, and present such broad surfaces to it that no cutting or tearing of the capsule would be done. I accordingly de- signed the instruments shown in Fig. 21. The two blades grasp the prostate with broad surfaces, so shaped as to hold, but not to cut the lobe when pressure is applied (Fig. 22). The lobes usually come out each in one piece, and it is possible to apply considerable traction without tearing them, thus greatly facili- tating the deeper enucleation. Much of the enucleation is done 26 Hugh H. Young. Fig. 22. — Enucleation of lobes. Forceps in position. Fig. 22a. — Two lobes removed by perineal prostatectomy. Actual size. study of lJf5 Cases of 'Perineal Prostatectomy. 27 with the blunt dissector, but when the intravesical portion of the lateral lobe is reached I generally use the finger so as to avoid tearing through the thin mucous membrane covering it. The intravesical blade of the prostatic tractor, which can be dis- tinctly palpated through the mucous membrane by the enucleating finger, serves to direct the separation of the deeper portion, and warns against tearing into the bladder. It also shows when some of the lobe has been left behind. The condition present after the enucleation of the two lateral lobes, as described above, are shown in Pig. 23. Fig. 23. Fig. 24. ■ Fig. 23. — Schematic cross section after enucleation of lateral lobes, showing ducts and median bridge of tissue. Instrument in urethra. Fig. 24. — The blade rotated so as to engage middle lobe. As shown in this schematic cross-section, the urethra, which contains the tractor, is left intact. Beneath is the bridge of tissue surrounding the ejaculatory ducts. The empty capsule is shown on each side. Enucleation of the middle late. — After the lateral lobes have been shelled out, attention should be directed to the median portion of the prostate. If the previous cystoscopic examination has demonstrated a thin transverse bar, it will sometimes be found that removal of the lateral lobes has allowed it to collapse, showing that it was really an artefact, a fold of mucous membrane hooked up by the lateral out- growths, and not containing any hypertrophied tissue. Fig. 25. — Shovring teclinique of delivery of middle lobe imo cavity of left lateral lobe. study of 1J/-5 Cases of Perineal Prostatectomy. 29 On the other hand, there is most often a more or less extensive hypertrophy of the prespermatic group of glands, and the mass can be easily seen, or felt by the finger in one of the intracapsular cavities (Fig, 25). Further examination will generally reveal a fair amount of tissue between the median lobe and the region of the ejaculatory duets, which, as I have previously pointed out, lie well forward on the posterior surface, and close to the capsule. The median enlarge- ment is generally more or less definitely attached to one or both of the lateral lobes so that there is no difficulty in shelling it out through Fig. 25a. — Photograph of a pedunculated median lobe which was re- moved through the cavity left by left lateral lobe without tearing urethral or vesical mucosa. The three lobes are shown in exact size. one of the lateral cavities — without disturbing the integrity of the ejaculatory ducts and prostatic tissue immediately surrounding them. The prostatic tractor may be used with great advantage in removing a median lobe, and the technique which I generally employ to draw it down into one of the lateral cavities where it can be enucleated, is as follows: Push the tractor backward until free in the bladder cavity, depress the handle of the instrument so that the shaft can lie on the top of the middle lobe, and then rotate the instrument 90 degrees, so that one of the blades projects downward behind it. Out- 30 Hugh H. Young. ward traction should then engage the lobe, as shown in Fig. 24, and drawn down where it can be seen by the operator. To get it into one lateral intracapsular cavity (say to the left) two manoeuvres are of help : Pushing against it with the index finger of the left hand, which has been inserted in the right intracapsular cavity, as seen in Fig. 25, and rotation of the blade engaging the middle lobe in the same direction, making traction on it all the while. Fig. 25a shows a pedunculated Fig. 26. Fig. 28. Fig. 26. — Photograph of prostate in which the left and median lobes were enucleated in one piece. Exact size. Fig. 27. — Longitudinal section after enucleation of median lobe through a lateral cavity. Fig. 28. — Cross section at level of cavity left by median lobe. median lobe that was removed in this way without injury of the mucosa covering it (Case No. 12). After the median lobe has presented in the left intracapsular cavity, the operator turns the tractor over to an assistant who continues the traction, while he grasps the lobe with the forceps described above and then rapidly enucleates it. study of lJj.5 Cases of ■Perineal Prostatectomy. '61 In many instances I have found the median mass to be directly con- tinuous with the left lateral lobe, and when the deeper portion of that lobe was being freed, that the median lobe was disposed to come with it. I have then rotated my tractor so as to engage the median, and have readily drawn it down and enucleated the two in one piece, as shown in Fig. 26. In another case a collar-like growth, consisting of a median bar and two lateral masses, was easily enucleated in en- tirety through the left intracapsular cavity without tearing the ducts beneath or the mucous membrane of the urethra or bladder. Fig. 29. — Blade engaging anterior lobe. I have now had many cases with very great intravesical median lobes, and have experienced little diflQculty in drawing these down with the tractor into a lateral cavit}^ where enucleation was easily accomplished. A large median lobe is no longer considered more suitable for suprapubic prostatectomy. The condition present after the enucleation of a median lobe, as described above, is shown schematically in Figs. 37 and .28. Fig. 2T is a longitudinal section showing the cavity left by removal of this lobe, the ejaculatory ducts being below and in front and quite distant from it. In Fig. 28 the median cavity is seen to communicate with the lateral cavities on each side, beneath the intact urethra. The seminal ducts are separated from the capsule by the posterior capsule. Tlie removal of an anterior lobe. — The presence of a definite isolated 32 Hugh H. Young. anterior lobe is of rare occurrence. We occasionally see with the cystoscope small anterior outgrowths, but they are generally continuous with a lateral lobe. One of my cases was of this character, and, although it looked through the cystoscope like a large rounded mass, I found that it came away easily with the lateral lobe. I employed a procedure the reverse of that which I have just described for posterior middle lobes, the Fig. 30. — The use of index finger to deliver a small median lobe into lateral cavity. anterior lobe being engaged by a blade which was directed upward, as shown in Fig. 29. The entire mass (left lateral and anterior lobe) was very large, measuring 7x6x5 cm. In another case a large detached anterior lobe was easily drawn down and enucleated through the right lateral cavity. The ability to make traction on any desired portion of the prostate is of the very greatest value and assistance, especially in enucleating these unusual outgrowths of the hypertrophied gland. study of H5 Cases of ■Perineal Prostatectomy. 33 THE USE OF THE INDEX FINGER AS A RETRACTOR. There are some cases, however, in which the median enlargement is in the shape of a small bar or lobe, so adherent that it is difficult to engage it with the blade of the tractor, as described in my first paper, and for these I have of late employed the index finger of the left hand in place of the tractor in the urethra, to push the lobe into the lateral cavity. After the tractor has been withdrawn the left index finger is inserted gently through the prostatic urethra, until the tip is free in the bladder. Examination will then reveal the median bar or lobe which remains, and it is an easy matter, by crooking the finger over it, to carry it into the left lateral cavity where it can be enu- cleated (Fig. 30), If an adherent bar is encountered a sharp periosteal elevator is a good instrument with which to peel it out. Occasionally it may be necessary to use scissors for this purpose, and to get hold of the mass to be removed as it begins to be separated, a long forceps may be required. In several of my cases it has been impossible to engage with the blade of the tractor a very small rounded or pedunculated median lobe, but I have been able, by using the finger instead of the tractor, to successfully remove it without injuring the urethra or the ejaculatory ducts. The technique described above is entirely different from that of Albarran, who draws the median lobe into the widely opened urethra with the finger.' A very pedunculated middle lobe may evade both the finger and the tractor, and in such instances it may be best to insert a curved clamp and draw the middle lobe down the dilated urethra where it may be enucleated or divided with scissors. This is the technique employed by Albarran. A SUBURETHRAL METHOD OF REMOVING A MEDIAN BAR OR LOBE. In case the patient has already lost his sexual powers the reason for preserving the ejaculatory ducts does not hold, and in such cases, when the median bar or lobe is too small or too adherent to be deliv- '' Albarran's technique may sometimes be of value in cases of pedun- culated middle lobes of small size. I have used it several times, but usually- considerable laceration of the urethra has been produced and there is more hemorrhage than with my technique in which the mucous membrane is not removed. Vol. XIV.— 3. 34 Hugh H. Young. ered into a lateral cavity with the tractor, I have removed the mass subiirethrally, after transverse division of the ejacnlatory bridge, as shown in Fiff. 31. Fig. 31. — Showing suburethral method of enucleating median bar. Fig. 32. — Schematic longitudinal section of the urethra, showing the median enlargement enucleated beneath the urethra. After stripping back the capsule (Fig. 32) it is an easy matter to shell out or to excise the median bar or lobe without opening the urethral or vesical mucous membrane coverinsr it. study of 145 Cases of 'Perineal Prostatectomy. 35 Fig. 33 shows a small median bar which was removed in this way after the enucleation of two large lateral lobes. The patient had been castrated and there was therefore no object to be gained by preserving the ejacnlatory ducts. (Case 25.) In some cases in which it is desirable to preserve the ejacnlatory ducts, a fibrous median bar may be removed through one of the lateral cavities of the prostate, after division of one of the lateral walls of the urethra, as shown in Fig. 34. In this way the " ejaculatory Fig. 33. — Photograph, natural size. bridge " is preserved. This method has been employed in several cases. In the great majority of cases the median mass can be enucleated through the lateral cavity — the larger the lobe the easier it is. TEEATMEXT OF VESICAL CALCULUS AS A COilPLICATIOX OF EXLARGED PROSTATE. When calculus is present, either litholapaxy, before or during the prostatectomy operation, or suprapubic or perineal lithotomy may be performed. Without going into arguments for or against either of these procedures, it is evident that if a perineal prostatectomy is to !6 Hugh E. Young. be performed the ideal procedure is to remove the calculus at the same sitting, without crushing it, for litholapasy is in these cases a tedious procedure. If, however, the removal of the calculus intact will seriouslj^ injure the urethra, the ejaculatory ducts or the neck of the bladder, such a method is contraindicated. To drag a calculus by main force out through the urethra, as left by the technique Fig. 34. — Division of lateral wall of urethra to allow extraction of large calculus through left lateral cavity. which I follow, would be at once dangerous and destructive, except when it is small. I have therefore endeavored to devise a method which would be free from the dangers mentioned above, and which would also provide for the removal of large stones. The technique which I have found most satisfactory is graphically shown in the accompanying drawing (Fig. 34). study of IJfO Cases of ■Perineal Prostatectomy. 37 x\s seen here, tlie urethra is split with scissors along its left lateral wall, from the urethrotomy wound in the membranous urethra up to its vesical orifice. By this procedure, the urethra becomes a common cavity with that left by the enucleation of the left lateral lobe, and abundant room is furnished for the extraction of calculi. If the cystoscope has shown the calculus to be only moderately large it is usually only necessary to dilate the vesical orifice with a uterine dila- tor in order to extract it with forceps. If the calculus is too large to be thus withdrawn, the orifice is enlarged by a cut through the vesical mucous membrane covering the left lateral cavity of the pros- tate, while the stone is held firmly against it by forceps. Fig. 35. — Exact size of calculus removed through perineal incision. I have followed the technique described above in 24 cases of calculus which are described in full in another part of this paper. Fig. 35 shows the calculus which was removed by this method in one case. The ejaculatory bridge containing the ducts is not injured, no ureth- ral nor vesical mucous membrane is removed, and the perineal wound heals just as rapidly as after the simple prostatectomy; in one case, perineal leakage ceased after the ninth day. I have not found it neces- sary to close the divided urethra with sutures, but have simply provided the double urethral catheter drainage through the urethrotomy wound and the gauze packing for the lateral cavities as usual. The great advantage of perineal over suprapubic lithotoni}^ is that the patient can be propped up in bed at once, and moved into a wheel-chair on the 38 Hugh II. Young. third or fourth day. The secret of success in these cases, is to flush the kidneys and to get the patients out of bed quickly, and this cannot be done after the suprapubic operation with the same impunity and rapidly as in the perineal cases. In some cases sectio alta may be necessary, though an attempt to crush the stone through the perineal wound may be a decided one. A very careful search should be made for additional calculi. If much blood has been collected in the blad- der it is often advisable to evacuate it and wash out the bladder thoroughly before continuing the search. " Eecurrent calculi " after prostatectomy are usually calculi or fragments of calculi left behind at operation. Fig. 36.^ — Showing how the tractor may slip beneath prominent lateral lobes. Searching for undetected intravesical lohes. — The median and the two lateral lobes should generally be completely removed each in one piece. If the cystoscope has shown any peculiar intravesical out- growth, an effort should be made to remove it with the lobe to which it is attached by engaging it with the tractor. In order to secure it, several successive attempts may be necessary. By palpating the entire prostatic margin with a finger in a lateral cavity against the blade of the tractor a lobule which has been left behind can usually be discovered. When there is no median bar or lobe to hold up the intravesical por- tion of the prostatic tractor, the blades may slip beneath prominent intravesical lateral outgrowths, as shown in Pig. 36. This happened in one of my early cases and is the cause of an imperfect result. Eo- study of 145 Cases of 'Perineal Prostatectomy. 39 tation of the tractor and palpation with the finger, as described above, should prevent such an oversight. In rare instances it may be neces- sary to use the index finger in the urethra in place of the tractor, particularly in small pedunculated middle lobe cases, as described above. Whenever one fails to find what has been shown by the cysto- scope the digital exploration should be employed. The only objection to it is that the urethra is usually split open by the procedure. Drainage. — Before withdrawing the tractor a careful examination should be made bv inserting the fino-er into both of the lateral cavities Fig. 37. — Scheme of continuous irrigation apparatus. and palpating the blades through the vesical mucosa, in order to determine that no important glandular mass has been left behind. The tractor is then removed by first rotating the blades until they come together and then withdrawing the instrument. Abundant ves- ical drainage should be provided, as a small tube may easily become plugged by blood-clots and give great annoyance afterwards. I now use two catheters of fairly good size. These are fastened together by ligatures and are prepared before the operation, so that as soon as the tractor is withdrawn they can be inserted through the perineal wound into the urethra and bladder. In order to facilitate their introduction it is best to cut obliquely across the end of each 40 Rugh H. Young. catheter and then fasten the cut surfaces together with a single suture, thus making a common point for the two catheters. If this is not done one of the catheter ends may catch in a fold of mucous membrane. One catheter is immediately connected with a tank of normal salt solution, and the bladder thoroughly washed clean of blood. After the tubes have been properly adjusted, they are tied by a Fig. catgut. 58.— Approximation of levator ani muscles with single suture of heavy silk suture to the skin at the upper angle of the wound. The lateral prostatic cavities are then firmly packed each with a small strip of gauze, but care is taken that the packing is confined to the lateral cavities of the prostate and especially that none may be allowed to press against the rectum. The tube and gauze drainage as thus provided is shown in Fig. 37. Approximation of the levator ani muscles. — Before closing the cu- study of 1J/-5 Cases of 'Perineal Prostatectomy. 41 taneous woiind one should always examine the rectum. With a gloved finger inserted through the anus and another in the wound the rectal wall should be carefully examined for lacerations or weaknesses. During this procedure it is well to hold the gauze packing and tubes out of the way by means of anterior retraction (Fig. 38). The rectal wall above the anal sphincter is usually found quite thin even in cases where no injury has been done to it, and in cases where it has been very adherent to the prostate the musculosa may be some- what torn and should be drawn together with a suture or two of fine catgut. If a definite tear into the rectal cavity should be found (and this occurred four times with me, two being in cases with large opera- tive cicatrices between rectum and prostate) careful closure should be made first with a layer of interrupted very fine silk sutures for the submucosa, then one for the musculosa, and finally a reinforcing layer of catgut sutures. Xo trouble should be experienced in effecting a solid closure if the proper needles (very fine curved patent-e3'e needles) are at hand. After satisfying yourself that the rectum is uninjured the levator ani muscles should be drawn together to their normal position in front of the rectum. This can be accomplished with a single suture of heav}' catgut, as shown in Fig. 38. It is remarkable what a difference this one suture will make. Before its insertion the levators will be found widely separated (by the traction which has been made against them) and the thin rectal wall will be found bulging between them, as shown in Fig. 38. It is then easy to understand how rectal fistuls occur, for if great force were put on the thin unsupported rectum (as at stool) it might easily give way, and if a gauze pack were allowed to press against it, necrosis might quickly result. When the levator sutTire is placed, the picture changes immediately, the rectum disappears behind the firm buttress of reapproximated levators and the danger of rectal breakdown vanishes. Partial closure of the wound. — If the median perineal incision has been used, the posterior portion is closed by buried catgut for the muscle, and silk or catgut interrupted for the skin. While no im- portant muscles have been divided (only the central tendon and the recto-urethralis muscle), it is nevertheless advisable to draw together the structures which have been so widely separated by retraction. If the inverted V-incision has been employed the two branches of Vol. XIV.— 4. 43 Hugh H. Young. the incision are partly closed, as shown in Fig. 39, leaving a small area in front of the gauze and tube drains. Using this method of closure thgre is no more distortion of the perineum after this incision than after the median, and there should not be, as there is no more destruction of muscular continuity in one than in the other; in fact, they only differ in the cutaneous incision. After-treatment. — The patient is generally returned to his room accompanied by an assistant who sees that the irrigation is going well, and arranges to have it continued after he has been placed in bed. The apparatus used is indicated in Fig. 37, but a much larger tank is employed. We now use a two-gallon porcelain tank with an outlet at the side. The flow is regulated by a clamp on the Fig. 39. — Final closure. inlet tube. The outlet tube drains into a jar by the side of the bed. If the end is kept immersed in water, air cannot get up the tube, and siphonage is obtained, thus keeping the bladder empty and pre- venting leakage around the perineal tubes. The task of keeping the reservoir supplied with salt solution is not a difficult one, the nurse having to add a quart about every half hour. It is not necessary to maintain an even temperature — 110° to 120° F. in the tank is about right — and the temperature is maintained between these fairly well by the half-hourly addition of the hot salt solution. A submammary infusion of 1000 cc. salt solution is given either on the operating table or after the return to bed. This is considered so valuable, both as a preventative to shock and anuria, and as a cure for post-operative thirst, that it is never omitted. The gauze drains are removed on the day after the operation and no more packing put in. The tubes are pulled out a few hours later, and on the next day the patient is usually placed in a wheel-chair, and carried out-doors. ISTo sounds are passed and stricture never study of 1J/.5 Cases of 'Perineal Prostatectomy. 43 results. Urotropin is administered early, and water is given in abundance (by infusion every two or three days if advisable). Within a few days the patient is generally walking about the hos- pital. IvTothing is done to the wound except to keep it clean, and to occasionally cauterize exuberant granulations. I may say that the instrument which I have called " prostatic tractor " has transformed, for me, the operation of prostatectomy. Where before (with me — perhaps not with others) an operation was done somewhat haphazard, depending largely on the sense of touch, and in the dark; now the entire operation is performed in a shallow wound, accurately under visual control, proper regard being paid to the urethra and to the ejaculatory ducts. III. An Analysis of 145 Cases of Perineal Prostatectomy for Hypertrophy of the Prostate in which the Operation Described Above has been Employed. a. the onset of the disease. etiology. The ages of the patients were as follows : 35 to 39 1 40 " 44 45 " 49 3 50 " 54 9 55 " 59 20 60 " 64 29 65 " 69 38 70 " 74 24 75 " 79 , 16 80 " 84 4 85 " 90 1 Total 145 A glance at this table shows that prostatic enlargement and obstruc- tion occur most frequently in the five years between the ages of 65 and 69 inclusive, there being 37, or 26% of the eases during that period of life. The decennium 60 to 69 contains &% cases, or 46%. The 15 years between 60 and 74 contains 90 cases, or 62%, and the 25 years between 55 and 79 contains 126 cases, 87%. There are only 13 cases under 55 years of age and five cases over 80 years of age. The cases under 55 years of age were briefly as follows, between 35 and 39 years of age, one case : 44 Hugh H. Young. No. 137, age 37, had never had gonorrhoea, had suffered with difficulty and frequency of micturition for many years. The prostate was not enlarged, but there was a small median bar and 440 cc. residual urine. Microscopically, chronic prostatitis. Forty-five to 49 years of age, three cases : No. 37, age 47. History of gonorrhoea and stricture, calculus, duration 12 years. Catheter life two years. Small median bar, microscopically, chronic prostatitis. No. 8, age 45 years. No history of gonorrhoea. Urinary difficulty and frequency for two years, occasional complete retention of urine. Prostate not enlarged, small fibrous median bar. Microscopically, chronic prostatitis. No. 133, age 47. No history of gonorrhoea. Frequency of urination for 10 years. Complete retention of urine two years ago. Residual urine 360 cc. Prostate not enlarged, soft, small median bar. Microscopically, chronic prostatitis. Fifty to 54 years of age, 9 cases : No. 90, age 50. Gonorrhoea. Difficulty of urination 10 years. Occasional complete retention. Prostate very little enlarged, small round pedunculated median lobe. Microscopically, glandular hypertrophy with prostatitis. No. 61, age 50. No gonorrhoea. Duration of urinary symptoms eight years. Recent complete retention of urine. Prostate slightly enlarged, a small median lobe. Microscopically, glandular hypertrophy and pros- tatitis. No. 102, age 52. No gonorrhoea. Urinary frequency and pain for seven years. Catheter life five months. Prostate slightly enlarged, small median bar. Microscopically, chronic prostatitis. No. 143, age 52. History of gonorrhoea. Frequency of urination and pain for one and one-half years. Prostate slightly enlarged, small median bar, large vesical diverticulum. Microscopically, chronic prostatitis. No. 89, age 53. History of gonorrhoea and severe stricture for 30 years. Great frequency, difficulty and pain. Contracted bladder, vesical ulcer. Extensive stricture of deep urethra. Small hard prostate, slight median bar. Microscopically, chronic prostatitis. No. 66, age 54. Gonorrhoea. Urinary difficulty and frequency for several years, previous suprapubic lithotomy. Residual urine 200 cc. Slight en- largement of prostate, small median bar. Microscopically, fibro muscular hypertrophy. No. 17, age 54. No history of gonorrhoea. Difficulty and frequency of urination 15 years. Residual 500 cc. Prostate slightly enlarged, small pedunculated median lobe. Residual 500 cc. Microscopically, glandular hypertrophy with chronic prostatitis. No. 19, age 54. No history of gonorrhoea. Intermittent severe hematuria one year. No difficulty or frequency of urination. Residual urine 220 cc. Considerable hypertrophy of lateral and median lobe. Microscopically glandular hypertrophy. study of 145 Cases of 'Perineal Prostatectomy. 45 No. 82, age 54. Gonorrhoea followed by stricture, complete retention of urine, catheter life for eight years. Small hard prostate, multiple vesical diverticula, severe fibrous stricture of the deep urethra, small median prostatic bar. Microscopically, fibro muscular hypertrophy, chronic pros- tatitis. In the four cases younger than 50 years of age there was no evi- dence of glandular proliferation or enlargement, and the obstruction was entirely due to a chronic inflammatory process which had trans- formed the median portion into a bar, which although small in amount caused very serious obstruction. In the nine cases, between the ages of 50 and 54, all but one showed evidence of chronic inflammatory changes, and in three there was slight evidence of glandular prolifera- tion and hypertrophy. In one case only was the prostate greatly enlarged, and in this case there was considerable hypertrophy of the lateral lobes and a large pedunculated median lobe, all three showing microscopically a pure glandular hypertrophy. It is interesting to note that in this case there was no urinary disturbance, the only complaint being a frequent profuse hematuria. The symptoms pre- sented were nothing like so severe as with the small inflammatory prostates which have been mentioned above. A review of these cases shows conclusively that chronic prostatitis may lead to severe obstructive symptoms, large residual urine, multiple vesical diverticula, complete retention of urine, pain and great dis- comfort, without the presence of any definite hypertrophy of the prostate. In five cases only was there a history of gonorrhoea, and in three of these stricture of the urethra was present, in two of very severe character requiring external urethrotomy and excision when pros- tatectomy was performed. In all of the 13 cases there was urgent need for the operation, and the splendid results which have been obtained justify the procedures undertaken. The urine was infected and contained pus and bacteria, generally bacilli in 11 of the 12 cases under 55 years of age. All of these 11 cases showed chronic prostatitis. The one case in which the urine was sterile showed considerable glandular hjrpertrophy and no prostatitis. The cases over 80 years of age were five in number, viz., 80, 81, 82,. 82, 87. In three cases sjmaptoms of obstruction had only been present for three years although in two of these the prostatic enlargement was 46 Hugh H. Young. considerable. In one case (patient age 82) there had been symptoms of prostatic obstruction for 24 j-ears and the prostate was so huge that it could be felt suprapubically where it was palpable as a hypo- gastric tumor four inches in diameter. The tissue removed weighed 340-G. and the patient is now well, two and a half years after the operation, and is 85 years old. In the fifth case symptoms had been present for 10 years and had been characterized by attacks of com- plete retention of urine which came but seldom, the rest of the time there being little disturbance. Maeital State. — One hundred and eleven were married, 19 widowed, 12 were single, and in 2 cases no note was made. The fact that only 8.6% of these 144 cases were single men might be taken at once as an indication that prostatic hypertrophy is one of the uncom- fortable consequences of matrimony, but without figures at hand to show what percentage of men over 50 years of age remain in single blessedness, it is impossible for me to judge in this matter. There have been many to assert that prostatic hypertrophy is largely due to sexual excesses, and were it possible for me to obtain a truthful history as to the sexual habits of my patients it might be possible to prove that such allegations are true. As bearing upon this subject it may be interesting to note that there is not a single case in my series in which the patient was a Catholic priest, whereas there are 10 cases in which the patients have been Protestant ministers and all of them married. That a history of frequent sexual indulgence is not a necessary pre- cedent I know from a few cases in which the patient distinctly de- clared that he had not had coitus for many years before the beginning of his prostatic trouble. GoxoREHCEA. — Only 46 patients admitted having had gonorrhoea some time in their lives, and in only rare instances was the infection apparently of severe character. In only eight of the 144 cases was there stricture present, and in only three of these was it severe. In four cases the prostatic trouble seems to have been a direct continua- tion of an old gonorrhoea, but in the remainder of the cases in which gonorrhoea had been present there is nothing to show that it had anything to do with the onset of prostatic hypertrophy. In fact, many of these cases in which gonorrhcea at some previous time was acknowledged, show no evidence of chronic inflammatory changes in study of lJf.0 Cases of 'Perineal Prostatectomy. 47 the prostate, and it therefore seems evident that gonorrhcea cannot be considered as an etiological factor in the development of true hyper- trophy of the prostate. That it may be the cause of a chronic pros- tatitis accompanied by marked obstruction to urination is undoubtedly true, but that it is not the sole cause or in fact the most frequent cause of chronic obstructive prostatitis is demonstrated by this series of cases, particularly those younger than 55 years of age, as described above. We may add in passing that it seems clearly proven that Ciechanow- ski's assertion that nearly all cases of prostatic hj-pertrophy are in- flammatory in origin is absolutely incorrect. That a certain amount of inflammation is undoubtedly present in many of the cases is per- fectly true, but it is easy to explain the presence of prostatitis when the bladder is almost invariably infected and the prostatic urethra is frequently irritated and inflamed by the passage of catheters and infected urine. Onset and initial symptoms. — The duration of time which had elapsed since the onset of trouble was as follows : One year or less 6 Between 1 and 2 years 19 3 " 13 4 " 8 5 " 13 6 " 15 7 " 8 8 " 7 9 " 3 10 " 16 Between 11 and 15 " 24 Between 16 and 20 " 6 Between 21 and 25 " 2 Between 26 and 30 " 2 Not noted 3 In reviewing these cases one is struck with the great variations as regards duration and course of the disease presented. In 108 cases the time elapsed was 10 years or less (70%), and in 45 cases (30%) less than five years had elapsed since the beginning of the trouble. In six cases the patient had noticed nothing unusual until the pre- ceding year. In one of these cases (19) there was no urinary dis- turbance, the only complaint being intermittent attacks of severe 48 Hugh H. Young. hematuria. On examination 220 cc. residual urine were found and a considerable enlargement of median and lateral lobes. In another case (138) the first symptom was nocturnal incontinence six months previously and up to time of admission there was no fre- quency or difficulty of urination, yet the catheter found 890 cc. residual urine and a very large prostate was removed. Three cases (14, 27, 115) had occasional complete retention of urine although there had been no symptoms up to a year previously. The sixth case (94) had a small cystin calculus and a pedunculated median lobe and contracted bladder, but had never used the catheter. In 10 cases the onset of the disease had been from 16 to 30 years before. One of these cases (50), age 71, had begun to have difficulty of urination 30 years before, but the disease had remained stationary until five years before, when he was catheterized for complete retention of urine. On entrance he was voiding urine every hour with consider- able difficulty and slight pain, but did not require a catheter. The prostate was small and soft and there was only a slight median bar, but 1100 cc. residual urine was present. Another case (137), also of 30 years' duration, was only 37 years of age, and at the age of seven noticed difficulty and frequency of urination which persisted up to time of admission. The prostate was not enlarged and there was only a small median bar present, but the residual urine varied from 400 to 600 cc. and the catheter was necessary once or twice daily. One case (89) which had persisted for 27 years had directly followed stricture of the urethra due to gonorrhoea. The catheter had been necessary at times. There was 100 cc. residual urine, a con- tracted bladder with a large ulcer, a prostate which was only slightly enlarged, with a small median bar inflammatory in character. In another case (16) symptoms of frequency and difficulty and occasional complete retention had been present for 25 years, and suprapubic drainage had been necessary one year previously. The prostate was very great in size, the tissue removed weighing G-240. In three cases (70, 84, 101) the onset was 20 years before, and during this time there had been pain, difficulty, and frequency of urination. ■ In two of these (70, 101) calculi were present. One had used a catheter for nine years, and one year previously suprapubic drain- study of llf.5 Cases of 'Perineal Prostatectomy. 49 age had been provided. The prostate in this case was large and adenomatous in type. In the other two cases (84, 101) it was small and inflammatory in type. One patient (120) complained only of painful erections which had been present for 19 years, and to relieve which he found it neces- sary to void urine several times during the night, but when erections did not occur he would sleep all night without urinating. Urination was somewhat difficult particularly at the beginning but there was no increased frequency of urination. The prostate was distinctly en- larged and the cystoscope showed a considerable intravesical hyper- trophy of the right lateral lobe, which was removed at operation. One case (4) had begun to have frequency and difficulty of urination 17 years before and during the last five years frequently re- quired catheterization. The prostate was only moderately hyper- trophied. The last case (63) in which the symptoms had been present for 16 years had had complete retention of urine 14 years before, and had been subjected to several suprapubic operations for calculus and severe hemorrhage from the median portion of the prostate, and a suprapubic drainage apparatus had been worn for seven years. A very large prostate was removed. The onset symptoms were as follows : Frequency of urination 88 Cases. Difficulty of urination 78 Pain 25 Hematuria 7 Complete retention of urine 8 Incontinence of urine 8 Painful erections 1 Frequency and difficulty of urination, as shown above, are by far the most frequent initial symptoms of prostatic hypertrophy occurring in 60% and 55% of the cases respectively. At the beginning both of these symptoms are as a rule very slight in character, and the onset is generally so gradual that it is difficult for the patient to state ex- actly when urination began to be abnormal. The increase in fre- quency has generally been recognized first, because the patient had to arise once or twice to urinate, and in many instances this was the only symptom for a considerable period of time. Difficulty of urina- tion has generally been discovered, first because the patient was unable 50 Hugh H. Young. to start the floTV of urine as quickly as usual when the desire came on. In other cases the patient has noticed that the stream was definitely smaller than normal and that force was required to void, so that defi- nite obstruction was recognized^ but in a great many cases no obstruc- tion has been appreciated for some time after the beginning of the disease. In a number of cases the frequency and difficulty of urination have been intermittent in character, and after the initial attack normal urination has followed for a time. Pain. — Pain has been noted as an onset symptom in 25 cases. In 12 cases there was only a slight burning in the urethra during urina- tion and in 3 the pain was merely the discomfort produced by severe straining to void. In one case there was a sharp pain which followed sudden stoppage of urine during micturition. One case (5) was characterized by a severe pain which came on at the beginning of uri- nation being apparently located in the base of the bladder, but rapidly radiating from there upward '' along the course of the ureter and terminating in the region of the right kidney^' where it would last with considerable intensity for three minutes. These symptoms which came on suddenly persisted for one month, during which time they recurred with each urination, they were finally relieved by going to a mineral spring and drinking water in abundance. Xo calculus was ever passed or found in the bladder. Eight of the 24 cases complaining of pain had calculus of the blad- der. In two cases (3?, 122) the first pain was a severe attack of pain in the back (probably renal colic), followed by vesical pain, due to the passage of stone into the bladder. In six of the cases there was no pain in the back and the stone was probably vesical in origin. In three calculus cases the pain at onset was a slight smarting during urination located in the urethra. Two of the calculus cases began witb sudden severe pain in the urethra, but in another case there was only a very slight irritation at the neck of the bladder. The last case (47), in which a very large oxalate calculus was after- wards removed, the onset symptom was a burning sensation in the urethra during the night, and a slight frequency of urination during the day, 10 years before admission. Six years later he began for the first time to get up at night to urinate and after that urination was very frequent during the day but there was no pain until one month before admission, and then onlv a slight dull feelinof of soreness in study of lJf5 Cases of 'Perineal Prostatectomy. 51 the urethra during and after urination. There was never any severe pain or hematuria, and yet at operation a mulberry calculus with very large rough spicules and about 6 cm. in diameter was removed. The fact that there was only 15 cc. residual urine and a bladder which was greatly contracted (capacity 50 cc.) makes the absence of pain all the more remarkable. One case (52) began with pain in the kidney three years before ad- mission. He died after operation and autopsy showed double pyone- phrosis. A most peculiar case (130) was one of considerable prostatic hyper- trophy in which the onset symptom, and in fact the only symptom during the 19 years preceding his admission to the hospital was a severe pain in the perineum and deep urethra coming on at night and always associated with erection of the penis. Although the prostate was quite large there was never any difficulty or frequency of urina- tion, but the patient would have to arise to urinate several times almost every night on account of painful erections, and it was on this account that he sought relief. Hematuria. — This was present as an onset symptom, as stated above, in seven cases. Only one of these patients suffered with cal- culus (case 23). In one case (19) without previous urinary trouble the patient voided several large clots and during the following year there were five attacks of painless hematuria during which much blood was lost. On admission there was no frequency or difficulty of urination, but a considerable enlargement of both lateral and median lobes was present. In another case (46) there were two hemorrhages from the blad- der which appeared some time before any other urinary disturbance, but did not reappear. In two cases (20, 27) there was hemorrhage at the end of urination, which reappeared at intervals for several years up to the time of operation. In one case (16) the disease began with hematuria 24 years previous to admission. After treatment at a mineral spring the blood did not appear again. The last case (84) began with profuse hematuria and a diagnosis of congestion of the kidneys was made, but after a short while the hemorrhage disappeared and did not reappear during the 20 years of his trouble. 52 Hugh H. Young. It seems remarkable that hematuria is so infrequent in cases of prostatic hypertrophy which were associated from the beginning with vesical calculus, and the fact that in the seven cases detailed above only one was associated with calculus shows that the latter has very little to do with initial hematuria. Of particular interest are the cases of profuse hematuria recurring at intervals (and shown later to come from considerable median prostatic enlargement), but en- tirely free from urinary disturbance of a serious character. Complete retention of urine. — This has been the first symptom in eight cases. One case (81) had complete retention of urine 12 years before admission and was catheterized for two days, but never re- quired catheterization afterwards. The second case (31) had com- plete retention of urine five years before, due to impaction of a small calculus in the urethra which was passed in three days. The third case (14) began with complete retention of urine and required catheterization at intervals afterwards. The fourth case (62) began with complete retention of urine three years before, and had to be catheterized for three months, but was never catheterized after that. Th fifth case (128) began with complete retention of urine 12 years before and required catheterization occasionally afterward. The sixth case (22) began with complete retention 10 years before, but voided without catheterization. Por two years before admission the catheter was used daily on account of incomplete retention. The seventh case (139) began with complete retention 10 years before but was relieved by medicines internally and began the use of the catheter again only five weeks before admission (on account of incomplete retention) . The eighth case (8) began with complete retention of urine during typhoid fever and was catheterized for several weeks. Afterwards the patient was catheterized occasionally owing to complete retention or dhficult urination. It will be noted that in none of these cases did retention of urine ever become permanently complete, and in fact it is remarkable that the subsequent course was characterized by less use of the catheter than is usually present in most cases of prostatic hypertrophy. It is also interesting to note that in four of these cases the complete reten- tion of urine came on 10 years or more before admission to the hos- pital, and yet none of these cases became dependent upon the catheter. Incontinence of urine. — As mentioned above this occurred in eight cases as an onset symptom, but in two of these there was merely a study of 145 Cases of 'Perineal Prostatectomy. 53 slight dribbling of urine at the end of micturition. In three cases, however (28, 136, 138), the only symptom was nocturnal incontinence of urine which occurred every night, and was not associated with any frequency or difficulty of urination. In one case this was present for three years, when complete retention of urine came on and catheter life was begun. In the second case (136) it persisted as the only symptom during the two years previous to admission, and in the third case (138) it had been the only symptom present for six months pre- vious to admission. All of these cases were similar in having no frequency or difiBculty of urination and no incontinence by day. Two were catheterized for the first time in the hospital and 580 and 600 cc. residual urine re- spectively was withdrawn. The sixth case (3) was associated with tabes dorsalis and came on with frequency and difficulty of urination, and nocturnal incontinence of urine 14 years before admission. These symptoms persisted for three months, when he was catheterized by a physician and after that was unable to void and led a catheter life for 14 years. (It is inter- esting to note that natural urination at normal intervals was estab- lished in this case by removal of the prostate, which was moderately but definitely hypertrophied.) The seventh case (119) began two years before admission with occa- sional incontinence of urine during the day and a feeling of pressure in the bladder, but with no difficulty or frequency of urination. There was also marked impairment of sexual powers and of the knee-jerks. He was catheterized and led a catheter life afterwards. After pros- tatectomy the incontinence persisted and girdle pains and other symp- toms of spinal disease showed themselves. The eighth case (100) began with incontinence, difficult and painful urination eight years before admission. The incontinence persisted for only a few weeks. Eemarhs. — A study of these eight cases with incontinence as an onset symptom shows that with exception of two cases the disease was due to over-distention of the bladder and not to spinal disease, and the fact that they have been cured by prostatectomy shows that this symptom is no contraindication to operation. The incontinence is probably due to the peculiar disposition of the prostatic enlargement at the vesical orifice leaving an opening through which the urine can continuously escape, but why the external sphincter does not prevent 54 Hugh H. Young. the incontinence is to me inexplicable, in view of the fact that after suprapubic prostatectomy the prostatic orifice is often very greatly dilated, and yet incontinence very seldom occurs. B. STATUS PR^SENS. The symptoms present on admission were as follows : a. Pain, slight 16 Cases. considerable 61 &. Hematuria, slight 7 considerable 15 c. Difficulty of urination, slight 10 considerable 78 d. Incontinence of urine 6 e. No increase in frequency or difficulty of urination 3 f. Frequency of urination, 95 cases in which the interval be- tween urinations was less than i/^ hour in 7 Between y^ and 1 hour in 25 1 hour in 37 2 hours in 19 3 hours in 7 a. Pain. — As shown above, pain has been present in over 50% of the cases. In some of the cases it was very slight, and evinced itself as a burning or aching pain in the deep urethra and generally worse during urination. In the majority of cases, however, it was fairly considerable and was characterized by pain which began in the neck of the bladder just before urination and radiated from there to the end of the penis. In some instances this pain was very severe and was accompanied by marked vesical tenesmus, straining and abdominal spasm, this was particularly true in 20 cases associated with calculus in the bladder, but there were many other cases in which the pain was just as severe in which no calculus was present. In a number of these cases a severe pain radiating to the end of the penis and felt most severely just behind the glans, and which is considered almost patho- gnomonic of vesical calculus was present. This severe pain without the presence of calculus was frequently due to cystitis and was often associated with vesical contracture. In other cases, however, it was associated with considerable distention of the bladder and a large residual urine. In some instances the pain came on when the bladder became full and completely disappeared after catheterization, but in several cases the catheter afforded no relief. One of these patients study of 14-5 Cases of 'Perineal Prostatectomy. 55 (54) catheterized himself 13 times a day. The bladder was con- tracted and considerably inflamed, but there was no stone found and natural urination has been established by prostatectomy. Another such case (10) voided urine every two hours with great pain and difficulty. There was only 100 cc. residual urine and the bladder was markedly contracted, but no calculus was present. Another case (117) voided urine every half hour with great pain, but there were only 80 cc. residual urine present, and no calculus. Several cases in which the prostate was not enlarged except in the shape of a small median bar and in whom the microscope showed chronic prostatitis, belonged to these cases of frequent and painful urination with contracture of the bladder and little residual urine. Two cases in which calculi were found were remarkable for the absence of pain. One (23) had a calculus about 2 cm. in diameter, but the bladder was very greatly distended, holding 2000 cc. residual urine. In the other (47) the bladder was greatly contracted and there was very little residual urine and the stone was very large, and it is difficult to explain the absence of pain. In several cases the patient complained of a dull aching pain in the back, and in four cases there was definite evidence of renal infection and a suggestion of renal cal- culus. A slight dull aching pain in the rectum was not an uncommon symptom and appeared most frequently during and after defecation, but in only a few cases (notably cases 114, 28) was there a severe aching pain present in the rectum. In both of these large vesical calculi were present. In one case ( 5 ) , mentioned before when discussing onset symptoms, the pain began in the bladder and radiated to the kidney. One case (130) was remarkable on account of very severe pain, which was located in the lumbar region of the spine and was accompanied by paroxysms of excruciating pain which occurred at frequent intervals and were provoked by movements of any sort. A spinal tumor was suspected but no other symptoms suggesting it were present. Remark. — In reviewing the occurrence of pain in these 145 cases of benign prostatic hypertrophy one is struck by the fact that it is limited almost entirely to the region of the bladder and urethra, and in almost all cases is intermittent in character, coming on generally as the bladder becomes full, generally increasing during urination and sometimes being very severe at the end. A pain radiating to the 56 Hugh H. Young. end of the penis, which is considered so suggestive of stone, is often seen, without the presence of calculus, and simply means that spas- modic pain originating in the prostate is generally referred down the urethra and most often to the end of the penis. It is interesting to note that the pains presented in these cases are entirely different from those generally seen in cases of carcinoma of the prostate, in which pain is a very much more prominent symptom, is often almost constantly present as a dull or severe aching in the pros- tate, rectum and perineum, and in the more advanced cases is asso- ciated with severe pain in the back, buttocks, thighs, and legs follow- ing the course of the pelvic nerves. h. Hematuria. — As stated above this was present in 22 cases (15%), but in seven cases was slight. It is interesting to note, that in the 24 cases which were associated with vesical calculus, hematuria was present in only seven cases. Among the 17 cases in which it was absent were three cases in which very large calculi were found, and in the other cases, from one to seven calculi were present, and of varying size and character. In many of these cases the bladder was contracted so that one would have expected hematuria as a result of the calculi being forced against the prostatic orifice at the end of urination, but such was not the case. In the five cases in which hemorrhage was a conspicuous feature of the disease, calculi were not present (cases 19, 74, 27, 63, 11). It is interesting to note also that in none of these cases was a catheter used, the hemorrhage coming on spontaneously and without apparent reason. In two cases (19, 11) in which the hemorrhage was very marked, urination was almost normal and there was little or no residual urine, and in another case (63) in which very alarming hemorrhages occurred, constant suprapubic drainage was present and there was no traumatism and no vesical spasm to account for the hemorrhage. These three cases, however, were each associated with considerable intravesical prostatic hjrpertrophy. c. Difficulty of urination. — The 10 cases in which the difficulty of urination was described as slight comprise very interesting cases. In three cases there was over 1000 cc. residual urine (44, 30, 107) and neither of these patients had been catheterized. One was associated with a very large diverticulum of the anterior wall of the bladder. One (94) had calculus. One (19) had had severe attacks of hema- study of 1J/.5 Cases of 'Perineal Prostatectomy. 57 turia. One (5) suffered severe pain in bladder and kidney, and two cases in which small median lobes were present occasionally had com- plete retention of urine. One ( 143 ) voided with ease at fairly normal intervals and there were only 65 cc. residual present, but the cystoscope showed a fairly large diverticulum (which had dragged the left ureter into this orifice) and other evidences of considerable intravesical ob- struction. In 78 cases there was considerable or very great difficulty of urina- tion, and many of these cases used a catheter more or less frequently to obtain comfort. In a number of instances efforts at urination were attended with very great difficulty, severe spasm of the abdomen and bladder, and not infrequently compulsory defecation so that it was necessary for the patient to go to stool every time the desire to urinate came on (and this very frequently). In many cases although the prostate was considerably enlarged, and a large amount of residual urine was present, micturition was not very difficult or frequent, and had it not been for the discomfort of a distended abdomen, slight pain and occasionally hematuria, the patient would probably not have sought operative relief. A number of the cases presented great variability as to the difficulty of urination, at times going several weeks with almost normal urination, when sud- denly an attack of difficulty, frequency and pain on urination would come on without apparent cause, and not infrequently requiring catheterization. d. The six cases of drihhling of urine have been spoken of be- fore (see onset symptoms). With one exception they were all char- acterized by a greatly distended bladder which had never been cathet- erized. In one case (84) the bladder was contracted, irritable, there was only 250 cc. residual urine, and the prostate was of the small inflammatory type. e. The three cases in which there was no difficulty of urination were each characterized by considerable enlargement of the prostate, and in two cases, both of which had never been catheterized (cases 118, 138) there was 660 cc. and 890 cc. residual urine respectively present, and both suffered from nocturnal incontinence of urine. The third case (120) showed 35 cc. residual urine, but the bladder was trabeculated and contracted. The only complaint was pain in the perineum, associated with frequent erections at night. Vol. XIV.— 5. 58 Hugh H. Young. Sexual Powers. The following tabulation gives the condition as regards presence of erections and indulgence in sexual intercourse on admission. The eases have been grouped according to age as follws : Erections. Under 50 yrs. 60 to 59 60 to 69 TO to 79 80 to 90 Present 5 Cases. 21 Cases. 30 Cases. 9 Cases. Cases. Impaired " 3 " 13 " 4 " " Not present " 3 " 14 " 15 " 2 " Not noted " 5 " 9 " 12 " 3 " Sexual Intercourse. Normal 4 Cases. 17 Cases. 17 Cases. 4 Cases. Cases. Impaired " 5 " 11 " " " Not performed .... " 1 " 14 " 15 " " Painful " 1 " 3 " " " Not noted 1 " 5 " 11 " 14 " 4 " According to the above figures the sexual powers in patients under 50 years of age were normal in 100% of the cases. Between 50 and 60 years of age, erections were normal in 78% of the cases noted, and present but impaired in 11%, and coitus was normal in 74% of the cases noted, and present but impaired in 21%. Between the ages of 60 and 69, erections were normal in 55% of the cases, and impaired in 25%. Coitus was normal in 38%., and present but impaired in 32%. Between the ages of 70 and 79, erections were present in 32% of those noted, and impaired in 14%. Coitus was normal in 21%. Catheter Life, a. Complete retention of urine occurred at some time in 64 cases, and required the use of the catheter. The time at which this occur- red was as follows: Less than 1 month before admission 13 Cases. Between 1 and 6 months 1 year 2 years 3 years 4 years 5 years 6 to 10 years 14 years 6 7 13 7 1 5 11 1 Time not noted 1 Total cases with complete retention at some time 65 study of IJfO Cases of 'Perineal Prostatectomy. 59 &. No attack of complete retention, 45 cases. c. No catheterization for any cause, 20 cases. d. The catheter had been employed more or less regularly for in- complete retention of urine in 70 cases, as folloTvs : Less ttLan 1 month 9 Cases. Between 1 and 6 months 20 " 1 year 9 2 years 8 " 3 " 4 " 5 " 3 " 7 " 1 " 8 " 2 " 9 " 2 " 12 " 1 " 14 " 1 " 16 " 1 " Time not noted 9 " e. The patient led a catheter life, retention of urine being complete in 35 cases, as follows : Less than 1 month 12 Cases Between 1 and 6 months 2 " 1 year 5 " 2 years 6 3 " 2 " 4 " 1 " 6 " 1 " 7 " 1 " 8 " 2 " 9 " 1 " 14 " 1 " Not noted 1 " /. In these 35 cases in which retention of urine was complete (e) the catheter was employed by the patient when admitted to hospital at the following interyals daily. 2 hours 1 Cases. 3 " 2 4 " 3 5 times daily 5 4 " " 9 3 " " 6 2 " " 3 Occasionally complete 5 Not noted 1 60 Hugh H. Young. g. In 55 cases the retention of urine was incomplete, but the catheter was employed at the following intervals daily : 2 hours 1 Cases 4 " 2 5 times daily 4 " " 2 " 3 3 " " 6 2 " " 20 " 1 " " 8 Occasionally Not noted 11 " 2 " h. The catheter had never been used in 31 cases. i. In cases it was not being used on admission to hospital al- though it had been necessary at some previous time owing to one or more attacks of retention of urine. j. In seven cases suprapubic fistulse were present, and no urine came through the urethra. ]c. In three cases the urine passed through a retained catheter in the urethra. Z. In two cases catheterization was impossible and suprapubic aspi- ration was employed. w. The amount of residual urine found with a catheter was as fol- lows: Less than 50 cc 11 Cases. Between 50 and 100 cc 16 100 cc 13 150 cc 7 200 cc 10 250 cc 11 300 cc. 350 cc. 400 cc. 500 cc. 600 cc. 660 cc. 890 cc. 940 cc. 1000 cc. 1100 cc. 1150 cc. 1200 cc. 2000 cc. study of 145 Cases of 'Perineal Prostatectomy. 61 n. The bladder capacity on examination was found to be as follows : 50 cc 4 Cases. 100 cc 3 " 150 cc 14 200 cc 11 " 250 cc 16 300 cc 22 400 cc 54 " 500 cc. 600 cc. 700 cc. 800 cc. 900 cc. 1000 cc. 1100 cc. 1200 cc. 2000 cc. 0. In 35 cases with calculus present the residual urine and bladdei capacity was as follows : Less than 50 cc Retention inc R. U. 5 Cases. omplete. B.C. 2 Cases Retention complete. B.C. 50 cc 2 100 cc 4 " 3 1 Case 150 cc 3 3 3 1 200 cc 4 " 250 cc 4 400 cc 2 " 2 1 " 500 cc 2 2000 cc 1 " 1 " Suprapublic fistula 325 cc 1 " Tlie Condition of Patient at Time of Operation. As bearing somewhat upon the condition of the patient it will be interesting to refer to the table of ages, which shows that 45 cases were over 70 years of age (31%) and that 16 cases were be- tween 75 and 79 years of age, four between 80 and 84 years of age, and one 87 years of age. Eighteen cases were described as being in a very weak condition, and one of these had developed the morphia habit. In seven cases there was marked emphysema of the lungs. Arteriosclerosis was a very common finding, but in six cases it was very marked, and in one case was associated with severe attacks of 62 Hugh H. Young. angina pectoris (67), and in another case with hemiphlegia (91). In 32 cases heart murmurs and other evidence of old endocarditis were present, and in eight cases the heart was enlarged although no mur- murs were heard. In many cases the heart was well compensated, but in several instances there was considerable lack of compensation, and the condition of the heart was serious. Two of the fatal cases were classed among these. There was definite kidney infection in six cases (69, 109, 24, 75, 70, 52) and in two cases nephrolithiasis. Five patients were suffering from uremia, in two cases of a very severe type and associated with considerable fever (109, 52). Urinayses. — The urine was of low specific gravity and of low area content in so many cases that it is impossible to say just how many were suffering from definite nephritis. That a great many cases were complicated with more or less severe kidney lesions is undoubtedly true. The correct estimation of albu- min and the finding of casts was interfered with in most cases by the large amount of pus present, but in 10 cases granular casts were found, and they were probably present but not detected in many others. In one case (20) there was complete suppression of urine before the operation, and in three other cases nausea and vomiting with other symptoms of uremia. The urine was acid in 111 cases and alkaline in 14, and neutral in five cases. It was clear and contained no pus in eight cases. Pus was present and noted in 126 cases, and in 13 cases the presence of casts was noted. In most cases the urine was examined immediately after voiding in a clean vessel, a stained specimen being made after centrifugalizing. In 53 cases bacilli of the colon type were present. In 14 cases cocci, probably staphylococci, were present. In 18 cases the urine was sterile, no bacteria being found after careful examination. In 13 cases bacteria were found, but the character was not noted. Epididymitis. — Epididymitis had been present at some time before operation in 29 cases (20%). In 19 cases it was single and in 10 cases both sides were involved. In three cases acute epididyraitis was present at the time of operation. Hernia. — Hernia were present in 16 cases, single in 11 and double study of lJf5 Cases of 'Perineal Prostatectomy. 63 in 5, all in the inguinal region. One case also had a ventral hernia following suprapubic prostatectomy. Hemorrhoids were frequently present and generally gave no trouble after the prostatic obstruction had been removed. Stricture of Urethra. — Definite stricture of the urethra was present in eight cases. In two cases (82 and 89) dense hard strictures of small caliber were present in the bulbo membranous region. Three cases (141, 133, 73) had strictures of the bulbous urethra of large caliber, but in the last case quite fibrous in type. In three cases (95, 55, 53) strictures of the pendulous urethra were present, and in two cases were quite fibrous and required dilatation. It is probable that strictures of large caliber were present in other cases, but as a careful examination of the anterior urethra with bougies-a- boule was not made a routine procedure, some cases may have been overlooked. A careful examination for strictures should always be made as their presence has much to do with the closure of perineal fistula after prostatectomy, which fact a study of the above cases forcibly brought out. Previous operations. — A Bottini operation had been performed in six cases, four by myself. These cases are of interest. Case I (108) had considerable enlargement of both median and lateral lobes. Two attempts were made to perform the Bottini operation, but both were unsuccessful owing to the burning out of the electrical transformer which was used in this particular hospital (not the Johns Hopkins). This is the only case in which this accident happened in my practice. Case II (11), characterized by two very large lateral lobes, was completely relieved of all urinary obstruction and urinary frequency by the operation, but began to have severe hemorrhages one year later and perineal prostatectomy was performed to remove the very large intravesical lobes and the bleeding ceased. Case III (24) had a small median lobe, a contracted bladder and little residual urine, and was not improved by the Bottini operation. Case IV (145) was exactly similar to case III. Case V (71) had been subjected to two Bottini operations and one perineal prostatectomy in Germany without success. An examination showed a small globular median lobe. Case VI (9) had had three Bottini operations and suprapubic drainage. 64 Hugli H. Young. Suprapubic prostatectomy had been previously performed in two cases (by others) with unsuccessful results. In both of these cases (83, 116) considerable enlargement of the prostate remained. Perineal prostatectomy had been performed in one case mentioned above. Castration had been performed in three cases (24, 25, 145), in all with unsatisfactory results. In two cases perineal prostatectomy showed the lateral lobes very little enlarged and possibly atrophic, but an obstructing median bar was present. In the third case the pros- tate was very large and showed not the slightest evidence of atrophy. Suprapubic drainage had been supplied in eight cases, and the pa- tients wore some form of drainage apparatus on admission to the hos- pital, and were unable to void through the urethra. Suprapubic lithotomy had been employed in one case and was fol- lowed by closure of the bladder. In three of the cases in which the sinus persisted calculi had been present. Litholapaxy had been performed several years previously in one case. 'Perineal section on account of stricture of the urethra had been performed in two cases (89, 82). In both of these cases very severe urethral strictures were present and the prostatic obstruction was inflammatory in type. The Character of Prostatic Enlargement. Rectal examination. — The size of the prostate as determined by rectal examination was as follows : Apparently not enlarged, 4 cases ; slightly but definitely enlarged, 36 cases; moderately enlarged, 50 cases ; considerably enlarged, 52 cases ; very greatly enlarged, two cases ; huge, one case. The exact description of the size of a prostate as felt by rectal ex- amination is always difficult, and I have as yet found no satisfactory method of stating the size that I think a prostate is, on rectal exami- nation. In almost all of these 145 cases the record of examination is my own, so that variations which may arise when examinations are made by numerous observers is largely eliminated. The facility with which a prostate may be felt in a given case has much to do with the impression one gets of its size, e. g., in a very thin person with a slight amount of perineal tissue the prostate usually study of IJi-o Cases of 'Perineal Prostatectomy. 65 seems larger than in cases in vrhicli the perineum is fatty and the prostate difficult to reach. The four cases in which the prost-ate was apparently not enlarged were shown with the cystoscope to have definite enlargement of the median portion (bar or lobe), and in many of the cases, in which the enlargement was described as slight, the obstruction was largely of this t}"pe, but although these cases showed only a slight hypertrophy of the prostate they were accompanied by symptoms sufficiently severe to require relief, and in many instances the obstruction was as com- plete as with some of the largest prostates. In this series of cases it was shown conclusively that cystoscopic examination was absolutely necessary to determine the cause of the obstruction, for in many of these small prostates one would not have been justified without cysto- scopic examination in saying that the prostate was responsible for the symptoms and obstruction present. In many of the larger prostates the rectum was considerably im- pinged upon by the prostatic mass and in some cases very little space was left between the posterior surface of the prostate and the sacrum. ^Many of these cases suffered with considerable bowel obstruction, chronic constipation, and in some cases defecation was not only difficult but painful. It is remarkable, however, that pain in the rectum was notable particularly for its absence, thus differentiating these cases from the malignant prostates. Surface. — The posterior surface of the prostate was described as irregular in 14 cases and nodular in one. This irregularit}- usually consisted in the presence of one or two prominent lobules which pro- jected from the general level of the prostate. In four or five in- stances it seemed as if a small lobule of gland tissue had broken through the capsule and developed extraprostatically (so to speak). This was most commonlv present at the upper end of one of the lateral lobes, by the side of the ejaculatory duct, where the capsule is known to be least dense. In other cases, however, the surface of the prostate was distinctly irregular. This irregularity was most common at the upper end of one or both of the lateral lobes, and was usually associated with a cer- tain amount of chronic prostatitis and seminal vesiculitis. Occasion- ally, however, the lateral borders of the prostate presented an irregu- lar ridge. Periprostatic adhesions and bands were present in a few cases, in some instances producing septa which stood out prominently in the rectum. 66 Hugh H. Young. In the vast majority of cases, however (130 out of 145), the sur- face of the prostate was smooth and the general contour fairly regular and symmetrical with the exception of an occasional greater enlarge- ment of one of the lateral lobes. The median furrow and notch were obliterated in many cases, but in others they were wide and deep. I could make out very little relationship between the character and amount of obstruction present and the presence or absence of furrow or notch. It is generally held that when the median lobe is enlarged the superior notch is obliterated, and while this is true in many cases, and particularly those of large median lobes, I have seen a number of cases with little or no median enlargement in which the notch and furrow were obliterated, and cases of median enlargement in which the notch was present. My opinion is that the notch and furrow are dependent upon the direction of growth of the lateral lobes and whether they are closely bound together by the capsule or not. Where the capsule is lax and thin the lateral lobes frequently have a divergent growth, a tendency to grow laterally, and upward and outward into the region of the seminal vesicles, and in such cases we frequently find wide and deep furrows and notches. I have noticed that such cases are frequently associated with very little rbstruction to urination in comparison with the size of the prostate, and I believe it is because, not being firmly held together by the capsule, they do not greatly compress the urethra, and urination is little interfered with. Consistence of prostate. — The prostate was described as distinctly soft in 56 cases; elastic in 26 cases; firm in 45 cases; moderately hard in 14 cases; very hard, no cases. The seminal vesicles were slightly indurated in 19 cases, and moder- ately indurated in five cases, in the remaining cases there was no induration found. The intervesicular space was slightly indurated in two cases and moderately indurated in two cases. The whole base of the bladder felt hard in one case. Grlands were palpable in the pelvis in five cases. As shown by the above figures the soft and the elastic prostates form by far the greater number, in fact these two varieties should be classed together, as there is only a slight variation between them. The pros- tate in such cases was soft, compressible, generally elastic but at times study of 145 Cases of 'Perineal Prostatectomy. 67 boggy. The capsule covering it was apparently very thin and the consistence was usually uniform, though small areas or lobules of a firmer consistence were sometimes present. The size of the prostate in these cases was generally considerable, there being only eight out of the 40 cases which were described as slightly enlarged in which the prostate was soft. The 45 cases in which the prostate was described as firm comprise cases in which there was no induration present and in which the prostate was elastic, but the elasticity was of moderate degree and evident only on moderate pressure. The consistence in these cases was usually uniform and the surface smooth. In the 14 cases classed as moderately hard the consistence was not elastic, but quite firm, although not of stony hardness. In these cases there was usually no uniformit}^ in consistence, there being places of greater induration than others and often slight irregularity of sur- face, and the induration was generally most marked at the upper end along the region of the ejaculatory ducts and adjacent to the bases of the seminal vesicles. The complete absence of cases of stony hardness of the prostate is interesting as showing an important differentiation between benign and carcinomatous enlargement. The figures in regard to the seminal vesicles are not entirely accurate owing to the fact that they could not, owing to the size of the prostate, be reached with the finger in many cases, but among the 90 cases of slight and moderate enlarge- ment of the prostate it should have been possible in nearly all cases to appreciate induration in the region of the seminal vesicles and in the intervesicular space had it been present. I therefore feel safe in asserting that in the great majority of cases of enlarged prostate, the seminal vesicles are negative. A study of the cases in which the prostate was described as moder- ately hard shows that the prostate was only slightly enlarged in most of the cases, and microscopic examination showed a condition of chronic prostatitis or fibro-muscular hypertrophy. In five cases in which a single hard area, usually a small rounded lobule which pro- jected beyond the limit of the prostatic capsule at the upper end of the prostate on one side, was present, the prostate was more or less con- siderably enlarged, but the rest of the prostate in each of these cases was described as smooth and elastic. N'o case of considerable enlarge- ment of the prostate with marked general induration is present in this 68 Hugh H. Young. series, and this is all the more remarkable because there are many cases of considerable prostatic hypertrophy in which the microscope shows marked prostatitis. There is, however, usually a large amount of adenomatous tissue present, and the softness which this imparts has apparently been sufficient to keep the prostate from feeling hard. In two cases small smooth isolated lobules with marked induration projected from the anterior portion of a prostatic lobe, and the sections in both of these cases showed localized prostatitis in these portions. Two cases in which the prostate was considerably indurated and irregular were found at operation to contain numerus seed calculi, which was scattered throughout the prostate, but were particularly numerous just beneath the posterior capsule. In both of these cases the induration was sufficient to make us suspect carcinoma. A review of the 24 cases which showed more or less induration of the seminal vesicles or intravesicular space reveals but three cases of more than slight enlargement of the prostate. In the majority of instances the prostate was of a small fibro-muscular or chronic inflammatory type, and the process in the vesicles was evidently similar in character. In most cases it was shown merely as a slight thickening of the seminal vesicles. In four cases an indurated cord or two was present in the region of the vesicle, and in iive cases one or more enlarged glands could be felt adjacent to the seminal vesicle or along the pelvic wall a little further out. The great rarity of palpable or enlarged glands in the pelvis in these cases is all the more remarkable when we consider the large number of cases in which there is considerable vesical infection and inflammation which has extended to the prostate and seminal vesicles. This observation is true also as regards cases of chronic gonorrhoea! prostatitis and seminal vesiculitis, in which I have made many care- ful examinations and have only found palpable glands in very rare instances. The fact, too, that in fatal cases of carcinoma of the pros- tate, enlarged glands have been found at autopsy in the pelvis in only 27 out of 100 cases would seem to show, along with the findings given above, that the pelvic glands are little prone to involvement either in inflammatory or in malignant disease of the prostate, and therefore their presence or absence is apparently of very little diagnostic value in differentiating benign and malignant prostatic enlargement. The indurated cords which have been mentioned above were similar to those which are commonly felt in chronic inflammation of the study of IJfO Cases of 'Perineal Prostateciomy. 69 prostate and seminal vesicles, and are in some cases, I believe, simply indurated vasa deferentia. In other cases, especially wliere multiple, they are certainly indurated lymphatics "o-hich accompany the seminal vesicle. In view of the importance of induration in the region of the prostate and seminal vesicles, I will give briefly the rectal findings in four cases which were afterwards found to be carcinomatous. Case I. — No. 10, carcinoma series. Frequency and difficulty of urination for three years; no pain until recently. He has complete retention of urine and 1500 cc. is withdrawn. The prostate is only slightly larger than normal, smooth, uniformly indurated and of stony hardness. Both seminal vesicles are slightly indurated. The cystoscope shows no intra- vesical lobe, but a small hypertrophied collar all around the orifice. "With finger in rectum and cystoscope in urethra there is considerable Increase in the median portion. At operation both lobes were extremely :tfbrous, closely attached to the capsule and had to be excised with scissors and scalpel. The tissue removed weighed only G-8, and microscopically showed carcinoma. Case II. — No. 11, carcinoma series. Frequency and difficulty of urin- ation for four years. Pain in bladder, no hematuria. The prostate is moderately enlarged, round and smooth. The right lobe is the larger and is slightly indurated, but is slightly hard, but the induration does not extend into the region of the seminal vesicles. Several indurated cords run upward from it to the lateral walls of the pelvis. The left lobe is smaller, softer and there are no indurated cords. The seminal vesicles are not palpable, there is no intervesicular mass and no enlarged glands. The cystoscope cannot be introduced into the bladder. At operation the prostate was not difficult to separate from the rectum and was only slightly indurated. At the upper end the right lateral lobe was adherent and had to be excised with scissors. Examination showed an area deep yellow in color and hard as cartilage. The rest of the hypertrophy was benign in appearance. Sections from the suspicious area showed adenocarcinoma. Case III. — No. 9, carcinoma series. Frequency and difficulty of urin- ation two years. Pain in the urethra, no hematuria. The prostate is considerably enlarged, smooth, rather hard in consistence, the median furrow is shallow, but the notch is quite deep. The seminal vesicles cannot be palpated, but the lateral lobes extend upward and outward into the region of the seminal vesicles and are quite closely adherent to the pelvic walls. The cystoscope shows two large intravesical lateral lobes; no median lobe present. At operation the lateral lobes were surprisingly small and very adherent. Microscopic examination showed benign h3T)er- trophy with one small area of definite malignancy. 70 Hugh H. Young. Case IV. No. 12, carcinoma series. Occasional frequency of urination for one year. Pain during urination for six months. The prostate is very slightly enlarged, irregular and very hard. At the base of the right seminal vesicle there is a small area of induration 1 cm. in size, above that the seminal vesicle is negative. The left vesicle is negative. The membranous urethra is enlarged, hard, the induration being continuous with that of the prostate and extending to the bulb. No enlarged glands felt. It is impossible to pass instruments owing to tight stricture in the membranous urethra. At operation the prostatic tissue was very hard, adherent to the capsule, and had to be cut away with scissors especially in the region of the base of the right vesicle. The microscope showed carcinoma. Benign cases suggesting malignancy: I (105). Cystitis and frequency of urination 15 years ago. No history of complete retention of urine. Micturition three or four times at night and twice in the day. No hematuria nor pain. The prostate is moderately enlarged, smooth, firm but not of stony hardness and slightly elastic. There is induration at junction of prostate and seminal vesicle on both sides, and several firm fibrous cords are felt extending from the middle and from the upper end of the prostate to the pelvic wall on both sides. The seminal vesicles are not markedly indurated and there is no inter- vesicular mass. The outer borders of the seminal vesicles are adherent to the lateral structures on both sides and several enlarged glands are felt in the left side next to the pelvic wall and also in the sacral fossa. The cystoscope shows a small sessile rounded median lobe. There is no subtrigonal thickening, but the median portion of the prostate is enlarged and quite hard. In this case the history and cystoscopic findings were against cancer, and the induration of the prostate was not typical, but the presence of indurated lymphatics and enlarged glands made one suspect cancer. At operation the prostatic tissue was firm and showed small yellowish dots and lines resembling cancer, but the microscope shows simply a chronic prostatitis, and the patient is well now one year after operation. II (140). Began one and one-half years ago with burning during urin- ation, frequency and difficulty, since then considerable pain and hematuria. The prostate is not much enlarged, smooth, moderately indurated, but not of stony hardness. The right seminal vesicle is not enlarged, but several hard cords are felt in this region and three or four enlarged indurated glands are present at the outer border along the pelvic wall. Cords are similarly present on the other side, and in the sacral fossa there is a small mass suggesting glands. The cystoscope shows a large, smooth, oval calculus, and moderate enlargement of the median portion of the prostate. With finger in rectum and cystoscope in urethra there is no subtrigonal thickening and only a moderate enlargement of the median portion of the prostate. At operation benign hypertrophy with prostatitis was demonstrated. The lobes enucleated easily. study of 14-5 Cases of 'Perineal Prostatectomy. 71 III (131). Frequency of urination for 15 years. Considerable difficulty and hematuria. The prostate is considerably hypertrophied, smooth, firm, elastic, no areas of induration and no tenderness in the prostate. Extend- ing upward and outward from the upper end of each lateral lobe is an area of induration in the region of the seminal vesicle which is particularly marked on the right. This induration is not of stony hardness, but is quite firm and irregular. No enlarged glands are present. An intervesicular plateau of moderate induration is present. The cystoscope shows a median lobe of considerable size. At operation a typical benign prostate, with considerable prostatitis present, was removed. The Cystoscopic Findings. The cystoscope was employed in 133 of the 145 cases. It was not used in the 12 cases for various reasons : in four because the operation was done away from home and cystoscopy could not be carried out, in three cases because suprapubic fistulse were present, and a report was made as to the condition within the bladder, and in the other cases because the patients were too weak to be disturbed. In two cases cystoscopy was attempted but the instrument could not be introduced into the bladder. One of these cases had false passages in the region of the membranous urethra which prevented catheterization, and the second was a case of very great prostatic hypertrophy in which it was impossible to get the cystoscope over the median enlargement. In six cases cystoscopy was interfered with by hemorrhage so much as to render the examination unsatisfactory. In some other instances hemorrhage occurred, but not until late or not in sufficient amount to interfere with the examination. The condition of the intravesical portion of the prostate, as shown by the cystoscope in the 125 cases in which satisfactory examinations were obtained, were as follows : Median lohe. — Slight bar, 39; small round lobe, 37; moderate en- largement, 27; considerable enlargement, 14; great enlargement, two; huge enlargement, one. Right lateral. — Not intravesically enlarged, 11; slight enlargement, 55; moderate enlargement, 28; consderable enlargement, 17; great en- largement, two; huge, one. Left lohe. — ISTo intravesical enlargement, 13; slight, 52; moderate, 25; considerable, 19; great, two; huge, one. Anterior lohe. — Five cases. Circular collar around the entire orifice, one case. 72 Hugh H. Young. Intraurethrally projecting lohes. — Four cases. Vesical calculi present. — Twenty-five cases. Vesical diverticula present. — Seventeen cases. Pouches and cellules. — IsTumerons cases. In another portion of this volume so much space is devoted to the importance of the cystoscope as a diagnostic aid in diseases of the prostate that it will be out of place to discuss the question in detail here. The cystoscopic chart (elsewhere described) has been used in almost all of the cases and has proved invaluable in the interpretation of the many and peculiar forms of intravesical outgrowths of the prostatic lobes, and without its use I feel absolutely certain that it would have been impossible for me to interpret the findings in many cases. This is particularly true in the case of median lobes in which the cystoscope may lie either on top or in the sulcus to the right or the sulcus to the left of the median lobe, and in each position an entirely different and apparently contradictory set of pictures will be obtained unless elucidated by the method of charting spoken of above. In regard to the findings tabulated above one is struck with the fairly large number of cases in which there is no intravesical enlargement of the lateral lobes shown. It not infrequently happens, especially if there is a small median lobe present to lift up the prostatic orifice, that the lateral lobes do not grow towards the bladder, but push upward into the region of the seminal vesicles so that on cystoscopic examina- tion no intravesical enlargement of the lateral lobes is seen, although there may be a considerable enlargement of the lateral lobes found on rectal examination. Another interesting finding has been that when one lateral lobe presented more prominently to the examining finger in the rectum the other lateral lobe would be found to present more prominently into the bladder with the cystoscope. This has been noted in a great many cases, and it seems evident that in the constricted space in which these enlargements are produced, occasionally one will be crowded posteriorly and the other anteriorly. Median lohes. — One is also struck with the number of cases in which the median enlargement is only slight in degree. As noted above, in 37 cases the median enlargement was in the shape of a small globular, sessile or pedunculated median lobe. In many of these cases it was not more than 1 or S cm. in diameter, and yet the obstruction was often just as great as in some of the very great hypertrophies. In study of lJf.0 Cases of ■Perineal Prostatectomy. 73 39 cases the median enlargement was in the shape of a small trans- verse bar and on cystoscopic examination the instrument shoTs^ed no sulci on either side, and it was impossible to get the triple set of pic- tures which can usually be obtained when the lobe is globular in shape with a deep sulcus on each side. In most cases this median bar was a distinct hypertrophy or thickening of the median portion of the prostate, but in a few cases it was a mere septum-like membrane which joined intravesically enlarged lateral lobes, and was apparently an artefact or fold of mucous membrane produced by the upward growth of the intravesically enlarging lateral lobes. In such cases it was often completely hidden behind the approximated lateral lobes, but on elevating the handle of the cystoscope so as to separate the lower portions of the lateral lobes the median fold was brought into view (cases 120, 5). In 12 cases the middle lobe was considerable in size, in two cases great, and in one case huge. In the latter case the intravesical mass, which was composed of median and lateral lobes fused together, was about the size of a cocoanut, and completely filled the bladder (which was large). In two cases middle lobes the size of an orange were present, and in 12 cases from the size of a hen^s egg to that of a lemon. In some instances these lobes were directed anteriorly, but in others they lay upon the floor of the bladder completely covering the trigone and in some cases much of the base of the bladder. Tlie lateral lohes. — As seen in the tabulation above, the right and left lateral lobes were about equally subjects of intravesical enlarge- ment. As remarked above, in about a dozen cases there was appar- ently no enlargement towards the bladder of the lateral lobes, and this was so, not only in some cases in which the lateral lobes were small, but also in a few cases in which the lateral lobes were fairly large. In these cases the lateral lobes had grown laterally or posteriorly rather than intravesically. In one remarkable case, however (126), in which rectal examination showed the prostate very little larger than normal, and cystoscopic examination showed no intravesical en- largement of the lateral lobes (and also very little of the median), I was surprised to find at operation that the lateral lobes were quite large, but that their growth had been directed toward the s}Tnphysis pubis, so that they presented practically no enlargement posteriorly or intravesically. In this case the posterior capsule of the prostate was extremely thick and dense, and the vesical neck was also very Vol. XIV.— 6. 74 •;. Hugh H. Young. thick and firm, and admitted the index finger only after considerable pressure was made. I have no donbt that the firmness of the prostatic capsule in these two directions was responsible for the peculiar anterior growth of the lateral lobes described above, I have never seen this condition in any other case or any reference to it in the literature. Anterior lohe. — In five cases a fairly considerable lobule was seen anterior to the urethral orifice, and so separated from the lateral lobes that it really presented as an anterior lobe overhanging the urethral orifice (50, 6, 120, 104, 65). The cystoscope, however, showed that the sulcus separating it from one of the lateral lobes was much deeper than that separating it from the other, and at operation a definite connection with one of the lateral lobes was determined in two cases, and the lobe was easily removed along with or after the lateral lobe through the lateral cavity. It cannot, therefore, be said that any of these cases presented a definite anterior lobe which was connected in no way with the lateral lobes and was entirely separate in its growth. I have seen one such case in the Museum of the Eoyal College of Surgeons, London, the enlargement being entirely of the anterior commisure of the prostate. In one case (53) the anterior portion of the prostatic margin formed part of a definite collarette around the prostatic orifice and was un- doubtedly definitely thickened, and in several cases in which the lateral lobes had grown out quite far into the bladder, I have seen the an- terior margin of the prostate appear as a septum-like fold as happens also in the median portion posteriorly in certain similar cases, but a study of these cases shows conclusively that it is very rare indeed for the anterior portion of the prostate to furnish any obstructing enlarge- ment, and, therefore, that the anteriorly directed incision which has been generally employed in the Bottini operation has had no patho- logical justification. Intraurethral enlargements. — In two cases I discovered definite lobules projecting intraurethrally. One of these cases (82) has been described in full in the article on the use of the cystoscope in diseases of the prostate, case 21. The other case is given briefly elsewhere (case 119). In both of these cases when the cystoscopic prism was drawn outward beyond the vesical sphincter, lateral enlargements projecting toward the urethra were seen, and undoubtedly furnished considerable obstruction to the outflow of the urine. study of llf.5 Cases of 'Perineal Prostatectomy. 75 It seems probable, however, that had it been possible to cystoscope the posterior urethra, as was done in these two cases, we would have found intraurethrally projecting lobules in a number of cases. Vesical diverticula. — The cystoscope was not only of very great value in mapping out the character and size of the various prostatic outgrowths, but also in determining the condition of the bladder. In practically all cases more or less trabeculation of the bladder was found. In cases where the obstruction was apparently of recent origin the trabeculation was often not very great and was usually associated with a contracture of the bladder. In the older cases the hyper- trophied muscle bundles were more prominent and there was more or less extensive pouch formation between them. In a number of cases, where the pressure had been considerable, the orifices of small intramuscular cellules were seen, particularly on the posterior and posterolateral aspects of the bladder. In 18 cases the presence of defi- nite extravesical diverticula was made out. These occurred usually just external to one of the urethral orifices. Occasionally they were found in the vertex of the bladder in the region of the beginning of the urachus, and these three positions furnished by far the most com- mon sites for their occurrence. Not infrequently diverticula were seen in all three locations. As remarked in the article on this subject in Vol. XIII of these reports, diverticula occurring in the region of the ureteral orifices are capable, not only of pressing upon the ureters and thereby obstructing the flow of urine, but also draw- ing the ureteral orifice into their cavities in their progressive en- largement. Such was the case in two of these cases, and it was on account of the fear of subsequent injury to the kidney and ureter, on that side, that I advised removal of the prostatic obstruction in one of these cases (143). In one case (30) a very large diverticulum was present and communicated with the bladder by a small orifice on the anterior wall slightly to the right of the median line. In this case it was possible to introduce the cystoscope through the orifice and care- fully examine the interior of the diverticulum which was found to extend far backward along the lateral walls of the bladder and rectum as far as the sacrum. On account of the fear of serious complications which might follow infection of this large extravesical pouch I advised and carried out excision of the diverticulum suprapubically pre- liminary to perineal prostatectomy. This was the only case in which a very large diverticulum communicated with the bladder on the 76 Hm^k H. Tmtm^. anterior wall m^ ssadi & sjmgM fmBie&. and in. tbe oilier ca^s Hie direirticsiilla irere m. sradh positiom or of msA size ItUt I did mot fear tibe idtenUoii of septic prodmcls -witMm itiirar cawi&s, and was contait to mnqply nanore iSie olieir"i :iiii.z iris' "- " t :: gtimg tlnat; Hiie dinrerticinila ■wouild imoie or Itejas ©DiriT.e'rlj :•:_!'£- ~. ia. aM impedi- ment to free -mdoaalioii was iiranc'ri. Tiis Isope lias lie@a xeaMsed in pKadticaIfy aQ of liiese cases, sotatify mm i^}i in iK^iidi Mwb fms^ lai^ divt'ei'liciiLBa m^e presomL De^ intrawe^cal poiudiies willi proatniiiiiatit septa of mimcoiiiffi wmn^ bjame aii; .1 I't" T ~-:'t ^r-fz :~ fr"-:.-. ';--^ ~ airtticnilffirly oni ft© posttEsoor waini of '- ' -■ - -'■--. :':: :~±r:::rL:.- • -■eiii poiiiiA was pisfflsnt Ibe- Thiiinid a ni;:: j."— 'rrTr itI/.t : izi -::n..::z* /rMmCTitnm iMiksnuiffidEr- ienm, ani iz. :~t -; _ ..i"r srrz. "It .17:^1 ;:m i ~riy pOTiminciilt tiaiBSweirsT -r :";:;:. ""'„::.:. i:"^-"T7 :it :..iiir7 Tri~i"Tr=4ely into an antamor An- "-Tt:::: T'::?:::: 11.: ::r:_iTi 2, zii.r^ri : ::-?rrBetioii to uranatio:!.. Zi: in '.i~ zii;::LT7' :: :L;"::,~:r; ^TTti. "■:":ir:;. iri diveriaciii-j, ri"^ "^^17 _~-r T::"i.:-r i^i:.: i:ir i: ji'^in: iZ_L3g£i:ii^: :ii-5 been rerr :~fc m one c:i^ eoliis, istt: iniBieiri; Ihey iper-r cnlns oir :: stances r:: mmllniirwCTi'- , In iffiir-r and ^i& ': nsmatunni IsfflmoncLj; r fedtOEJ ~-'. cowered. tBcted. A a SEEfflELr" ' letusneii '~ liave cc-r. bladder tnd^BE study of IJ+o Cases of 'Perineal Prostatectomy. 77 In a number of these cases the knowledge that a calculus "was present was of very great value during the operation for only by persistent searching -with forceps and spoons were the calculi secured. The advantage of cystoscopy in all cases of prostatic hypertrophy before 'operation is therefore very great as demonstrated in the cases mentioned above. Xot only is the operator forewarned as to the presence of calculi or diverticula or intravesical tumors, but the accu- rate knowledge obtained as to the location, character, and size of the prostatic enlargements enables him to operate with a confidence of removing all the obstructing portions and with the least loss of time and mutilation of unobstructing parts. I cannot too severely con- demn the obstinate refusal of certain operators to make use of this valuable and enlightened addition to our diagnostic measures. C. PEELIMIXAET TEEATMEXT. In more than half of the 145 cases here reported the operation was done within three or four days of the examination of the patient after admission. In a few public ward cases the operation was delayed owing to the press of other work, and in several private cases the operation was deferred either to suit the convenience of the operator or the patient, but in only 41 cases was definite preliminary treatment thought to be advisable. It was carried out in these 41 cases for the following length of time : 4 days 5 Cases. 5 6 7 8 10 11 12 13 between 2 and 4 weeks 4 3 " 4 " 4 1 montli 4 2 " 1 4 " 1 6 " 1 7 " 1 In five cases the patients were very weak old men, aged 77 (125),. 78 (20), 76 (54), 81 (23), 82 (49). Tour of these case's were treated 78 Eugh H. Young. by continuous drainage with the catheter, four, eight, eight, and 24 days respectively. The fifth case, aged 81, was catheterized twice daily for four days and then aspirated twice daily for six days. In this case the bladder was greatly dilated, holding over 2000 cc, and this was the only case in which the operation was not successful. This patient died 30 days after the operation. The bladder did not regain its tone. In 10 cases (20, 44, 118, 77, 136, 50, 107, 138, 23, 126) the pa- tients had never been catheterized and there was a very large amount of residual urine present, in six cases being between 500 and 1000 cc. and in four cases between 1000 and 2000 cc. Eight of these cases were treated by catheterization from two to four times daily for periods varying from one to three weeks. One case was treated by continuous drainage through a catheter for eight days and one by intermittent catheterization followed by suprapubic aspiration for six days. In all, nine cases were treated by continuous drainage through a catheter retained in the urethra, and the remainder, with exception of one case of suprapubic drainage for seven months, were treated by intermittent catheterization, generally three times daily, occasion- ally only twice daily, and in three cases from four to six times daily. In five cases (53, 37, 89, 82, 58) strictures of the urethra were present, and dilatations were given for protracted periods varying from three weeks to several months. In one case (38) the operation was delayed eight days on account of epididymitis, which was treated by ice bags. In two cases (52, 109) marked symptoms of renal infection were present (nausea, vomiting, fever, etc.), and in one continuous cathet- erization was maintained for 10 days; in the other intermittent catheterization for four days. In neither instance was there any im- provement in the uremia and it was thought best to supply perineal drainage at operation. Both of these patients died, 14 and 27 days respectively after the operation, of pyonephrosis and uremia. In one case (18) continuous drainage through a retained catheter was maintained for 10 days on account of severe urethral hemorrhages. In two cases (72, 85) the operation was delayed 10 and 18 days respect- ively on account of pleurisy. Two cases (51, 8) were treated for two and four months respectively on account of contracture of the bladder associated with chronic obstructive prostatitis with small median lobe enlargement, by urethral dilatations and attempts to dilate the bladder by hydraulic pressure, but without success. One case (75) had sugar study of lJf.5 Cases of 'Perineal Prostatectomy. 79 in the urine and was put upon antidiabetic diet for six days. During this time bicarbonate of soda and urotropin, water, catheterization, three or four times daily were employed. Eight cases (6, 1, 124, 117, 91, 132, 60, 74) were treated by intermittent catheterization for periods varying from four to 27 days. All of these patients were weak subjects, and four at least showed evidence of renal insufficiency. One had had hemiphlegia. All of these patients recovered and were cured by operation. One case (84), with a small sclerotic inflamma- tory, prostate, 250 cc. residual urine and contracted bladder, was given local treatment as an experiment, viz., catheterization twice daily, irrigations, urotropin, and urethral dilatations for 12 days, but without benefit and operation was therefore decided upon. One case (67) had a considerably distended bladder, urine of very low specific gravity containing very little urea, nausea, and other symp- toms of uremia. He was treated by catheterization, at times continu- ous and at other times intermittent for 43 days, and during this time the specific gravity of the urine improved steadily until it finally reached 1015 and operation was followed by perfect success. In the 41 cases given in more or less detail above, the patient has nearly always received urotropin from 15 to 30 grains daily and water in abundance by mouth and sometimes by infusion or by ene- mata. In very few instances has liquid diet been employed. During the past year the number of patients receiving preliminary treatment for three or four days has been considerably less than formerly, and the operator has become more and more impressed with the fact that it is not necessary in the great majority of cases. Where the patient is using a catheter regularly two or three times a day, the kidneys are in fair shape and the general health good, it seems entirely unnecessary to delay operation for any length of time. In cases with calculus present the sooner the operation can be per- formed the better it is generally for the patient. In patients who have never used a catheter, in good general health, with urine of fairly good specific gravity, with no definite evidence of more than slight change in the kidneys, and a residual urine less than 500 cc. only a few catheterizations are necessary as a rule before the operation. As soon as it has been demonstrated that anuria does not result in a given case after drawing off the urine, it is generally better to operate soon rather than expose the bladder to almost certain infection, when catheterization for a protracted period is carried out. 80 HugJi H. Young. In patients with very large residual urine, who have never been catheterized previously and the urine sterile, we must decide between continuous drainage of the bladder through a retained catheter, and frequent catheterization for a protracted period (with the ever-present danger of vesical infection), and operation after only a few days catheterization, before infection of the bladder occurs. These cases are undoubtedly among the most dangerous with which we have to deal owing to the fact that the ureters and renal pelves are almost always greatly dilated, and the renal cortex correspondingly atrophied. A study of these eases would seem to show that catheterization three times a day for a period of a week is generally sufficient to provide against sudden anuria, to cause a certain amount of contraction of the dilated ureters and renal pelves, and sufficient improvement in the urine to render operation safe, and if urotropin and water in abun- dance be taken, and great care observed in catheterization, the bladder can generally be kept free from infection. The best catheter to use is as a rule a French gum coude catheter of medium size (16 to 18 F.) the Forges make which can be sterilized by boiling before being used. Strict precautions, such as thoroughly cleansing the glans penis and the anterior urethra (by irrigation), and by irrigation of the bladder with boric acid solution after evacuation of the urine, should be taken. In cases where marked evidence of poor kidney function, as in the case mentioned above (67), is present, it may be advisable to supply catheterization for a protracted period, and it is remarkable how great improvement in the character of urine will result. In cases where the patient is uremic and definite evidence of severe renal infection is present, frequent catheterization or constant drain- age along with hydrotherapy and urotropin should be tried. In several instances this has been entirely sufficient to relieve the renal infection and restore the patient to a sufficiently good condition for prostatectomy though in one of my cases (No. 2, carcinoma series) it was necessary to maintain continuous drainage for five weeks. Where the patient does not improve under this treatment it is difficult to say what is the best procedure to adopt. In two cases (52, 109) in which I per- formed perineal prostatectomy in order to supply better drainage, the patients finally succumbed to their kidney disease. Perhaps simple suprapubic drainage will prove preferable, but in my two cases the patients died 14 and 27 daj's after the operation, and not as a result study of lJf.5 Cases of 'Perineal Prostatectomy. 81 of it, and it is -difficiLlt to see how suprapubic cystotomy could have supplied better drainage. As long as certain physicians allow their patients to get into this desperate position just so long will there remain a certain number of cases with renal lesions too severe to admit of a cure of the patient by any means. In conclusion I may say that prolonged preliminary treatment should rarely be necessary. Urotropin should usually be administered at once before cystoscopy is performed and continued through the convalescence after operation, but care should be taken not to produce stomachic irritation by it. Where the catheter has not been used and the amount of residual urine present is not very great (400 cc. or less), and the physical and urinary examination show no evidence of marked organic lesions, and in cases where regular catheterization is being performed several times daily, it is not necessary to wait for a protracted period before performing the operation. Where definite evidences of organic diseases are present, and where a very large amount of residual urine is present, in cases which have never been catheterized, a certain amount of preliminary treatment will be advisable as indicated above, but as a rule need not be protracted to any great length. Intermittent catheterization is in a way better than continuous drainage in that the bladder does not become contracted, but in cases with severe renal lesions continuous catheter drainage is generally more eflScacious, and if the catheter be kept closed by means of a clamp which is removed at stated intervals to allow the escape of urine, vesical contracture can be prevented. The objection to continuous catheter drainage is the considerable urethral and vesical irritation which is often excited. D. THE OPERATIOIsr. Character of Teclmique. The operation performed in 145 cases was in most all of the cases exactly in accordance to the technique described in another portion of this paper. Among the early cases, when the operation was in its developmental stage there were slight differences, e. g., in the first case a transverse capsular incision was used; in the second case, after stripping back the posterior capsule the urethra was opened in the median line posteriorly. In the fourth case, however, the im- portance of preserving the ejaculatory ducts was recognized and since then the bilateral capsular incisions with preservation of the sub- urethral tissues immediately surrounding the ejaculatory ducts has 83 EugJi H. Young. invariably been employed ,except in six cases. Four of these patients had lost their sexual powers, and two had been castrated, and the sub- urethral method of removing the median portion was employed. The median skin incision was used only in one case and was found to be so inferior as regards the exposure afforded that since then the inverted V incision had been used. The fact that with the latter incision all of the operation is by blunt dissection except in the median line and exactly the same as would be employed with the median skin incision has convinced me that it is foolish to attempt to do the operation through a median incision, when with the inverted V-incision no more deep structures axe divided and. an infinitely better exposure afforded. In one case a preliminary incision was made in the bulbous urethra and through this the tractor was introduced into the bladder. This was done with the idea of leaving the posterior urethra entirely intact, but a great objection was found to this method in that the prostate was drawn by the tractor, not toward the field of operation, but toward the triangular ligament, so that the exposure afforded was much less satisfactory and nothing like the same facility of making one particular portion of the prostate present for enucleation was obtainable. It is evident that with a tractor inserted through the meatus the same objections, but still greater in character, would occur. Very early in the development of this operation I had a tractor made of extra length with the idea of introducing it through the meatus and thus avoiding any incision into the urethra, but I soon found that with this instrument the prostate would be drawn toward the symphy- sis pubis and away from the field of operation. The dependent drainage afforded by the urethrotomy in the membranous urethra is of very great value after the operation, particularly in those cases in which the bladder is badly infected and in which the freest possible escape for the urine is desirable owing to impaired kidneys. Another reason for the perineal drainage tube is that ocasionally a tear is made in the urethra and hemorrhage from the prostatic cavity escapes into the bladder, and unless continuous irrigation is afforded the tubes (or the urethra if not tube drainage is furnished) may become plugged with blood. I therefore consider the opening in the mem- branous urethra the best, not only on account of the excellent traction afforded, but the great value for subsequent drainage. study of lJj.5 Cases of 'Perineal Prostatectomy. 83 In four cases, owing to the absence of infection, no tube drainage for the bladder was furnished. In two cases the result was ideal in that the patient voided almost immediately tlirough the urethra the bladder did not become infected, and the perineal fistula closed in six days. In the other two cases the urethra became plugged with blood and catheterization had to be employed, much to the discomfort of the patient and entirely vitiating the object of this method. I now invariably employ double tube vesical drainage through the in- cision in the membranous urethra. Continuous irrigation from a large tank of sterile salt solution is maintained until the morning after the operation. In cases where fairly abundant hemorrhage into the bladder occurs after the operation, it is necessary to have fairly free irrigation until the hemorrhage stops and all danger of plugging of the tubes with a clot of blood is passed. In most cases, however, after the first hour or two it is possible to clamp off most of the lumen of the tube leading from the tank so that it is very little trouble for the nurse to add warm salt solution from time to time sufficient to keep the irrigation going. In cases where the blad- der is not infected great care has been taken to prevent infection, all tubes and solutions used being carefully sterilized, the exit tube ending in a bottle which contains a solution of bichloride of mercury, to prevent ascending infection from this receptacle. In two cases the middle lobe was drawn into the urethra and there removed. In both of these cases the middle lobe was of a peduncu- lated character and difficulty was experienced in getting it to present into one of the lateral cavities. In the other median lobe cases it was always possible, either with the tractor, or with the index finger in the urethra to enucleate the lobe through one of the lateral cavities, and this latter method is much preferable in that the base of the middle lobe is much more completely removed, the mucous membrane is not usually disturbed, and the rather abundant hemorrhage, which sometimes follows its incision along with the middle lobe, is thus pre- vented. The ideal, which is to make no tear into the mucous mem- brane adjacent to any of the lobes, can very frequently be accom- plished even in middle lobe cases, and in several instances I have been able to enucleate very large intravesical lobes without even tearing the mucous membrane covering them. In other cases small tears have been made and in very rare instances a small area of mucous membrane has been removed with the median lobe. Tears in 84 Hugli H. Young. the lateral walls of the urethra have been a much more common occur- rence, but in only two or three cases at most has any of the lateral walls of the urethra been removed, and the floor of the urethra and ejaculator}- ducts have been preserved in all cases except those six cases mentioned above in which the suburethral portion of the pros- tate was removed intentionalh- (cases 55, 25, 145, 53, TT, 57). It is interesting to note that three of these patients had epididymitis after the operation, of which two went on to abscess formation, and that two others had been castrated at a previous operation. These three cases prove conclusively that preservation of the ejaculatory ducts is of very great importance as a preventive of epidid}Tnitis. Anterior lobes were drawn down into lateral cavities, and easily enucleated in five cases (50, 6, 120, 104, 65). ■ In two cases in which the irregular, almost villous, character of the intravesical portion of the prostate led me to suspect malignancy, an exploratory suprapubic operation was performed (96, 97). In two cases (89, 82), associated with severe stricture of the urethra, a median perineal incision was added to the inverted Y, and excision of the fibrous tissue in the region of the stricture carried out. Vesical calculi were removed through the perineal wound after enucleation of the prostatic lobes in 23 cases. These cases are de- scribed at length elsewhere. In one case (30) a large vesical diverticulum was excised through a suprapubic incision (but without going into the bladder) before the perineal prostatectomy was done. Several accidents occurred during these operations. In four cases the orderly holding the stafE in the urethra allowed the beak to slip out of the membranous urethra, and when instructed to introduce the instrument again through the sphincter, false passages were produced, so that the operator found the instrument outside of the membranous urethra. This acident, which is very disagreeable to the operator, should never occur if the orderly holding the instrument takes care not to allow the instrument to move from the position it occupies when entrusted to him by the operator. The only ujitoward effect of this traumatic rupture of the bulbous urethra that I have seen has been a difficulty in introducing the catheter after operation (in two cases requiring filiforms, but no definite strictures were produced). In four cases (101, 103, 71, 42) a tear has been made into the rectum in exposing the posterior surface of the prostate. Two of study of llfO Cases of 'Perineal Prostatectomy. 85 these cases (71, 42) had previously been subjected to perineal pros- tatectomy, there was a large amount of cicatrical tissue present, the rectum was very adherent to the prostate, and although great care was taken, the rectum was torn into. Both of these cases were care- fully closed with layer sutures of fine silk, and one healed per primam. In the other two cases the rectum was quite adherent to the prostate and the operator endeavored to hasten their separation by the forcible use of his finger and the tear was thus made into the rectum. In both of these cases the suture of the rectum was successful. These two cases are very instructive in showing the importance of not at- tempting to forcibly push the rectum away from the posterior surface of the prostate with the finger in adherent cases. The handle of the scalpel is a much safer instrument, and if it is always directed along the posterior surface of the prostate and not towards the rectum no tear should ever be made into the rectal cavity. In some cases, owing to intimate fibrous adhesions, it may be necessary to use the scalpel or even to leave a small portion of the posterior surface of the prostate attached to the rectum. If these precautions are taken a tear should never be made, but one should always examine the rectum with a gloved finger inserted through the anus before final closure, as de- scribed in another portion of this paper. If this is done and the levators are drawn together with a single suture of catgut into their normal position in front of the rectum, rectal fistula should never follow. The lateral wall of the urethra was intentionally excised in one case because the anterior portion of one of the lateral lobes contained a markedly indurated nodule which was slightly suspicious of carcinoma, but afterwards proved to be chronic prostatitis (128). Operative Sliock. In only three of the 145 cases was there severe shock after the opera- tion. These cases were performed under spinal anesthesia. One patient was 82, one 76, and the other 75 years old, and all were very weak subjects. In one patient the pulse was quite weak after the operation, but he reacted rapidly. In one case the respiration became very rapid after the operation. In one case there was a slight amount of shock. In all other cases there was absolutely no shock from the operation, the patient being in good condition when he left the table and after his return to the ward. 86 Hugh H. Young. The surprising manner in which these weak old men, 21 of whom were over 75 years of age and five over 80, have stood this operation has heen to me indeed very surprising not to say remarkable. Per- haps the fact that the patient has been made to drink water in abundance up to the time of operation and in frail subjects a sub- mammary infusion of salt solution has been given on the table, has had much to do with the absence of shock. The position of the patient has, however, I believe much to do with it, as in the exaggerated dorsal or lithotomy position the blood pressure in the chest and head remains strong although fairly considerable hemorrhage may occur. Spinal AncBsthesia In 11 cases spinal anesthesia was employed (cases 49, 50, 16, 23, 55, 56, 54, 28, 25, 52, 33). All of these patients were over 75 years of age except two and one of these was in desperate shape owing to pyonephrosis (52). Three cases were over 80 years of age. The reasons for employing spinal anesthesia were old age, very weak condition, the fear of existing renal impairment, and the desire to avoid pulmonary complications after the operation. As remarked above, the only cases in which there was severe shock following the operation were among these spinal anesthesia cases (16, 54, 28). The shock in these cases came on not during the operation but after removal from the table, and I cannot help but believe that it was in some way connected with the method of anesthesia as it has not been present in any cases in which ether has been employed. In fact one of the surprising results of this study of cases has been the demonstration that ether anesthesia could be employed with such perfect results in patients of great age, in weakened condition, many with severe renal disorders, cardiac lesions, emphysematous lungs, and otherwise unfit for general anesthesia as usually considered. The reasons for the absence of lung complica- tions is I believe due to the elevated dorsal position which effectually prevents the passage of mucus into the trachea while the patient is on the operating table. I have yet to see a single case in which the ether has had any definite effect upon the renal secretion after operation. Perhaps this might occur did we not give submammary infusions either on the table or after return to the ward in every case, and fol- low these up by considerable dosage of water by mouth or by rectum. study of lJf5 Cases of 'Perineal Prostatectomy. 87 where nausea is present. The result of this discovery has been that I have ceased to employ spinal anesthesia because I can see no objection to the use of ether. Duration of Operation. In performing the operation no great attempt has been made to work with extreme rapidit}\ The time consumed from the first in- cision to the tying of the last suture after placing the tube and gauze drainage has varied from 15 to 30 minutes^ 22 minutes being about the average. An effort is made to give as little ether as possible, the patient being placed on the table as soon as anesthesia is complete and ether removed considerably before the end of operation. I think it of much greater importance to do a careful operation^ to obtain a good view of the prostate, to do no injury to the rectum, to carefully secure the edges of the urethral mucosa before attempting to insert the tractor and to see what you are doing, to be sure that all obstructing lobes have been removed and that no nonobstructing but important anatomical structure, such as the urethra and ejacu- latory ducts, have been removed, than to try to make record time in each case. ]\Iy statistics conclusively show that there is no reason why prostatectomy should not be done according to the dicta of modern surgery, and not blindly, blunderingly and barbarously, simply to save a little time. Characteristics of the Prostatic Loies Removed at Operation. ^°ment^®" Slight. Moderate ^"^abfe!"" Great. Very great. Huge Right 4 53 55 21 7 2 1 Left 4 57 50 21 8 2 1 Median 18 67 44 8 4 2 1 Entire intravesical portion 6 71 40 16 7 2 1 In the tabulation above, the four cases in which the lateral lobes were not at all enlarged were characterized by small median bar ob- structions. In these cases the lateral lobes were removed (leaving however a fairly broad ejaculatory bridge) although it was possible that they were producing very little obstruction. It seemed best, however, to remove the three portions of the prostate in order to be certain of removing all obstructions. In two of these cases the erec- 88 Hugh H. Young. tions have returned and one reports sexual intercouse entirely normal, the other has not attempted intercourse, and the third and fourth cases are now in the hospital. I mention these results as showing that there is no objection to removing the lateral lobes even if appar- ently not enlarged, and in order to thoroughly expose the median bar it is important that this should be done. In the above statistics the statement that no enlargement of the median lobe was present is misleading. It should read that no por- tion of the median lobe was removed at operation in 18 cases. This differs so markedly with the cystoseopic finding, given in another part of this paper, in which only four cases without any enlargement of the median lobe are recorded that some explanation is necessary. In four cases (11, 120, 64, 5), although the lateral lobes were quite considerably enlarged, the cystoscope showed no median enlargement, and this was confirmed by the operation and none of the median por- tion of the prostate was removed. The result has been excellent in all of these cases. In four cases (23, 43, 48, 49) the cystoseopic exam- ination was not satisfactory on account of hemorrhage, but in three of the cases the result has been excellent, so that apparently there was very little median obstruction present. In the fourth case, one in whch it was impossible to introduce the cystoscope through the pos- terior urethra, examination at the time of operation showed appar- ently no enlargement of the median enlargement worthy of removal and in view of the age of the patient (81 years) it was thought unwise to prolong the operation. The patient lived 30 days and died of general weakness and hypostatic congestion of the lungs, but his blad- der did not functionate properly and it was necessary to drain it with a catheter. Owing to the fact that the bladder was dilated (with over 2000 cc. residual urine before operation) it was impossible to say that atony of the bladder was not the chief cause of failure to evacuate urine, but I believe that there must have been some obstruction in the median portion of the prostate which, although slight, should have been removed. In the remaining 10 cases (50, 10, 8, 83, 126, 94, 3, 47, 15, 36) although the c3^stoscope showed a small median bar, after removal of the lateral lobe examination of the median portion seemed to show that there was not sufficient enlargement in this region to cause obstruction, and as it was impossible to make this portion present into one of the lateral cavities with the tractor it was thought unnecessary to split open the urethra and excise this study of lJj.5 Cases of 'Perineal Prostatectomy. 89 median poxtion. Accordingly nothing was removed from this region. The results obtained in six eases show that this decision was entirely correct, but in the first five cases mentioned above there is a question whether the results obtained might not have been better had the median portion been excised. One of these patients although re- lieved of the complete retention, from which he suffered before opera- tion, complained of severe pain in the wound during the three weeks he lived after operation (83). One case (50) had an atonic over dis- tended bladder with 1100 cc. residual urine before operation and the residual is now 300 cc. and the cystoscope shows a small median bar, so that I do not believe the obstruction was completely removed. The other two cases consider themselves greatly improved but suffer from slight frequency of urination. Another case (126) who also had a very large residual urine (9-10 cc.) now had 150 cc. residual urine although he does not get up at all at night to urinate and micturition is normal. Although there is definite evidence of residual urine after the operation in but three cases, all of whom had about 1000 cc. residual urine and very weak atonic bladders before operation, I feel certain that even better results might have been obtained by the routine removal of the median portion of the prostate in these cases although it did not seem enlarged at operation, and in the future this shall be my practice. A review of the cases in which the lateral and median portions re- moved at operation were slight shows many very severe cases of ob- struction. A large number of these patients had complete retention of urine and depended entirely upon the catheter, and in others catheterization was necessary owing to a large amount of residual urine and great difficulty and frequency of urination. In this class there were probably more cases of contracture of the bladder and small residual urine, and more cases associated with calculus than among the large prostates, but in every case operated there was definite evidence of serious obstruction present and the excellent results obtained show the wisdom of intervention. In these cases of slight enlargement of the lateral lobes I usually found very little difficulty in removing the lateral lobes each in one piece. By making the initial capsular incisions deep the lobes are easily freed from the urethra and no difficulty is experienced in separating them from the capsule, but the vesical end of each lobe is often quite adherent and in Vol. XIV.— 7. 90 Hugh H. Young. some cases cannot be enucleated with the finger, in such cases I have found the use of broad sharp periosteal elevator of considerable use in freeing the deeper portions. In the case of a very small median lobe, when pedunculated it has usually been an easy matter to cause it to present into one of the lateral cavities with the tractor or the finger in the urethra, but in the case of a small fibrous median bar it has occasionally been necessary to split the urethra along one of the lateral walls and, thus exposing the median portion of the prostate, to grasp it with tooth forceps and excise it with its mucous covering through the lateral cavity and urethra combined. Several recent cases (133, 137, 143, 141) have shown the importance of this method of technique. Whenever it has been impossible to engage the median portion of the prostate with the tractor, and the index finger meets with a firm cicatricial ring around the prostatic orifice, although no en- largement may be evident it is extremely important that the median portion should be excised to prevent the continuance of obstruc- tion as in case (126). By the technique mentioned above the ejacu- latory ducts are not disturbed and only a small bit of mucous mem- brane at the vesical orifice is removed. The absence of epididymitis following the cases operated upon by this technique and its presence in all cases in which the suburethral method was used, show conclusively that the former is greatly to be preferred. As regards the cases of moderate hypertrophy there is little to be said. The enucleation especially of the median portion has nearly always been easier than in the cases of slight hypertrophy. As seen in the above table these cases form about one-third of the entire num- ber of prostatic hypertrophy and along with the cases of slight en- largement form about 70%. In the cases described as considerable enlargements it is noticed that the portion affected was more commonly the lateral than the median, and the same is true with the great hypertrophies. In one case (11) in which there was a considerable hypertrophy of each of the lateral lobes, there was no enlargement at all of the median portion of the prostate, the intravesical portions of the lateral lobes being flattened against each other like two halves of an orange. The urethra in this case was about 5 cm. wide. Seven cases (65, 96, 20, 29, 122, 13, 114) have been classed as great enlargements. In these cases there was an involvement of both lateral and median portions of the prostate in an extensive intra- study of IJfB Cases of 'Perineal Prostatectomy. 91 vesical outgrowth. The weight of tissue removed in these cas6s varied from 80-G to 100-G. Two cases (109, 73) have been classed as very great hypertrophies. Here also all three portions of the prostate were involved, forming a very large intravesical mass, the tissue removed weighing 150 and 145-G. In one case (16) the prostate has been classed as 4iuge, the intra- vesical portion of the prostate forming a mass about 9 cm. in diameter and weighing when removed 210-Gr. In none of these cases, although the prostatic enlargement was largely intravesical and of great size, was an}^ special difficulty experienced in enucleating the prostatic lobes through the perineum, in fact the operation was, in many cases, much easier than some of the small fibrous prostates. In most cases the lateral lobes have been removed each in one piece and the median lobe in one or two pieces, though in some instances they have come away in several large lobules. In the case weighing 240-G. the pros- tatic mass was so large that it could not be drawn between the ischio- pubic rami and the tractor was so small that it would not take hold upon the huge intravesical mass after a portion had been removed. It was necessary to draw down large lobules with forceps and enucleate them separately. Had the patient been under general anesthesia abdominal pressure would have been a great assistance in this case, but he would not allow it. In nearly all other cases of the great hypertrophies the ordinary tractor has been entirely sufficient to engage and draw down the intravesical portions, but in two cases of very large pedunculated median lobes it was necessary to introduce the finger into the bladder through the urethra for assistance in the traction. A review of these cases show conclusively that even the very great- est intravesical prostatic enlargements can be removed through the perineum with ease and without destroying the ejaculatory ducts or removing more than a very small part of the mucous membrane covering the median lobe. At one time I was of the opinion that cases of this character would be unsuitable for perineal operation, but I am now convinced that complications of a different character must be present before it can be said it is advisable to attack the prostate through the suprapubic route. The convalescence in these cases has been very satisfactory, the results obtained excellent, and 92 Hugh H. Young. they furnish, I believe, the strongest evidence of the great advantages of the perineal route as a routine operation for the removal of ob- structing prostates regardless of their size. Operations in the 'Presence of Vesical CaJcuIi. Vesical calculi were present in 25 cases (23, 29, 32, 33, 36, 45, 47, 48, 62, 66, 70, 81, 83, 85, 92, 94, 101, 104, 114, 115, 116, 122, 135, 140, 144). In 13 cases one stone was found, in five cases two stones, in three cases three stones, and in one case each four, five, seven, and " several " stones. In most cases the stones were not very large, and in several cases quite small. In two cases (47 and 140) the stones were quite large. In one of these, although the stone was a rough spiculated oxalate calculus, the patient had been almost entirely free from pain. In one case (115) the calculus was quite small and was apparently lost in a blood-clot which was removed from the bladder in searching for the calculus. It seems probable that it was removed since the patient has had an excellent result and cystoscopy is negative. In case ISTo. 114, although a large calculus had been distinctly seen with the cystoscope, repeated attempts by the writer and his assist- ants failed to find it at operation, although prolonged searchings were made, and the wound was closed without removing the calculus. The search had been so careful that I felt sure the cystoscope had deceived me. The patient returned several months later complaining of pain and the c^'stoscope again showed a very large calculus, which was removed suprapubically. I believe the failure to find the calculus was due to the fact that its large size made it difficult to encompass with calculus forceps, and a coating of blood prevented us from obtaining crepitus with the instru- ments. I do not remember whether a search was made with a finger inserted through the urethral orifice into the bladder. Such a pro- cedure should have detected the calculus in a contracted bladder. At any rate it was an unpardonable mistake to desist without finding the calculus when it had been so clearly seen with the cystoscope. In the other cases no difficulty was encountered in extracting cal- culi through the perineum. When they were small they were some- times removed through the prostatic urethra without tearing its walls. In a few other cases it had to be dilated before forceps could be intro- duced or calculi removed. study of lJf5 Cases of 'Perineal Prostatectomy. 93 In most instances, however, it was thought best to divide the urethra along a lateral wall thus throwing the urethra and the capsu- lar space on that side into a common cavity (as described in the chap- ter on operative technique) through which it was an easy matter to remove calculi 5 or 6 cm. in size. In only one case was it necessary to do more than dilate the vesical orifice, and in this ease (47) a short incision was made through the vesical wall which was brought well into view by traction with the stone grasped by the forceps. By making a longer incision a much larger calculus could have been removed. I therefore feel justified in saying that the presence of even very large calculi should not, as a rule, be considered a contraindication to perineal prostatectomy. The markedly lower mortality shown by the perineal route in these cases (see another article in Volume XIII on perineal lithotomy) is a strong argument for adoption of the perineal route when stones are present, unless they be within diverticula with small orifices. E. THE CONTALESCENCE. In the preceding chapter we have described the way in which the patient reacted after the operation. The subsequent convalescence has in the vast majority of cases been remarkably simple and rapid. In all but three cases (barring the fatal and rectal fistula cases) the patient was out of bed within a week. As a rule the patient was put in a wheel-chair on the second or third day after the operation and carried out on a veranda, and within a week most patients have been walking about the ward. During the past two years it has been my custom to remove the gauze from the wound on the morning after the operation, and the tubes have been removed on the same day or the day following. Since following this custom the rapidity of the con- valescence has been remarkabh' better, and the fistulfe have closed much more quickly. For example, in 40 cases operated on in the two years from 1903 to May 25, 1904, there were 11 cases in which the fistula persisted more than two months. Whereas, during the two years, 1904 to 1906, 105 cases have been operated on with only nine cases in which the fistula persisted longer than two months. The same thing is true in regard to the length of stay in the hospital. In 1902 to 1904, out of 40 patients 12 remained in the hospital 94 Hugh H. Young. over 50 da^'s; whereas, in the 12 montlis, June, 1905, to June, 1906, among 50 cases there was no one in the hospital as long as 50 days, and only two cases over 40 days. Fifty per cent did not remain longer than 22 days, and two cases left within two weeks after the operation. In seven cases the urine began to flow through the anterior urethra on the second day, in four cases on the third day, in 10 cases on the fourth day, in 15 cases during the second week, in 12 cases during the third week, and in one case during the fourth week. In the great majority of cases urine passed through the penis during the first week, and inside of two weeks there was only a slight escape of urine through the perineal fistula. Interval urination T\-ith fairly good control has been established re- markably early in the convalescence. In four cases in which no drain- age tubes were used the patient had control at once and voided urine at stated intervals beginning immediately after the operation. In six cases in which tubes were employed, voluntary urination at intervals was established on removal of the tubes on the second or third day. The same thing probably occurred in many other cases, but unfortu- nately accurate notes on this point have been kept in only a compara- tively small number of cases. In 16 other cases, in which notes have been kept, interval urination was established between the third and eighth day, and although the patient did not void all of the urine through the meatus he has been able to retain urine for a definite period and frequently has employed a commode rather than allow the urine to escape into the perineal dressings. The latter plan has added considerably to the comfort of the patient as the presence of dressings wet with urine is always a source of annoyance. The establishment of early control and voluntary urination shows conclusively that in the operation which I have emplo5^ed the vesical sphincter is not greatly injured, and this fact has been frequently demonstrated at operation, when after the removal of even large me- dian and lateral lobes an examination with the finger has demonstrated the vesical sphincter entirely preserved, though often dilated. The fact that the entire operation is done between the external and inter- nal sphincters without destroying either explains, I believe, the reason why incontinence never follows this operation, whereas it occasionally foUows suprapubic prostatectomy in which the internal sphincter is considerably injured, and perineal prostatectomy through the ordinary study of IJfO Cases of 'Perineal Prostatectomy. 95 perineal section in which the external sphincter is divided and often considerably lacerated. During the period in -vrhich the fistula is small hut still open there is a marked difference in the comfort of the patient in perineal and suprapubic prostatectomy cases. In the former the urine is voided at intervals through the urethra at which time a small amount escapes through the perineal fistula, but by using the water-closet the patient is able to avoid any soiling of his clothes and it is unnecessary to wear absorbing dressings, whereas in the latter the urine constantly escapes through the suprapubic fistula generally until its final closure which is usually longer delayed than in perineal prostatectomy cases. Complications During ConvaUscence. Epididymitis occurred as a sequel to the operation in 20 cases. In 15 cases it was slight and it involved only one testicle in all but two cases. In many cases it was merely a slight transitory enlarge- ment of the epididymis which was moderately tender and rapidly dis- appeared under applications of ice and in several instances without any treatment. In five cases the i nfl ammation went on to abscess for- mation and required incision after which it promptly healed. In the 50 cases operated on during the past year epidid}Tnitis has occurred six times, in all cases slight and not requiring operative interference. As remarked before, three of the cases of epididymitis were in the cases in which the suburethral method of removing the median por- tion of the prostate was employed. Excluding the atypical cases we have then 138 cases in which the tj-pical operation was employed with epididymitis as a complication in 16 cases (in three of which abscess formation occurred), 12%. This corresponds exactly to the figures for the past year. When we consider the fact that 20% of all the cases had had epi- didymitis before coming to the hospital, and that those cases coming on after operation occurred usually during the second or third week of the disease we see how little the operation had to do with it. The fact that it occurred in all cases but one in which the ejaculatory ducts were removed shows conclusively that the conservation of these ducts is of very great importance as a preventative of epididymitis. Suppuration of ivound. — The sutured portion of the wound became infected and partially broke down in three cases and completely broke 96 Hugli H. Young. down in three cases. In the other cases although the packed portion of the wound became infected from preexisting cystitis the sutured wound healed by first intention. This has been to me one of the most remarkable findings after this operation, for it seems wonderful that wounds could heal so well when immediately adjacent to an abundant infection and suppuration, and the contrast between these cases and those in which suprapubic prostatectomy was performed is very great. Since it has been my practice to remove the gauze on the day after the operation and the tubes on. the second day the wounds have healed much more rapidly. Post-operative hemorrhage occurred in four cases, in two on the second day, after removal of the gauze and in both cases of moderate degree and readily controlled by repacking the wound. In one case (89) severe post-operative hemorrhage occurred from an extensive vesical ulcer which had been curetted at operation, and resulted in death on the eighth day. In one case (9) there was moderate hemor- rhage on the night after the operation and an assistant thought it necessary to forcil^ly pack the wound with gauze. As a result necrosis of the rectal wall followed. It may be remarked here that a certain amount of hemorrhage may always be expected after the operation, and one should not })e surprised if it is more abundant than he is accustomed to see, especially in operations where it is possible to ligate all bleeding points. As a rule the irrigation fluid comes away slightly stained with blood for several hours and in cases where the mucous membrane covering a median lobe has been lacerated in its removal, there may be fairly abundant hemorrhage, but a hot irrigation will generally cause a ces- sation of the bleeding. As a matter of fact hemorrhage has not been a matter of alarm in any but the single fatal case mentioned above. Recto-urethral fistulce followed the operation in seven cases and are discussed at length in another paper in this volume. Phlebitis of the veins of the thigh occurred in two cases. Purpura in one case, pleurisy in one case, cholecystitis in one case, severe pain in the back which had been present before operation persisted after operation in one case (130). In one case the exit tube became blocked in some way and the scrotum became distended with salt solution, and two small incisions were required to evacuate it. The patient (139) made a satisfactory convalescence, and although a weak old man, left the hospital on the 29th day. study of IJf-o Cases of 'Perineal Prostatectomy. 97 In two cases internes failed to remove a portion of the gauze pack- ing, in one case, until the fifth week (12). In the other case (7) all of the gauze was thought to have been removed and the patient was discharged on the 20th day. The fistula closed on the 30th day and the patient had no discomfort with exception of a urethral dis- charge until five months later when a perineal abscess formed. After that a perineal fistula persisted. An operation was performed 10 months after the prostatectomy in order to close it, and greatly to the surprise of the operator a large piece of gauze was found within one of the prostatic capsules. After that the perineal fistula promptly healed. Stricture of the urethra. — I have yet to see a definite case of stricture of the urethra following this operation, and I see no reason why one should occur. The small linear incision which is made in the mem- branous urethra back of the sphincter should never lead to the forma- tion of stricture as the coaptation of the two edges of the wound should restore the urethra to its normal caliber. In one case (25) in which the floor of the urethra was removed along with the median portion of the prostate (by the suburethral method) the patient's physician reports that he found a stricture which was easily dilated with sounds. In two cases in which rupture of the bulbous urethra has been produced by an orderly holding the urethro- tomy staff, some difficulty has been experienced in passing a catheter after the operation, but no definite stricture has been present. As stated elsewhere, I have not found it necessary to pass sounds after the operation, and in no cases, except the one mentioned above have they been employed. In fact I believe it is very important to avoid instrumentation, and usually pass no instrument except a small silver catheter to determine whether any residual urine is present on the departure of the |)atient, and in many cases in which urination is apparently normal as regards interval and force of stream and there is every evidence that the obstruction has been removed, I have not even passed the catheter. In conclusion I may say that the convalescence even in the serious cases is usually a very simple and rapid affair. With the use of an infusion after the operation and copious imbibition of water beginning as soon as possible, early purgation, getting the patient out of bed as soon as possible, and the early removal of gauze and tube drainage, the patient is usually walking about the hospital and voiding urine at 98 Hugli H. Young. stated intervals declaring that he feels well enough to leave at the end of the first week. Length of Time in Hospital. The following table gives the duration of the time during which the patient remained in the hospital after operation. 4 cases between 10 and 14 days. 20 " " 15 " 19 36 " " 20 " 24 25 " " 25 " 29 16 " " 30 " 34 5 " " 35 " 39 9 " " 40 " 49 6 " " 50 " 59 12 " over 60 Fifty per cent of the cases left the hospital within 25 days after the operation, and only 21% remained longer than one month. Thirty-two cases remained in the hospital longer than 35 days. Many of these were very weak patients, in poor condition before the operation, who convalesced slowly. In five cases the cause of delay was a recto- urethral fistula. In five cases it was due to the presence of a supra- pubic fistulas which was difficult to heal. In nine cases it was due to epididymitis, in three of which abscess formed and incision was necessary. In seven cases it was due to a tardy closure of the perin- eal fistula, in two cases to old stricture of the urethra which required dilatation. In one case each to cholecystitis, tabes dorsalis, a burn from a hot-water bag on the leg, a fragment of calculus left in the bladder, and a piece of gauze packing left in the perineum for four weeks. In one case (50) the patient remained in the hospital 37 days owing to an imperfect result, there being 200 cc. residual urine present which caused urine to be voided at intervals of two hours, A review of these cases shows that the delay was due in many cases to causes not attributable to the operation, such as previous suprapubic fistula, stricture of the urethra, cholecystitis, tabes dorsalis, gauze left in the wound, a burn on the leg, in all eleven cases. There was also one case of suppurative epididymitis which was present before operation and which was the cause of the patient remaining in the hospital for 39 days (61). In the remaining 20 cases the prolonged stay was due more or less study of 1J/.5 Cases of 'Perineal Prostatectomy. 99 directly to the operation, the most important of which was recto- urethral fistula, but since the technique has been modified so as to include an approximation of the levator muscles this complication has disappeared, and during the past year in 50 cases we find only six eases have remained longer than 35 days. Closure of the fistula. — The following table shows the time of closure of the perineal fistula : 4 cases between 21 31 17 7 7 3 6 1 13 " over 17 " fistula closed but time not noted. 6 " " still open. (2 recent.) 10 " died before closure of fistula. 2 " operated during the past 3 weeks. " 10 ' 14 " " 15 ' 19 " " 20 ' 24 " " 25 ' 29 " " 30 ' 34 " " 35 ' 39 " " 40 ' 49 " " 50 ' an 59 " Total 145 As stated above there are present only four cases of permanent perineal fistulge. One of these patients (26) had a recto-urethral fistula after the operation for which two subsequent operations were performed (not the most recent method, however). There is pres- ent now a pin-point urinary fistula through which only occasionally a few drops of urine escape. The second case (12) is the one in which a piece of gauze was discovered in the wound four weeks after the operation. A pin-point fistula now persists through which only two or three drops of urine escape during each urination. In both of these cases the patients sufl'er no discomfort and refuse treatment for the fistulge. The third case (14) is one in which I operated for Professor Casper in Berlin. He reported one year later that a minute fistula was present through which a small amount of urine escaped during urination. The fourth case (44) is one in which the median portion of the prostate was not completely removed, and 400 cc. of residual urine are still present. The fistula is minute and only a small amount of urine escapes through it during urination. In two 100 Hugli H. Young. cases (122, 136) the operation was performed six and two months ago respective!}', and the fistulse are healing under treatment. Among the 10 patients who died before closure of the fistula three (55, 24, 107) lived 5, 12, and 10 months, respectivel)^ after the operation and died, two of accident and one from pyonephrosis. In these three cases small perineal fistula were still present. The other seven cases died from 8 to 31 da^'s after the operation, and their his- tories are given in detail later on (see mortality). In the two cases which are still in the hospital the fistula has not healed, but a month has not yet elapsed. In IT cases the fistula closed shortly after leaving the hospital, but unfortunately we have been unable to learn exactly when the final closure occurred. As remarked above, fistulse cannot be considered complications of any moment after perineal prostatectomy. In 62% of the cases the fistula has closed within 24 days after the operation, and during the past year in the 50 cases operated it was closed within 24 days in T5% of the cases. The fistula at the end of two weeks has usually been only a very small affair through which a little urine would escape during urination, and those wliich have persisted longer than 24 days have been of pin-point size, allowed the passage of only a few drops of urine, and have not been enough to cause the patients more than slight annoyance. There has been no case of perineal fistula in which there has been a continous leakage of urine, such as is present in nearly all cases of suprapubic fistula until the very time of final closure. The persistance of the fistula has usually been due to suppurative conditions in the urinary tract and perineal wound. In many of these cases the bladder infection has been very great, and this con- dition has been communicated to the perineal wound and led to the formation of unhealthy granulations. In two cases urethral stric- tures were responsible for the delay in the closure of the fistulte, and in cases where the rectum has broken down the perineal fistulas have always persisted until the rectum was closed. The employment of suprapubic drainage in these cases has been followed by a prompt closure of the perineal fistula. In many of the cases in which the fistulse were slow in healing, the patient has left the hospital too soon and has not received appropriate study of lJf5 Cases of 'Perineal Prostatectomy. 101 treatment after return home. With the exception of one case (44) I have been able, in every instance, to hasten the closure of fistulge by occasional curettage with the gimlet curette (Fig. 39^) and applica- tions of nitrate of silver. F. IMMEDIATE RESULT OF OPERATION. CONDITION ON DISCHARGE. Voluntary urination was established in every case by the operation. On discharge from the hospital there was not a single case that re- quired catheterization, although on entrance the catheter was neces- sary in 134 cases, 64 of whom had complete and 70 incomplete re- tention of urine. Fig. 39\ This restoration of the power of voluntary urination in every case is indeed remarkable when we consider that in 21 cases there were over 500 cc. residual urine present, in five cases over 1000 cc, and that one patient had used the catheter for seven years, two for eight years, one for nine years, and one for 14 years, the retention of urination being complete during these periods. In 98 cases the fistula was completely closed on discharge of the patient from the hospital; in fact it has been my practice to try to keep the patient in the hospital until the fistula closed. In 39 cases the fistula was open when the patient left the hospital, but in 31 of these cases it has since closed. In eight cases the fistula is still open, but four are recently operated cases. In the majority of cases the condition of the patients were so good that they were allowed to go home without being catheterized after the operation, and the subsequent history shows excellent final results in all these cases. Two cases with vesical contracture and cystitis left without our consent on the 14th and 22d days without having been catheterized, and in both of these cases the ultimate results have not been satisfactory (46, 51). 102 Hugh II. Young. In 59 cases record has been kept of the finding witli a catlieter passed immediately before departure of the patient, as follows : cc. residual urine 34 Cases. 10 ' 20 ' 30 ' 40 ' 50 ' 75 ' 100 • 110 ' 150 ' 200 ' 2 " 1 " 1 " 1 1 " 1 " As remarked above, when we consider the number of patients who led catheter lives and the frequent presence of extreme vesical distention it is indeed remarkable that there were only 12 cases in which 40 cc. or more residual urine was found on discharge, the examination gener- ally occurring within two or three weeks after the operation. These cases demonstrate well the wonderful power the bladder has to resume its normal functions when obstruction is removed even though it may have been dilated to three or four times its normal capacity, markedly altered by inflammation, the formation of diverticula, and the pres- ence of calculi and although it had been evacuated only by catheter for many years. In order that we may arrive at some conclusion as to the cause of residual urine in the 12 cases in which 40 cc. or more was present, and the subsequent course of these cases I vrill give each in brief detail. Case I (17). — 40 cc. R. V. on discharge. Over distention of the bladder with incontinence. Catheterization for two weeks. Residual urine 500 cc, small prostate with small globular pedunculated median lobe. Total weight 15-G. Microscopically, chronic prostatitis. On discharge from the hospit:al on the 22d day voided urine at intervals of four hours, fistula closed, condition excellent. Report 31 months after operation. Urination free, five times during the day and twice at night, often a pint at a time. " I am cured." Case II (95). — 40 cc. R. U. on discharge. Catheter life for two years, bladder capacity 600 cc. Moderate enlargement of lateral and median lobes. Weight of prostate 20-G. Fistula closed 15th day. Discharged 20th day with urination normal at intervals of five hours. Report 12 months later. " Perfectly cured. Void urine naturally and only rarely get up at night." study of 1J/.5 Cases of 'Perineal Prostatectomy. 103 Case III (48). — 40 cc. R. U. on discharge. When admitted urination was every 15 minutes with great pain. Bladder irritable, small, several calculi present. Prostate moderately enlarged. The lateral lobes were removed, but the median portion was not. The fistula closed on the 27th day, patient discharged on the 34th day voiding naturally at intervals of five hours. R. U. 40 cc. B. C. 210 cc. Report 20 months after operation. "In perfect health; urination natural; retain urine from three to five hours." Case IV (114). — 40 cc. R. U. on discharge. When admitted catheter- ization was necessary every six hours. Considerable enlargement of prostate. A large median lobe and a large calculus seen with the cysto- scope. Perineal prostatectomy. Removal of three large lobes weighing G-80. A very careful search was made for the calculus but it could not be found. Thinking that the cystoscopic examination was erroneous the wound was closed. The convalescence was very satisfactory; the patient was discharged on the 14th day, no stone could be detected with a silver catheter. The bladder capacity was 230 cc, R. U. 40 cc. Cystoscopy would not be permitted. Six months later the patient returned complaining of pain, cystoscopy showed a large calculus which was removed by supra- pubic route three weeks ago. At the prostate orifice was a small fold of mucous membrane in the median portion. Case V (103). — 55 cc. R. U. on discharge. Catheterization required for three months. A slight enlargement of the prostate was present. Three small lobes were removed weighing G-15. Discharged on the 34th day, voiding urine at intervals of three hours. Report 11 months later. " I am cured. Void naturally, once during the night, 15 ounces at a time." Case VI (45). — 50 cc. R. U. on discharge. Complete retention of urine for three weeks before admission. Moderate enlargement of prostate with small median bar, four vesical calculi, which were removed at operation along with a small median bar and small lateral lobes. Dis- charged on the 21st day in good condition, voiding urine at intervals of four hours. Report by letter 15 months later. " During the night I can sleep for four hours without urinating, but during the day I suffer pain and void very frequently, and have a feeling as if a gravel was trying to pass." Case VII (41). — 40 cc. R. U. on discharge. Catheter life three months. Residual urine 500 to 800 cc. Small median lobe and moderate lateral lobes removed. Fistula closed in 10 days, discharged in 24 days, urination normal, at intervals of four hours. Residual urine 40 cc. Bladder capacity 300 cc. Report 22 months after operation — letter. " I am cured. I void three times during the day and once at night without difficulty or pain." EemarJiS. — A review of the seven cases above in which the residual urine on discharge was from -iO to 55 cc. shows excellent ultimate 104 Hugh E. Young. results in all but two cases. In case lA' the failure to remove the cal- culus was apparently responsible for the residual urine, frequency of urination, and pain., In case YI the present symptoms point to stone in the bladder, perhaps a recurrence since the operation, but possibly due to the failure to remove all the stones at operation. The fact that the patient is able to retain urine for four hours during the night and voids without difficulty seems to show that the obstruction has been completely removed. Five cases in which the residual was more than 55 cc. : Case I (107). — 75 cc. R. U. on discharge. Dribbling of urine for one year. Over distended bladder with 1100 cc. residual urine. Removal of moderate enlargement of median and lateral lobes. Discharged from hospital on the 40th day, voiding urine freely at intervals of five hours. The fistula did not close. Report two months after the operation. " The fistula is present. Urine is voided naturally but with little force, three times during the day and four times at night. The catheter is not necessary." The patient was killed in an accident 10 months after operation. Case II (37). — 100 cc. R. U. on discharge. Prostatic trouble 12 years. Multiple vesical diverticula, small median lobe. 180 cc. residual urine, con- tracted bladder. Three very small lobes were removed. The patient improved rapidly and was discharged on the 18th day voiding urine at intervals of three and one-half hours, but the catheter showed 100 cc. residual urine. On examination 23 months later 30 cc. residual urine was obtained by catheter. The cystoscope showed a small median fold and the diverticula still present but smaller than before operation. TTie bladder was contracted, holding only 150 cc. Under treatment it was dilated up to 325 cc. and after a month's treatment, patient voided urine twice at night and four times during the day. Case III (64). — 110 cc. R. U. on discharge. Complete retention of urine, over distended bladder, capacity 800 cc. Cj'stoscope showed a slight median bar, but at operation only the moderately enlarged lateral lobes were re- moved. The fistula closed on the 10th day and the patient was discharged on the 16th day, voiding urine freely at intervals of four hours during the day and seven hours at night. R. U., 110 cc. B. C, 310 cc, no discomfort. Report 18 months after operation. " Urination normal, three times during the day and twice at night, but I drink much water. Consider myself completely cured." Case IV (126). — 150 cc. R. U. on discharge. Over distended bladder. R. U. 940 cc. Cystoscope showed a slight median bar which was not removed at operation. Moderately enlarged lateral lobes removed. Rapid convalescence. Fistula closed 16th day, discharged 21st, voiding urine freely at intervals of five hours. The catheter showed 150 cc. residual urine. Report four months later. Has improved steadily. Urination four study of 1J/.5 Cases of 'Perineal Prostatectomy. 105 times during the day, none at night, micturition normal, considers himself entirely cured. The catheter shows 150 cc. residual urine. Case V (50).— 200 cc. R. U. on discharge. Over distended bladder, 1100 cc. R. U. Cystoscope showed small median bar, and a prominent anteriorly projecting left lateral lobe. At operation the lateral lobes were removed, but the median bar was not. The patient convalesced well and on discharge from the hospital on the 37th day voided urine at intervals of five hours. The catheter showed 200 cc. R. U. Five months later the patient returned, the catheter withdrew 400 cc. residual urine and the cystoscope showed a small median bar. A Bottini operation was performed, two cuts being made. Six weeks later a catheter found 250 cc. R. U. and B. C. 740 cc. with poor tonicity. Letter one year after Bottini operation. " Urination is free and satisfactory. I void 12 times during the day and six times at night, and from one-quarter to three-quarters of a pint at a time. The result of the operation is entirely satisfactory." The following two cases showed residual urine soon after discharge from hospital, and are therefore given here : Case VI (42). — Catheter life for three years. Bladder large, tonicity good, catheter used four times daily. Cystoscope showed a small round median lobe which was removed at operation and was 1 cm. in diameter. Small lateral lobes were also remoyed. The patient voided urine naturally but frequently and with difficulty after the operation, and examination three months later showed 500 cc. residual urine, and a small rounded median bar. A second operation was performed one year after the first and a tear was made into the rectum. A small median bar 1x1x2 cm. in diameter was removed. The rectal wound broke down and a recto- urethral fistula still persists, but the perineal fistula is closed and frequently no urine passes into the rectum and no feces into the urethra. Urine is voided without difficuty at intervals of six hours during the day and he does not have to urinate during the night. He is free from pain and he suffers so little discomfort that he has refused to have anything done to the recto-urethral fistula which is apparently steadily diminishing in size. Case VII (44). — Very frequent urination, over distended bladder, 1000 cc. residual urine, small median bar. At operation slightly enlarged lateral lobes and a small suburethral median lobe were removed. The patient convalesced well and was discharged on the 25th day, but urination was quite frequent and examination several months later showed 200 cc. residual urine, and with the cystoscope a small but definitely round median bar was seen. May 19, 1906. — (21 months after operation.) The catheter withdraws 400 cc. R. U. and the cystoscope shows a small rounded median lobe. Urine is voided without much difficulty at intervals of two hours. He catheterizes himself at bed time and sleeps all night. He is so comfortable that he refuses further operation. This is the only patient who uses a catheter. Vol. XIV.— 8. 106 Hugh H. Young. The following case in which the ohstruction was not completely removed, until a second operation had been performed one week after the first operation should be included here: Case VIII (141). — Catheter life for two years. Small prostate with globular median lobe. Removal of small lateral lobes, and a pedunculated median lobe through the urethra. Examination with the finger showed no remaining obstruction, but an unusually strong or firm sphincter. It was thought unnecessary to do more than to dilate this. After removal of the tubes urination was difficult and painful and the catheter showed 500 cc. residual urine. One week after the first operation the wound was broken open, and the median portion of the prostate along with a piece of the vesical sphincter and the small capsule left by the median lobe was excised leaving a large opening at the vesical orifice. The edges of the wound were reunited, the tubes were withdrawn on the next day. The convalescence was rapid and in a few days the urine began to fiow through the anterior urethra, the perineal fistula closed in 12 days (20 days after the first operation) and the patient was discharged on the 22d day after the first operation voiding urine freely at intervals of four hours and the catheter showed no residual urine. Remarl-. — In Cases II and III the residual of 100 cc, which was present on discharge from the hospital, has since disappeared, one case being entirely well and the other case (II) suffering only from contracture of the bladder and diverticula. Cases VI and VIII are apparently identical in that the removal of small globular median lobe was not sufficient to provide free evacuation of urine, and it was necessary at secondary operations to excise the median portion of the prostate along with that part of the vesical sphincter. The splendid result obtained in Case VIII shows the advisability of doing the second operation without delay. In both of these cases the entire prostate was very small and of the inflammatory sclerotic variety (the kind which Albarran declares are unsuitable for prostatectomy by the perineal route), but the results obtained in these two cases show con- clusively that if the median portion of the prostate beneath a peduncu- lated lobe is excised in these cases and a free opening provided, excel- lent results can be obtained. In Cases I, IV, V, and VII, the bladder was markedly overdis- tended, and atonic before operation, and this probably had a good deal to do with the incomplete evacuation of urine, but in the last three cases the median portion of the prostate, which was shown by the cysto- scope to be distinctly, although slightly, enlarged, was not removed. study of lJf.5 Cases of 'Perineal Prostatectomy. 107 and I feel certain that had this been done very thoroughly there would be no residual urine present. In ordinary cases (where the bladder is not atonic and greatly distended before operation) the small amount of obstruction which these cases present, would not, I believe, be sufficient to prevent complete evacuation of urine. I confess that an incomplete operation has been responsible for the imperfect re- sults shown in the five cases mentioned above (Cases IV, V, VI, VII, and A^II). In all other cases the operation has been entirely satis- factory in that the obstruction has been completely removed and free urination established. In the majority of cases the interval between urinations was four hours or more on discharge from the hospital. In a number of in- stances it was more frequent than normal owing to cystitis and con- tracture of the bladder. This was particularly true in cases where calculi had been present, where the bladder had been drained for a long time through a retained urethral catheter, or by suprapubic fistula, (These cases will be discussed later.) Voluntary control of urination. — As remarked before, one of the most remarkable results of the operation is the rapidity in which voluntary control with interval urination is established, in many cases coming on immediately after removal of the drainage tubes. At first the sphincter is usually a little weak and a few drops of urine may escape when the patient suddenly changes his position, coughs, or sneezes, but in all but a small number of cases complete control was established before the patient left the hospital. In six cases there was for a short time a slight incontinence when the patient was on his feet. This occurred only occasionally, however, and there was no incontinence during the night. In only three cases has this slight occasional diurnal incontinence persisted. These cases will be referred to at length in discussing the ultimate results. Suprapubic fistulce were present in eight cases (96, 13, 16, 9, 69, 63, 131, 70), but in only two cases required a second operation to effect a closure. In both of these cases (16, 63) the fistula was sur- rounded by considerable scar tissue which was excised at the second operation. Where suprapubic fistulte are present I usually put only one catheter in the perineal wound and another in the suprapubic. The continu- ous irrigation being maintained through one and out the other. The Vol. XIV.— 9. 108 Hugh H. Young. perineal tube is removed on the next day, but the suprapubic drainage is maintained until the perineal wound is completely healed, when the tube is removed and the fistula thoroughly curetted. Prompt closure has been thus effected in all but the two cases mentioned above. The great objection to suprapubic fistulse is that the bladder is usually contracted, and often never regains its normal capacity. G. THE CONDITION OF PATIENTS AFTEE LEAVING THE HOSPITAL. At intervals of six months (and sometimes less) I have sent circu- lar letters to all perineal prostatectomy cases with a set of questions to be answered. In these* the patient was asked whether the perineal fistula was closed, whether a catheter was used, how often urine was passed by day and by night, the amount voided at one time, as to the presence of pain, the return of erections, whether sexual intercourse was possible and in what way it differed from condition previous to operation, as to complications, treatment, general health, gain in weight, and finally whether they considered themselves cured. I have been remarkably successful in keeping track of these cases, and up to ISTovember 30, 1905, failed to hear each time from but one case. This patient (35) who was operated upon March 22, 1904, replied on May 22, 1904, saying that the wound was closed, that he considered himself cured, and that his general health was fairly good. I have since written him, his physician, and his wife several letters but have not received any answer. On May 5, 1906, the last circular letter was despatched, and replies have been received from all but six cases (but these had answered November 30, 1905).' * October 1, 1906. — Just before the correction of the page proof circular letters were again sent to the 50 cases which had been operated during the year previous to June, 1906. Replies have been received from all but seven of these, and their answers have been attached to their histories reported In the appendix. All of the seven cases who failed to reply had been fol- lowed for several months after the operation, and I am confident that they are all in good condition. A review of the final answers of these 50 cases shows a continued improvement in their condition. In many of the recent cases in which the sexual powers had not returned the patients now report a return of erections. We still have to record only one death in the 50 cases operated during that year, and the functional results ob- tained fully bear out the statements made previously in other parts of this article. study of lJf5 Cases of 'Perineal Prostatectomy. 109 Fifteen patients have died since leaving the hospital. The earliest case is that of No. (73) who died one month after the operation from " cerebral hemorrhage." The immediate result in this case was ex- cellent and the operation apparently had nothing to do with his death. Two patients committed suicide four and six months after operation (cases 51, 55). Two patients (6, 9) died five months after the opera- tion of intercurrent diseases. Both had been completely cured by the operation. One patient (case 107) died seven months after the opera- tion in a runaway accident, and one (49) died four months after operation, of apoplexy. One patient (case 5) died eight months after the operation of angina pectoris. He had been completely cured by the operation. Three patients (31, 24, 33) died one year after the operation, one of pneu- monia, one of uremia, and one of causes which cannot be ascertained. The first patient had been completely cured by the operation, the sec- ond and third cases had suffered severely from severe cystitis, con- tracture of the bladder, and autopsy on one showed double pyone- phrosis. Two cases died 23 months after the operation, one an acci- dental death while exploring in Africa, and the second of unknown cause. Both had been cured by the operation. One patient (4) died 3 months after the operation of " catarrh of the stomach." He had had no urinary trouble since operation. The only patient among these 15, who have died since leaving the hospital, in whom the obstruction to urination had not been completely removed was that of case 50, who died 20 months after the operation suddenly of unknown cause. I received a letter from him three months before his death in which he said that the result of the opera- tion had been entirely satisfactory, but at an examination one year before I had found 300 cc. residual urine. A review of these 15 cases shows that the operation was not re- sponsible for the death in a single case. In four cases there had been evidence of impairment of the kidneys, one had definite nephritis and the autopsy in one case showed pyonephrosis. The other patients met accidental deaths (three) or died of intercurrent diseases in no way connected with the urinary tract. Six of these patients were in splendid condition before and after operation, and in the other cases the general condition was not nearly so bad as in many of the patients who are still living. 110 Hugli H. Young. The number of months elapsed between operation and last report are as follows : 1 months Cases. 19 months 2 Cases. 2 " 4 " 20 " 5 " 3 " 2 " 21 " 3 " 4 " 4 " 22 " 3 5 " 7 " 24 " 6 " 6 " 3 " 25 " 1 " 7 " 4 " 26 " 3 " 8 " 3 " 27 " 2 " 9 " 3 " 28 " 2 " 10 " 3 " 29 " 1 " 11 " 9 " 30 " 4 " 12 " 14 " 31 " 2 " 13 " 7 " 32 " • 1 14 " 7 " 36 " 4 " 15 " 5 " 38 " 2 18 " 7 " 42 " 1 H. COXTRACTURE OF THE BLADDER BEFORE AND AFTER OPERATION. In 50% of the cases the capacity of the bladder before operation was distinctly contracted, i. e., less than 400 cc. In 52 cases (37%,), the contracture was marked, and the capacit}^ of the bladder between 50 and 300 cc. Seventeen of these cases w^ere complicated with stone in the bladder, three had previously had calculus, two had calculi after the operation, and 30 were not associated with calculi. The following table shows the capacity of the bladder and residual urine in these 30 cases in which no calculi were present: Retention Incomplete. B.C. Ke tention Complete. B.C. Cases. Cases. 1 " " 2 " " 7 " 11 " " 2 " 7 " " R. TJ. 50 CC 15 Cases. 100 " 5 " 150 " 2 " 200 " 2 " 250 " 5 " 300 " " Among 25 cases in which calculi were present the bladder capacity was between 50 and 250 cc. in 18 cases as follows : 50 cc 2 Cases. 100 " 4 " 150 " 4 " 200 " 3 " 250 " ■.. 5 " study of 1J/.5 Cases of 'Perineal Prostatectomy. Ill In eight eases in which the urine escaped through suprapubic fistulge the bladder was contracted in every case. A review of these cases shows that where calculi are present the bladder is apt to becojne contracted in the vast majority of cases, there being only three in our series in which it was as large as normal (500 cc). In these cases the contracture is undoubtedly due to the frequency of urination produced by the presence of calculi. In cases where suprapubic drainage has been provided contracture almost always results owing to the removal of all intravesical pres- sure. But in those cases in which neither of these conditions are present the explanation is not so easy. In some case severe cystitis, pericystitis, vesical ulcers, and diverticula are responsible for the condition, but in many instances none of these etiological factors have been present. In such cases I believe the contracture is due to a thickening of the muscular coats of the bladder brought about by efforts to force the urine through the narrowed orifice. This condi- tion of contracture apparently persists as long as the retention of urine is not complete and the residual urine is not very large, as a review of my cases shows no case with contracture of the bladder and com- plete retention of urine except those in which calculi were present or the bladder had become contracted from long drainage through a su- prapubic or a urethral catheter. Contracture of the bladder appears therefore to be the first change which occurs in the viscus as a result of prostatic obstruction. Later, residual urine begins to appear and gradually increases in amount until it approaches that of the vesical capacity. When the residual urine becomes very large the bladder apparently begins to dilate in a certain number of the cases, and as remarked above, is almost always large in uncomplicated cases when the retention of urine is complete. The formation of trabeculse, pouches, and diverticula occur simultaneously with the thickening of the muscular coats and the increase in intravesical tension, and in a few cases diverticula may form an important complication, as shown in cases (30, 143, 82, 37). A study of the cases in which frequency of urination has been present after the operation shows that it is almost always due to previous contracture of the bladder. In 30 cases urination was more frequent than usual at the time of discharge from the hospital, varying from one to three hours, and in one case being every half hour, and all of these cases were character- 112 Hugh H. Young. ized by contracture of the bladder before operation and in 16 calculi had been present. The treatment adopted in these cases was simply to have the patient drink water in great abundance and retain urine as long as possible in the bladder to dilate the bladder by hydraulic pressure, given with or without a catheter. The results have been remarkably good and in many instances where the bladder was con- siderably contracted before and immediately after operation, the capacity has gradually increased until now the patient voids as much as 500 cc. at one time. A careful study of the ultimate results of these 145 cases shows only 23 in which urination may be said to be too frequent, and in all but four of these cases more or less marked contracture of the bladder was present before operation. One case with a bladder capacity of 500 cc. before operation and complete retention of urine voids, now five months after the operation, at intervals of three hours, and 300 cc. in amount (125). The other three cases were those in which the obstruction was not completely removed (44, 50, 51) and will be given in full later on. Eeports from the remaining 19 cases show that the amount of urine voided at a time is about 60 cc. in two cases, " small " in four cases, 125 cc. in one case, 150 cc. in two cases, 200 cc. in one case, 250 cc. in two cases, 300 cc. in four cases, 500 cc. in one case, " abundant " one case. The interval between urination is two hours in four cases, two and a half hours in one case, three hours in eight cases, one hour during the day and four hours at night one case, two and a half hours during the day and five hours at night in two cases. In the three cases mentioned above in which the obstruction was not removed the interval was one hour in two cases and "very fre- quent " in one. A review of these cases shows conclusively that the most common cause of frequency of urination after prostatectomy, when the ob- struction has been completely removed, is contracture of the bladder. In cases where poh-uria is not present and the patient voids about 1500 cc. of urine a day, a bladder capacity of 300 cc. causes no incon- venience, and the patient does not have to void more than five or six times a day. But in most of these old men polyuria is present in marked degree, and when the bladder is at all contracted urination is necessarily more frequent than normal. A. peculiar feature in re- study of IJ^B Cases of 'Perineal Prostatectomy. 113 gard to these polyurias is that more urine is secreted at night, when the patient is supine, than during the day, and this accounts for the frequency with which some of these patients have to arise at night to urinate. In one of my cases 60 to 80 ounces of urine was secreted during the night and only 10 ounces during the day. In such a case nocturnal frequency of urination is necessary although the bladder may be fairly large. In conclusion I may say that in only those cases characterized by contracture of the bladder is the patient disturbed at all by frequency of urination (barring the three cases of incomplete prostatectomy mentioned above). I. ULTIMATE RESULTS. Mortality. There have been seven deaths following the operation. In none of the cases was the death directly in consequence of the operation, as shown by the fact that one occurred during the fifth week, two during the fourth week, three during the third week, and one during the second week after the operation. The cause of death was as follows : Pulmonary thrombosis, one case ; hypostatic congestion of the lungs, two cases ; double pneumonia, one case; pyonephrosis and uremia, two cases; secondary hemorrhage from a vesical ulcer on eighth day after operation, one case. All but one of the patients were in weak condition before the opera- tion, and two were over 80 years of age, one being 87 years. Two were markedly uremic, going down rapidly, and were operated on as a last resort. The seven cases were briefly as follows : Case I (21). — Age 73, admitted November 20, 1903. Examination shows a diastolic murmur and a blurring of the heart sounds in the aortic area. The prostate is only slightly hypertrophied and the cystoscope shows a small median lobe. Operation, Novem'ber 20. — Removal of median and lateral lobes. The patient reacted well, pulse 88 at the end, temperature 99 on the following night. In a few days the patient was out of bed and walking about the ward. 13th day. — Patient in excellent condition, voiding urine through urethra, almost ready to leave hospital. December 3, 1903. — The patient has become constipated and a soap-suds enema is ordered. The enema caused considerable tenesmus and im- mediately afterward the patient vomited and suddenly collapsed, dying within five minutes. Autopsy. — There is a firm organized clot with fresh clot built on it 114 Hugh H. Young. extending from the left auricle down the inferior vena cava. Condition of bladder and wound excellent. Case II (23).— Age 81, admitted November 14, 1903. Considerable gen- eral arteriosclerosis and intermittent pulse. Bladder greatly distended reaching two inches above umbilicus. Catheter removes 2000 cc. residual urine without emptying the bladder. After four days, catheterization became impossible and suprapubic aspiration was performed for five days. Operation, November 2Jf, 1903. — Removal of lateral lobes, a small median bar which was present did not seem sufficiently large to warrant removal. The patient reacted well, but when the tubes were removed the bladder became distended and they had to be reinserted. Three weeks after the operation the patient became weak, hypostatic congestion of the lungs developed and on December 24 he died (31st day). Case III (52).— Age 65, admitted September 20, 1904. Patient in bad condition, frequent nausea and vomiting, symptoms of uremia of long duration. Catheterization impossible, aspiration performed. Later suc- cessful catheterization. Constant drainage of bladder with catheter for 10 days. At the end of this time the urethra was irritable, catheter caused pain, the patient was still uremic and nauseated. Operation to supply better drainage decided upon. September 30. — Removal of three moderately enlarged lobes. Following operation the uremia, nausea, and vomiting continued. The patient took no food and on October 13 enterostomy was performed to supply nourish- ment. The patient died on the 14th day. Autopsy showed double hydro- pyonephrosis. Case IV (65).— 'Age 87, admitted December 3, 1904. Arteries moderately sclerotic and heart enlarged. Prostate very large. Operation, December 7. — Enucleation of very large lateral and median lobes. The patient reacted well, and on December 27 was in excellent condition voiding through the anterior urethra and walking about the ward. On the next day, three weeks after the operation, his temperature began to rise and was associated with severe bronchitis which rapidly changed into pneumonia, and the patient died January 1, 24th day. Case V (83).-^Age 73. admitted April 17, 1905. Suprapubic prostat- ectomy had been performed four years before by another surgeon and patient was in desperate condition after the operation. The lungs are hyperresonant, the heart enlarged and several murmurs are present. The prostate is considerably enlarged and the cystoscope shows two calculi. Opetation, April 24. — Removal of lateral lobes; median portion slight and not removed. The patient reacted well, but on May 1 had a chill followed by fever, drowsiness and hiccoughing which persisted until his death. May 14. Death from hypostatic congestion of the lungs on the 21st day. No autopsy. Case VI (89). — Age 53, admitted August 1, 1904. Severe stricture of urethra and cystitis following gonorrhoea 18 years ago. Dilatation of stricture afforded no relief, the bladder was contracted, there were 100 cc. study of 145 Cases of 'Perineal Prostatectomy. 115 residual urine present. The cystoscope showed a large vesical ulcer involving the entire trigone and a slight median bar. The prostate was indurated but very little enlarged. The patient was pale, weak, despondent. Prostatic massage and urethral dilatations was used intermittently for nine months without benefit and finally it was decided to perform urethrotomy for the stricture and at the same time to perform partial prostatectomy and curette the vesical ulcer. Four days after the operation there was considerable bleeding, seemingly from the bladder, which was apparently controlled, but several days later there was more hemorrhage and pain in the bladder followed by the passage of clots and on May 10 a suprapubic operation was performed and a large clot evacuated from the bladder which was then packed with gauze. The patient did not improve, however, and died the next day. Autopsy not allowed. Case VII (109).— Age 73, admitted July 20, 1905. A very weak sick old man. The prostate is markedly enlarged. The patient was treated by frequent catheterization for four days, but his condition grew steadily worse, fever, nausea, and vomiting were present and he was drowsy and irrational. Catheter drainage did not seem sufficient and it was thought best to supply perineal drainage after removal of the prostate. The patient stood the operation well, and for a few days seemed to improve, but he soon showed evidence of uremia again and finally died on August 17 (the 27th day after the operation) of uremia. Autopsy was not allowed. Although in several of the seven fatal cases reported above death was in no way caused by the operation, it is necessary to include all of them in figuring the mortality.* *Final Note as to Mortality, January 7, 1907. — Just before going to press I take the opportunity of bringing my statistics up to date, thus covering the period of six months since the manuscript was finished and sent to the printer. The many apparent unavoidable delays in the publication of this volume thus gives me an opportunity of adding many other cases. I am glad to report that there have been no other deaths or imperfect results; that all the patients have left the hospital well, and that as a whole the convalescence has become steadily better. I have now had 185 consecutive cases of perineal prostatectomy with seven deaths as above recorded, a mortality of 3.7%. This includes all of the early cases, when the operation was in a developmental stage and much less satisfactory — the patient being confined to bed and the drainage not removed for much longer periods. It certainly does not represent the true mortality. During the past two and one-half years there have been 100 cases with only two deaths, a mortality of 2%. But the most con- vincing evidence of the benignity of the operation of conservative perineal prostatectomy is the fact that in the last 60 consecutive cases there has not been a single death or bad result. 116 HugTi H. Young. The Removal of Obstruction. There are only four cases presenting evidence that the obstruction to free urination has not been completely removed. In three of these cases definite evidence of obstruction with residual urine manifested itself, but in only one case did complete retention of urine supervene. In the fourth case the patient voids freely at normal intervals and does not arise at night, and was greatly surprised when 150 cc. resi- dual urine was obtained. This case (136) was one in which the bladder was greatly distended and atonic, with a residual urine of 940 cc, and as only five months have elapsed since the operation it is possible that this residuum may eventually disappear. The three cases in which definite obstruction has shown itself are as follows: Case I (50). — Age 71, admitted September 7, 1904. Difficulty of urination has been present for 30 years, and for 25 years bas had to arise 10 or 12 times at night to urinate. The bladder is greatly distended, the catheter withdraws 1100 cc. residual urine and the vesical tonicity is poor. The prostate is moderately bypertrophied and the cystoscope shows a slight median bar. After three weeks catheterization, the amount of residual urine was still 900 cc. Operation, September 21. — Removal of the lateral lobes, median thought to be too small to warrant removal. The patient reacted well and was discharged on the 37th day, but the catheter showed 200 cc. residual urine. Three months later it had increased to 400 cc. and the cystoscope showed a small median bar. A Bottini operation was performed and six weeks later only 200 cc. residual urine was found. February 5, 1906. — Letter. " Although I void urine about a dozen times during the day and six times at night, urination is free, the amount voided is sometimes three-fourths of a pint at a time and the result of the operation is entirely satisfactory." Case II (44). — Age 65, admitted August 5, 1904. Difficulty of urination for three years. On admission urination every 15 minutes during the day and eight times at night. The bladder is greatly distended and 1000 cc. residual urine are withdrawn. The cystoscope shows a slight enlargement of the median and lateral lobes. On rectal examination the prostate is only slightly enlarged. Catheterization three times daily for two weeks. Operation, August 18, 1904- — Enucleation of two small lateral lobes each in one piece and a small rounded median lobe. Patient convalesced well and was discharged on the 25th day. Seven months after the operation the catheter found 200 cc. residual urine. The cystoscope showed a slight rounded median bar. With finger in rectum and cystoscope in urethra the median portion of the prostate was no thicker than normal. 3Iay 19, 1906. — The patient voided 100 cc. and the catheter withdrew 500 study of 145 Cases of 'Perineal Prostatectomy. 117 cc. The cystoscope shows a small rounded median lobe. The patient uses a catheter at bed-time and in the morning, but during the day voids urine naturally at intervals of two hours, and is entirely comfortable. He refuses further operation. Case III (51). — Age 67, admitted August 1, 1904. Difficulty of urination for two years, considerable pain, voiding at intervals of 15 minutes. The prostate is small and hard. The cystoscope shows a small median lobe, the residual urine is only 20 cc. and the bladder irritable and contracted holding only 140 cc. Operation. — Excision of two small lateral lobes and a small globular suburethral median lobe. The convalescence was very satisfactory, and two months later a catheter showed no residual urine and a bladder capacity of 300 cc. The urine was voided freely at intervals of an hour and the condition of the patient was good. May, 1906. — The patient's family report that some time after discharge the patient began to suffer pain, urination became difficult and very frequent and finally catheterization was necessary for four days when the patient committed suicide. In reviewing these three cases it is evident that the obstruction was not completely removed from the median portion of the prostate. It is interesting to note that the prostate was of the small sclerotic variety, and as remarked in an earlier chapter of this paper it is evident that in these eases there is generally a fibrons ring at the vesical neck which requires more than removal of a pedunculated median lobe to relieve the obstruction completely. These three cases occurred dur- ing xVugust and September, 1904. It is now my practice in cases where the prostate is of the small fibrous variety to insert the index finger through the urethra into the bladder after the removal of the prostatic lobes, and, if I find at the vesical orifice a very tight sphincter or a mass of tissue remaining in the median portion after removal of the intravesical middle lobe, I expose the median portion of the prostate by dividing the lateral wall of the prostatic urethra, and then excise the median portion of the prostate along with the mucous membrane covering it. In the several cases in which this has been done the results have been perfect, and it is remarkable to note that voluntary urination with perfect control was established within a few days after the operation. An examination of the tissue removed showed that the ejaculatory ducts had not been disturbed. In fact it is an easy matter to attack this median portion even when not enlarged and not injure the ducts, which are quite remote in this region. 118 Hugh H. Young. Perineal Urinary Fistulce. See Chapter on Convalescence, p. 93. Frequency of Urination Due to Contracture of tlie Bladder is present in five cases. In two of these cases (32, 70) calculi Avere present before operation. In both of these cases the interval be- tween urination is about two hours, but the stream is large, the patient suffers no pain, and but for the frequency of urination the result is entirely satisfactory. In three cases (10, 14, 105) no cal- culi were present, but the bladder was markedly contracted, the capacity being about 160 cc. These cases have been free from resi- dual urine since the operation, and urination is free, painless, and the stream is large, but the interval between urination is about two hours and is apparently entirely due to the small size of the bladder. Cases Now Suggesting the Presence of Calculi. In five eases the reports received suggest the presence of calculi. In all of these cases pain was a prominent S5^mptom before operation and in three cases calculi were present and removed (85, 33, 45). In these cases examination with a searcher after operation failed to reveal the presence of calculus, but the bladder was contracted and considerable cystitis was present. In two cases (46, 54) the symptoms strongly suggested vesical calculi, but owing to hemorrhage cysto- scopic examination was unsatisfactory. A careful search failed to reveal any calculi, and at operation none were removed, but no notes have been made as to whether a very careful search was made. One of these patients (54) considers himself entirely cured although he suffers from " a scalding pain when the bladder is nearly empty." The other case, however, complains of frequent and painful urination, and other symptoms of vesical calculus are present. A review of these five cases in which pain is present suggests that stones have formed since the operation in three cases, and that in one case at least calculi were present before operation and were not re- moved (46). It is only necessary to examine a few autopsy specimens to see how easy it would be to fail to detect calculi with a searcher before operation and in some cases to find them at operation in these cases. The frequent presence of pouches, diverticula, and pockets l)ohind enlarged lobes is one of the strongest arguments for the neces- study of IJfd Cases of Perineal Prostatectomy. 119 sity of cystoscopy before operation. I feel sure that in many of the cases in which calculi were present, had I not been aware of the fact from previous cystoscopic examinations, they would not have been found. Often it was only after repeated endeavors and careful search- ing with forceps and scoops that the calculi were finally removed. It is remarkable how seldom, however, calculi encysted in diverticula have been found, there being only one case in which this condition was present. In this case a suprapubic prostatectomy was performed after the calculi had been removed from the diverticulum. In such cases the suprapubic route is distinctly preferable, though it should be pos- sible to remove small calculi from diverticula with large orifices through the perineum, if the location of the diverticula is definitely determined by the cystoscope beforehand. Two Cases Report a Peculiar MarTced Nocturnal Frequency of Urination. One of these cases (8) was characterized by a small inflammatory prostate, severe cystitis, and vesical irritability. The patient con- siders himself greatly improved by the operation, but urination is particularly frequent at night. In the second case (35) the patient is now 80 years of age. The prostate was very large, and the blad- der contracted and a severe cystitis present. Urination is free, the patient can empty bladder and retains urine for three hours during the day, but during the night he frequently voids from 10 to 20 times. In some cases nocturnal frequency is explainable by a mark- edly increased production of urine during the night, but in these two cases no such explanation seems applicable. An interesting case is (106), in which, although there is no residual urine present and the bladder capacity is 360 cc. the patient voids at intervals of two hours, night and day, and not more than 180 cc. at a time. Urination is free and there is no explanation for this frequency unless it be cystitis. Becto-Urethral Fistulce are present in two cases. Both are minute and give very little dis- comfort. In both cases urination is normal at normal intervals, and the patients suffer no inconvenience (cases 26 and 42). 130 Hugli E. Young. Incontinence of Urine. Although incontinence of urine "u-as present before operation in six cases it has persisted since operation in only one case, the history of which is briefly as follows: (119). — ^Age 55, admitted November 4, 1905. Gonorrhoea 36 years ago, no note as regards sj-philis. Two j-ears ago he began to have severe inter- mittent pains in his legs. About the same time he began to have a decrease in his sexual powers, a feeling of discomfort in the region of the bladder and incontinence of urine. He was catheterized and a large amount of residuum was withdrawn, since then he has occasionally had complete retention of urine. The incontinence and pains have persisted, but the catheter is necessary three times daily. On admission the retention of urine was complete and the bladder very large. The prostate was only slightly enlarged, the cystoscope showing a small median bar. Examin- ation showed a decrease in the deep reflexes, but the only sj'mptoms of tabes were loss of sexual power and the history of lightning pains. (See complete history.) At operation slightly enlarged lateral lobes and a small middle lobe were removed. The convalescence was satisfactory, the fistula closing on the 14th day and the patient leaving the hospital on the 18th day. He was able to retain urine for six hours at night, but during the day there was incontinence which has persisted up to the present time. Five months after the operation he began to have peculiar painful seizures in the abdomen, a girdle sensation with an extremelj^ sensitive area eight Inches wide around the body, corresponding to the lower dorsal and sacral segments. His physician writes that he is convinced that he has spinal disease. The patient reports (May, 1906), that he voids urine naturally at intervals of three or four hours, during the day and only once at night, that there has never been any nocturnal incontinence and that his ability to retain urine during the day is improving. Three patients, all very old men (78, 80, and 85 years of age) re- port that occasionally, when the bladder is allowed to become very full, and the desire to urinate is imperative, and unless a urinal is near, a few drops of urine may escape. In two of these cases (93, 128) this happens but seldom, causes no inconvenience, and can- not be considered incontinence. In third case (16) there is apparently a slight weakness of the sphincter. In this case the prostate was huge and in its removal through the perineum it was necessary to excise a good deal of the mucous membrane covering the median portion of the prostate, and the vesical neck was left greatly dilated. Perhaps this has something to do with the sphincteric weakness. In reviewing these cases it seems highly probable that spinal disease study of lJf.5 Cases of 'Perineal Prostatectomy. 121 is responsible for the only definite case of incontinence which I have had as a result of perineal prostatectomy by this method. These sta- tistics absolutely disprove the statements of Freyer and others that incontinence frequently results from perineal prostatectomy. In the technique which I employ both external and internal sphincters are usually left intact, and incontinence should never occur, and does not as my cases show. In cases where the prostatic lobes are removed through a median perineal incision involving the external sphincter of the urethra, and where the prostate has been excised after hemi- section of the posterior surface, as employed by Albarran, a good portion of the urethra being sacrificed, it is easy to understand how incontinence may occur. Pain. Although pain was a very prominent symptom in 50% of the cases (occurring in 76 cases before operation, in 61 cases being considerable, and often excruciating) there are only four cases in which the pain has been considerable since operation. One of these cases (51) had a recurrence of prostatic obstruction and has been mentioned above. Two of the cases (45, 33) had calculi and it seems probable that they are again present. The fourth case (46) is one in which calculi were suspected but could not be found, and the painful symptoms have persisted. In three cases (85, 54, 4) urination is entirely satisfactory with the exception of a slight pain which comes on at the end of urination. In one of these cases a calculus was removed at operation; in the second it was suspected but was not found, and in the third several were passed after operation. In the remaining cases the patients are entirely free from pain, with the exception of a few instances in which a burning sensation or slight pain is present in the urethra during urination. All of these patients, but one, have cystitis. It is indeed remarkable that so few patients complain of any pain although cystitis in more or less severe degree is present in the great majority of cases. Two good examples of the complete disappearance of very severe pain are cases 96 and 102. The Preservation of Sexual Powers. In an earlier part of this paper condition of patients as regards sexual powers were given in tabulation. As stated there the sexual 122 Hugh H. Young. powers in those under 50 years of age were normal in 100% of the cases. Between 50 and 60 years of age erections were normal in 78% of the cases noted, and present but impaired in 11%, and coitus was normal in 74% of the cases noted, and present but impaired in 21%. Between the ages of 60 and 69 erections were normal in 55% of the cases, and impaired in 25%. Coitus was normal in 38% and present but impaired in 32%. Between the ages of 70 and 79 erections were present in 32% of those noted, and impaired in 14%. Coitus was normal in 21%. I have made careful inquiries to obtain if possible the present con- dition of all cases upon which I have operated, and the following tabulation will show the condition of the patients before operation and their present status. I. Erections present and coitus normal before operation, ^1 cases Status prsesens : Erections returned, 28 cases: Coitus satisfactory, 17 cases. Coitus impaired, 5 cases. No coitus attempted, 6 cases. Ages of these patients : 37 years 1 Cases. 40 to 49 " 1 " 50 " 59 " 14 " 60 " 69 " 11 " 70 " 79 " 1 " Erections not returned, 8 cases : Ages: 58 years 2 Cases. 60 to 69 " 5 " 70 " 1 " Eecent cases operated within the last month, 4. Not heard from, 1 case. II. Erections present hut coitus impaired before operation, 1 case. Status prsesens : Erections returned, coitus still impaired, 1 case. study of 145 Cases of 'Perineal Prostatectomy. 133 III. Erections present, coitus not performed before operation, 16 cases. Status prgesens : Erections returned, 12 cases. Erections not returned, 4 cases. Ages of the 12 patients in which erections have returned. 56 years 1 Cases. 60 to 69 " 5 70 " 79 " 6 " IV. Erections and coitus impaired before operation, 18 cases. Erections returned, coitus now satisfactory, 8 cases. Erections returned, coitus still impaired, 5 cases. Erections not returned, 5 cases. V. Erections impaired, coitus not possible or not attempted before operation, 7 cases. Erections returned, 4 cases. Erections not returned, 3 cases. YI. Erections absent before operation and coitus impossible for a considerable period, Jj.2 cases. Of these erections have returned in 5 cases. Coitus satisfactory, 3 cases. Coitus not attempted, 2 cases. Erections not returned, 37 cases. VII. No note as to erections and coitus before operation, 19 cases. In these cases erections have returned in no case. J. THE PATHOLOGY OF PROSTATE HYPERTROPHY AS SHOWN BY A STUDY OF 120 CASES. (By John T. Geraghty, in collaboration.) The opinions of various authors regarding the nature of prostatic hypertrophy are varied, and numerous pathological varieties have been enumerated. Albarran and Halle, as the result of their study of 100 cases, recog- nized three varieties of benign hypertrophy, (1) a glandular form, (2) a fibrous, and (3) a mixed form. The fibrous form is rather rare, there being only three cases in the series examined, while Motz in 30 cases found only one. 124 Hugh H. Young. Yirchow thonglit that the hypertrophy was due to the formation of lobular tumors which he described as hyperplastic myomata, but also admitted the existence of a rare form of hypertrophy produced solely by the development of the glandular tissue. Motz has seen a case of this rare form described by Virchow and applies to it the term diffuse polyadenoma. W'e have not encountered a like form of hyper- trophy in our series. According to Eindfleisch and many others, two forms exist, a so- called soft form, glandular in character, and a hard form, the fibro- muscular. Eindfleisch considered that the usual prostatic hypertrophy was a fibro-muscular increase of the peritubular stroma with at the same time lengthening and marked folding of the tubules themselves The first changes take place in the subepithelial tissue, and the peri- tublar stroma of the individual gland segments. If now in the further development there is a rapid growth of the stroma elements the glands are destroyed and the fibro-myomatous form of hypertrophy is the result. If, however, there is a rapid increase in the gland ele- ments at the same time that the interstitial tissues hypertrophy, the glands are preserved and the so-called soft form is produced. Eind- fleisch thought that the primary change was in the stroma. Alexan- der, Gouley, Caminiti, and others think there exist two periods in prostatic hypertrophy; during the first the glands develop excessively and in the second an excessive development of the stroma occurs. Jores insists that prostatic hypertrophy is not of the nature of a neoplasm while Albarran and Mansell Moulin consider it an adenoma. Motz holds that the hypertrophy is a hyperplasia of all the elements of the prostate as a result of repeated congestions (which of course would make sexual affairs a strong etiological factor). Velpeau was struck by the microscopic appearance of the spheroidal tumors which one sees in the hypertrophied prostate. He at first considered these spheroids to be of a fibrous nature, but later ad- mitted that glandular elements may take part in their formation. Ciechanowski insists that the hypertrophy is the direct result or it might be termed the end result of chronic prostatitis. As a result of the prostatitis the excretory ducts become narrowed or occluded with a consequent dilatation of tributary acini. With the gradual in- crease in the fibrous tissue resulting from the prostatitis the dilated acini are divided by constricting fibrous bands and thus is produced study of lJj-5 Cases of Perineal Prostatectomy. 125 new culs-de-sac. N"owliere, lie saj's, does lie find any evidence of glandular proliferation. Motz in a recent splendid contribution has called attention to the fact that hypertrophy practically always begins in the glands close to the urethra. Thus we see that numerous opinions regarding the nature of prostatic hypertrophy are held and numerous theories have been proposed to explain the pathological processes in this common senile affection. Although many differences exist regarding the varieties of prostatic hypertrophy nearly all authors of recent years are agreed that the glandular form is the most frequent. Taking as a basis of classification the composition of the hyper- trophy we have been able to distinguish three t}^es of cases: (1) Glandular, (2) fibro-muscular, and (3) inflammatory. The first two forms alone represent true hypertrophies. The in- flammatory form is not a true hypertrophy but we include it because it represents a form of obstructing prostate about which we will say more later. Although here and there one encounters a picture typical of the glandular and the fibro-muscular varieties, various transitions exist and a clear-cut boundary line cannot always be easily drawn between them. This classification which we have employed is not to be under- stood as representing distinct anatomical varieties, but rather ij]ies of cases which are but different phrases of evolution of the same pathological process. Hypertrophy is to be considered a hyperplasia of all the elements of the prostate the various elements undergoing augmentation in different prostates and often in the same prostate in varying degree. We have every transition from prostates in which the glandular tissue entirely dominates the field to those in which there is very little glandular element present and the tissue is almost entirely stroma. This stroma in one instance may be largely con- nective tissue, in another the muscular element may be considerable, while again we find areas in which muscle exists in almost pure form. Various combinations may be present in the same prostate so that it is not always possible to draw a sharp line of demarcation. The various forms which we have distinguished in our study of 120 cases occurred in the following frequency: Glandular 100 Fibro-muscular 14 Inflammatory or fibrous 6 Vol. XIV.— 10. 136 Hugh H. Young. Gross appearance of glandular form. — When enucleated the surface is usually lobulated and the consistency is generally soft and elastic. On cutting into such a prostate the tissues may be more or less sponge- like due to dilated glandular acini while here and there are seen the gaping orifices of small retention cysts which have been cut across. An abundance of secretion oozes forth. Usually the cut surface pre- Fig. a. — This represents a picture commonly seen in the glandular form of hypertrophy. The acini are for the most part dilated and several have undergone cystic dilatation. Epithelial proliferation is active. sents the picture of numerous spheroidal tumors, differing in size, separated from each other by encircling and interlacing bands of tis- sue of a denser character and of varying thickness. These spheroidal lobules project beyond the surface and are sometimes distinctly en- capsulated and can be quite readily enucleated. At times the ten- dency to formation of these lobules is only indistinct and the picture presented resembles somewhat that of a diffuse glandular hypertrophy. The interspheroidal tissue is as a rule largely composed of a fibro- muscular stroma although sometimes it contains a fair number of acini. In less glandular prostates the spheroids are less numerous with an increased amount of interlobular stroma which contains sparsely disseminated acini or the spheroidal bodies may be numerous but comparatively poor in gland acini. In such prostates the tissue is study of 11^5 Cases of •Perineal Prostatectomy. 127 denser and more compact although here and there may be spongy- looking areas due to dilated culs-de-sac. On microscopic examination the gland tissue for the most part occurs in lobules and when these are not present the acini seem to have a tendency to segregate in well-defined areas. The acini are usually dilated, often elongated or ovoid, and with ratlier complex lumina ^■?:;^*<-*®;iaife&fci^-~Swi®»^ST!<:3i.-^ :..;i ^1" ^.: '*;' _ Fig. B.— The epithelial activity in one of the acini shown, has resulted m the formation of capillary loops. Note the very high character of the epithelium. due to infolding and often papillomatous-like proliferation of the lining wall (see Fig. A). The epithelium lining the acini presents a variety of pictures. One acinus may be lined by a double layer of cells, the internal being a high cylindrical type with the nucleus near the basal end and an in- 128 Hugh H. Young. ternal layer of rather cuboidal-shaped cells. Again there may be but a single layer of high cj^lindrical cells. In the cnls-de-sac where proliferation is active there may be beneath the layer of cylindrical cells numerous layers of i-ather polygonal-shaped cells. Very often Fig. C. — A very glandular form of hypertrqpliy. The acini are dilated and show a rather unusual amount of intraacinous proliferation. in the same acinus at one point a single layer of cylindrical cells may be seen and at other points there may be accumulated heaps of small epithelial cells. Occasionally capillary loopings of epithelium are noted as seen in study of 14-5 Cases of Perineal Prostatectomy. 129 Fig. B. The internal layer of cells lining the acini in the hyper- trophied prostate is much higher than the epithelium lining a normal acinus. In areas where the glandular proliferation is active the walls of the acini are serrated and well-marked papillomatous projection Fig. D. — A higher magnification of portion of the field shown in C. The papillary projections in some instances have slender pedicles of stroma, while at other times they consist only of knuckles of epithelium. into the lumina of the dilated acini may he present (see Pigs. C and D). More or less numerous culs-de-sac which have undergone cystic degeneration are encountered. Sometimes there may be but a few in 130 Hugh H. Young. a given area and again cystic degeneration of nearl}' all the acini within one or more lohules may be present (see Fig. E). These acini are usually lined by a sin,gle layer of rather flattened epithelium and rarely give evidence of a proliferative activity. About the periphery of the spheroidal lobules the tissue is as a rule condensed and contains ^^^t' ^^ -6/- ;/ f 'i '■\ m- ^ /u4v .. U At : "^„ ^'t \ < , #^4: '-^v^ .^ Fig. E. — In the center is seen a rather extensive degree of cystic dila- tation of numerous acini. acini in varying numbers most of which are compressed and elongated (see Figs. E and F). Fibro-muscular. — The fibro-muscular forms seldom reach the large size attained by the glandular. The largest in our series weighs 25-Gr., while all the very large prostates are of the glandular type. The consistencv is much firmer than the glandular although it never study of llf5 Cases of Perineal Prostatectomy. 131 has the induration whicli one encounters in the carcinomatous pros- tate. On section it is less succulent and distinctly more homogeneous in appearance although isolated spheroids are noted which may be mostly if not entirely composed of a fibrous or fibro-muscular tissue. •// 4 «J ; Jj- Fig. F. — A section from the periphery of a hypertrophied lobule showing the condensation of the tissue and the flattened and elongated acini. The surface is as a rule moderately lobulated. The dilated orifices of gland acini are sometimes seen and occasionally small retention cysts are noted. The gross picture presented is usiially quite different from that which is seen in the glandular forms. On microscopic examination the acini are rather regular in outline, 132 Hugh H. Young. separated by broad bands of stroma and seldom show much signs of active gland proliferation (see Fig. G). They are sometimes dilated but seldom display a degree of cystic degeneration which one finds in more adenomatous h}"pertrophies. The stroma varies a great deal from one which is mostly connective tissue to t^'pes where the muscular ':'J^ Fig. G. — Represents a fibro-muscular form of hypertrophy. The stroma is much in excess of the glandular elements compared with C. element predominates and the stroma is of course much in excess of the gland element. Both the adenomatous and fibro-muscular forms contain spheroids in varying number. Fibrous. — Under the fibrous or inflammatory form of hypertrophy we have included a very interesting group of cases with marked pros- tatic sj'mptoms and partial or complete retention of urine. The pros- study of llfo Cases of Perineal Prostatectomy. 133 tates in this group are not enlarged or at most very slightly so (cases 87, 89, 101, 133, 137, 143). On gross examination they contain no spheroids, but the cut sur- face is rather homogeneous and apparently fibrous. These are not true hypertrophies, but represent a type of prostatitis. The prostatic obstruction is consecutive to inflammatory processes which produce a fibrous h}^erplasia about the vesical orifice or result in the formation of an infiammatory median bar. The microscopic examination of the median bar in these cases has always demonstrated its inflammatory nature while the lateral lobes present no changes other than those noted in chronic prostatitis. Chronic prostatitis has been found very frequently in our series of cases, but of course a large percentage of the patients were leading a catheter life or suffering from chronic cystitis. N'aturally then one would expect prostatitis to be a frequent complication. A well- marked prostatitis was present in 58% — a slight prostatitis in 31%, viz., a few limited areas of mild prostatitis — no prostatitis was found in 11%. We have before referred to the views of Ciechanowski regarding the role which prostatitis plays in the production of prostatic hyper- trophy. A review of Ciechanowski's cases shows that he was dealing almost entirely with small prostates found at post-mortem while ours are only cases requiring operation. If Ciechanowski's views as to the etiology (obstruction of the excre- tory ducts) are correct, one would naturally expect to find the acini lined by a flattened and not by a tall cylindrical epithelium as we have found. As the process of glandular proliferation proceeds, some acini and sometimes groups of acini probably become separated from the excretory ducts and as a consequence these culs-de-sac undergo cystic dilatation. In such acini the lining epithelium most frequently con- sists of but a single layer of flattened epithelium. Such a character of epithelium one would expect in all the acini if Ciechanowski's views as regards the formation of new acini were the correct ones. Again it is inconceivable that hypertrophy of large size and rich in gland tissue could be produced by any process similar to the one he describes. Chronic prostatitis vsdth the production of a large amount of fibrous tissue is generally accompanied by atrophy of the gland elements rather than an increase in their volume. In our examinations the 134 Hugh H. Young. areas of prostatic tissue where the chronic inflammatory tissue forma- tion was most marked tlie acini were diminished in number, often compressed and atrophic, and again nothing but vestiges of former acini remaining. Furthermore, in 11% of the prostates examined no evidence of an inflammatory process were found. Again in the vast majority of cases where prostatitis was present the prostatitis was confined to definite limited areas, the greatest portion of the hypertrophied tissue being free from inflammatory infiltration. We have seen one case where the prostatitis was entirely confined to the peripheral non-hypertrophied portion of the prostate. Indeed, one seldom sees any prostatitis in the areas where the most active gland proliferation is in progress. Lastly there is distinct evidence of gland proliferation such as one sees in other glandular organs. Arteriosclerosis. — The arteriosclerotic theory of Guy on has prac- tically no adherents to-day. Casper insists on the rarity of arterio- sclerosis, only finding it in four out of 24 hypertrophied prostates ex- amined and practically all recent writers are of one accord on this subject. In 54 prostates we found only 10 with rather extensive arterial thickening. The arteriosclerosis when present is usually irregular in distribution in one portion and end-arthritis of considerable degree being present, and in other portions the vessels appearing practically normal. Development of prostatic hypertrophy. — The different steps in the formation of the new gland acini can often be followed in the several areas of a section from a portion where active proliferation is present. The initial activity is in the epithelium, the epithelial increase result- ing in a protrusion or folding of the epithelial lining towards the lumen of the acinus, this being the line of least resistance. We have seen numerous such pictures where the stroma had not yet followed, knuckles of epithelium projecting into the lumen without a supporting pedicle of stroma. At other points one sees delicate fibrils of con- nective tissue pursuing the epithelial proliferation and at a later stage fibres of smooth muscle entering into the composition of the pedicle of the new-formed villus. By the continued growth of these protru- sions from the periphery the acinus becomes subdivided and new acini are formed. One sometimes sees two, three, or more acini, which are the direct descendants of a single original acinus. If the glandu- study of 145 Cases of 'Perineal Prostatectomy. 135 lar activity is very pronounced the interacinous stroma may consist of but very delicate fibrils of connective tissue^ but where the prolifera- tion is slower the stroma is more abundant. It is the primary activity of the epithelium which stimulates the connective tissue and muscular elements of the stroma to activity. Prostatic hypertrophy is not a diffuse hyperplasia of all portions of the prostate but a h3rperplasia which begins in separate foci and results in the formation of more or less numerous spheroidal tumors (see Figs. H and I). That this hypertrophy always begins in the central group of glands can be readily seen by an examination of pathological specimens of early hypertrophy. Fig. H. Fig. I. Fig. H. — A cross section of a prostate which represents an early stage of hypertrophy. The small spheroidal tumors have formed in the central portion and are compressing the tissue Immediately surrounding them. Fig. I. — A cross section of a hypertrophy somewhat more advanced than that seen in H. In the lower portion are visible the ejaculatory ducts and the dilated orifices of some gland acini. Albarran in his classical studies on the disposition of the glands of the normal prostate has shown that they can be definitely divided into a peripheral and a central group of glands. The central group can again be divided into distinct segregations of glands and neoplastic processes occurring in one or more of these various groups produce the different anatomical varieties of prostatic hypertrophy. Should hypertrophy occur in the subcervical group of glands immediately beneath the vesical neck or in the prespermatic group^ we have formed as a result a median lobe or bar. As the hypertrophy in the central portion increases the peripheral tissue is condensed, thus forming a pseudo-capsule (see Fig. J). 136 Hugh H. Young. It is inside this pseudo-capsule that the usual enucleation is per- formed. In the compression of the peripheral portion of the pros- tate the ejaculatory ducts are pressed towards the posterior surface so it is easy to understand why in some cases of suprapubic pros- tatectomy the ejaculatory ducts are not destroyed. The subcervical and prespermatic portions can be removed without disturbing them. Xature of prostatic hypertrophy. — That prostatic enlargement is a true hypertrophy is very improbable since it begins at a period when the functional activity of the gland is on the decrease while the hyper- trophies occurring in all other glandular organs are at a much earlier period. Furthermore, the hypertrophy is not diffuse but occurs in distinct well-defined areas. In great prostatic enlargements an s.jf^ Fig. J. — The hypertrophy here is advanced still further than that seen in H and I. The central portion is entirely replaced by the hypertrophied tissue while the peripheral portion assumes the role of a thickened capsule in the periphery. The ejaculatory ducts are seen towards the posterior surface. astonishing number of these " spheroids " may be present. Each of these, however, does not represent a primarj^ tumor formation. The growth in an area undergoing hyperplasia is not always equal at every point, the result of this inequality being the production of rmmerous spheroids, the direct descendants of one primary focus of activity. The size of the h^'pertrophy depends upon the number and volume of these tumor formations. These spheroidal tumors vary in their composition. Most frequently they are fibro-myo-adenomata, but aU variations from an almost pure adenoma to pure myoma or fibroma are encountered. The pure myomata and fibromata are uncommon. In only one prostate have we study of 14-5 Cases of Perineal Prostatectomy. is: found myomatous nodules (see Fig. K), while in nearly every instance where the spheroids were entirely fibrous in character the condition seemed to be the result of a chronic prostatitis, vestiges of former acini ^v^'^jje*. vr,f ^/^,«r^-| L VM N FoKrf ' ','/. » / ?, \ Fig. K. — A myomatous nodule. The myomatous hyperplasia is forcing the glandular elements towards the periphery where they form small accumulations of compressed acini. occasionally persisting. The tissue forming the periphery of the spheroids usually contains sparsely scattered acini which are com- pressed and elongated. Occasionally in the interspheroidal stroma 138 Hugh H. Young. areas of gland accumulation are seen which represent new tumors in the process of formation, the increase in growth not being sufficient to produce condensation of the surrounding tissue. At other times a partial condensation is noted. Epithelioma adenoid. — Albarran and Halle in their examination of 100 hypertrophied prostates obtained from autopsies at Hospital Necker found 14 carcinomata in prostates clinically diagnosed as benign hypertrophy. In a large number of these cases the macroscopic ap- pearance did not suggest malignancy, and the picture was that of the ordinary benign hypertrophy. It was only on microscopic examina- tion that in certain lobules adenomatous changes were discovered which to them suggested early or beginning malignancy. They have applied the term " epithelioma adenoid " to these changes and have classed as cancer all prostates containing areas in which such changes were present. Out of 120 enucleated prostates which clinically were diagnosed as benign and in which on gross examination of the tissue no suspicion of malignancy was entertained in only one was distinct carcinoma found on microscopic examination. In this prostate a small carci- nomatous nodule about 2 mm. in diameter was noted in an otherwise benign prostate (see No. 9 in paper on carcinoma). We have not infrequently found areas where active gland prolifera- tion was proceeding in which the epithelium lining the acini and the intraacinous papillary projections presented a rather wild profusion and showed some slight involution changes. These changes were never sufficiently marked to warrant more than a mere conclusion that the glands were displaying changes seen also in carcinomata and cer- tainly would not justify a positive diagnosis of carcinoma. It is very doubtful whether the deviations described by Albarran and Halle should be considered malig-nant changes since adenomata may display so many variations, some of which may closely simulate malignancy, but still remain in the field of benign tumors. Cases with sterile urine. — It seemed interesting to see whether in eases in which the urine is sterile the prostate would be free from inflammation. In three cases, in which the urine was sterile and absolutely free from pus, the prostatic secretion was obtained by massage. In two study of lJf5 Cases of 'Perineal Prostatectomy. 139 cases, the microscope slicsved no pus cells, and in the other onh' a very few pol}Tiuclear leucocj^tes were present. Spermatozoa were present in all three, along with lecithin and granule cells. ^licroscopic ex- amination of the tissues removed by prostatectomy showed no pros- t-atitis in one case in which no pus cells were present in the secretion. In the other case the specimen has been lost. In the third case in which a few pus cells were present in the secretion, the microscope shows a glandular hypertrophy with considerable interstitial and glandular prostatitis. In seven cases in which the prostatic secretion was obtained, where the urine contained pus and bacteria, pus cells were present in con- siderable number in all cases, and the microscope showed considerable prostatitis in the tissues removed at operation. The urine was sterile in 18 eases, five of these, however, contained free pus in all three glasses and the sections show prostatitis. In one case shreds were present in the first glass of urine, but the second and third glasses were clear. The specimen at operation has been lost. The urine was clear, contained no pus or bacteria in 12 cases. Eight of these had never had gonorrhcea, but in two cases calculi were present, and in both of these considerable prostatitis was found. In the six cases in which no calculi were present, three showed no evidence of prostatitis. In one specimen there were only a few areas of inflam- matory infiltration and in one there was considerable prostatitis, both glandular and interstitial. The specimen from the sixth case was lost. Among the 18 cases in which the urine was sterile pain was present in 10 cases and all showed evidence of more or less considerable pros- tatitis on microscopic examination of the specimens. In eight cases no pain had been present. In four of these the specimen showed no inflammation, and in two cases it was very slight, there being only a few leucocytes seen. In two cases, however, there was considerable prostatitis present. K. COXCLUSIOXS. Prostatic hypertrophy is of neoplastic nature and in the vast ma- jority of cases is of an adenomatous or flbro-myoadenomatous form. Pure mvomata and fibromata are occasionallv seen. 140 Hugh H. Young. The characteristic lesion of h3^ertrophy is the formation of sphe- roidal tumors which arise in the central group of glands. The primar}^ activity is in the epithelium of the acini. Chronic prostatitis may produce obstruction similar to true pros- tatic hj'pertrophy, but does not lead to a true hypertrophy of the gland. That perineal prostatectomy is applicable to all forms of prostatic hypertrophy, even the greatest intravesical enlargements being easily removable through the perineum (one of my cases weighing 240 gm.) is shown by the cases reported here. The ease of access to the prostate, the excellent view obtained, and the abilit}' to use other instruments than the finger, make it the only reasonable method of attacking a non-enucleable fibrous prostate. The fact that a large percentage of enlarged prostates are carcino- matous, and that these if taken early can be completely eradicated through the perineum by an operation described in another portion of this volume renders it the onl}^ justifiable route in man}^ cases which may be shown to be cancerous by frozen sections prepared at the operation while the operator awaits their decision. While some prostates can be shelled out more quickly through the suprapubic region, the convalescence is longer, more disagreeable and more fatal than after the perineal, and it is the operator's duty to consult his patient's welfare rather than his personal convenience. The method of conservative perineal prostatectom}^ employed in the preceding cases affords an excellent view of what one is doing, avoids injury of all important structures, preserves the urethra, ejaculatory ducts and vesical sphincter intact, so that control is sometimes estab- lished immediately after the operation, and permanent incontinence never results from it. The fact that there was a mortality of only 4.3% in 163 cases, five of whom were over 80, one 87, and 21 over '75 years of age, that many of these patients were in bad condition and two in extremis, that the earliest death was eight da3'S after the operation, and the majority were after the third week, that the cause of death in not one case was immediately due to the operation, and that during the past 14 months* there has not been one death in 50 cases shows that it is a method of wonderful benignity. The absence of stricture and incontinence, and also of rectal fistula *Nov. 16, 1906. There liave now been over 50 consecutive cases without a death, and all have been entirely successful. study of Ilj-B Cases of 'Perineal Prostatectomy. 141 (since its cause and remedy were discovered) show that they are bugaboos held out against a procedure by those who have never tried it. The complete restoration of normal urination, except when some cystititis and vesical contracture was present, and the lasting results obtained testify to the completeness of the removal, except in the four cases given above in which the operator did not do what the cystoscope showed should be done, and are not to be placed against the method. The complete return of sexual powers in nearly all cases where present before operation and the wonderful restoration of lost puis- sance recorded in five cases show the value of the conservation of the ejaculatory duets, a point which the infrequency of epididymitis (12%) also attests. These results demonstrate that with a careful anatomical technique, avoiding non-obstructive and valuable struc- tures (the external and internal sphincters, the urethra and ejacula- tory ducts) with the excellent drainage afforded through the peri- neum, perineal prostatectomy is a benign procedure, applicable to all forms of prostatic enlargement, affording a much quicker and more comfortable convalescence than suprapubic prostatectomy, and fol- lowed by permanent results as good as could be expected or desired. After having tried both the suprapubic and Bottini methods, and having employed them in 30 and 85 cases, respectively, I feel I can say with all sincerity that the results obtained by me did not compare in any way — ^mortality, convalescence, ultimate results, and restora- tion of normal functions — ^with the results obtained by " Conservative Perineal Prostatectomy.^^ I wish to thank Dr. Halsted and Dr. Bloodgood for many courtesies. Literature. Albarran and Halle. Annales des Maladies des org. gen. urin. Feb. and Mar., 1900. Voilleime et Le Dentu. Traite des maladies des voies urinaries, Vol. II. EiNDFLEiscH. Traite d'Instal. pathoL, p. 627. MoTZ. Contrib. a I'etude d'hyp., de la Prostate, Th., Paris, 1896; Annales des Maladies des org. gen. urin., Oct., 1905. SociN". Krank. der Prostata. Yelpean. Quoted by Motz above. JoRES. Handbuch der Urologie, by Von Frisch. GouLET. New York Med. Eecord, 1890, Xo. 1. CiECHANOWSKi. Ann. des Maladies des org. gen. urin., 1901. Vol. XIV.— 11 143 Bugli H. Young. APPENDIX. Detailed Eepoet of Ixdiyidual Cases in 145 Operations by Con- SEKVATITE PERINEAL PROSTATECTOMY FOR BeNIGN HYPERTROPHY.' Case 1. — Moderate enlargement of median and lateral lobes of the pros- tate. Catheterism. Cured. No. 726. S. T. A., age 66, married, admitted October 11, 1902. No his- tory of gonorrhoea nor previous urinary trouble. Onset began six years ago with slight diflBculty of urination. During the next four years there was a gradual increase in the difficulty and frequency and occasionally a slight incontinence. About six months ago a physician treated him by dilatation of the posterior urethra, under which treatment the patient rapidly grew worse, and for the past two months retention has been com- plete and the catheter necessary from four to six times a day. He has suffered a great deal of late with tenesmus in the lower abdomen, espe- cially during the trip which he has just made from Honolulu to Balti- more. Recently he has been able to void very small amounts of urine, but if he is not catheterized every four or five hours he suffers very se- vere pain in the bladder. Catheterization at times is very difficult and considerable hemorrhage Is produced. He is now weak and exhausted from his long trip. Examination. — The patient is a thin, weak, very sick looking man. A harsh, aortic, regurgitant murmur is present. Examination of kidneys negative. On the lower portion of the abdomen are several severe burns due to hot water compresses. He is unable to void urine, A small coude catheter passes with ease; 350 cc. of urine evacuated. The cystoscope shows two moderately enlarged lateral lobes joined by a median bar with- out intervening sulci. The bladder wall is considerably inflamed, markedly trabeculated with numerous pouches and some diverticula. The ureters cannot be seen. Rectal examination. — The prostate is considerably enlarged, smooth, round, elastic, fairly soft and not nodular. Urine is acid. Specific grav- ity 1018. Albumin, fairly heavy cloud. Pus and bacilli in great numbers. Preliminary treatment. — For two weeks the patient was catheterized about every three or four hours and the bladder irrigated. Water and urotropin in abundance were administered by mouth. Under this treat- ment the irritability of the bladder disappeared and the patient became ^ It has seemed necessary to give all the details of the cases, although consuming great space. The numbers given are those of my office index, unless " S. No." is used, when the surgical No. of the Johns Hopkins Hos- pital Is supplied. In the later reports from patients by letter, quotation marks are not used because their replies have been abbreviated so as to save space. study of 1J/-5 Cases of Perineal Prostatectomy. 143 much stronger. The total quantity of urea varied from 6 to 11 grams daily, and although this amount was very small, the patient seemed strong enough to attempt the radical operation. Operation, October 24. — Ether. An inverted Y-shaped incision was made in the perineum. The central tendon and recto-urethralis muscles were divided, and the posterior surface of the prostate divided by blunt dis- section. The urethra was then opened upon a sound in the membranous Fig. 39a. urethra, and after dilatation of the prostatic urethra the single-bladed tractor, Fig. 39a (which was the first instrument which I had made for this purpose) was passed into the bladder with ease, and the beak turned downward over the median portion of the prostate. Traction was then made, and it was found possible to draw the prostate so far downward that it was almost on a level with the skin. A transverse incision was then made in the prostatic capsule near the apex. A blunt dissector was Fig. 40. — Lateral lobes, median bar, and floor of urethra removed in one piece. inserted and the posterior capsule rapidly freed from the prostate. The lateral surfaces were likewise freed. An effort was then made to strip the lobes from the urethra, but with only partial success, and when the prostate had been completely enucleated it was found that the entire floor and a portion of the lateral walls of the urethra (and the ejaculatory ducts) had been removed in one piece. The specimen removed consisted of the two lateral lobes joined by the median bar, as shown in Fig. 40. 144 Hugh H. Young. A small retention catheter was passed through the perineal wound into the bladder. The lateral cavities were not packed with gauze, but the packing was placed outside of the capsule so as to force it up against the urethra and form a new floor. The levator muscles were brought together on each side by silk sutures and the skin wound partially closed with in- terrupted sutures. The patient was infused on the table. Convalescence. — Immediately after the operation the large single drain- age tube became plugged with blood clots, and the bladder became dis- tended with urine, necessitating the removal of the gauze and tubes be- fore the clot could be removed and the urine evacuated. Considerable difliculty was experienced in Introducing another tube, there was consid- erable hemorrhage and the patient was quite shocked. The wound was repacked with gauze and after that the patient reacted well. Perineal drainage was kept up for about a week when the perineal tubes and gauze were removed. Subsequently a retention catheter was placed in the ure- thra to facilitate closure of the fistula. On December 8 the following note was made: The patient voids urine without difficulty at intervals of about three hours. There is no inconti- nence and the stream is large. On November 3 examination showed the bladder capacity to be 210 cc. The bladder has been dilated through a catheter, and it now holds 460 cc. and the patient can void as much as 300 cc. at a time. He has had slight epididymitis. The patient was discharged December 8, 1902, on the 45th day. He was able to retain urine for three hours and voided naturally, but a slight fistula was present, and this fin- ally closed four months after the operation. January 1, 1903. — »I void urine once at night and have gained eleven pounds in weight. May 28, 1903. — I void urine naturally four times during the day and once at night. There is no incontinence. I have erections, but have not attempted intercourse. February, 1901). — I can retain urine from six to eight hours. Urination is satisfactory. I have no pain; erections occur occasionally, but I have not attempted intercourse. My general health is excellent. Islote. — The patient took a trip to South Africa and lost his life in an accident at Victoria Falls, September 10, 1904. Pathological report. — Specimen, G. U., 63. The entire prostate has been removed in one piece and weighs about 50 grams. The union be- tween the median bar, which measures about 2x3 cm. in size, and the lateral lobes has not been disturbed; and the mucous membrane covering the front of the median bar and a portion of the internal surfaces of the lateral lobes has been removed along with the lobes. The external sur- face shows numerous small lobules covered by a smooth capsule, and the section shows some enlarged spheroids in an enlarged stroma. The con- sistence is everywhere elastic. Microscopic examination. — The hypertrophy is a glandular one. The acini are dilated and show considerable papillomatous intra-acinous growth. study of 145 Cases of ■Perineal Prostatectomy. 145 The epithelium lining the acini in most areas shows a rather profuse pro- liferation. The glandular tissue is arranged for the most part in lobules, the periphery of the lobule is composed of compressed stroma containing elongated acini. In the middle lobe there is present a marked prostatitis with the formation of a great deal of scar tissue in the stroma which in places has almost completely obliterated the acini. The arteries in these rather fibrous areas show considerable thickening, while in the glandular areas they seem about normal. There is a moderate amount of muscle present in the stroma except in the areas where there has been a forma- tion of quite marked inflammatory tissue. Case 2. — Considerable enlargement of median and lateral lobes. No complication. Cure. Followed 42 months. No. 368. J. W. L., age 59, married, admitted December 6, 1902. Old Dominion Hospital, Richmond, Va. Complaint. — " Frequency and difiiculty of urination." No history of gonorrhoea. In 1893 patient had nephritic colic, and a second attack in 1898, no other colic since then but has frequently passed sand. Present illness began in 1895 with frequency of urination, this gradu- ally increased, and in 1898 complete retention of urine requiring cathe- terization came on. Since then has had frequent and diflicult urination and occasionally retention requiring catheterization. 8. P. — Urination every hour with great difficulty. No history of hema- turia or pain. Has lost about 20 pounds in weight. Sexual powers. — No note made. Examination. — The patient looks pale, but his muscular strength seema good. The heart, lungs and abdomen negative. There is a small inguinal hernia present. Rectal. — iProstate is considerably enlarged, about the size of a small or- ange. It is rounded, smooth, symmetrical, elastic, there are no nodules or areas of induration. The seminal vesicles are not palpable. Cystoscopy. — A silver catheter passes with ease and finds 165 cc. residual urine, and a bladder capacity of 250 cc. Cystoscopy is impossible on ac- count of hemorrhage. Urinalyis. — Acid, albumin in small amount, no sugar, urea G-25 in 24 hours. Microscopically, pus cells and bacilli. Operation, December 6, 1902. — Chloroform. Perineal prostatectomy. In this case I decided to operate by a different technique so as to preserve, if possible, more of the prostatic urethra than I had in Case 1. The inverted Y-incision was used, the bulb and central tendon exposed, and central tendon and muscle beneath it were divided. The levators were separated by the fingers, thus exposing the membranous urethra which was incised upon a grooved director just in front of the apex of the prostate. A large sound was passed into the bladder through the opening and the single bladed tractor easily inserted into the bladder and turned downward over 146 Hugli H. Young. the median portion of ttie prostate. Outward traction was ttien made, drawing the tractor well up into the wound. A V-shaped incision was made through the prostatic capsule, the point being forward near the apex of the prostate. With a blunt dissector the capsule was then rapidly stripped back from the posterior surface of the prostate until the entire posterior and lateral surfaces had been separated from the capsule which was thus turned back as a cuff. In order to preserve the urethra the prostate was then bisected, beginning in the median line at the apex and extend- ing backward for 1% cm. In order to separate the urethra from the lateral lobes it was found necessary to make a longitudinal incision on each side with the scalpel parallel to the urethra. A blunt dissector was then inserted and the urethra rapidly stripped away from the inner surface of each lateral lobe (this was practically the method of Proust which I had not heard of at that time) . The lateral lobes were then enucleated and removed each in one piece, the tractor being turned so as to engage each lobe, while it was being enucleated. A median lobe 2 cm. in diameter was then drawn down by the tractor into the urethra and enucleated to- gether with a narrow strip of mucous membrane which covered its anterior surface, the verumontanum and the terminal portions of the ejaculatory ducts. During this operation considerable difficulty was experienced in employing the tractor which continually slipped out and had to be intro- duced with considerable difficulty. (This led to the addition of a shoul- der to the end of the blade to prevent its slipping out) . A large reten- tion catheter was passed into the bladder. One small piece of gauze was packed into the prostatic cavity and two pieces were placed back of the prostatic capsule, the object being to cause the collapse of the cavity after removal of the piece of gauze from the interior of the capsule. The separated levator muscles were joined with sutures of catgut and the wound was partially closed with catgut externally. The patient stood the operation well. Saline infusion. Convalescence. — The patient reacted well. The highest temperature was 100.50. "When last seen by the operator, 30 hours after the operation, his condition was excellent. He was discharged on the 14th day in excellent condition. May 24, 1904. — Letter. The wound has remained closed. I void urine with perfect satisfaction at intervals of from two to four hours during the day and four to six hours at night. I suffer no pain and my general health is excellent. May 20, 1906. — ^Letter from physician. Micturition is normal. He voids about every three hours during the day and one to three times at night. There is no evidence of stricture and very rarely a little dribbling. His condition is fine. Pathological report. — Specimen, G. U. 60. The entire prostate has been removed in three pieces and weighs 70 grams. The median lobe measures 3 X 2 X iy2 cm., the lateral lobe, each 5x4x3 cm. The summit of the median lobe is covered by mucous membrane about l^o cm. in diameter. study of IJfO Cases of 'Perineal Prostatectomy. 147 The appearance of the lobes exteriorly and on cross section is that of numerous spheroids; they are elastic and there are no areas of induration. Microscopic examination. — The hypertrophy is a moderately glandular one, areas rich in acini and forming spheroids alternating with areas con- taining rather a large amount of stroma. Often the tissue outside of these spheroids contains numerous culs-de-sac, showing signs of activity. The stroma contains a large amount of muscle, at times being considerably in excess of the connective tissue. There is present in areas a well marked chronic prostatitis and the blood vessels exhibit a moderate degree of ar- teriosclerosis. Case 3. — Moderate hypertrophy of prostate. Catheter life I4 years. Tabes dorsalis of 16 years' duration. Restoration of normal urination. Followed 5 months. No. 297. T. C. L., age 60, married, admitted November 17, 1902. Complaint. — " Enlarged prostate. Catheterism." Gonorrhoea many years ago, and was perfectly cured. In 1863 had a sore on the penis which he thinks was syphilitic. His physician told him that he had blood poison and gave him internal treat- ment which he took for a month. Sixteen years ago he began to have sharp severe pains which came on suddenly, and were localized in the right thigh and later in the right leg. No trouble with bladder, rectum or locomotion at that time. Present illness began 14 years ago with difficulty and frequency of uri- nation. About the same time he began to have incontinence of urine at night. After three months his condition was not improved, and his phy- sician passed a catheter withdrawing about a quart of residual urine. The diagnosis of enlarged prostate was made. Following this examination the patient had a chill, fever and pain in the region of the left kidney. He was unable to pass urine except in very small amounts and with great difficulty and began a catheter life which has continued up to the present time. He has continued to suffer greatly from " sciatica." Two years ago he noticed for the first time an instability of gait, particularly at night. Recently his eyesight has become impaired. 8. P. — The patient is unable to void and catheterizes himself five times a day. His general health is good, has not lost weight, but he still suffers from an occasional attack of " sciatica," and instability of gait. Sexual powers. — Erections have been absent for many years. He finds the catheter life a terrible burden and begs to be relieved from it. Examination. — The patient is a sparely built, but healthy-looking man with lips of good color. The chest and abdomen are negative. Examination of nervous system by Dr. Thomas. — Vision good, optic nerves are normal. The pupils are contracted, there is no reaction to light and very slight reaction to accommodation, the other cranial nerves are normal. The walk is slightly ataxic. There is a marked swaying with his feet together and eyes closed. The knee and ankle jerks are absent. 148 Hugh H. Young. There is a marked lack of muscle tone and a retardation of the perception of pain throughout the legs. No other very pronounced sensory disturb- ance. Diagnosis. — Tabes dorsalis with unusual involvement of the bladder. Rectal. — The prostate is moderately but very definitely hypertrophied, forming a bulging rounded mass about the size of a small orange, smooth, elastic, but harder than usual. The lateral lobes are about equally en- larged, the median furrow and notch are obliterated. The seminal vesicles are not indurated, and there are no palpable glands. The sphincter ani is peculiarly lax and atonic and the rectal mucosa is very redundant. Cystoscopic. — A coude catheter enters easily, retention of urine is com- plete, bladder capacity 600 cc, the tonicity poor. The cystoscope shows a definite rounded intravesical hypertrophy of both lateral lobes and fairly deep sulcus between them in front, and a small median lobe with a shal- low sulcus on each side. The ureters could be easily seen and they are situated in prominent ridges. The bladder wall is only slightly trabecu- lated and there are no large ridges with deep pouches intervening. Urinalysis. — tCloudy, alkaline, sp. gr. 1022, no albumin, no sugar. Total quantity of urine 760 cc. Total urea G-14.5. Microscopically, pus cells and bacteria. Note. — 'It seemed very evident from the history and age of the patient that the urinary trouble, which began 14 years before, was due to tabes. There was no question, however, of the fact that the prostate was then distinctly hypertrophied, and that possibly prostatectomy might restore normal urination, though it might also lead to incontinence. The patient was going to Boston, and I asked him to see Dr. A. T. Cabot, who advised prostatectomy. Dr. H. M. Thomas, who, after careful examination, had confirmed our diagnosis of tabes dorsalis, thought that prostatectomy might have the desired effect. The patient was so anxious to get rid of the catheter that he gladly accepted the chance of continual incontinence. Operation, Dec. 9, 1902. — Ether. Perineal prostatectomy. This was the third case operated upon, and the following technique was used. A median line perineal incision, insertion of a single-bladed tractor through ure- throtomy of membranous urethra. Inverted V-incision through capsule of prostate which was stripped back, thus exposing the posterior surface of the prostate. Hemisection of the urethra was then performed in the median line, and the urethra separated from each of the lateral lobes beginning with an incision and completed by blunt dissection. The lateral lobes were then enucleated each in one piece. The right lobe measured 3x3x4 cm. The left lobe 3x4x4 cm. Examination of the median portion showed very little enlargement, not sufficient to warrant removal. Large drain- age tube was placed in the bladder through the perineal wound, the cap- sule was drawn forward and sutured so as to surround the tube. Two gauze packs were placed back of the prostatic capsule with the object of obliterating it. The levator muscles were drawn together with sutures and the skin wound partially closed. Infusion at end of operation. Pulse 94, condition excellent. study of 145 Cases of 'Perineal Prostatectomy. 149 Convalescence. — The patient reacted well. The temperature rose to 101° for three days after the operation, after which it was practically normal. He suffered greatly from severe attacks of pain in both legs, which came on suddenly and were very severe, but lasted only a few minutes. Intra- vesical irrigations of boric acid were given twice daily until the tube was removed on the ninth day. The gauze was removed on the next day and the patient was gotten up in a wheel-chair. Two weeks after the opera- tion urine began to flow through the meatus. The retained catheter was then placed in the urethra, where it remained for eight days. After its re- moval there was no leakage through the perineum, which remained healed. He was discharged from the hospital on the 42d day. At that time he was able to retain urine for three hours during the day and eight hours at night. There was no dribbling at all during the night, and during the day there was only occasionally when walking about an involuntary es- cape of a few drops of urine. Micturition is slow, but without difficulty, and when the bladder was quite full the stream was good. A catheter was passed with ease and found no residual urine. The bladder had become slightly contracted and would hold only 340 cc. The vesical tonicity was better than before operation, but was still only moderately good. The patient was instructed to use urotropin two or three times a day, and to irrigate the bladder with boric acid. February 6, 1903. — " "While irrigating the bladder by hydraulic pressure the perineal wound broke open again. There is now slight leakage, other- wise the condition is good." March 12, 1903. — " I am able to urinate all right, but the perineal fis- tula is still open and a few drops of urine escape through it during urina- tion." He was advised to cauterize the wound. May 21, 1903. — Letter from wife. On March 16 the patient had a sudden severe collapse which was thought to be uremic. He seemed to rally from this, but the old enemy " neuralgia " kept coming with the least exposure to cold and these attacks kept him indoors. The strain weakened him, and finally the stomach lost its tone, his appetite failed, the bowels became affected, dysentery set in, and at the end of two weeks death ensued. May 20, 1903. Pathological report. — Specimen, G. U. 61. The prostate has been removed in two pieces and weighs 50 grams. The right lobe measures 5 x 4 x 3^^ cm., the left 4.5 x 4 x 3 cm. No mucous membrane has been removed. Ex- ternally and on section numerous small lobules and spheroids are seen. There are no areas of induration nor suggestion of malignancy. Microscopic examination. — The hypertrophy is a moderately glandular one. The acini are grouped in small spheroidal areas, and the interlacing stroma contains but very few acini. The stroma contains a fair amount of muscle, but the connective tissue is somewhat in excess. The blood ves- sels show a marked degree of arteriosclerosis. 150 Hugh E. Young. Case 4. — Moderate hypertrophy of median and lateral loies. Vesical calculus. Cure. Follotved tico years. 370. J. P. D., age 57, married, admitted Dec. 17, 1902. Complaint. — ■" Frequent and painful urination." The patient never had gonorrhoea. Present illness began about 17 years ago with slight diflBculty and in- creased frequency of urination. About five years ago he had complete re- tention of urine and had to be catheterized for two days. Since then he has had complete retention at gradually lessening intervals, but alwaj's after two days he would be able to void again. He has had a pain occa- sionally during and at the end of urination, but there has been no pain in the rectum. jS. p. — 'The patient now voids three or four times during the night in a small, slow stream. He dees not use the catheter unless unable to uri- nate. Sexual powers present. Examination. — ^Well nourished man with lips of good color. Heart, lungs, abdomen, and genitalia negative. Fig. 40 a. Rectal. — The prostate is considerably and equilaterally enlarged, about the size of a small orange. Smooth, rounded, elastic but not soft. The seminal vesicles are not palpable. Cystoscopic. — A small coude catheter passes with ease withdrawing 75 cc. residual urine. The bladder capacity is 340 cc. The cystoscope shows a slight intravesical enlargement of the lateral lobes joined by a small me- dian bar. No calculus seen. Examination unsatisfactory on account of hemorrhage. Urinalysis. — 1020, neutral, no sugar, no albumin, microscopically, pus cells. Preliminary treatment for four weeks, catheterization and irrigation of bladder. During this period had complete retention of urine several times and catheter withdrew 500 cc. of urine. Operation, January 10, 1902. — .Ether. Perineal prostatectomy. This is the first case in which an attempt was made to preserve the ejaculatory ducts by means of bilateral capsular incisions. The lateral lobes were enucleated, and the median bar was removed in two pieces through the lateral cavities. The incisions were made very superficially, and it was found very difficult to separate the lateral lobes from the urethra. The ejaculatory bridge, however, was not very badly torn and none of the mucous membrane of the urethra was removed. The original single blade prostatic tractor was used and, although it had been provided with a "barb" (see Fig. 40a), after the lateral lobes had been removed the study of llf5 Cases of 'Perineal Prostatectomy. 151 instrument slipped out of the bladder and was very difficult to introduce again. The need of an instrument which would not slip out was forcibly impressed upon us and led to the construction of the double-bladed rotating tractor. The lateral cavities were packed with gauze and a single large drainage tube was placed through the perineum into the bladder. Patient stood operation well, pulse at end 80, infusion on return to ward. Convalescence. — About 12 hours later the drainage tubes be- came plugged with a clot of blood and were accidentally removed by the orderly. The interne experienced a great deal of difficulty getting the tube back into the bladder and considerable hem- orrhage occurred. On the fourth day the drainage tube was finally re- moved. On the seventh day the patient was allowed to get up in a wheel- chair, but on the fourteenth acute epididymitis set in and went on to abscess formation, which was incised five weeks after the operation. Dur- ing the seventh week the patient passed a small calculus, and after that seven or eight others. During the third week after the operation most of the urine was coming through the urethra. The temperature reached 102° on the fourth day, but after the seventh day remained normal until March 1, when temperature rose to 103.8° followed by a urethral chill. March 8, 1903. — A catheter passes with ease and there is no residual urine. The bladder capacity is 3-50 cc. The cystoscope shows a small mass of granulation tissue in the anterior portion of the trigone just back of the median portion of the prostate, and on top of this is a calculus of small size, but firmly fastened to it. There is no free calculus in the bladder. The prostatic margin is irregular, but there is no evidence of prostatic hypertrophy. The perineal fistula is very small, only a few drops escape through it and the patient is able to retain his urine well. An effort was made to dislodge the calculus with the cystoscope. March 25, 1903. — Two calculi have been passed since the cystoscopic ex- amination. The cystoscope shows no calculi present and the mass of gran- ulation on which one was incrusted has entirely disappeared. In the an- terior portion of the prostate several large granulations are seen. With the finger in the rectum and cystoscope in the urethra the amount of tis- sue between the two is less than normal. March 27, 1903. — The patient is discharged. Condition is excellent. Both epididymes are indurated, small fistula is still present. The patient voids at intervals of five hours with a large stream and perfect control. Letter, January 20, 1904- — The fistula closed four months after the op- eration. I now urinate once during the night and at intervals of three to four hours during the day. I have not used a catheter and urination is satisfactory. Occasionally I have a slight pain in the bladder. I have erections once or twice a week and have sexual intercourse. June 4j 1904. Letter. I can hold my urine six to eight hours at night and four hours during the day . Urination is normal, but I have a slight pain occasionally in the bladder. I have erections and intercourse, but ejaculations are not normal. 153 Hugh H. Young. January IS, 1905. — I am cured with the exception of a slight pain which I occasionally have in the bladder. I have had no instrumentation since my discharge. I urinate once at night and three to six times in the day, and pass large amounts. Erections and intercourse are present, but are not as satisfactory as before operation. My general health is excellent. December 7, 1905. — Letter from wife. My husband died September 12, 1905, of catarrh of the stomach. Case 5. — Moderate enlargement of lateral lobes. Pain suggesting renal calculus. Cure. Followed 20 months. No. 289, J. S. S., age 65, married, admitted January 14, 1903. Complaint. — •■" Bladder trouble." Gonorrhcea in his youth was cured without complications. Present illness began 15 months ago with pain at the beginning of uri- nation which radiated from his bladder upward along the right side and apparently terminated in his right kidney. The pain was very severe in character, lasting about three minutes, at no time radiated to the penis and was not associated with hematuria. Irrigations of the bladder seemed to relieve him. During the next month every time he urinated he had a pain which seemed to start from a point deep down in the pelvis, and from there traveled upward to beneath ribs on the right side. There was no pain in the testicles, thigh, bladder or penis. Urination was markedly frequent and the amounts voided small. Considerable diflBculty in starting the flow of urine. He then went to a mineral springs and the pain dis- appeared. In August, 1902, a physician pronounced his case catarrh of the bladder and gave him a catheter to use. In November he went to an- other physician who writes as follows: His urine was filled with pus, the prostate was inflamed and tender. A catheter found 10 ounces of residual urine. I treated him by irrigations, massage of the prostate, instillations. He now has a residual of four ounces. Urine is voided more easily and his general health is better. There is still pain in the region of the bladder. S. P. — There is considerable hesitation at the beginning of urination, and a pain at the end which is dull in character and occasionally travels upward from the bladder towards the right kidney, but is not nearly so severe as at onset. There is no great increase in the frequency of urina- tion, and he often only gets up once during the night. Sexual powers. — .Sexual desire has been absent for the past six months, previous to which coitus was normal. Examination. — The patient looks well. Lips of good color. Heart and lungs negative. There is no tenderness in the region of either kidney and no enlargements to be made out. Rectal. — ^The prostate is moderately but symmetrically enlarged, and the median furrow is broad and shallow. The surface is slightly irregular towards the upper end, but the consistence is generally elastic. The semi- nal vesicles are not indurated. Cystoscopic. — A coude catheter passes with ease and finds 160 cc. resid- ual urine. The bladder capacity is 700 cc. The cystoscope shows two study of 1J/.5 Cases of 'Perineal Prostatectomy. 153 fairly large intravesical enlargements of the lateral lobes with a deep sul- cus in front and a deep sulcus behind. A small transverse fold of mu- cous membrane was seen in the median portion of the prostate connecting two lateral enlargements. The bladder is remarkably trabeculated with numerous small pouches. Urinalysis. — Cloudy, acid, 1010, albumin in small amount. Urea 23-G. per liter. Microscopically, pus cells, a few hyaline casts and bacilli. Operation, ■January 20, 1903. — Ether. Perineal prostatectomy. The tech- nique which is now employed was used in this case with the exception that the single-bladed tractor was used. The bilateral capsular incisions which have been used with the idea of preserving the floor of the urethra and ejaculatory ducts were made. The right lateral lobe came away in one piece, and measured 2x3x3 cm. The left lateral lobe came away in three pieces which together form a mass larger than the right lobe. The tractor was then withdrawn and the finger inserted and showed no enlargement of the median portion of the prostate. The entire urethra and ejaculatory ducts were preserved intact. The tractor employed in this case was the single-bladed tractor with a shoulder across the front of the blade at its end. The same difficulty was experienced from its slipping out of the bladder when one lobe had been removed. Two catheters were fastened together and placed in the bladder for drainage. This was done because in previous cases difficulty had been experienced on account of the single drainage tube becoming plugged with blood. Gauze packs were placed two in the capsule of the prostate and two behind it, the latter to be removed last and thus obliterate the cavity left after removal of the first. Levator muscles were brought together with several catgut sutures and the skin wound partially closed. Convalescence. — The patient stood the operation well, but the pulse at the end was very rapid, 140 to the minute. He was infused on the table and half an hour after the operation his pulse had fallen to 88, and his con- dition was excellent. The highest temperature was 100.8° on the day after the operation. After four days it was normal. Continuous irrigation was maintained for seven days when the tubes and gauze were removed. Urine began to come through the anterior urethra on the 14th day. On the 12th day the patient began to walk. The perineal fistula closed finally on the 18th day, and the patient was discharged on the 21st day. At that time he was voiding urine freely at intervals of five hours and felt per- fectly well. March 15, 1903. — ^I void urine naturally at intervals of from six to eight hours. Have a slight pain in the groin, otherwise feel perfectly well. Sept. 28, 1903. — Letter from physician. The patient is perfectly well, very seldom rises at night to urinate. He has complete control, no dribbling. October 6, 1903. — Letter. I do not get up at all to urinate at night, am free from pain. I have had no erections as yet. May 20, 1904- — I void urine naturally at intervals of seven or eight hours 154 Hugh H. Young. at night, four or five during the day. I suffer no pain. Urination is nor- mal. Erections have returned. March 9, 1905. — >Letter from physician. The patient died September 9, 1904. Previous to his death urination was normal. He seldom had to rise during the night to urinate. There was about 15 cc. residual urine, and the bladder capacity was over 500 cc. He had been entirely free from all pain for some time. Erections and sexual powers were normal, and his ejaculations were satisfactory. He died suddenly while sitting in a chair from angina pectoris. Case 6. — Large hypertrophy. Catheter life eight years. No stone. Cured. No. 341. S. T. A., age 70, single, admitted February 28, 1903, complain- ing of obstruction to urination, and catheterism for eight years. He has never had gonorrhoea nor any previous urinary trouble. P. I. — Onset 15 years ago with slight frequency and difficulty of urina- tion which grew gradually worse during the next seven years until finally he was urinating from five to eight times during the night. He then con- sulted a physician who catheterized him and found a large quantity of re- sidual urine. Since then the patient has never been able to void urine naturally and has catheterized himself three to four times a day. 8. P. — The patient is using a catheter three times a day, and is unable to void any urine naturally. Occasionally he suffers a slight pain in the rectum, and urethra and sometimes catheterization causes considerable hemorrhage. Erections have been absent for five years. Examination. — Lungs negative. Heart: An aortic insufficiency is pres- ent, but no dilatation of the heart. Abdomen negative. The prostate by rectum is considerably hypertrophied, the left lobe larger than the right. The contour is rounded, surface smooth, consistence elastic, no induration present. Cystoscopic examinatioii. — The patient is unable to void urine. A soft rubber catheter passes with ease, and the bladder is easily washed clean. Examination of the prostatic orifice shows a moderate-sized median bar, a considerable intravesical hypertrophy of the left lateral lobe attached to which is a fairly large anterior lobe. The right lateral lobe is not intravesically enlarged. There is considerable trabeculation of the bladder wall, chronic cystitis of moderate degree. No calculus present. The urine is acid, specific gravity 1019, no sugar, no albumin. Microscop- ically, pus cells, bacilli and cocci. Urea .024 G. per 1 cc. Preliminary treatment for 10 days, during which the patient was cath- eterized, the bladder was irrigated, and urotropin administered internally. Study of the urine showed no evidence of kidney disease, and although the patient was a rather weak old man, prostatectomy was decided upon. Operation, March 10, 1903. — (Ether. Perineal prostatectomy. Enucleation of a small right lateral lobe, and a very large left lateral lobe with the median bar and anterior lobe attached to it. The regular technique was followed. The ejaculatory ducts and urethra were preserved, and only a study of IJf-o Cases of ■Perineal Prostatectomy. 155 small area of mucous membrane covering the anterior lobe was removed. The wound was closed as usual. The levators were not approximated. Saline infusion of 1200 cc. of salt solution on the table. Double catheter drainage provided through perineal wound. There was only a moderate amount of hemorrhage and the patient stood the operation well. Convalescence. — The drainage tubes became plugged with a blood clot and had to be removed two hours after the operation. Evacuation of clots consumed considerable time and the patient was quite shocked for a short while. The tubes Avere removed on the seventh day. On the 21st day the urine still came entirely through the perineum and a retained urethral catheter was applied. The perineal fistula did not close com- pletely until two months after the operation. No epididymitis. Examination, May 29, 1903. — (Two and one-half months after operation). The catheter has not been required since operation. Urine is voided in a large stream at intervals of three hours. There is no incontinence, no hesi- tation, and perfect control. The fistula is closed, his strength is good. The catheter passes with ease. Residual urine 25 cc. Bladder capacity 240 cc. Discharged on the 83d day. Remarh. — The result is excellent, but the patient is advised to dilate the bladder by hydraulic pressure to increase its capacity and the inter- val of urination. Final note. — The patient remained well for five months. He then died suddenly of some intercurrent disease, the nature of which was not clear. His physician reports that he was entirely cured of his prostatic trouble. PatJiological report. — Specimen, G. U. 62. The prostate has been removed in two pieces and weighs 70 grams. The right lateral lobe weighs 20 grams, and the left lateral 50 grams. The inner portion of the left lateral lobe has two large lobules separated by deep fissure, and is probably the median and anterior portion of the prostate. The consistence of the lobes is elastic and they show numerous small spheroids bound together by connective tissue. There is no induration nor euggestion of malignancy. There are no mucous membrane nor ejaculatory ducts removed. Microscopic examination. — The hypertrophy is a moderately glandular one, the various acini being separated by fair amounts of stroma. There seems to be but slight tendency to arrangement of the acini in spheroids nor do the lumina of the acini present the same complexity of outline which one so frequently sees. There are very few intraacinous projec- tions, and there is present very little dilatation. The stroma contains more connective tissue than muscle, but the muscle element is fairly abundant. The blood vessels show a moderate degree of arteriosclerosis. There are some areas of prostatitis present. Case 7. — Moderate hypertrophy of median and lateral lodes. Catheter- ism. Complication — gauze pack not removed. Second operation 10 months later. Removal of gauze. Cure. Followed 3S months. No. 340. W. S. O., age 58, married, admitted February 26, 1903. Complaint. — <" Prostatic hypertrophy." No history of gonorrhoea. 156 Hugh H. Young. Present illness began eight years ago with slight difficulty of urination. In February, 1S96, acute retention of urine came on and he had to be catheterized, and two months later had to be catheterized again for the same reason. Since then the patient has catheterized himself every day. In September, 1S96, both epididymes became inflamed. During the past seven years, in which he has used a catheter at bed time, he has had as a rule very little discomfort with the exception of epididymitis and occa- sional hematuria and fever. His general health has remained good. S'. P. — iThe patient catheterizes himself at bed time, and during the day is able to void small amounts. Sexual powers. — Erections are apparently normal, but sexual powers have been slightly impaired. Examination. — The patient is a healthy looking man. Chest and abdo- men negative. Rectal examination. — 'The prostate is moderately hypertrophied, fairly hard, slightly irregular, but not nodular. The median furrow and notch are obliterated and the seminal vesicles are not palpable. Urinalysis. — Cloudy, slightly acid, sp. gr. 1010, albumin in slight amount, no sugar. Microscopically, pus cells in moderate number and bacilli. Urea 9 grams per liter. Cystoseopic examination. — A coude catheter passes with ease and finds 140 cc. residual urine. The bladder is apparently large and of good ton- icity. The cystoscope shows a moderate intravesical enlargement of both lateral lobes and a rounded median bar continuous with the left lateral lobe, but separated from the right lateral lobe by an intervening sulcus. The bladder is slightly inflamed, moderately trabeculated, with several small cellules present. The right ureter can be seen and appears normal; the left cannot be seen on account of the median bar. Operation, March 2, 1903. — Perineal prostatectomy by the usual tech- nique. The lateral lobes which were moderately enlarged were removed each in one piece. The median lobe was then drawn into the left lateral cavity and easily enucleated. The floor of the urethra and ejaculatory ducts were preserved and the wound was closed with double tube drainage and light gauze packs for the lateral cavities. Convalescence. — The patient reacted well from the operation. The tem- perature reached 102° on the gecond and third days, but after that it was practically normal. The gauze packing was gradually removed, beginning on the third and completed on the sixth day. Continuous irrigation of the bladder was kept up for nine days and the tubes then removed. For one day all of the urine came through the perineal wound. A catheter was then inserted through the urethra, and maintained there for four days. After that the patient voided partly through the penis and partly through the wound. The patient was up in a wheel-chair on the twelfth day and was walking during the third week. He was discharged on the twentieth day. At that time he was voiding urine at intervals of four hours, had no inconvenience, only a small amount of urine came through the perineal fistula. The fistula finally closed one month after the operation. study of Ho Cases of •Perineal Prostatectomy. 157 May 1, 1903. — Perineal wound lias been closed for a month. The patient voids urine every three or four hours, suffers no pain, and feels well. There has been no incontinence, but he has had a urethral discharge and once or twice a small amount of blood at the meatus. Partial erections have occurred. Examination. — The perineal wound has healed. A catheter passes with ease and finds no residual urine. The bladder capacity is 300 cc. The urine contains considerable pus in the first and third glass, but the second is practically clear. October 8, 1903. — 'A urethral discharge persisted during the summer, and in August he began to suffer pain in the perineum, an abscess developed and was incised in Mexico. Since then perineal fistula has never closed and there has been a considerable discharge from the meatus and from the fistula. There has also been considerable hemorrhage at times, but al- ways with the first urine. A catheter passes with ease and shows 10 cc. residual urine, there is no stricture present. The cystoscope shows a slightly irregular prostatic margin, but no evidence of prostatic enlarge- ment or obstruction. January 11. 1904- — The fistula persists. Rectal examination shows a small oval mass about the size of a normal prostate in the region of the prostate. Examination causes blood to escape through the fistula. Op- eration upon the fistula is advised. Operation, Jamiary 15, 1904- — Ether. The perineal fistula was excised and found to lead into the left lateral cavity of the prostate where a con- siderable piece of gauze forming a mass about 3 cm. in diameter was found imbedded. It was extracted without difficulty, and the cavity thor- oughly curetted. The bulbous urethra was opened and a retention catheter fastened to the skin by silk sutures. Convalescence. — The patient reacted well. The retention catheter was maintained for 19 days. At that time the posterior fistula had closed tight. Since the removal of the catheter the bulbar urethrotomy wound has healed slowly, and to-day, four weeks after the operation, all the urine passes through the meatus. June 17, 1904- — The patient is able to retain urine for five or six hours, and urination is normal. His sexual powers have gradually improved. Erections are fairly good, but he has not attempted intercourse. Fe'bruary 1, 1905. — Letter. I void urine naturally, do not get up at night and consider myself cured. November 30, 1905. — ^Letter. I void urine naturally once at night and twice during the day and large amounts at a time. I have no pain, no fis- tula and consider myself cured. Erections are fair and sexual intercourse fairly satisfactory. My health is excellent. May 8, 1906. — Letter. I void urine naturally, and often do not urinate at all during the night. I have no pain. I have erections and sexual in- tercourse, but the erections are slightly imperfect. My general health is excellent, and I consider myself cured. T 158 Hugh H. Young. Pathological report. — Specimen, G. U. 64. The specimen consists of two pieces, the median and lateral lobes and weighs 30 grams. The left lobe measures 4.5x3.5x2 cm. The right lobe 4.5x3x2 cm., the median 4 X 2.5 X 1.5 cm. No mucous membrane or ejaculatory ducts have been removed. The surface shows numerous small lobules and spheroids, and is elastic in consistency. Microscopic examination. — The hypertrophy is of a mixed type, in some areas glandular, in others fibro-muscular. Some formation of spheroids, the spheroidal areas being glandular. The acini within these spheroids present the usual intra-acinous off-shoots, often of papillomatous type. The stroma contains a large amount of muscle, which is equal to, if not in excess of the connective tissue. The blood vessels seem about normal. Case 8. — Chronic prostatitis with median Tjar formation. Complete re- tention of urine. Severe cystitis and vesical irritability. Operative result, iyiiproved. No. 364. P. F. E., age 45, ma,rried, admitted November 4, 1902. Complaint. — " Bladder trouble which came on after typhoid fever." He never had gonorrhoea. Present illness. — ^Two years ago the patient had typhoid fever and re- quired catheterization. Since then the catheter has been necessary most of the time, and of late he has had to use it very frequently, generally every two hours and sometimes as often as every half hour. On admission he was using the catheter from 10 to 18 times at night, and would often experience great difficulty in introducing it. He suffered severe pain In the bladder which was markedly contracted, and has lost a great deal of weight. He has had no sexual intercourse for over two years, but has had erections frequently and nocturnal pollutions occasionally. Examination. — The patient is a weak-looking, nervous man. Heart, lungs and abdomen are negative. A soft rubber catheter meets with an impassable obstruction 21 cm. from the meatus. A silver catheter passes with ease and withdraws 420 cc. residual urine. Rectal examination. — The prostate is only slightly enlarged, indurated and continuous with the seminal vesicles which are also indurated and adherent to surrounding structures. Running from one seminal vesicle to the other is a connecting mass of indurated tissue. The picture is that of chronic prostatitis and seminal vesiculitis. Cystoscopic examination. — (The bladder is very irritable and appears to be contracted. The cystoscope shows a markedly inflamed, trabeculated bladder. The lateral lobes are not at all enlarged, but there is a small median bar present. Treatment. — At first the patient was catheterized four times a day and the bladder irrigated with boric acid. Under this treatment he improved considerably, and after 53 days in the hospital he returned home able to void his urine without a catheter. Very soon the vesical irritability re- turned and catheterization again became necessary. On second admission, February 2, 1903, he was using a catheter several study of lJf5 Cases of •Perineal Prostatectomy. 159 times a day, and was able to void only wittL great difficulty. The urine was acid, 1018; no sugar; albumin, a trace; microscopically, pus, epithe- lium. No casts. February 22, 1903. — Cystoscopic examination. A catheter finds 250 cc. residual urine. The cystoscope shows a definite, but small, median bar, but no enlargement of the lateral lobes. The bladder is markedly trabe- culated. Numerous pouches and small diverticula are seen in the region of the ureteral orifices. With the finger in the rectum and cystoscope in the urethra a definite increase in the median portion of the prostate is made out. Operation, March 5, 1903. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were enucleated, and when removed were found to be very little enlarged. No note is made as to the median lobe, but this was apparently left behind, as it was impossible to get it to present into one of the lateral cavities. (This was one of the early operations and a different technique would now be used.) The wound was closed as usual with gauze drainage for the lateral cavities and double tube drain- age for the bladder. Patient stood operation well, pulse at end 80. Con- tinuous irrigation was kept up for 10 days. Convalescence. — Satisfactory. The temperature did not rise above 100^ and bis condition was always good. The drainage tubes were removed on the tenth day, and on the sixteenth day a retained catheter was placed in the urethra in order to facilitate closure of the perineal fistula. He was discharged from hospital on May 10, his general condition being good, but a small perineal fistula was still present. April 28, 1903. — The perineal fistula persists, and probe passes directly into the urethra. To-day the edges are freshened up with scissors. May 5, 1903. — The perineal fistula is healed except for a small opening. During the day he is able to hold his urine for several hours, but during the night there is occasional incontinence. His general condition is ex- cellent. May 25, 1903. — The patient got up once last night to urinate. This morning he has held his urine for four hours. He voids urine easily with- out hesitation and has no dribbling. The fistula is closed. Silver catheter passes with ease and finds 25 cc. residual urine and a bladder capacity of 350 cc. January 20. 190'). — Letter. I can hold my urine for three hours during the day, but have to arise about every 1% hours at night. The fistula closed three months after the operation. I still suffer pain in the bladder and my urine is cloudy. I have no erections. May 22, 1904. — Letter. I void urine about every two hours during the day and about every six hours during the night. The stream is small and the amount of urine voided about 125 cc. I have never used a catheter. November 30, 1905. — I am greatly improved by the operation, but have more frequent urination during the night than I have during the day. I do not use a catheter. I have pain in the back. I have gained in weight. I do not have erections any more. Vol. XIV.— 12. 160 Hugh H. Young. May Hi, 1906. — Letter. The wound has remained healed and I have not used a catheter. I hold my urine very well during the day, but not very well at night. The amount voided is not regular. If I overdo myself I suffer some pain. I have no erections. My general health is only fairly good. I have gained in weight, and I am cured in some ways. Case 9. — Moderate enlargement of median and lateral lobes.. SuprapuMc cystostomy and three Bottini operations done previously. Perineal pros- tatectomy. Cure. Rectal fistula. Plastic operation to close it. Cure. Followed 22 m,onths. No. 351. J. M. L., age 63, married, admitted March 11, 1903. Complaint. — " Prostatic obstruction. Suprapubic fistula." No history of gonorrhoea. Present illness began six years ago with slight difficulty and increased frequency of urination. In 1898, the difficulty had increased greatly and finally complete retention of urine came on requiring catheterization. After that the catheter was used, at first every day, but after that more frequently, and after 1899 the retention of urine was complete. In Octo- ber, 1902, the patient suffered great pain, tenesmus and catheterization was necessary about every hour. On October 28, 1902, the bladder was punc- tured with a large trocar and canula, and a small soft catheter inserted through the canula and left in the bladder for continuous drainage. On December 16, 1902, a Bottini operation was performed in an adjacent city. Two incisions were made, both lateral with a negative result. On January 11 a second Bottini operation was performed, a median incision 214 cm. being made. Results again negative. On February 1, 1903, a third Bot- tini, two lateral incisions between the previous lateral and median cuts. Results negative. The suprapubic catheter drainage was maintained and the patient was unable to void urine. S. P. — No urine is voided through the urethra, but all escapes through a small suprapubic catheter drain. The patient suffers constant pain in the bladder for which he takes morphine. Sexual powers. — Normal; erections occurred at frequent intervals up to the time of the first Bottini operation. Since then has had no erections. Examination. — The patient is well developed. General condition good. The chest abdomen and genitalia are negative. There is a direct reduci- able hernia on the left side. There is a small suprapubic sinus in which the patient wears a small catheter. Rectal. — The prostate is moderately enlarged, rounded, elastic. At the upper end of the right lobe there is a small nodule, but the seminal vesi- cles are negative. Urinalysis. — Moderately cloudy, acid, 1015, albumin in slight amount, pus cells and bacteria numerous. Total urine in 24 hours, 1260 cc. Total urea G-22.7. Cystoscopic. — The bladder capacity is 200 cc. The cystoscope showed two fairly large intravesically hypertrophied lateral lobes connected by study of 145 Cases of ■Perineal Prostatectomy. 161 a moderately large median bar without intervening sulci. Two depres- sions, probably cystoscopic cuts, were seen, but they were very shallow. The suprapubic catheter was seen, and its end is slightly encrusted with calcarious salts. There is no calculus in the bladder. The trigone and ureters could not be seen. Operation, March 19. 1903. — :Ether. Perineal prostatectomy by the usual technique. The lateral lobes were moderately hypertrophied and easily enucleated Along with the left lateral lobe the median bar and a portion of the right lateral lobe was enucleated in one piece without injuring the urethra or the ejaculatory ducts. The entire right lateral lobe could easily have been drawn through the suburethral cavity made by the freeing of the median lobe into the left lateral cavity and removed in one piece with the median and left lobe had the operator not been afraid of tearing the ejaculatory ducts. The wound was closed with double tube drain- age and light packs for the lateral cavities. The superficial perineal muscles were approximated with three buried sutures of catgut (but ap- parently the levator muscles were not drawn together over the rectum). The skin wound was partially closed on each side with catgut. The patient was infused on the table. He stood the operation well, but his pulse was quite rapid, 140 at the end. Continuous irrigation on return to the ward. Convalescence. — The suprapubic drainage was maintained. There was practically no rise of temperature and the patient convalesced well. On the night after the operation an assistant, thinking the hemorrhage was too profuse, packed a considerable addi- tional amount of gauze into the perineal wound, and none of this was removed until the sixth day when the perineal tubes and most of the gauze were extracted. Nine days after the operation all of the stitches were removed on account of suppuration, and the wound irrigated and repacked. On the eleventh day a catheter was placed in the suprapubic sinus for drainage. The patient then complained of gas es- caping through the perineal wound for the first time. Two weeks after the operation a definite rectal fistula was discovered. The perineal urinary fistula closed about 30 days after the operation, and the patient was dis- charged from the hospital May 24, 66 days after the operation. At that time there was no leakage of urine through the perineum or into the rec- tum, and the suprapubic fistula had closed. There was a very fine perineal- rectal fistula present through which a small amount of gas occasionally escaped. His general health was excellent. He was able to retain urine for two and one-half hours, but still suffered pain. A catheter passed easily and showed no residual urine. Bladder capacity was 400 cc. October 26, 1903. — The patient reports that the communication between the perineum and the rectum has never closed. In July, after a forcible urethral irrigation, urine began to escape during micturition through the perineal fistula. Since then gas has occasionally escaped through the ure- thra, but never any feces. Urination is satisfactory, at intervals of six hours at night and three to four hours in the day. Examination.— A small perineal fistula is present, through which a fine 163 Hugh H. Young. probe can be passed into the rectum, the rectal opening being about 3 cm. above the anus. No urine escapes into the rectum and only a few drops through the perineal fistula. Operation, October 21, 1903. — iEther. Closure of rectal and urethral peri- neal fistula. An inverted V perineal incision was made in the site of the old scar and the fistulous tract excised. Urethrotomy of the anterior por- tion of the bulbous urethra was then performed and the tractor inserted. The opening into the urethra was then sutured with several layers of cat- gut, and after that the rectum was closed with several layers of inter- rupted catgut. The skin wound was partially closed and lightly packed with gauze and a permanent perineal drainage tube. Convalescence. — The patient reacted well. The perineal drainage tube was removed after eight days, after that urine was voided freely through the Incision for several days, but there was never any leakage of the sut- ured urethral wound. The rectal wound broke down on the seventh day and gas and feces escaped through the perineum for about a week, and he thinks a small amount of gas escaped through the meatus. Since the 14th day the rectal wound has remained closed, and the perineal wound has healed. The bulbar urethrotomy wound has been closed since the 21st day. Decemder 20, 1903. — Examination. The patient voids urine at intervals of three and one-half hours, occasionally six hours. Both wounds in the perineum are solidly healed and the rectal fistula is closed. The silver catheter passes easily and finds 10 cc. residual urine. The urine is acid, cloudy, contains pus cells and bacilli in large number. May 20, 190^. — Letter. The wounds have remained healed, and I void urine at intervals of five or six hours at night and three or four hours in the day, about one-half pint at a time. I have a slight pain in the urethra. I have had no erections. February 1, 1905. — (Letter. I void urine naturally at intervals of one to two hours during the day and two to three at night. The amount voided each time is abundant. I suffer some pain during urination. I have not had erections. My general health is very good. The patient died March 31, 1905. Cause of death not stated. Pathological report. — The specimen G. U. 271, consists of one piece which represents the left lobe of the prostate, median bar and a portion of the right lobe, and weighs in all about G-10. The portion forming the left lateral lobe is a globular mass about 3 x 2.5 x 2 cm. in size. The me- dian portion is about 2 cm. thick. Only a small portion of the right lateral lobe has been removed, being a mass about 2 cm. in diameter and .5 cm. thick. On section there is a moderate amount of stroma, and con- siderable dilatation of the acini. No mucous membrane, no ducts re- moved. Microscopic examination. — The hypertrophy is a glandular one with moderate dilatation of the acini. The acini show a rather unusually large number of intraacinous projections, often papillomatous in type. These intraacinous off-shoots are often formed of pure epithelium, the stroma as yet not having grown into them. It would seem that the epithelial activity study of 140 Cases of 'PerineaJ Prostatectomy. 163 was unusually marked wittLin the acini. The stroma contains a large amount of muscle, in many areas being considerably in excess of the con- nective tissue. Some embryonic tissue formation is seen. The blood ves- sels for the most part are normal, but here and there there is present a moderate degree of arteriosclerosis. Case 10. — Small sclerotic prostate. Pain and great irritation. Con- tracted bladder. Cured of obstruction. Slight contraction remains. Fol- lowed three years. No. 398. E. J. H., age 62, admitted May 1, 1903. Complaint. — "Frequency of urination." Gonorrhoea at the age of 28, a light attack lasting only three days. Pres- ent illness began about seven years ago with frequency of urination and burning in the urethra and slight difficulty. After that intermittent at- tacks of irritation and frequency every few weeks. For the past five years has had a continuous pain in the bladder with difficulty and frequency of urination. He had complete retention of urination in January, 1903, four months ago and required catheterization twice. S. P. — The patient urinates five times during the night and about as often during the day. During urination he has a burning pain in the ure- thra, but the stream is small and slow. He has suffered so severely that he has been unable to attend to business. His sexual powers were good until six years ago, since then ejaculation has been extremely painful, and he has ceased having coitus. Nocturnal emissions cause a burning which he says is like a coal of fire. His general health is rather poor; he is extremely nervous. Examination. — The patient is fairly well nourished, but extremely neu- rotic in appearance. The chest and abdomen are negative. Rectal. — The prostate is moderately enlarged. The right lobe is smooth, but quite hard. The left lateral lobe is smaller than the right, its surface is a little irregular, two or three nodules being present, and is quite in- durated. The seminal vesicles, however, cannot be palpated and are evi- dently soft. Cystoseopic. — A coude catheter passes easily and finds 100 cc. residual urine. The bladder is considerably smaller than normal. The cystoscope shows prostatic enlargement in the shape of a collar around the orifice. The lateral lobes are definitely hypertrophied with a definite sulcus be- tween them in front. The median bar is slight, and there were no sulci between it and the lateral lobes. The ureters and much of the trigone could be seen behind the bar. The bladder is considerably trabeculated, no cystitis, no calculus. "With finger in rectum and cystoscope in urethra the beak could be felt, and there is a moderate increase in the median portion of the prostate and a considerable increase in the urethtral length. Urinalysis. — Clear with a few shreds in Lhe first glass which under the microscope are found to be pus cells. The urine is neutral, 1010, slight trace of albumin, Urea G-8 to the liter. Microscopically negative. Operation, May IS. 1903. — -Ether. Perineal prostatectomy by the usual 16-i Hugh H. Young. technique. The lateral lobes were only moderately hypertrophied, were quite adherent and removed with some difficulty, but each came away in one piece without tearing the urethra or bladder, and measured 5I/2 x 3% X 3 cm. Examination of the median portion showed that it was only slightly larger than normal, and it was thought unnecessary to remove this. The wound was closed as usual with double tube drainage, light packs for the lateral cavities, and continuous irrigation on return to the ward. The patient stood' the operation well. The pulse at the end was 104. Convalescence. — The patient reacted well. The highest temperature was 101.2 on the day after the operation. He had some fever for the four suc- ceedings days, and after that the temperature was practically normal. The irrigation was continued for four days when the tubes were removed, and the gauze was removed on the third day. Interval urination was estab- lished early, and oh the eighth day two-thirds of the urine came through the anterior urethra. The perineal fistula closed on the 14th day and the patient left for home on the 19th day. Urination was almost normal, no incontinence, and condition excellent. November 3, 1903. — ^I suffered for a time with irritability of the bladder, but have improved, and can now retain urine for three or four hours and have no incontinence. November 28, 1903. — I retain urine for four or five hours during the day. At night I sometimes urinate every hour and always after having drank a good deal of water. May 20, 1904. — I void urine about every four hours during the day, more frequently at night, about six ounces at a time, do not use a catheter. Uri- nation is satisfactory. I have no erections. January 15, 1905. — I void urine normally and have no pain, about six times in the day and six times at night, about six ounces at a time. I have no erections. November 30, 1905. — The wound is closed. I void four or five times during the day and about the same number of times at night, but I drink a large amount of lithia water. I have never used a catheter s'ince the operation and consider myself cured. I have no erections. My health is good. Case 11. — Very large hypertrophy of the two lateral lobes. No median lobe enlargement. Complete retention of urine for 10 days. Catheter withdrew 4500 cc. urine. Bottini operation. Relief of obstruction. Fif- teen months later severe hemorrhages. Perineal prostatectomy. Cure. Followed three years. No. 173.^W. F. S., age 55, single, admitted January 10, 1902. Complaint. — " Complete retention of urine." The patient had gonorrhoea twice in his youth, but no stricture devel- oped. Present illness began five years ago with slight difficulty in urina- tion and since then his condition has gradually grown worse, urination gradually becoming more frequent and difficult. Three months ago large clots of blood passed with the urine. On January 1, 1902, he was suddenly study of lJf.5 Cases of 'Perineal Prostateciomy. 1G5 seized with pain in the bladder and was unable to void urine. His phj^- sician was able to withdraw only a small amount of urine with the cathe- ter. A chill followed by fever, nausea and vomiting came on, and although he was able to void but little urine he was not catheterized again until January 10. He was then seen by Dr. Pancoast, who found the abdomen greatly distended, and the bladder palpable three fingers' breadths above the umbilicus. A catheter was introduced with difficulty and 4500 cc. of cloudy urine withdrawn. The patient was then sent to the Johns Hop- kins Hospital, where the following notes were made. " The patient is fairly nourished and mentally clear. His tongue is dry and red, his pulse of good volume and tension regular, the vessel wall considerably sclerosed. Very fine rales are present at the bases of both lungs, a slight systolic murmur is present at the apex of the heart and the second aortic is accentuated. The lower abdomen is full (17 hours after catheterization by Dr. P.). The bladder dullness extends two fingers' breadths above the umbilicus. A catheter passes with ease and 2800 cc. of urine is with- drawn. Catheter is fixed in the bladder for permanent drainage." January 16, 1902. — The patient has improved, but still has a slight tem- perature, but the urine contains pus, and the bladder is irrigated twice daily. February 1, 1902. — ^The bladder has been drained by permanent catheter for three weeks, and the patient's condition is excellent. The prostate is considerably enlarged in both lateral lobes, consistence soft, elastic, smooth, seminal vesicles not indurated. Cystoscopic examination. — Although the patient has had continuous cath- eterization for three weeks, the bladder capacity is very large and the ton- icity very poor. The cystoscope shows two large intravesically hypertro- phied lateral lobes, the bladder wall is only moderately trabeculated, and no diverticula are present. Urine. — On admission the analysis showed sp. gr. 1010, reaction acid, no sugar, trace of albumin, a sediment tinged with blood, and microscopically, pus, red blood corpuscles, hyaline and coarsely granular casts. A daily urine chart was kept and the amount of urine was always large, varying from 2160 cc. to 4370 cc. on January 17. Sp. gr. was generally about 1010, and the total urea varied from 15 to 28 grams in 24 hours. Hyaline and granular casts were constantly present. March 15, 1902. — During the past six weeks the patient has been cathe- terized five times a day. He is unable to void urine, and produces from 1600 to 2300 cc. urine daily. The urine is still purulent and still contains hyaline casts, no granular casts seen. His general condition is excellent. March 16, 1902. — Operation. 4% cocaine in the urethra. Bottini opera- tion. Three cuts, one posterior, 2.8 cm. long, two lateral with blade No. 3, each 3 cm. long. There was very little hemorrhage and the patient suf- fered no pain. Convalescence. — Immediately following the operation the patient began to dribble urine. A catheter was passed during the evening and 700 cc. urine withdrawn. 166 Hugh H. Young. March 17, 1902. — The patient has been voiding all day, a catheter finds 600 cc. residual urine. There has been no chill or fever following the op- eration. The patient was out of bed on the third day, and he was dis- charged on the 12th day, in excellent condition. June 21, 1902. — The patient is in excellent condition. Voids urine twp or three times in the day and once at night, about 500 cc. at a time. The urine is cloudy, acid, sp. gr. 1018, and albumin, pus cells and bacilli are present. July 19, 1902. — The patient voids a good stream and does not get up at night. April 14, 1903. — About 10 days ago the patient began to have hematuria, the hemorrhage was very severe and lasted for several days. The urine is now free from blood. A catheter passes with ease and finds only 16 cc. residual urine. The bladder capacity is large and the tonicity is good. The cystoscope shows two very large intravesically hypertrophied lateral lobes with only a small fold of mucous membrane joining them in the me- dian portion. It was impossible to find the point from which the bleeding came. As the patient is otherwise normal, and often does not get up at all at night to urinate, no operation is advised. May 15, 1903. — The patient has had another severe hemorrhage in the bladder, and an injection of adrenalin is required this morning to stop it. May 16, 1903. — The urine is again clear. General condition is excellent. Voids urine in a large stream four or five times a day, and has apparently a perfect result from the Bottini operation with the exception that when he has intercourse no semen appears at the meatus, although the act is otherwise normal. He is advised to have perineal prostatectomy in order to remove the tremendous prostate and relieve him of the dangerous hem- orrhages. Rectal examination shows the prostate to be very large, smooth and soft. The lungs are negative. There is a systolic murmur at the apex of the heart. Operation, May 25, 1903.— -lather. Perineal prostatectomy by the usual technique. Each lateral lobe which was very large was removed in three large pieces, this was necessary because the blade of the tractor would not remain on top of the very large intravesical lobes, but constantly slipped beneath them so that when one large lobule was removed on each side it was necessary to again place the tractor upon the summit of the re- maining intravesical mass, draw it down and enucleate again. In this way it was very easy to remove completely a very large, probably pedunculated median lobe on each side. The urethra and ejaculatory ducts were pre- served intact, but two small tears were made in the vesical mucosa, none of which was removed. The median portion of the prostate was not dis- turbed. The wound was closed as usual with double catheter drainage and light gauze packs for the cavities. Patient stood the operation well. Infusion and continuous irrigation. Pulse at end of operation 80. Convalescence.— The highest temperature was on the fifth day after the operation, 100.8°; after that it was practically normal until June 15, when study of 145 Cases of ■Perineal Prostatectomy. 167 it suddenly arose to 103.5°, but quickly fell to normal. The continuous irrigation was kept up for nine days "when the tubes and gauze were re- moved. There was incontinence for three or four days, but after that con- trol was established and he could retain urine for five hours. The urine did not pass through the urethra until the 12th day, and the fistula closed on July 6, the 42d day. On June 6 a retained catheter was placed in the urethra and remained for three days. Following the patient had a rise of temperature and developed epididymitis which continued for a week, but subsided without operation. On July 3 the patient had another sud- den rise of temperature to 102°, but it subsided at once and the patient left the hospital July 19 in excellent condition, able to retain urine all night and voiding only three or four times in the day. January llf, 1904- — Urination is normal and at intervals of five hours in the day and seven hours at night, no incontinence. Sexual powers are good. After ejaculation the semen is now thrown cut of the meatus (after Bottini it was not). Examination of the semen caught in a condom shows numerous spermatozoa. February 1, 1905. — I urinate at normal intervals and am entirely cured. My sexual powers are normal. 'November 13, 1905. — I void urine naturally, once at night, three or four times during the day, a half a pint or more at a time. I have no fistula, no pain. Intercourse is entirely satisfactory, and my general health good. May 8, 1906. — 'Letter. I void urine naturally three or four times during the day, and twice at night, a half pint or more at a time. I have no pain. Sexual intercourse is entirely satisfactory. My general health is excellent, and I consider myself cured. Case 12. — •Slight hypertrophy of the lateral lobes. Small pedunculated median lobe. Post operative complication: gauze left in toound. Pin point fistula. Cure. FoUoiced three years. , No. 408. J. R., age 70, married, admitted May 26, 1903. Complaint. — '^' Diflicuty in urination." No history of gonorrhcEa. Present illness began nine years ago with difficulty of urination. At the end of four years he began to have pain during urination located about the middle of the urethra. In February, 1902, he was catheterized and a quart of residual urine obtained. Since then he has used a catheter off and on, although he has never had a complete retention of urine. ,Sf. P. — He voids urine five or six times during the night, micturition be- ing difficult and painful. If he uses the catheter he is able to go four hours without urinating. During the last six months he has lost very little weight, and his general condition is good. Sexual powers have dimin- ished. Erections only occasionally and desire for intercourse practically lost. Examination. — The patient is a fairly strong looking man, lips of good color. Heart, lungs and abdomen negative. 168 Hugh H. Young. Rectal examination. — The prostate is slightly but symmetrically enlarged. It is firm in consistence, but is not markedly indurated and has no nodules. Cystoscopic examination. — A coude catheter passes with ease and finds 480 cc. residual urine. The vesical tonicity is good. The cystoscope shows a small sessile rounded median lobe with a deep sulcus on either side. A chronic cystitis is present, but no calculus. Prostatic secretion contains pus cells, a few lecithin and granule cells, no spermatozoa. Urinalysis. — ^Acid, sp. gr. 1018, no albumin in filtered specimen, no sugar. Urea G-19 per liter. Microscopically, pus cells, bacilli and cocci, no casts. Total urine voided in 24 hours 1750 cc. Operation, May 29, 1903. — 'Ether. Perineal prostatectomy by the usual technique. The right lateral lobe was not at all enlarged, was quite fibrous and came away in small pieces. The left lateral lobe came away in one piece measuring 4 x 2% x 2 cm. The median lobe was removed through the left lateral cavity without tearing the mucous membrane of the urethra or bladder and leaving the ejaculatory ducts intact. A speci- men removed is shown in the photograph (see Fig. 25a) which is actual size. The wound was closed as usual with double tube drainage, lateral cavities being packed with gauze. Commlescence. — Patient reacted well. Continuous irrigation was kept up four days. The packing was removed during the first week, and the tubes on the tenth day. The wound broke down and healed slowly by granulation. After removal of the tubes there was incontinence of urine which persisted until the patient was discharged. Several weeks after the operation as the fistula did not heal, during my absence in Europe, a catheter was placed in the urethra and kept there for eight days. Exami- nation at the end of that time showed that a piece of the packing had been left in the wound, and after its removal healing proceeded rapidly. He was discharged on August 6, 1903. A small urinary fistula was present, and the patient was able to retain his urine for several hours. His gen- eral condition was excellent and he was free from pain. January 20, 1904. — Letter. The fistula is not yet closed, but I void urine in a large stream through the urethra at intervals of from three to five hours. I have no pain, have erections occasionally. April 22, 1904. — I have perfect control of my urine, but a pin point fis- tula is present. I can retain urine for five hours. February 1, 1905. — I void naturally at intervals of from three to six hours. A pin point fistula persists, but I have no pain and feel well. November 30, 1905. — Letter. I void urine naturally once at night and about three- times during the day. Have no pain. A pin point fistula per- sists, but often there is no leakage and at other times only a few drops. I feel perfectly comfortable, my general health is excellent and I have gained 40 pounds in weight. I have erections occasionally. May 7, 1905. — Letter. I void urine naturally, once at night and three times during the day, large amounts at a time. I have no pain, no erec- tions. My general health is excellent and I consider myself cured. study of lJf-5 Cases of Perineal Prostatectomy. 169 Pathological report. — The specimen, Path. 35, consists of three lobes weighing Gr-17. The median lobe weighs G~7, and measures 3x2x2 cm. The left lateral lobe is about the same size. The right lobe is composed of several small pieces and weighs much less than the median. On sec- tion there is a thin capsule surrounding the lobe, and the typical adenoma with numerous dilated acini. Microsco-pic study shows the typical spheroidal arrangement with cap- sules containing compressed acini. There are many dilated acini with compressed epithelium of a columnar type. The stroma is composed of fibrous tissue and smooth muscle loosely bound together with very few areas of interstitial inflammatory deposits. The epithelium is well pre- served, no glandular prostatitis present. Corpora amylacea fairly num- erous. Case 13. — Yery large Jiypertrophy of median and lateral lobes. Old suprapubic fistula. Contracted bladder. Cure. Followed three years. No. 518. G. G. H., age 74, married, admitted May 28, 1903. Complaint. — " Enlarged prostate. Suprapubic fistula." Gonorrhoea in 1850, light attack, no complications. ^ Present illness began eight years ago with difficulty, pain and frequency of urination. Progress of the disease was gradual until June 11, 1902, when retention of urine became complete and his physician was unable to pass a catheter and performed suprapubic cystotomy. Since then he has worn a supi-apubic drainage apparatus. S. P. — The patient wears a suprapubic apparatus, no urine comes through the urethra, there is considerable leakage around the tube, he suffers pain and is uncomfortable. Sexual powers. — He has erections occasionally, but has not had inter- course for a year. His general health is good. Examination. — The patient is a robust man, lips of good color, arteries slightly thickened, pulse 82. The chest and abdomen are negative. There is a large suprapubic fistula in which the patient wears a tube connected with a Bloodgood bag. Examination of the bladder through the fistula with the finger shows a very large collar-shaped hypertrophy of the lateral and median lobes which stands up three and one-half inches above the trigone into the bladder, the upper limits reaching to within 1 cm. of the suprapubic opening. Rectal. — The prostate is greatly hypertrophied, the right lobe being the larger, and having a peculiar lobule projecting from its lateral border. The prostate is smooth, elastic, the notch and furrow are obliterated. The seminal vesicles cannot be reached. Cystoscopic. — The cystoscope was introduced through the suprapubic opening. The intravesical prostatic enlargement consisted of a huge mid- dle lobe which coalesced without intervening sulci with two large lateral lobes, between which there was a deep sulcus in front. The ureters lay beneath the median lobe and could not be seen. An attempt was then made to cystoscope the bladder through the urethra, but the intravesical 170 Hugh H. Young. portion was so great that the instrument could not be passed over the top of it. The finger in the suprapubic wound showed that the end of the cystoscope lay in the space in front of the median lobe. Operation, May 30, 1903. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes, which were very large, were removed each in three large lobules. The median lobe was delivered into the left lat- eral cavity and enucleated vrith ease, without removing any of the mucous Fig. 41. — Large lateral and median lobes. Exact size. membrane which covered it. This lobe was 5 cm. long, 3i^ cm. wide, and 2^2 cm. thick. The accompanying photograph shows the lobes in their relative position (Fig. 41). The urethra and ejaculatory ducts were pre- served intact. At the end of the operation a finger was inserted in the suprapubic fistula and showed no intravesical prostatic enlargement, the mucous membrane covering the same having contracted down so that the vesical neck felt almost normal in smoothness. The perineal wound was study of lJ+5 Cases of 'Perineal Prostatectomy. ITl closed as usual ^\-itli double catheter drain, and light packs for the lateral cavities. Infusion and continuous irrigation. The condition of the pa- tient at end of operation was good. Convalesceyice. — The patient reacted well. His highest temperature was 101°, and there was very little hemorrhage. The gauze was not removed from the perineal wound until four weeks after the operation (the op-' erator was away on vacation), and the suprapubic tube in six weeks. At that time the perineal wound was entirely closed. He left the hospital on the 55th day, his condition was excellent. Six days later an abscess developed in the perineal wound, was opened by his physician and a silk ligature removed. After that the perineal fistula healed promptly, and urination soon improved. ■January 23, 1904- — Urination is easy but painful, and occurs at intervals of one or two hours night and day Both wounds are healed. I never use a catheter. An abscess developed in the perineum shortly after my return home, but after the removal of a silk stitch the fistula healed. I suffer all the time with a pain in the neck of my bladder and penis. My general health is good. May 20, 1904- — " Urination is free but painful. I void urine at intervals of two hours during the day and three or four at night. I do not have erections." The patient was directed to have bladder examined for cal- culus. If his bladder was found to be contracted, to use hydraulic dilata- tion. February 1, 1905. — I urinate about every three hours during the day and four or five hours during the night, one-half pint at a time. Micturi- tion is natural, but I still suffer pain in the penis which is worse during urination. Xovemter 30, 1905. — Last August I went to Eureka Springs and drank large quantities of the water there. My bladder became three times as large as before and the pain disappeared. I now feel better than I have for six years, in fact, I am entirely cured. Can retain urine five hours during the day and nine hours at night, and sometimes void a pint at a time. I have no pain. I do not have erections. May 8, 1906. — Letter. The wound has remained closed. I am cured. [ void urine naturally as much as I ever did and often pass over a pint at a time. I have no pain. I do not have erections nor sexual intercourse. My general health is excellent. Pathological report. — Specimen, G. U. 44, consists of the lateral and median portions of the prostate removed In six pieces and weighs about Gl~80. The left lateral lobe has been removed in one piece measuring 4-X 3.5 X 2.5 cm., is globular in shape, encapsulated and on section shows large spheroids with a moderate amount of stroma and considerable dilatation of the ducts. The right lateral lobe has been removed in two pieces which measure together 5 x 3.5 x 2.5 cm., and is similar to the left, except that the ducts are more dilated. The median portion of the prostate has been re- moved in three pieces, forming together a mass 5 cm. long and 6 cm. wide 172 Hugh H. Young. as shOTrn in photograph. It is smooth and on section shows more gland tissue and less stroma in the lateral lobes. No mucous membrane, no ejaculatory ducts, no calculus. Microscopic examination. — The hypertrophy is a glandular one, with the acini arranged in lobules, and there is marked cystic dilatation. The ma- jority of the dilated acini are lined by flattened epithelium, sometimes one layer and sometimes two layers thick. In areas there is considerable pros- tatitis present with endoglandular proliferation and desquamation and considerable periacinous formation of fibrous tissue. The stroma has a considerable excess of .fibrous tissue over muscle, and there is a fair amount of inflammatory infiltration. The arteries for the most part apparently show no thickening, although here and there one sees a vessel whose walls are somewhat thickened. Case 14. — Slight enlargement of median and lateral loies. Residuum 50 cc. Capacity 150 cc. Result: Cure of obstruction. Frequent urination due to vesical contracture. Followed two years. No. 45S. J. M., age 57, married. Seen at request of Dr. Casper in Ber- lin, Germany, July 23, 1903. No history of gonorrhcEa. Present illness began seven months ago with sudden complete retention of urine. He was catheterized and one and one-half liters of urine with- drawn. Immediately afterwards he had a convulsion and for four days was comatose and was expected to die. He finally rallied and left the hospital February 27; micturition very frequent, generally every hour during the day and night. He consulted Dr. Casper on March 13, 1903, and was treated by intravesical irrigations through a catheter with con- siderable improvement. He returned, however, in July, complaining of frequent urination, great difficulty, pain and spasm in the bladder. S. P. — The patient voids urine every hour with a great deal of difficulty and pain. Sexual powers: No note made. Examination. — The patient is a sturdy-looking man, with lips of good color. Heart, lungs and abdomen: No note made. Rectal examination. — The prostate is slightly hypertrophied, smooth, hard, but not of stony hardness, no nodules, no induration in the region of the seminal vesicles. Cystoscopic examination. — A catheter passes with ease and finds 150 cc. residual urine (later examination residual urine 50 cc, bladder capacity 140 cc). The bladder is small and irritable. The cystoscope shows mod- erate intravesical hypertrophy of both lateral lobes and a small media lobe with a shallow sulcus on each side. "With finger in rectum and cysto- scope in urethra there is only a slight increase in the median portion. The urine contains considerable pus. Operation, July 2Jf, 1903. — ^Ether. Perineal prostatectomy by the usual technique with the kind assistance of Dr. Casper. The lateral lobes were only slightly hypertrophied and were removed each in one piece. The median portion of the prostate was small and removed through the left study of 145 Cases of ■Perineal Prostatectomy. 173 lateral cavity without tearing the urethra, bladder or ejaculatory ducts. Double tube drainage, light paclvs for the cavities and the usual closure. The patient stood the operation well. ConvaZescence.— 'The temperature did not rise above 38° C. and the pulse ranged between 70 and 75. On July 30 the patient began to have pain in the wound and his bowels were moved for the first time. The catheters were removed on the eighth day. August 13, 1903. — The patient is now walking about, his health is ex- cellent. Urine passes through the urethra. Hydraulic dilatation of the contracted bladder is to be begun. July 13, 1904. — Letter from Dr. Casper. The patient is in good health, urination is satisfactory and the stream large. He suffers no pain, voids urine three or four times during the night and about every two hours during the day, 100 cc. at a time. He has not used a catheter. A fistula continued for a long time, then closed, but recently has opened again, but only a few drops of urine escape through it. The patient has erections about every 10 days, but has not attempted intercourse. Case 15. — Considerable enlargement of lateral lobes. Slight median bar. Catheter life tico years. Cure. Followed 32 months. No. 477. T. C. W., age 67, married, admitted September 5, 1903. Complaint. — " Retention of urine." No note as to gonorrhcea. Present illness began three years ago with slight difiiculty at the begin- ning of urination. There was a gradual increase in the trouble and two years ago complete retention of urine came on. Since then the patient has been catheterizing himself about three times every day. For the first few months of catheter life the patient had considerable hematuria, but since then the urine has been free from blood. Erections and sexual powers are normal. Examination. — The patient is a well nourished man with lips of good color. Heart, lungs and abdomen negative. Genitalia negative. No hernia present. There is considerable arteriosclerosis. Rectal examination. — 'The prostate is considerably enlarged in both lat- eral lobes, the left of which is the larger and more prominent. The upper end of the prostate cannot be passed. Cystoscopic examination. — A coude catheter passes with ease and finds 115 cc. urine. (Retention of urine is complete, this does not represent the residual.) The bladder capacity is 340 cc. The tonicity is good. The cystoscope shows considerable intravesical hypertrophy of both lateral lobes joined by considerable median bar. The bladder is trabeculated and inflamed, there is no stone present. "With the finger in the rectum and cystoscope in the urethra the beak can be felt and the thickness of the median bar is moderately increased. Urinalysis. — ^Pale, 1015, acid, no sugar, considerable albumin, pus and epithelium. Urea, G-14 to liter. 174 Hugh H. Young. September 11, 1903. — Operation. Ether. Perineal prostatectomy by the usual technique with the exception that the prostatic tractor was intro- duced through a urethrotomy wound in the bulbous urethra before the inverted V incision or the prostatic enucleation was made. DiflBculty was encountered in getting the tractor through the urethra into the bladder, and when the prostate was exposed through the usual technique it was found that the tractor drew the prostate, not into the wound, as usual, but up against the triangular ligament. The exposure was not so good and the manipulation of the tractor was more difficult. The left lateral lobe was quite large and removed in one piece about the size of a hen's egg. The right lobe was smaller and came away in two pieces. Examination seemed to show no remaining median bar and nothing was removed from this region. A small tear was made in the lateral wall of the urethra, but no mucous membrane was removed, and the ejaculatory ducts were preserved intact. The lateral cavities were packed with gauze, a soft rub- ber catheter was introduced into the bladder through the urethrotomy wound in the bulbous urethra and both cutaneous wonds were partially closed with interrupted sutures. An infusion of salt solution was given on return to the ward and continous irrigation of the bladder was kept up for four days. Convalescence. — The patient reacted well, and suffered slight pain in the bladder while the catheter remained. The highest temperature was 101.2° on the day after the operation. The gauze and tubes were all removed on the eighth day, and on the tenth day a catheter was introduced through the penis into the bladder. The catheter was finally removed during the third week, but the fistula did not heal until one month after the operation, and a nocturnal incontinence persisted for five weeks. During the fifth week epididymitis came on, but subsided in four days. The right epididy- mitis was alone involved. October 17, 1903. — A silver catheter passes with ease and finds 15 cc. residual urine. The bladder capacity is 400 cc. The fistula is closed and the patient has complete control. The patient can hold his urine several hours. The urine is acid, sp. gr. 1015, contains considerable albumin, pus cells and bacteria. October 19, 1903. — The patient is discharged. Conditions excellent. Letter. Urination is easy and satisfactory, and I can hold my urine four hours in the day and only get up twice at night. The fistula closed on the 21st day. I have not used a catheter, have suffered no pain. Erections have returned, and I have had intercourse about once in two weeks. May 20, 1904- — I can hold urine for five hours and pass about 200 cc. at a time. Urination is normal, I have no pain, and my sexual powers have returned. February 1, 1905. — 'I void naturally and consider myself cured, only hav- ing to arise once at night to urinate. My sexual powers are the same as before operation. November 30, 1905. — I void naturally and consider myself cured, as I study of IJfO Cases of 'Perineal Prostatcctomij. ITS only have to urinate once during the niglit and three or four times during the day. Sexual intercourse is the same as before operation. My general health is excellent. May 29, 1906. — Letter. I void urine naturally four or five times during the day and only once at night, about half a pint at a time. I have no pain. I have intercourse the same as before operation, but the penis does not get so hard. My general health is good, I have gained in weight, the wound has remained closed, and I consider myself cured. Pathological report. — The specimen, G. U. 30, consists of three pieces, the left lateral lobe is in one piece and measures about 4x3x2 cm. in size. The right lobe is in two pieces and is smaller than the left. Both lobes present the usual character of adenomatous hypertrophy. Microscopic examination. — The hypertrophy is a lobulated glandular one. The acini are for the most part dilated, and in certain lobules have under- gone cystic degeneration. In some areas the acini have very little sup- porting stroma, their orifices are serrated, and there is at times much in- traacinous papillomatous proliferation. The epithelial cell is of a tall cylindrical type, the lumen, end being rather granular and degenerated. At times there is only one layer of these tall cells, but often in many points of the acini the epithelium may be several layers thick, the deeper layers being rather cuboidal in type. Glandular proliferation within many of the lobules seems very active. The stroma contains a fair amount of muscle, but the connective tissue predominates. There are some few areas of prostatitis, but these are not noted in areas where proliferation is ac- tive. The arteries show moderate degree of arteriosclerosis. Case 16.^" — Huge intravesical hypertropliy of median and lateral lo'bes in man aged 82. Bemoval of 240 grams of prostatic tissue. Cured. No. 541. J. A. K., age 82, single, admitted October 17, 1903. Complaint. — " Prostatic obstruction. Suprapubic fistula." No history of gonorrhcea. Present illness began 24 years ago with difficulty of urination, accom- panied by hematuria aud pyuria. His condition improved on treatment by hydrotherapy, but he continued to have trouble, and in 1887 had complete retention of urine for the first time and was catheterized once. After that he used a catheter occasionally on advice of his physician. In April, 1902, catheterization was impossible and a suprapubic cystotomj^ was performed in Washington. Since then the patient has been wearing a rubber catheter in the suprapubic wound, and all of the urine has come through this. He is unable to keep dry, is uncomfortable and suffers pain. Sexual poicers. — ^No note made. Examination. — The patient is a fairly strong man for 82 years. His lips are of good color. The heart and lungs are negative. Ahdomen. — There is a small suprapubic urinary fistula in which the pa- tient is wearing a soft rubber catheter. " Case No. 56 should have been placed here as Case 16. To change the position now (in proof) seems inadvisable. 176 Hugh H. Young. Rectal. — The prostate is greatly hypertropliied, presenting a broad flat mass, the upper limits of which cannot be reached. It does not bulge greatly into the rectum, but it extends far upward into the bladder, and with a hand above the symphysis pubic it presents as a large intravesical mass about the size of a large orange which is easily palpable, especially on bimanual palpation with finger in rectum and hand on abdomen, when the immense size of the prostate is easily made out. Rectally its surface is smooth, soft and not tender. The seminal vesicles cannot be palpated. Cystoscopy. — tA small silver catheter is passed with great difficulty, owing to the immense size of the intravesical portion of the prostate. Urine es- capes after the catheter has entered for a distance of 15 inches. An at- tempt was made to 'perform cystoscopy through the suprapubic opening, but although it was easy to introduce the cystoscope through the supra- pubic sinus, the beak entered at once into the cavity in front of the me- dian portion of the prostate which projects far up into the bladder, al- most completely filling its cavity and rendering it almost impossible to introduce the cystoscope into the bladder behind the middle lobe. Urinalysis. — Acid, 1020, albumin a heavy trace. Urea G-17 to liter. Pus cells numerous. Operation, Octo'ber 20, 1903. — Spinal anesthesia with one-fifth of a grain of cocaine. Perineal prostatectomy. The prostate was easily exposed through an inverted V incision. The urethra was opened as usual, and the tractor inserted. The posterior surface of the prostate was so immense that it could not be drawn down between the ischio-pubic rami, and the blades of the tractor were so short that they would not take hold upon the very great intravesical lobes. The prostate was therefore removed in large lobules piecemeal. The operator attempted to make pressure upon the abdomen and thus push down the prostate, but the patient could not stand the abdominal pressure which gave pain, although operation upon the prostate was painless. No attempt was made to preserve the urethra or ejaculatory ducts, and considerable mucous membrane was removed. The right lateral lobe and median lobe were completely removed, but the deeper intravesical portions of the left lateral lobe had not been completely removed when the patient became so weak that the operator decided to stop and close the wound, nevertheless 240 grams of prostatic tissue were removed. The immense cavity was packed with gauze, a large rubber tube was placed in the bladder through the perineal wound and a catheter into the suprapubic sinus. There was only a moderate amount of hemorrhage. Pulse at the beginning of the operation was 80, and at the end 68 but weak. Submammary infusion was given during the operation. The anesthesia in the region of the perineum and prostate was excellent, but suprapubic pressure caused pain. The patient vomited frequently during the opera- tion and was distinctly shocked at the end. Convalescence. — After injections of strychnia and water the patient re- acted well and drank large amounts of water and ate a fairly good supper. For one week he had a temperature between 101° and 102°, and at times was slightly irrational. He was infused on the fourth day. On the ninth study of lJj.5 Cases of ■Perineal Prostatectomy. 177 day a large sloughing lobule of prostatic tissue measuring about 8x5x4 cm. in size was found in the perineal wound and withdrawn. Several days later a second lobule was removed in the same way. These were apparently portions of the left lateral lobe which had been loosened by the operator, but had not been removed on account of the condition of the patient. The perineal fistula being still open five weeks after the opera- tion, a retained catheter was placed in the bladder through the urethra. This catheter was left in place for several days, and the perineal fistula promptly healed (38th day). After that the patient passed urine through the penis in small amounts, but the suprapubic sinus which was lined with epithelium, although reduced to a pin point opening refused to heal. He left the hospital eight weeks after the operation, 55th day, in excellent condition. January 14, IQOJf. — The suprapubic fistula is leaking slightly, at night I urinate two or three times through the urethra; if I let too long a time elapse there is some involuntary discharge, showing a lack of force of contracture at the neck of the bladder. January 20, 1904- — A pin point suprapubic fistula persists. The patient is advised to have this excised. February 3, 1904- — Operation. Cocaine. Excision of muco-cutaneous su- prapubic urinary fistula. The fistulous tract was very fibrous, and was excised in one piece. As the dissection proceeded, it was possible by mak- ing traction upon the fibrous tube to draw the bladder in the shape of a cone up into the skin wound where a circular suture of catgut was placed in the bladder muscle around the base of the fistulous tract which was then divided. The purse string suture was then drawn tight, thus effec- tually turning in and closing the vesical wound. By means of this tech- nique it was possible to effectually suture the bladder through a very small skin incision. The muscle and subcutaneous tissue were drawn to- gether with silver sutures. Convalescence. — The suprapubic wound healed per primam, there being no leakage at any time. The patient left the hospital in 12 days, voiding urine naturally through the urethra. M.ay 23, 1905. — Letter. I void urine in a good stream at intervals of from three to five hours during the day and five to eight hours at night. I suffer no pain. My sphincter is a little weak and at times there is a slight leakage. The patient is advised to wear a jock-strap, thus holding the penis against the abdomen with the idea of doing away with the slight leakage. November 30, 1905. — The wounds have remained closed. I void naturally once at night, sometimes not at all, 14 ounces at a time. During the day the interval is about four hours, but there is occasionally a slight leakage which requires the use of a cloth. My general health is excellent. I am now 85 years of age. May 10, 1906. — My condition remains the same as stated in the last letter with the exception of a slight leakage. My general health is good. Vol. XIV.— 13. 178 Hugh E. Young. Pathological report. — The specimen consists of many lobules of various sizes with smooth encapsulated surfaces varying from 1 to 5 cm. in diam- eter, and weighs 200 grams. The sloughing piece removed later weighs about 40 grams. A number of lobules are covered with mucous membrane, the total area of which would probably amount to about 6 cm. in diameter. Section of the lobules show typical spheroids of the usual adenomatous hypertrophy. Microscopic examination. — Two sections have been taken. I. Through a lobule covered with mucous membrane, a portion of which is vesical, and a portion urethral, both fairly well preserved. In the submucosa there are considerable cedema and round celled infiltration and numerous bundles of smooth muscle. The lobule is composed largely of glandular tissue with little stroma. The ducts are moderately dilated, and there is considerable intracystic outgrowth of epithelium of a papillomatous type. Epithelium is a tall colum- nar variety except in the few dilated acini where it is moderately flat. The stroma is composed of fibrous tissue and smooth muscle arranged more or less circularly around the acini in a rather loose structure. There are no masses of pure fibroma or myoma — considerable evidences of in- flammatory processes are present. II. Section of another lobule shows more dilated ducts, and here and there considerable inflltration of round and polynuclear cells in the stroma. The lobule is surrounded by a thick flbrous capsule in which flattened acini are seen. Case 17. — Small hypertrophy of median and lateral loies. 500 cc. re- siduum. Cure. Followed 31 months. No. 493. J. T. McL., age 54, married, admitted October 4, 1903. Complaint. — " Frequency and diflBculty of urination." The patient had gonorrhoea about 23 years ago. Present illness began about 15 years ago, the first symptom being fre- quency of urination which was most marked during the night. About five years later he noticed that the stream of urine was small, spiral and some- times divided. In the next few years both difficulty and frequency in- creased and a burning during urination gradually appeared. About one year ago the patient began to have incontinence both night and day. He has suffered considerable pain in his bladder, but has never passed a cal- culus. Four years ago, on the advice of a physician, he used a catheter for two months, but he found the operation disagreeable and has only used the catheter occasionally since. S. P. — The patient is now using a catheter on the advice of his physi- cian. If he does not do this he has incontinence of urine and a large re- siduum. Sexual powers present. Examination. — The patient is a fairly well nourished man with lips of good color. Heart and lungs negative. Pulse 96 to the minute, but of poor volume and tension. Abdomen negative. Right inguinal hernia is present. Left inguinal ring enlarged, but no hernia present. study of lJf-5 Cases of 'Perineal Prostatectomy. 179 Rectal examination. — ^The prostate is very little enlarged in the right lateral lobe, but the left lateral lobe is distinctly enlarged in length and breadth, and is closely adherent to the structures along the outer border. The contour is smooth, consistence firm, but not markedly indurated, sem- inal vesicles are not palpable. The fluid obtained by prostatic massage contains spermatozoa and pus cells, very few normal elements. Cystoscopic examination. — Catheter passes with ease and finds about 500 cc. residual urine. The vesical tonicity is good. Cystoscope shows in- travesical hypertrophy of slight degree of both lateral lobes with a sulcus between the two, and a small median lobe separated from each of the lat- eral lobes by a small sulcus. The bladder is considerably trabeculated, but there are no diverticula. Considerable cystitis. With finger in rec- tum and cystoscope in urethra the median portion is found to be thick, but the beak is palpable above the prostate. Preliminary treatment. — 'The patient is advised to catheterize himself three times a day, to take urotropin and to drink water in abundance. Urinalysis. — Slightly acid. Sp. gr. 1008. Trace of albumin. Micro- scopically, pus cells. Operation, October 26, 1903. — tEther. Perineal prostatectomy by the usual technique. The lateral lobes which were very small were easily enucleated, and the median bar was removed with the assistance of the tractor through the left lateral cavity without disturbing the urethra or the ejaculatory ducts. After the removal of the tractor the finger was inserted into the bladder and showed a small pedunculated median lobe which was too small to be engaged with the blade of the tractor. With the aid of the finger it was easily drawn into the left lateral cavity and enucleated, although only 8 mm. in diameter and weighing only G-2. The total weight of the pros- tate was 15 grams. A small tear was made in the mucous membrane cov- ering the middle lobe. The wound was closed as usual with double tubes and gauze drainage. There was very little hemorrhage. Continuous ir- rigation was instituted on the return to the ward. Pulse at the end of op- eration 112, condition excellent. Convalescence. — The patient reacted well. The temperature did not rise above 100°, and after the third day was normal. The gauze was removed on the second day and tubes on the fourth day, continuous irrigation being kept up for four days. Urine began to come through the penis about the 15th day, and on the 16th day a note was made that he was able to re- tain his urine for four hours. The fistula closed on the 21st day, and he was discharged on the 22d day. He had been walking about the wards since the 12th day. The catheter passed with ease, showed no evidence of stricture, and withdrew 40 cc. residual urine. Sounds up to No. 26 F. showed no evidence of stricture. December 7, 1903. — Letter. I have been dohig well, but one week ago epididymitis set in. May 22, i9(?4-— 'Letter. I void urine about every three hours. I have never used a catheter and have had no instrumentation sir'^'^ the operation. 180 Hugh H. Young. I void about one pint of urine each time, and the stream is large and free and without pain. I have erections twice a week and satisfactory sexual intercourse. The sexual desire seems to be slightly diminished. My gen- eral health is excellent. I urinate about three times every night, a pint at each time, and often pass three and one-half pints during the night. 'November 30. 1905. — I void urine naturally a pint at a time at intervals of three hours. I have erections occasionally and sexual intercourse, but it is not entirely satisfactory. I have no -fistula and my general health is fair. May 7, 1906. — ^Letter. I void urine naturally five or six times during the day and two or three times at night, about one pint at a time. I suffer no pain. I have erections and sexual intercourse. My general health is much improved. I have gained 20 pounds, and consider myself completely cured. Pathological report. — The specimen, G. U. 48, consists of three pieces of prostatic tissue weighing in all 15 gm. The consistence is rather firm, and an occasional spherical lobule is seen. The ejaculatory ducts have not been removed. No calculus present. Microscopic examination. — The hypertrophy is a moderately glandular one with some formation of lobules which are rather rich in acini. The acini within these lobular areas are moderately dilated, the lumen is ser- rated, and they are lined by columnar epithelium. The epithelium in some acini is one or two layers in depth, the deeper layer being rather cuboid in type. In other acini the lining consists of numerous layers of epithelium. There is present in many quite extensive areas a well marked glandular and interstitial prostatitis. The arteries show a considerable degree of arteriosclerosis in many areas. Numerous corpora amylacea are noted. Case 18. — Considerable lateral enlargement. Very large median lobe. Complete retention of urine. Cure. No. 520. W. H. H. F., age 63, single, admitted October 16, 190.3 Complaint. — '" Complete retention of urine." The patient had gonorrhoea in his youth. Present illness began about two years ago with slight difficulty of uri- nation. He soon began to have considerable dribbling at the end of urina- tion. During the past year urination has become much more frequent and during the past month he has had to get up eight or ten times at night to urinate, voiding urine in small amounts and with considerable pain. During the last few days he has required catheterization. Erections have been absent for ten years. Examination. — The patient is a sturdy-looking man. Mucous membranes of good color. Lungs somewhat emphs'sematous but clear. Heart slightly enlarged, but no murmurs. Abdomen negative. Note on admission. — The patient has complete retention of urine. A catheter passes with difficulty and withdraws very bloody urine. The pros- tate is markedly enlarged, being about the size of a large lemon with the long diameter transverse. The median furrow and notch are obliterated. study of 145 Cases of 'Perineal Prostatectomy. 181 The contour is rounded, and the prostate is smooth, elastic and fairly soft. Cystoscopic examination is impossible, owing to hemorrhage. Preliminary treatment. — ^A catheter was fastened in the urethra and con- tinuous irrigation of the bladder secured. Urotropin grains 20 to 30 daily by mouth was administered. On October 22 the patient developed a left epididymitis. Octoter 26. 1903. — Operation. Ether. Perineal prostatectomy by the usual technique. The lateral lobes were fairly large and easily enucleated. The middle lobe measured 4x5x5 cm. and was easily delivered into the left lateral cavity and enucleated without tearing the bladder. The lateral cavities were packed with gauze, double catheter drainage was supplied to the bladder and the wound was closed as usual. Patient stood operation well, pulse at end 70. Continuous irrigation and infusion on return to the ward. Convalescence. — The patient reacted well. The gauze packing was re- moved on the sixth day and the tubes on the eighth. A catheter was intro- duced into the urethra on the thirteenth day and removed on the eight- eenth. He was up in a wheel-chair on the nineteenth day, and was dis- charged on Dec. 7, the forty-third day. His general condition was excel- lent, but there was still a small fistula in the perineum. Highest tempera- ture after operation, Nov. 8, 102°. January 29, 1904- — The fistula is closed. The patient says that he voids urine in a large stream and about 250 cc. at a time. When the bladder be- comes full and the desire to urinate comes on, there is apt to be a leakage of a few drops of urine, otherwise there is no incontinence. A catheter passes with ease and finds 40 cc. of urine. He has not been instrumented and there is no evidence of stricture. Bladder capacity 395 cc. March 29, 1904- — A silver catheter passes with ease. Residual urine 5 cc. is present and bladder capacitj^ 450 cc. The cystoscope shows a fold of mucous membrane in the median portion of the prostate and a small lobu- lar projection from the left lateral lobe of the prostate. There is no ob- struction present. The ureters are easily seen and they are functioning normally. There is very little trabeculation and there are no pouches nor diverticula. The patient has been treated daily by intravesical dilatation from February 9 to March 29. At the beginning the bladder only held 220 ce. On the second day it held 260 cc, on the third 310 cc, on the fifth 345 cc, and on the sixth 410 cc On March 21, 1904, 470 cc. were intro- duced at one time. Since then the amount has been slightly less. Under treatment the frequency has been considerably diminished. April 19, 1904- — The patient voids urine once at night and four times during the day. His condition is excellent, there is no fistula, no incon- tinence. February 1, 1905. — I void urine naturally and consider myself cured. Drink large amounts of water and void urine about nine times in twenty- four hours. 183 Hugh H. Young. November 30, 1905. — I get up twice at night to urinate, but pass 250 cc. each time. I have no difficulty in urination, no incontinence and can hold urine from four to six hours during the day. I have not had erections for 10 years. Catheter passes with ease and finds 20 cc. of residual urine. There is no stricture or fistula present. His general health is excellent. May 10, 1906. — The patient voids urine naturally at intervals of four or five hours during the day and once or twice at night, about half a pint at a time. He has no pain, no incontinence, no difficulty in urination, and considers himself cured. Erections which were absent before operation have not returned. Pathological report. — Specimen G. U. 221. The specimen consists of two small lateral lobes, the left in two pieces, one 1 cm. in diameter, and the other 3x2x1 cm. The right lateral lobe measures 3x2x1 cm., and on section shows several distinct spheroidal lobules. The left lobe is firmer, and apparently very fibrous in character. Several areas of hemorrhage are seen. The prostate weighs about 15 grams. Three sections were taken for study. Microscopic examination. — The hypertrophy tends towards the fibro-mus- cular type, although in some areas the bland tissue is fairly abundant. The acini in these areas show the usual typical picture. The stroma is largely composed of fibrous tissue, there being present practically no muscle. Some areas of prostatitis. The arteries &how a moderate degree of arteriosclerosis. Case 19. — \Large intravesical median lobe. Hematuria. Little difflculty. Cured. Followed 25 months. No. 504. R. M. D., age 54, married, admitted November 28, 1903. Complaint. — " Hematuria." Patient has never had gonorrhoea. About four years ago patient con- sulted Dr. DaCosta for supposed kidney trouble. The urine was found negative except for excessive acidity. He was advised to drink water in abundance and for this reason urination has been somewhat frequent for the past three years. He dates the actual onset about one year ago when he passed a few clots of blood with the urine without pain. During the past year he has had five attacks of painless hematuria, the last about one week ago. He has never passed gravel and never had any pain in the re- gion of either kidney. At present he voids urine about every three hours during the day and once at night. He has never used a catheter, and uri- nation is not very difficult. His sexual powers are slightly diminished, erections being insufficient, but ejaculations are normal. Examination. — The patient is pale, but otherwise well in appearance. Heart, faint systolic murmur at apex; lungs and abdomen are negative. Rectal examination shows a considerably enlarged prostate forming a rounded mass about the size of a medium-sized orange, smooth, soft and elastic. The seminal vesicles are felt and there is no induration present. A catheter passes with ease and finds 220 cc. residual urine. The bladder study of lJf5 Cases of 'Perineal Prosiatectomy. 183 capacity is 450 cc. The cystoscope shows moderate enlargement of the two lateral lobes, and a sessile rounded median lobe. The mucous mem- brane covering the prostate is smooth and the source of hemorrhage can- not be made out. The bladder is moderately trabeculated, there is no cys- titis present and no calculus. No vesical ulcer or tumor is to be seen. The ureters are hidden behind the median portion of the prostate. Urinalysis. — iClear, neutral, sp. gr. 1022, no albumin, no sugar. Micro- scopically negative. Note. — 'Although the patient suffered very little difficulty and frequency of urination, on account of the considerable size of the prostate and the attacks of intermittent hematuria, perineal prostatectomy was advised. Operation, December 1, 1903. — Ether. Perineal prostatectomy by the usual technique. The left lateral lobe was the largest, measuring 5x3x2 cm. The right lateral lobe was smaller and was removed in two pieces. The median lobe was removed through the left lateral cavity and proved to be a globular mass about 3 cm. in diameter. The deeper portions of the lateral lobes were markedly adherent and a small area of mucous mem- brane was removed. The floor of the urethra and ejaculatory ducts was preserved. There was considerable hemorrhage, but this was controlled by a pack in each lateral cavity. Two rubber drainage tubes were passed through the urethra into the bladder and the wound closed as usual. An infusion of 1000 cc. of salt solution was given on the table, and his condi- tion at the end was fair. Convalescence. — The patient reacted well. Continuous irrigation was not used, on account of the desire to avoid vesical infection. The drain- age tubes were placed in a receptable containing a solution of bichloride of mercury. The gauze was started on the second day and finally removed on the sixth. The rubber drains were removed on the eighth day. For two days the urine came entirely through the perineal wound, but on the tenth day it suddenly ceased and came entirely through the urethra, and after that there was no leakage through the perineum and the wound closed rapidly. As soon as the tubes were removed the patient had conti- nence. Temperature between 100° and 101° for two weeks after the opera- tion. He was walking about the hospital on the 14th day and was dis- charged on the 21st. Examination of the urine showed a few bacilli. He had been taking urotropin, seven and one-half grains three times a day, and this was then increased to five times a day. December 29, 1903. — 'The patient is drinking large amounts of water and voids a great deal of urine, about 320 cc. at a time and at intervals of about two hours. There is no incontinence, but urination is often impera- tive. The urine is cloudy, and contains pus, but no bacteria. Silver cath- eter passes with ease, shows no evidence of stricture and finds only 10 cc. residual urine. The bladder capacity is large and the tonicity is excellent. Patient says he had one erection yesterday. He is discharged with direc- tions to continue urotropin and helmitol intermittently. Letter, June 16, 1904- — I void urine normally, do not have to get up at 184 Hugh E. Young. night, and have no pain. The amount voided at each time is about one pint. The stream is large and micturition normal. Erections have re- turned, and I indulge in sexual intercourse. There is no incontinence. December 2, 1905. — iThe wound has remained closed. I void urine natu- rally, four or five times during the day, not at all at night, and as much as a pint at a time. I have erections and satisfactory intercourse, but there seems to be less power. My health is excellent and I consider myself cured. Pathological report. — Specimen G. U. 59. The prostate has been removed in four masses, and weighs 60 grams. The middle lobe was removed in one piece and weighs 10 grams. The left lateral lobe was removed in one piece and measures 5x3x2 cm. in size. The right lateral lobe is in two pieces, which together form a mass about the size of the left. A small area of mucous membrane has been removed along with the apex of the median lobe and measures about 1x1 cm. in size. The outer surface of the lobules and the cut surface shows numerous spheroids with interven- ing fibrous stroma. The deeper portion of the left lateral lobe is firmer in consistence, and on section shows numerous pin-head areas yellowish in color, and suggests malignancy slightly. Microscopic examination. — 'The hypertrophy is a glandular one, the acini for tlie most part being arranged in lobules. Within these glandular sphe- roids the stroma is very small in amount, the acini are dilated and there are numerous off -shoots in the lumina of the ducts, oftentimes papillomatous in type. The interlobular stroma contains acini scattered here and there, and many of these show signs of activity. A few small areas of prostati- tis are present. The stroma contains distinctly more connective tissue than muscle, and the blood vessels seem about normal. The area which sug- gested malignancy shows the acini crowded together, and filled with pro- liferating and degenerating cells, but no evidence of malignancy. Case 20.. — Considerable enlargement of lateral lobes, small median. Ne- phritis, suppression of urin^. Cure. No. 517. M. V. C, age 78, married, admitted November 11, 1903. Complaint. — " Hematuria. Frequent and i ainful urination." The patient denied gonorrhoea. Is the father of 16 children, the young- est five years of age. Present illness began 12 years ago when he passed a small amount of blood without pain. After that he had slight difficulty in urination and occasional hematuria. During the next few years hematuria became more frequent, but pain was always absent. Of late micturition has become very frequent and difficult, and on November 10, 1903, complete retention of urine came on for the first time. His physician was unable to catheterize him and brought him to the Johns Hopkins Hospital where a catheter was passed 32 hours after the onset of retention. His sexual powers are good, and his desire unchanged. Examination. — The patient is well nourished. Mucous membranes of good color. Heart and lungs negative. Urine is slightly cloudy. Sp. gr. 1015. Albumin present. Microscopically, granular casts and pus cells present study of lJf5 Cases of 'Perineal Prostatectomy. 185 Rectal examination shows the prostate moderately hypertrophied, soft, smooth, tender and about the size of a small orange. Preliminary treatment. — Soon after admission a coude catheter was fast- ened in the urethra. On the next day he had a chill and fever of 102°. During the next three days almost complete suppression of urine super- vened, but after infusions and rectal injections of salt solution kidney ac- tion was again established. On November 16 attempt was made to per- form cystoscopic examination, but without success, owing to tendei-ness, pain and hemorrhage. The bladder would hold only 40 cc. fluid. The urine still contains albumin, granular and epithelial casts and pus cells. Operation, November 19, 1903. — ;Ether. Perineal prostatectomy by the usual technique. Two large lateral lobes and a small median lobe were easily enucleated. The urethra and ejaculatory ducts were preserved, but a small tear was made in the bladder in removing the median lobe. The wound was closed as usual with gauze packing for the lateral cavities and double drainage tubes for the bladder. A submammary infusion of salt solution was given and the patient stood the operation well. Convalescence.-^Tla.Q patient reacted well, but had a chill soon after the operation. His highest temperature was 100°. Saline irrigation of the bladder was discontinued on the third day and the gauze completely re- moved on the fourth. The tubes were removed on the fifth day, and the patient was up in a wheel-chair on the sixth. Noveniber 29, 1903. — For the last few days the patient has been irra- tional and temperature has been subnormal, but his pulse has been good. He was infused and 400 cc. salt solution given per rectum every four hours. December 8, 1903. — The patient is improving slowly. Sinus in perineum persist. December 16, 1903. — Slight pleurisy is present on the left side, but his temperature, pulse and respiration are normal. December 19, 1903. — 'The patient has improved rapidly, is up and walking about. December 23, 1903.—<'His general condition is excellent. The sinus is closing slowly, and most of the urine comes through the urethra. The pa- tient is discharged (34th day). Urine is acid. Sp. gr. 1016. Albumin is present, and numerous pus cells, but no casts are seen. The fistula closed on about the 45th day. January 20, 190 4. —'Letter. The fistula has been closed for some time. I have little if any pain. I have no inflammation of the bladder and the urine seems normal. I void urine about every two hours, and have not used the catheter. May 22, 1904. — Letter. I urinate once during the night and about every three hours during the day. The stream is large and free. Erections have returned and I have indulged in intercourse. February 1, 1905.— Letter. Urination is normal, about six times in 24 hours, once or twice at night, and about a pint at a time. I have no pain. I have ceased to have erections, and this is what I regret the most. 186 Hugh H. Young. November 30, 1905. — Letter. The perineal wound has remained closed. I void urine naturally about a pint at a time occasionally, about three times during the night and eight times during the day. I suffer no pain. Have no erections. My general health is good and I consider myself cured. 2ilay 9. 1906. — Letter. I void urine normally, about twice during the night and often a pint at a time. I have no pain, the wound has remained closed, and I feel perfectly cured. My general health is excellent. I do not have erections. Pathological report. — The specimen G. U. 53, consists of three lobes weighing in aggregate 90 gm. Two lobes are about equal in size and meas- ure each 4x5x5 cm. in size. The third measures 1 x 1.5 x 2 cm. The three lobes are similar in character: the surface is nodular and lobulated, consistence elastic, homogeneous, on section a profuse exudate of turbid milky fluid exudes from the surface which is composed of lobules with in- tervening fibrous trabecule. An occasional dilated duct is seen. JJicroscopic examination. — The hypertrophy is a lobulated glandular one with areas of dilatation and marked proliferation. Some cj'stic degenera- tion is present with flattening of the lining epithelium. The stroma be- tween the acini except in the interlobular spaces is rather loose, and con- tains fair amounts of apparently young connective tissue. There is pres- ent also considerable muscle. Numerous areas of chronic prostatitis with interstitial infiltration are seen. Case 21. — Sliglit liypertropliy of median and lateral lobes. Catheterism. EmpTiysematoiiS lungs. Cardiac murmurs. Excellent progress for 13 days. Sudden death from pulmonary thrombosis following enema on IJfth day. No. 627. W. E. :\I., age 73, married, admitted November 20, 1903. Complaint. — " Bladder trouble." No history of gonorrhoea. Present illness began two years ago with frequency and difficulty of uri- nation which gradually increased, and six months before admission mic- turition became very difficult and painful. Daily catheterization was be- gun two months ago. S. P. — Urination is very frequent, difficult and painful, and the catheter is used frequently by the patient on this account. The bladder is con- tracted and there is only a small amount of residual urine present. Examination. — The patient is a fairly well nourished man with lips of good color. The arcus senilis is well developed. Chest. — 'The chest is well formed, the lungs are clear throughout and somewhat hyperresonant. At the aortic area there is some blurring of the heart sounds with a suspicion of a diastolic murmur. The pulse is 70. The abdomen is negative. Rectal. — The prostate is only slightly hypertrophied, smooth, firmer than normal, not tender. The seminal vesicles are negative. Cystoscopic. — Coude catheter passes with ease and finds residual urine study of lJ/5 Cases of 'Perineal Prostatectomy. 187 320 cc. The cystoscope shows a slight intravesical hypertrophy of the lat- eral lobe and a small rounded median bar. The ureters are easily seen, and there is only moderate cystitis and no stone present. Urinalysis. — Cloudy, acid, 1020, albumin a heavy trace, no sugar, urea 15 gm. to the liter, 25 gm. daily. Microscopically, pus in considerable amount. No casts. Operation, November 20, i903.— 'Ether. Perineal prostatectomy by the usual technique. The posterior surface of the prostate showed only slight enlargement. The lateral lobes were very fibrous and removed with some difficulty. The median portion of the prostate was removed through one of the lateral cavities, and was small in amount, a small tear was made in the urethra. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well, the pulse at the end being 80. Infusion and continuous irrigation on return to the ward. Convalescence. — The patient reacted well. Pulse did not rise above 88 on the night of the operation and the temperature not above 99.2°. November 21, 190.3. — The patient has had a comfortable day. The pulse has varied between 68 and 88, and the temperature between 98.6° and 100.2°. He has been comfortable and the tubes have drained well. November 22, 1903. — The patient has had a good day. 1580 cc. urine se- creted, pulse good 72 to 84, temperature 99° and 100.4°. November 24, 1903. — The patient has been comfortable. The pulse be- tween 80 and 104, temperature 99° to 100.4°. The patient has been consti- pated, and received two enemata which were effectual. November 25, 1903. — The patient had a good night, slept seven hours, and his condition is excellent. His pulse varies between 82 and 92, tem- perature between 99.2° and 99.6°. 1800 cc. urine secreted. Slightly con- stipated, one enema given, quite effectual. The patient is on soft diet. Since operation the pulse has had a peculiar collapsing quality. November 26, 1903. — The gauze was removed to-day (sixth day). The condition of the patient is good. Temperature 99° to 100°, pulse 80 to 90. Urine acid, 1023, albumin a trace, no sugar, total amount 1800 cc. Total urea 34 gm. November 27, 1903. — The gauze and tubes have been completely removed, the patient is in good condition. Temperature 98.6° to 100°. November 30, 1903. — The patient is doing well. Pulse 70 to 80, tempera- ture 90° to 98°. December 1, 1903. — The patient has had a slight rise of temperature 100.4° associated with a slight epididymitis on the right side. Condition otherwise good. Pulse 75. December 2, 1903. — The epididymitis is subsiding, and causes very little inconvenience. Pulse 80, temperature 100.3°. Patient up and about the ward. Condition excellent. Wishes to go home. December 3, 1903, A. M. — The patient is in excellent condition. Tempera- ture 98.7°, pulse 80. He is constipated and a high soap-suds enema is ordered. 188 Hugli H. Young. p. 21. — This morning tlie enema was very effectual, but immediately af- terwards the patient vomited and suddenly collapsed. "When seen by one of the house physicians five minutes later he was pulseless, of a whitish gray color, but the respirations were fairly good. Strychnine, atropine and ether were administered without effect, and in a very short time the respira- tions stopped and the patient died. Autopsy. — (Resume.) There was a firm organized clot with fresh clot built on it extending from the right auricle down the inferior vena cava. There was also a thrombosis of the pulmonary artery. Careful examina- tion of the pelvic structures failed to throw any light on the origin of the embolus. There was some old clot in the region of the wound, but nothing unusual. Examination of the interior of the bladder shows no intravesical pros- tatic hypertrophy. The prostatic orifice is about 5 mm. in diameter. The median portion of the prostate looks as if it had not been disturbed, though it is possible that a pedunculated intravesical mass has been re- moved. The urethra in its anterior portion communicates along the lat- eral wall with the cavity left in the removal of the right lateral lobe. The ejaculatory ducts are apparently preserved intact. The verumon- tanum, floor of the urethra and left lateral wall are uninjured. Small portions of the lateral lobes in their deeper portions have not been com- pletely removed. There is no evidence of hemorrhage around the pros- tate or the rectum. Pathological report. — The specimen, G. U. 66, consists of the three lobes of the prostate removed in four pieces, and weighs about 20 gm. The me- dian lobe measures 2.5x2x2 cm., is oval in shape, somewhat irregular, and on section shows considerable gland tissue and a small amount of stroma. The left lateral lobe is a little smaller than the median, is com- posed of several large spheroids rather loosely bound together. The right lateral lobe is composed of two pieces measuring 3 x 2.5 x 2 cm. No mucous membrane, no ejaculatory ducts, no calculi. Microscopic examination. — The hypertrophy is of a rather glandular type, the acini being small, closely aggregated with quite marked com- plexity of the acini. The stroma is compact and contains more connective tissue than muscle. The blood vessels seem normal. Some few small areas of round celled interstitial infiltration are present. Case 22. — Moderate hypertrophy of lateral and median loltes. Catheter- ism. Cure. No complications. FoUoiced tico and one-half years. No. 488. W. T. W., age 76, married, admitted Nov. 20, 1903. Complaint. — " Incomplete retention of urine. Catheterism." No history of gonorrhoea. Present illness began four years ago with difiiculty of urination which culminated in retention, which required catheterization. After that he had to be catheterized for two weeks. In January, 1901, patient had a chill fol- lowed by great difficulty in urination, and after that he had to be catheter- study of lJf-5 Cases of 'Perineal Prostatectomy. 189 ized for 10 days during which time he had fever, severe pain in the back and urethra. During the past two years he has at times been able to void without the catheter, but at others urination was so difficult or frequent that catheterization from two to four times a day was necessary. He has had several attacks of fever, chills and pain in the back. 8. P. — The patient is catheterized three times daily, about three hours after catheterization he is able to void a small amount of urine. The total quantity of urine voided in 24 hours is usually 1300 cc, of which 800 is removed by the catheter and about 500 cc. voided. He suffers no pain, and his general health is excellent. Sexual powers. — He has erections, but has not had intercourse for sev- eral years. Examination. — 'The patient is a well nourished man with lips of good color. Chest and abdomen are negative. Rectal. — The prostate is considerably enlarged, is rounded, smooth, firm, but elastic, and has no areas of induration nor nodules. The seminal vesicles are not palpable. Urinalysis. — Slightly cloudy, acid, sp. gr. 1010, albumin a marked trace, no sugar. Urea, 15 gm. in 24 hours. Microscopically, pus cells, hyaline casts and bacteria. Cystoscopic examination. — A rubber catheter with a stilet passes with ease, and finds about 250 cc. residual urine. A cystoscopic examination made by Dr. Willy Myer, showed a moderately enlarged middle lobe on a broad base with very little enlargement of the lateral lobes. There was no calculus present. The bladder was trabeculated, but there were no diver- ticula. Owing to the pain caused by this examination the operator did not perform cystoscopy. Operation, November 22, 1903. — In New York. Ether. Perineal prosta- tectomy by the usual technique. The lateral lobes were moderately en- larged, very adherent and were removed in several pieces. The median portion of the prostate was only moderately enlarged, and was removed in pieces through one of the lateral cavities. Examination with the finger showed no remaining prostatic obstruction. The urethra was torn, but no mucous membrane was removed and the ejaculatory ducts were pre- served. The patient was infused during the operation and continuous irri- gation was begun at the end. Convalescence. — The patient was very little shocked and convalesced rapidly. He was up walking on the tenth day and the perineal fistula closed on the 16th day. Patient was discharged on the 28th day. Six weeks after the operation a catheter was passed and found a residual urine of 30 cc. and a bladder capacity of 120 cc. His physician then began hydraulic dilatation through a catheter and in two months the capacity had reached 250 cc. March 23, 1904- — ^The patient is in excellent health, voids urine normally. Erections have returned. Has not had intercourse for years. A catheter passes easily and finds 10 cc. residual urine. Bladder capacity 250 cc. 190 Hugli H. Young. Urine is acid and contains pus cells and bacilli. The perineal wound is healed and rectal examination shows an absence of prostatic enlargement. Urine is voided at intervals of from two to five hours. May 20, 190Jf. — Letter. -I can retain my urine five hours during the day and the same time at night. I pass 250 cc. at a time, have 10 cc. residual urine, suifer no pain, and my general health is excellent. May 20, 1906. — Letter. I void urine naturally, from 150 to 175 cc. at a time. I suffer occasionally a very slight pain in the perineal wound, but it is not important. The catheter is occasionally used to wash out the bladder and finds 15 cc. residual urine. My general health is good, I have gained in weight and I consider myself cured. Pathological report. — The specimen, G. U. 55, consists of the lateral and median portions of the prostate which has been removed in eight pieces, and weighs about 20 gm. The left lobe measures 3.5 x 2.5 x 2 cm. and has been removed in one piece. It is composed of small and large spheroids loosely bound together. The right lobe is in five small pieces, mostly sphe- roidal masses. The median bar and lobe is in two pieces, each about 2x1 X 1 cm. in size, and of similar appearance to the rest of the tissue. On sec- tion there is very little stroma, considerable dilatation of the ducts in places: but in other places there is considerable stroma, but no dilated acini. No mucous membrane has been removed, nor ejaculatory ducts. No calculi present. Microscopic examination. — The tissue is a moderately glandular one, the amount of gland and stroma varying in different areas, but as a whole the gland tissue is considerably in excess of the stroma. The acini are rather small with occasional areas of moderate dilatation, especially in the acini of the spheroidal lobules. The stroma is rather dense except in the more glandular lobules where there is considerable spindle-celled tis- sue present. There is a fair amount of muscle fibers present in the in- terstitial tissue. Case 23. — Patient aged 81 years. Moderate enlargement of the pros- tate v:hich %i}as considerably indurated. Pain and hematuria. Calculus. 2000 cc. residuum. Death thirtieth day. Hypostatic congestion of lungs. No. 623. H. C. N., age 81, married, admitted November 14, 1903. Complaint. — " Bladder trouble." No historj' of gonorrhoea. Present illness began about three years ago with irritation in the region of the bladder, and a little later hematuria. After that intermittent hema- turia, but no pain, no passage of calculus, no obstruction to urination. Six weeks ago he felt uncomfortable in his lower abdomen and examination showed that his bladder was greatly distended. There was no frequency of micturition, no pain, only slight difficulty in urination, but he has be- come weaker, and on advice of a physician he presented himself for con- sultation. Examination. — ^The patient is in good condition for his age, but his lips are pale. The lungs are negative, heart sounds are clear, but intermittent. There is considerable general arteriosclerosis. study of Ho Cases of 'Perineal Prostatectomy. 191 Ahdomeji. — It is impossible to palpate anything, for much of the abdomen is filled with a distended bladder which reaches two inches above the um- bilicus. Pressure on this area produces pain. The genitalia are normal. Rectal. — The prostate is considerably enlarged, very hard and induration extends upward on each side to the seminal vesicles, the groove is oblit- erated and the surface of the prostate is rough. No enlarged glands are to be felt. A small coude catheter passes with some diflaculty, owing to a constriction along the entire prostatic urethra. Two liters of pale urine are withdrawn. The bladder is still not emptied, but it was thought in- advisable to remove all. Urinalysis. — Lost. Preliminary treatment. — Catheterization twice daily. Urotropin. After four days, catheterization had become more difficult, and it was impossible to introduce a catheter, sounds or filiform into the bladder, owing to ob- struction at apex of the prostate. Retention of urine was complete. The bladder was distended to the umbilicus, and the patient was therefore advised to go to the hospital where his bladder was aspirated, 1800 cc. of urine being withdrawn. Urinalysis of aspirated urine. — Acid, 1015, albumin a trace, and micro- scopically, a few hyaline casts. The bladder was aspirated once every 24 hours for five days, about 1200 cc. of urine being withdrawn each time. The patient's condition re- mained good. The 24 hours total of urea was about 11% gm. and. as catheterization was still impossible, it was thought best to supply peri- neal drainage, and at the same time to remove a calculus which had been felt with the aspirating needle. Operation, Nov. 24, 1903. — Spinal anesthesia. Perineal prostatectomy by the usual technique. Lithotomy. The lateral lobes were very adherent and removed with difficulty, scis- sors being necessary. There was no median lobe present and with the fin- ger in the urethra the bar did not seem sufficiently large to warrant re- moval. Rough oxalate calculus about 2 cm. in diameter was removed through the dilated urethra. Examination showed no other calculus. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. He was infused on the table and stood the operation well, but while being returned to the room there was a sinking spell, pulse became irregular and weak. He was given strichnine one-twentieth of a grain and soon rallied. November 25. — Since operation yesterday patient has been comfortable. His pulse has varied between 88 and 100, his temperature 99.2°. 'Novemher 28. — The patient is doing well. There is profuse drainage through the tube, the temperature has not gone above 100.5°, pulse be- tween 90 and 100. December 3. — ^The patient has done well. Temperature 99°, pulse 95. Sleeps well. Total quantity of urine 1420 cc. to-day. Appetite is fairly good. He is on ordinary diet. The tubes and gauze are removed to-day. 192 Hugh H. Young. Deceml)er 5. — The tubes had to be replaced, owing to the fact that there was no drainage through the perineal wound, and the bladder became dis- tended and painful. The total urine to-day was 1380 cc. Highest tempera- ture 99°, pulse 88. Patient was up in a wheel-chair, and is quite com- fortable. December 11, 1903. — The patient has complained of pain, the pulse is weak and intermittent. A good quantity of urine has been secreted daily, 1200 to 1400 cc. Sp. gr. is 1010. total urea 15 gm., there is only a trace of albumin, some hyaline casts and pus cells. The tubes were removed again to-day, but as there was no drainage through the perineum for 12 hours he was catheterized, the bladder seems to have no tonicity. December 15. — The patient is unable to void and is catheterized four times daily. He is very weak, and his pulse is intermittent. Infusion 1000 cc. salt solution to-night. The patient is still unable to void and is catheterized four times a day. The total urine is about 1500 cc, sp. gr. 1014, and there is considerable pus and albumin. The patient was up in a wheel chair yesterday for three hours and was very comfortable. His temperature has been normal, and his pulse stronger, but he looks weaker to-day. December 20. — Lungs are clear but emphysematous. Heart sounds feeble with a faint systolic murmur. The pulse is very intermittent. December 21. — There is an abundant secretion of urine, 1500 cc. of fair quality, but the patient is gradually sinking. December 23. — ^The patient is much weaker and near the end. The lungs are full of fine rales, the pulse is rapid and shallow, 120 to 140. Still se- creting an abundance of urine, 1580 cc. to-day. Urinalysis. — Acid, 1017, albumin considerable, total urea 9.4 gm. Mi- croscopically, pus cells, hyaline and granular casts. Temperature 100.8°. The patient's mind is clear. The bladder is still atonic and there is no es- cape of urine except through the catheter which enters easily and meets no obstruction. December 24. — The patient died at 6 a. m. Remark. — 'The remarkable feature in this case was that with a bladder which was distended two inches above the umbilicus, urination was very little difficult and at normal intervals. His attention was attracted by swelling of the abdomen. The result of the operation was not perfect, in that normal urination was never established. This seems to have been due to the extreme atony of the bladder, as a very large tube could be inserted through the perineal wound with ease. Had the median portion of the prostate been removed, it is possible that drainage would have been estab- lished, but the patient died apparently ijot from vesical or renal complica- tions, but from old age and cardiac weakness. Occurring as it did one month after the operation it cannot be entirely attributed to the operation. Pathological report. — Specimen, G. U. 65. The prostate has been re- moved in numerous irregular pieces. The weight of the entire prostate is 45 grams. It is composed of numerous small and large spheroids more or less firmly bound together. No mucous membrane or ejaculatory ducts have been removed. study of 14-5 Cases of 'Perineal Prostatectomy. 193 Microscopic examination. — The hypertrophy is a glandular one with formation in spheroids, the spheroids being separated from each other by bands of stroma containing flattened acini. The culs-de-sac show the usual complexity due to the intraacinous growths. The stroma is rather dense, and is composed of connective tissue and muscle in about equal proportion, the relative amount varying in different areas. There is present quite an extensive prostatitis. The blood vessels are about normal. Case 24. — Slight enlargement of median and lateral lobes. Castration and Bottini operations previously. Perineal prostatectomy. Recto-urethral fistula. -Successful closure after two failures. Death at end of one year, pyonephrosis. No. 516. O. S., age 62, single, admitted May 22, 1902. Complaint. — " Bladder trouble." No history of gonorrhoea. Present illness began about 11 years ago with difficulty in urination, but he had very little trouble for four years, when urination became very difficult and frequent, finally complete retention of urine set in and he led a catheter life for nine months. After that he catheterized himself only when unable to void. Micturition is usually very frequent, often six or seven times at night. During the past year retention has again been com- plete, and he has catheterized himself four or five times a day. In October, 1901, castration was performed in another city, and after three or four days he began to void naturally, and has not used a catheter since. S. P. — Urination every hour, and always requiring considerable strain- ing, stream being small and slow. The patient suffers much pain in the bladder, but has never passed calculi nor blood. He is habitually consti- pated and his general health is poor. Examination. — The patient is a thin, nervous looking old man with lips of fairly good color. Pulse is 96, of good volume and only slight arterio- sclerosis. Heart, lungs and abdomen are negative. Genitalia. — Both testicles are absent. The scrotal wounds have healed firmly. Rectal. — The outlines of the prostate are indistinct. There is a broad flat mass with indefinite borders, extending across from one side of the pelvis to the other, and upward towards the region of the seminal vesicles. It does not bulge towards the rectum, and it is impossible to say how much of it is prostate. The seminal vesicles cannot be felt. Cystoscopic. — Rubber and gum catheters meet an impassable obstruction about seven and one-half inches from the meatus. A silver catheter passes with ease and finds 120 cc. residual urine and a bladder capacity of 250 cc. The cystoscope shows a moderately large intravesical hypertrophy of the lateral lobes and median portion in the shape of a collarette with a single sulcus between the lateral lobes in front. The bladder is markedly trabe- culated with numerous small pouches and the bas fond behind the median bar is quite deep. No calculi are seen. With finger in rectum and cysto- Vol. XIV.— 14. 194^ Hugh H. Young. scope in urethra the median portion of the prostate is definitely increased and the entire prostate presents as a hard collar 2 cm. thick around the shaft of the instrument. Urinalysis. — Cloudy, alkaline, 1010, albumin a trace, urea 13 gm. to the liter. Microscopically, pus cells and bacilli. Operation, June 2, 1902. — Cocaine and morphia. Bottini operation. With blade number two of my instrument, three cuts were made, one posterior and two lateral each 2 cm. long with the instrument at a white heat. The patient stood the operation well and there was very little hemorrhage. The median cut was made with the guidance of a finger in the rectum. Convalescence. — iThe patient reacted well, and urination was consider- ably improved. The residual urine rapidly decreased, but the patient con- tinued to suffer pain. He was treated for several months by intravesical irrigations and urotropin internally with very little benefit. He then be- came very melancholic, avoided the association of other people and often kept himself confined to bed. December 19, 1903. — The patient continues to be very melancholic. He suffers great pain in the bladder and urination is frequent and difficult. Examination. — A catheter finds 50 cc. residual urine and a bladder ca- pacity of 300 cc. The cystoscope shows a small rounded median lobe with a fairly deep cleft on each side. The incisions of the Bottini cannot be definitely recognized, but it seems probable that the clefts represent the two lateral incisions, and that the median portion has increased in size since the Bottini operation was performed. The bladder is only slightly trabeculated and there is no foreign body present. Remark,. — ^There is very little residual urine, and the patient urinates better than before the Bottini operation, but he complains considerably of pain and seems to strain during urination. It is therefore thought advis- able to perform prostatectomy. December 19, 1903. — Ether. Perineal prostatectomy by the usual tech- nique. Two small lateral lobes and a median lobe were removed with con- siderable difficulty, owing to the fibrous character of the prostate and marked adhesions to capsule and urethra. The wound was closed as usual with double tube drainage for the bladder and light packs for the ^lateral cavities. The levator muscles were not drawn together. The skin wound alone being approximated with interrupted sutures. The patient stood the operation well, pulse at the end being 80. Continuous irrigation on return to the ward. Convalescence. — ^When the gauze was removed on the third day a rectal fistula was discovered. The perineal catheters were removed on the ninth day and a catheter inserted through the meatus into the bladder. It re- mained in place for about a week, but as there was no apparent closure of the rectal fistula the rectal sphincter was divided, thus laying bare the fistula — (January 6, 1904. The penile catheter was retained until Febru- ary 13. March Jf, 1905. — The urinary fistula shows no evidence of healing and gas escapes through the urethra. study of lJj.5 Cases of ■Perineal Prostatectomy. 195 Operation, March If, 1904- — Ether. Closure of urethral fistula, repair of rectum. The urethra was opened In the bulbous region and the prostatic tractor introduced. The scar tissue was then dissected from the perineal wound, the urethral fistula closed with interrupted catgut, the edges of the rectum freshened and sutured with a continuous suture of silver wire reinforced by interrupted catgut. The skin wound was partially closed. Light iodoform gauze pack. A permanent catheter was placed in the blad- der through the bulbar urethrotomy wound. The patient stood the opera- tion well. Pulse at the end 78. Convalescence. — The patient had an uncomfortable convalescence. Both wounds broke down. Urine escaped into the rectum and gas through the penis. He continued to suffer pain, was uncomfortable, and a second at- tempt to close fistulEe was made. Operation, June 22, 1904. — Ether. Closure of recto-urethral fistula. The operation was done very much as before, except that the urethral fistula was not closed, but a drainage tube was brought out through it. The rec- tal opening was closed with interrupted sutures. Convalescence. — The bowels were kept tied up for a week, and the pa- tient suffered considerable pain. The gauze was removed on the fourth day and the drainage tube on the sixth day. The rectal wound again broke down, and urine again flowed into the rectum and out the perineal fistula and gas into the urethra. ^ Octoder 1, 1904- — The rectal, urethral and perineal fistulse persist. The patient suffers a great deal of pain, and voids urine very frequently. He has several times passed calculi, his bladder is contracted and there is con- siderable cystitis. Operation, October 6, 1904- — Ether. Suprapubic cystotomy for drainage. Removal of a vesical calculus. Closure of rectal and urethral fistula through perineal incision. Fine silk was used in the closure of the rectal fistula, several layers of interrupted sutures being employed. The levator ani muscles were drawn together over the wound with catgut. The urethral wound was closed with a single layer of fine silk sutures. A light gauze packing was inserted and the skin was partially closed with interrupted sutures of catgut. Suprapubic drainage was supplied through a large tube around which the bladder was sewed with catgut. The patient was infused on the table, and stood the operation well, his pulse at the end being 80. Convalescence. — The patient was put on diet of water and albumin. Lead and opium pills were given to prevent bowel movement. Suprapubic tube drained well, but on the third day urine leaked through the perineal wound. The bowels did not move for nine days. Calomel, Epsom salts, oil, and glycerine enema were used. Previous to this the patient suffered considerably from abdominal distention and pain. October 16, 1904- — The patient is more comfortable and his condition is fairly good. October 22, 1904- — The patient has been very excited to-day, thought he was in a cell and called for the police. 196 Hugli H. Young. 'Kovem'ber 1, 1904- — The patient is quiet mentally, and the suprapubic tube is draining well. The rectal wound has not broken down, and the perineal urinary fistula is small. Xovemier 21. 190If. — The suprapubic drain has been removed. A small amount of urine escapes through the perineum, but the rest is voided through the urethra. The patient complains of pain and requires morphine. Becemter 21, 190^. — The patient has been very melancholic during his entire stay in the hospital. He has had delusions of persecution and at times has been acutely insane for a short time. For the past 25 hours he has been irrational and has been crying almost constantly. His temper- ature which has been normal since October 9, suddenly arose to-day to 103.3°, and his pulse to 130. He was infused with 1000 cc. salt solution. December 22, 1904- — The patient continues irrational, weak, pulse 134 to 160, temperature 103.6^. The respiration is labored and he has diflBculty in swallowing. A catheter passes through the urethra into the bladder without difficulty, and finds no residual urine. The bladder holds only 50 cc. The perineal and suprapubic wounds are both open, but the rectal fistula is closed, and has been since the last operation. December 23. 190Jf. — The patient died to-day. Autopsy showed double pyonephrosis, pyoureter, a markedly contracted bladder, considerable cys- titis, small suprapubic and perineal fistulse. The rectal wound is tightly healed, and there is no prostatic obstruction present. Case 25. — Considerable eyiJargement of lateral lobes. Small median bar. Very frequent and difficult urination. Castration previously. Cure. Followed twenty-nine months. No. 528. R. M. W., age 78, married, admitted January 9, 1904. Complaint. — " Prostatic trouble." No history of gonorrhoea. Present illness began about ten years ago with increased frequency of urination. This gradually increased and urination became more difficult, until, in 1901 he voided as often as 30 times during the night and about every hour during the day. He had no pain and passed no blood. He then began to use a catheter and after that occasionally had complete re- tention of urine. In April, 1901, double castration was performed by a physician with some improvement, but the catheter was necessary as before. S. P. — The patient urinates 16 or 18 times during the night and about every l^o hours during the day, the catheter is only used occasionally. His general health is good, he suffers no pain. He has had no erections since he was castrated. Examination. — The patient is well preserved for his age, with lips of good color. His lungs are emphysematous. Heart, slight systolic murmur at apex; abdomen, negative. Rectal. — The prostate is considerably enlarged, symmetrical, smooth, soft and elastic. study of lJi.5 Cases of 'Perineal Prostatectomy. 197 Urinalysis. — Cloudy, acid, sp. gr. 1030, trace of albumin, no sugar, urea 24 grams to the liter. Microscopically, pus cells and bacilli in consider- able number. Cystoscopic examination. — Catheterization is difficult, owing to an ob- struction about the middle of the prostatic urethra. A very small silk coude catheter was finally passed. The urethral length is eleven inches. Residual urine, 100 cc. The cystoscope showed a fairly large median bar, a moderately enlarged right lateral lobe and a larger left lateral lobe, with a sulcus between the two. The bladder was trabeculated and inflamed. There was no foreign body present. With finger in rectum and cystoscope in urethra the beak could not be reached and a considerable median mass was felt. Preliminary treatment. — Regular catheterization, urotropin, water in abundance. Operation, January 12, 1904- — Perineal prostatectomy by the usual tech- nique, except that the ejaculatory bridge was cut through and a large median bar removed in this way from beneath the urethra. The usual bilateral capsular incisions were made and two very large lateral lobes were easily enucleated without tearing the urethra or bladder. After their removal it was decided in view of absence of testicles to cut across the ejaculatory ducts and remove the median bar, which was thick and fibrous, thus doing away with the necessity of extracting it through one or both of the lateral cavities. The bar which is shown in the accompanying photograph (Fig. 33) was easily enucleated in this way, but a small tear was made in the floor of the urethra. The operation was done under spinal anesthesia, cocaine gr. %, and was entirely satisfactory. A sub- mammary infusion of 1000 cc. salt solution was given during the opera- tion, which produced no shock. The wound was closed as usual wittt double tube drainage for the bladder, and light packs for the lateral cavi- ties. The entire prostate weighed 70 grams. The right lobe weighed 34, the left 30, and the median 6 grams. Convalescence. — The patient reacted well. The temperature rose to 101.5° on the day after the operation, but after that was very little above normal for two weeks. The gauze and tubes were removed on the fourth day. January 20, 1904- — The patient looks weak, is nauseated, but the wound looks well. January 31, 1904- — Since last note the patient has had very little appetite, an evening temperature ranging from 100° to 101° and occasional nausea. He has been given water in abundance, liquid diet, and has been up in a wheel chair as much as possible. Patient's appetite is good again and his temperature is normal. February 13, 1904- — The patient has improved steadily. Is walking about the hospital and is comfortable. Urine came through the penis on the 27th day for the first time. February 23, 1904. — The patient is discharged, forty-second day. The 198 Hugh H. Young. fistula closed on the thirty-eight day. The wound is healed, and the patient is voiding urine naturally. His general condition is fairly good. His urine is clear, contains no albumin, and microscopically, only a few- casts. May 20, 190If. — Letter from physician. " A stricture has formed at a place where the urethra was incised which I have gradually dilated with steel sounds up to 15 English, previous to that he had incontinence, but now this has ceased and his urine looks good." November 4, 1904- — Letter. " I have to void every one to three hours during the day, but my general health is good." He is advised to take bladder irrigations and to distend the bladder as much as possible by hydraulic pressure. February 1, 1905. — I void naturally about once in two hours, about one- fourth of a pint at a time. I am steadily improving. November 30, 1905.— I void urine about once in two hours, but during the first part of the night sleep three hours without urinating. I have some vesical irritability. My general health is very good. My wound is closed, and I feel very well for a man 80 years of age. May 8, 1906. — Letter. " During the day I void urine naturally about once in three hours. During the night I void very frequently, probably from 10 to 20 times, and pass from a teaspoonful to a gill at a time, but during the day perhaps a half a pint. I suffer some pain when urinating. I suppose that my trouble is catarrh of the bladder and also kidney trouble." Pathological report. — The specimen, G. U. 56, consists of four parts and weighs in all Gr-74. The right lateral lobe measures 6x4x2.5 cm., is fairly smooth, lobulated, elastic, and on section shows gland tissue with a moderate amount of stroma and some spheroids. The left lobe measures 5x4x2.5 cm., is smooth, oval and on section presents much the same appearance as the right. It weighs G-30. The median bar measures 3x2x1.5 cm., weighs G-9, and is fairly smooth and glandular. No mucous membrane or ejaculatory ducts are attached to this. The fourth piece is a portion of the posterior ca,psule and floor of the urethra, and contains a portion of the ejaculatory ducts. Microscopic examination. — The hypertrophy in all three lobes consists of very much more stroma than gland tissue. The acini are all small, sep- arated as a rule by very broad areas of stroma, and in many areas only vestiges of gland acini persist. Many times the acini seem like small tu- bules of solid cells, the acini being so compressed that no lumen is visible. Many of the larger acini are filled with proliferating epithelial cells. The stroma is almost entirely composed of fibrous tissue, and only occa- sionally are seen a few smooth muscle fibers. Everywhere throughout the stroma there is a marked round celled infiltration and occasional polynuclear cells are seen. About most of the acini there has been formed a large amount of new inflammatory tissue. The prostatitis is evidently one which is very extensive and of long standing. The arteries show a well marked degree of arteriosclerosis. study of IJf^o Cases of Perineal Prostatectomy. 199 Case 26. — Considerable JiypertropJiy of median and lateral lobes of pros- tate. Urination every half hour, pain. Perineal prostatectomy. Reeto- urethral fistula. Two operations to close fistula. Final cure. Followed 28 months. No. 584. R. K., age 61, married, admitted December 30, 1903. Complaint. — " Frequency of urination." No history of gonorrhcea. Present illness began about five or six years ago, with frequency of uri- nation. Since then there has been a gradual increase in difficulty and fre- quency. One year ago he began the use of a catheter on the advice of his physician. Of late he has ceased to use a catheter and finds that he has to arise very frequently, often 14 times during the night to urinate. He has pain when the bladder becomes full which persists during urination, but does not radiate to the end of the penis. There is considerable difficulty in starting the flow and much straining necessary before he starts to urinate. He has never had complete retention, no hematuria, no calculus. Sexual powers. — Erections are present occasionally, but the patient has not attempted intercourse for two years. Examination. — The patient is a well nourished man and his lips and mucous membranes are of good color. The lungs and heart are negative. Pulse of good volume and tension, but quite sclerotic, 88 to the minute. Hemoglobin, 70%. The abdomen is negative. Rectal examination. — The prostate is considerably enlarged in both lateral lobes, firm, but elastic, smooth, no nodules, no induration; seminal vesicles not indurated. Cystoscopic examination. — A coude catheter passes with ease and finds 400 cc. residual urine. The cystoscope shows only a slight intravesical enlargement of the lateral lobes with a fair sized rounded median lobe, with a deeii sulcus on each side. The bladder is chronically infiamed, but there is no stone present. Urine.- — Acid, 1013; cloudy; no sugar; albumin, a trace; microscopically, pus and bacilli. Preliminary treatment. — The patient was catheterized three or four times daily for 18 days, during which time the residual urine varied from 300 to 500 cc. He was able to void only small amounts, and the total daily quantity was from 1400 to 1900 cc. The urine varied in specific gravity from 1015 to 1022, there was a small amount of albumin, some pus cells and a few granular casts, and the urine was acid. Under the treatment above described the patient improved considerably. Operation, January 16, 190^. — Ether. Perineal prostatectomy by the usual technique, with the exception that no examination was made of the rectum at the end of the operation. The operator did not think, how- ever, that he had made a tear into the rectum and no note was made of any particular difficulty being encountered in freeing the rectum from the prostate. The lateral lobes, which were moderately hypertrophied, were easily enucleated and a fairly large median lobe was removed through one of the lateral cavities with ease by means of the tractor. 200 Hugh H. Young. With the finger a small pedunculated subcervical median lobe was re- moved (Fig. 42). A small tear was made in the urethra in so doing, but the floor of the urethra and ejaculatory ducts were preserved intact. The wound was closed as usual, with exception that the rectum was not examined and the levator ani muscles were not drawn together (up to this time this was not done as a routine procedure, although it had been done in the very first operation). Convalescence. — The patient stood the operation well, pulse at the end being 94. Continuous irrigation was kept up for four days, when the gauze and tubes were removed. Two days later, during a bowel move- ment, feces escaped through the perineal wound. On the day following Fig. 42. — Lateral lobes, moderate median bar, small pedunculated sub- cervical medium lobe. the operation the patient complained greatly of abdominal pain and later pain in the back. He was given calomel, and 400 cc. salt solution, with potassium citrate as an enema to be retained, this was repeated three times a day for at least four days, a large rectal tube being used each time. Remark. — In reviewing the case there seems to be no reason for this treatment as the patient was not nauseated, had no fever, temperature be- ing normal, and his condition was excellent, with the exception of pain in the abdomen. It is possible that the traumatism produced by the frequent introduction of the large rectal tube caused necrosis of the rectal wall adjacent to the wound and led to the fistula, but as the operator did not examine the rectum after the operation and did not cover it by approxi- study of lJf5 Cases of ■Perineal Frostatectomy. 201 mating the levator muscles tie cannot be certain what caused the break- down. January 30. — Four days ago the rectal sphincter was stretched with the patient under ether; since then the communication between the rectum and perineal wound has been very free. The patient feels well and sits up in a chair. All urine escapes through the perineum. February 4- — Most of the urine passes through the penis; some feces still discharge through the perineal wound. The perineal wound is packed with iodoform gauze. February 11. — Little improvement. The patient passes feces through the penis when the bowels move, and considerable urine comes through the rectum. February 20. — The urine starts through the penis but very soon goes into the rectum. Gas and feces escape through the penis. The patient voids urine at intervals, has good control and has no pain in his bladder. Operation, February 20, 1904- — Ether. Closure of urethro-rectal fistula. A probe was introduced through the sinus and perineum and the sinus was then excised through an inverted V-incision in a scar of the previous operation. After both fistulge had been thoroughly exposed an incision was made in the bulbous urethra and a catheter inserted through it into the bladder. The rectum and urethral openings were then closed with fine sutures of catgut, and these were reinforced with heavier catgut sutures. The urethral catheter was sewed to the edge of the bulbous urethrotomy wound for permanent drainage. Convalescence. — The patient suffered considerably from pain. The cath- eter did not drain well, and caused so much pain that it was removed on February 24. February 25. — Urine escapes through the perineum and rectum. The patient has suffered greatly from diarrhoea since the operation and this has caused the wou-nd to break down. March 2. — Fecal matter comes through the perineal wound in consider- able amount, and urine entirely through the perineum and rectum. March 12. — The patient is much improved. Nearly all the feces pass through the anus. Urine comes mostly through the penis. Sinuses show evidence of closing. March 19. — Patient is discharged to-day (four weeks after second oper- ation). He feels well, voids urine every four or five hours. At night does not void from 12 to 6 a. m. Most of the urine comes through the urethra in a large free stream and without pain. Ten days ago the amount of fecal matter coming through the perineum began to diminish and for the past few days there has been no escape of fecal matter. There has been no fecal matter nor gas come through the urethra since the second operation. April 16. — The patient is very comfortable. Only a few drops of urine escape through the perineum and very little gas and no fecal matter. There is no connection between the rectum and urethra. Voids urine at intervals of six hours with perfect comfort. 202 Hugh H. Young. August 2, 1904. — The patient feels well, voids urine at intervals of five or six hours. Both rectal and urethral fistula are closed. November 30, 1905. — I void urine naturally, one pint at a time, about every four hours. A few drops of urine still escape through the perineal fistula. Erections are present. My health is good and I have gained 50 pounds. I have no pain and I consider myself cured. February 16, 1906. — Letter. I void urine once during the night, oc- casionally twice, and generally six times in 2 hours. The fistula is improv- ing and sometimes for nearly a week there is no leakage. Occasionally a slight amount of gas passes through the penis, but never any fecal matter, and no fecal matter ever passes through the perineum. There is no tenderness about the bladder, but at times a little pain when urinating. My general health is very good. May 17, 1906. — Letter. I void urine naturally three or four times during the day and generally twice at night, about a pint at a time. At times I suffer slight pain during urination, but only occasionally. I have erections, but have not attempted intercourse. The perineal fistula is not en- tirely closed, occasionally eight or ten drops of urine escape through it. My general health is good, I have gained in weight, and I am entirely cured of my prostatic trouble. Pathological report. — Specimen G. U. 58. The prostate has been re- moved in four pieces and weighs about 35 grams. It consists of a left lobe 4.5x3x2 cm. in size, the right lobe 4.5 x 2.5 x 2 cm., a median bar globular in shape and about 2 cm. in diameter, and a small intravesical lobe about 8 mm. in diameter. The specimens are covered by smooth mucous mem- branes, are elastic and present the usual appearance of benign glandular hypertrophy. Microscopic examination. — The hypertrophy is a glandular one with the formation of spheroidal lobules. The acini show rather marked cystic dilatation in areas. The interlobular stroma contains • some acini which are fiattened and elongated. The stroma is comprised for the most part of connective tissue, although there is present a considerable amount of muscle. A rather extensive chronic prostatitis is present and in areas this has led to the formation of considerable periacinous sclerosis with conse- quent compression and partial atrophy of the acini. The picture in these areas would suggest a primary glandular proliferation with subsequent atrophy of the gland elements as a result of inflammation. The blood vessels show moderate degree of arteriosclerosis in these areas. Case 27, — Moderate hypertrophy of mediati and lateral lobes. Consider- able pain and hematuria. Cure. No. 606. J. T. N., age 58, married, admitted January 21, 1904. Complaint. — " Enlarged prostate — cystitis." The patient has never had gonorrhoea. Present illness began in May, 1903, with a slight difficulty of urination. At the end of a month blood appeared at the end of each urination, which study of UfO Cases of 'Perineal Prostatectomy. 203 was very difficult. His physician then passed a catheter and drew away about two quarts of urine. He was catheterized once daily for a month, and after that urination was fairly satisfactory until September, 1903, when dysuria and hematuria returned. His physician then passed sounds twice a week for a month, and during the next three months the patient got along fairly well by using the catheter at bed time. In January, 1904, urination became much more difficult and a severe hemorrhage occurred. S. P. — The patient is voiding urine every hour with considerable diffi- culty. Hematuria is present, sometimes large clots are passed. He has no pain except in his bladder, has not lost weight. His sexual powers are normal. Examination. — The patient is well nourished. Heart, lungs and abdomen are negative. There is no arteriosclerosis and his pulse is good. Geni- talia are negative. Rectal examination. — iThe prostate is considerably enlarged, smooth, fairly firm but homogenous and not nodular. The seminal vesicles are not palpable. Cystoscopic examination. — A catheter enters with ease, but withdraws only 32 cc. residual urine. (At a previous examination complete retention of urine was present and the bladder reached the umbilicus.) The cysto- scope shows two large intravesical lateral lobes with a very small median bar connecting them. The bladder is moderately trabeculated and inflamed. The urine is cloudy, acid, and contains pus cells in abundance. Operation, January 21, 1904- — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were moderately enlarged, soft and easily enucleated. The median portion of the prostate was delivered by the tractor into one of the lateral cavities and enucleated, being about 3 cm. in diameter. The urethra and ejaculatory ducts were preserved, but a small tear was made in removing the median lobe. The perineal wound was lightly packed with gauze, double catheter drainage was introduced into the bladder through the perineal wound which was closed as usual. The patient was infused on the table and continuous irrigation was provided on return to the ward. The patient stood the operation well. Convalescence. — The catheters were not removed for six days, and for four days there was considerable hemorrhage from the bladder (as before operation). Highest temperature was 102°, but on the fourth day the temperature was normal. Urine did not come through the urethra until the sixteenth day. February 22, 1904- — There has been no wetting of the perineal pad for the past four days. The patient is comfortable, but gets up three times at night to urinate. His condition is excellent. He is discharged to-day. April 19, 1904- — The fistula is again opened, but only a few drops escape through it. He suffers no pain, and voids urine in a large stream at in- tervals of five hours. Erections have returned. The fistula is curetted. (It closed finally three months after the operation.) May 19, 1904- — ^A pin point fistula is still present. Urination is normal. 204 Hugh H. Young. The patient goes to bed at 10 o'clock and gets up at 6 o'clock to urinate for the first time. Sexual powers are normal. Catheter passes with ease, no residual urine present, bladder capacity 500 cc. Urine very slightly cloudy, acid, a few pus cells and bacilli present. June 21, 1904- — The patient has been curetted with the gimlet twice. The fistula is now closed. Urination and sexual powers normal. February 1, 1905. — Letter. I am cured. I void urine four times during the day and once at night, one-half pint at a time. November 30, 1905. — Letter. I void urine once at night and four or five times during the day. Occasionally I suffer pain at the end of the penis and urination is slow. Erections and sexual powers are satisfactory. I have had no complication since the operation. February 7, 1906. The patient voids once during the night and at inter- vals of four hours during the day. Micturition free, and only a slight pain occasionally at the end of urination. He has erections and occasionally intercourse, but the amount of ejaculated fluid is slight and ejaculation is accompanied by a smarting sensation in the perineum. Examination. — The urinary stream is large, the urine cloudy, acid, con- tains a very few pus cells and no bacteria. The cicatrix is firm. Rectal examination shows no prostatic enlargement, a catheter passes with ease and finds no residual urine. The bladder capacity is 600 cc. Pathological report. — Specimen, G. U. 67, consists of four pieces and weighs 31 gm. The median lobe is almost spherical, about 1.7 cm. in diam- eter and weighs 3 gm. The left lateral lobe is the larger, has been removed in two pieces and measures 4.5x4x2.5 cm. The right lobe is about 2% cm. in diameter. The three lobes are similar in character, surface irregu- larly lobulated, cut surface showing numerous spheroids with moderate di- latation of the acini. There is no mucous membrane nor ejaculatory ducts present. Microscopic examination. — ^The hypertrophy is a moderately glandular one, the acini showing a tendency towards aggregation in areas. The acini are moderately dilated, and the lumina rather complex. Some of the acini show considerable adenocystic papillomatous changes. The stroma is rather dense; is largely made up of connective tissue, although here and there a fair amount of muscle is present. The arteries show a mod- erate degree of thickening. Case 28. — Slight enlargement of median and lateral lobes. Vesical cal- culi. Litholapaxy. Bottihi operation. Perineal prostatectomy. Com- bined operation to close recto-urethral fistula. Cured. Followed two years and four months. No. 379. H. S., age 75, married, admitted April 11, 1903. Gomplauit. — " Complete retention of urine. Catheterism — pain." Patient had gonorrhoea ten years ago. It lasted several months, but was finally cured without complications arising. No bladder trouble until three years later. Present illness began seven years ago with nocturnal incon- tinence of urine. During the next three years the bed was wet almost every night. study of lJf5 Cases of 'Perineal Prostatectomy. 205' About four years ago patient had difficulty in urination, and in a short time retention of urine came on. He was catheterized and since then has been unable to urinate. For two years it was only necessary to use the catheter twice a day, but for the past two years he has suffered gradually more and more pain, and he has had to catheterize himself more and more frequently. 8. P. — The patient catheterizes himself four times in 24 hours. Is un- able to void naturally. He suffers considerable pain in the bladder partic- ularly when it is emptied by the catheter, and at times severe pain in the rectum and urethra which is increased on walking. Sexual powers. — No note made. Examination. — The patient is rather emaciated, but with lips of good color. The pulse is 64 to the minute, volume good, moderate arterioscle- rosis. Chest and abdomen are negative. Genitalia. — The left epididymis is enlarged and tender. Rectal. — The prostate is slightly enlarged, contour is rounded, consist- ence soft, no nodules and no induration. Right seminal vesicle is soft, the left slightly indurated. Urinalysis. — Cloudy, alkaline. Sp. gr. 1018. IVIicroscopically, pus cells, blood, and bacteria. Cystoscopic examination. — lA coude catheter passes easily and finds 230 cc. of urine present. The patient has complete retention of urine. The cystoscope shows four stones, two small and two fairly large, all fairly smooth and white in color. Study of the prostatic orifice shows a small median lobe with a shallow sulcus on either side. The lateral lobes are very little enlarged, and there is no cleft between them in front. With finger in rectum and cystoscope in urethra the beak can be felt and the thickness in median portion is only moderately greater than normal. I. Operation, April 13, 1903. — Ether. Litholapaxy. The largest stone caught had a diameter of about 3 cm. Considerable difficulty was experi- enced in getting the calculi, owing to the trabeculated condition of the bladder and the middle lobe of the prostate, but as no " clicks " were fin- ally obtained by the evacuating tube no further attempts were made. Convalescence. — The patient did not convalesce well. The temperature rose only to 100.5°, but he suffered greatly with pain so that the retained catheter had to be withdrawn. After that he was catheterized every three 'Or four hours, but he became irrational and weak. It was evident that an- other operation was necessary to relieve the prostatic obstruction. II. Operation, April 24, 1903. — Bottini operation. Cocaine and morphia. Three cuts with blade No. 3. A posterior median 1.8 cm. long, right lat- eral 2 cm. long, left lateral 2.2 cm. long. There was very little hemorrhage and the patient suffered little. A catheter was fastened in the penis for continuous drainage. Convalescence. — The patient convalesced poorly. He had a slight fever, suffered considerable pain, voided with difficulty and had considerable re- sidual urine for which catheterization was necessary. For .many days he 206 Hugh H. Young. was uremic and irrational and had a severe bronchitis. He was treated by active hydrotherapy and was kept in a wheel-chair as much as possible. He finally left the hospital June 1, rational, but very weak, voiding urine in small amounts, but still dependent upon a catheter. February 1, 1904- — 'The patient has been unable to void urine and has had to catheterize himself twice daily. He has suffered severely from pain which was worse when he was on his feet, and as a result has re- mained in bed continually. Examination showed a prostate very little larger than normal with a finger in the rectum. The surface was irregu- lar and the consistence hard. A silver catheter entered with ease and found a large bladder. Careful searching failed to reveal a calculus. With finger in rectum and catheter in urethra the tissues between the two were very little greater than normal. Perineal prostatectomy was advised, al- though the patient was extremely weak. III. Operation, February 1, 1904. — Spinal anesthesia. Perineal prosta- tectomy by the usual technique. Two very small lateral lobes and a small median bar were excised with considerable difficulty owing to their fibrous character and adhesions to the capsule, urethra and bladder. A tear was made in the urethra, but no mucous membrane was removed. The blad- der was carefully searched with metal instruments and no stone was found. The wound was closed as usual with the exception that a gauze pack was placed between the posterior surface of the prostate and rectum which was not examined for a tear and the levator muscles were not drawn together with catgut sutures. The lateral cavities were also packed with gauze and double catheter drainage was supplied. The anesthesia was perfect. There was considerable shock after the operation and intra- venous transfusion of 1000 cc. salt solution was given. Convalescence.— T\ie patient reacted well, had no fever and suffered no pain. On the day following the operation bubbles of gas passed out through the wound, and after the gauze was removed on the third day fecal matter escaped through the wound. He convalesced slowly, but was able to void naturally and without pain. The rectal fistula did not close and urine escaped into the rectum and gas into the urethra. He left the hospital on March 28, much improved in general health. Octo'ber 9, 1904- — ^The patient continues to have pain, especially at the end of urination, and the rectal fistula is still present. Examination with the cystoscope shows three calculi, one of moderate size in the bladder. No prostatic enlargement was present. Urine is voided very frequently, and most of it passes into the rectum. The patient is weak and emaciated. IV. Operation, Novem'ber 10, 1904- — Ether. Suprapubic cystotomy for drainage. Perineal operation to close rectal and urethral fistulse and to remove vesical calculi. The patient was first placed in the Trendelenberg position, the bladder opened through a small incision and the calculi re- moved. Examination showed no fistula in the bladder and no prostatic obstruction. The vesical wall was then closed around a large rubber drain- age tube and the patient placed in the lithotomy position. The rectal and study of lJf5 Cases of 'Perineal Prostatectomy. 207 the urethral openings were exposed through incisions in the old scar. The rectal opening was small (less than 1 cm. In diameter) and connected di- rectly with the anterior portion of the prostatic urethra. After excision of scar tissue, the rectal wound was closed with interrupted sutures of fine silk and reinforced by a second row of fine silk and another row of catgut. The urethral wound was also closed with fine silk sutures, and the ca,vity between the two was lightly packed with gauze and the skin wound was partly closed with catgut. The patient stood the operation well and con- valesced satisfactorily. The suprapubic drain was kept in place for about four weeks until the perineal wound had healed completely. The rectal and urethral fistula healed per primam and after the removal of the supra- pubic drain this wound closed rapidly and normal urination was estab- lished through the penis. Fehruary 1, 1905. — Letter. I void urine naturally, retaining it six hours during the night and about three hours during the day. I have a slight irritation in the urethra but no pain. I have no erections. My health is fairly good and I consider myself cured by the operation. February 13, 1906. — The wounds have remained closed and there is no fistula. During the day I do not void urine for three or four hours, but for some reason after retiring after 10 p. m., I awake at 1 a. m. to urinate and after that I am awakened every two hours with a desire to urinate. My general health is fair, but I am getting old. I do not have erections. May 11, 1906. — Letter. I void urine naturally, three or four times during the day, and not until the latter part of the night. I am then wakeful and void frequently. I suffer no pain. I do not have erections. My general health is good, and I have gained in weight. I consider myself cured. Pathological report. — The specimen, G. U. 86, consists of the prostate re- moved in six pieces, and weighing in all about 15 gm. Each lateral lobe was removed in two pieces and they are about equal in size. The median lobe is in two pieces. The surfaces are irregular, considerably torn, and on section are rough and fibrous with here and there dilated acini and evident gland tissue is seen. There is no arrangement in spheroids in some of these pieces, but in others it is present. Microscopic examination. — The hypertrophy is of a rather mixed char- acter, there being considerable areas in which hypertrophy is of a fibro- muscular nature, and again other areas in which the acini are numerous, and show the picture presented by the usual glandular hypertrophy. The stroma contains a large amount of muscle, this being sometimes arranged in definite bundles. In the more glandular areas the muscle is not so evi- dent, although it is fairly abundant. There is considerable round celled infiltration in the stroma. The arteries show a moderate degree of arterio- sclerosis. Case 29. — Considerable enlargement, lateral and median lobes. Seven calculi. Patient in poor condition. Cured. Followed 27 months. No. 549. A. D., age 75, widowed, admitted February 11, 1904. Complaint. — " Difficulty in urination, catheterism." He never had gonorrhoea. 208 Hugh H. Young. Present illness began six years ago with diflBculty of urination and grad- ually got worse until complete retention of urine came on five years ago. He was then catheterized three times, but did not again require it until two years later, when he used the catheter four times. After that the catheter was employed once in every two or three months until three months ago, since which time he has used the catheter from three to four times a day. He is now able to void very little without the catheter. Dur- ing urination he occasionally has pain in the bladder and urethra. He has not lost weight and his general health is excellent. Erections of the penis are still present occasionally, but he has not attempted intercourse for years. Examination. — The patient is rather feeble in appearance, his arteries are markedly sclerotic, but his pulse is regular and of good quality, and 100 to the minute. The heart, lungs, and abdomen are negative. Rectal examination. — 'The prostate is considerably enlarged forming a smooth elastic mass about the size of a small orange. The seminal vesicles are not palpable, there is no induration, no glands and the rectum is not adherent. Cystoscopic examination. — A catheter passes with ease, but produces hemorrhage. The cystoscope came in contact with a calculus in the pos- terior portion of the prostatic urethra. There were present also three or four calculi in the bladder, but it was impossible to get a satisfactory ex- amination on account of hemorrhage. Operation, Fet)ruary 16, 190-'). — Ether. Perineal prostatectomy by the usual technique. The prostate was removed in three large and one small pieces and weighed 91 grams. A small tear was made in the left lateral wall of the urethra, but the bladder and the ejaculatory ducts were not in- jured. After removal of the tractor a finger was inserted and a small stone was found in the prostatic urethra and removed. A stone forceps was then introduced in the bladder and six calculi extracted through the prostatic urethra. The four larger calculi measured 2 x 1.5 x 1.5 cm. in size. The lateral cavities were packed with gauze. A double catheter drain was put in the bladder and the wound closed as usual. The patient stood the operation well. Pulse at the end of the operation 108. Infusion on table continued on return to ward. Convalescence. — The patient convalesced slowly, but had very little fever. The temperature for the first 17 days being normal, it then rose to 102° and was accompanied by nausea and vomiting, but fell to normal the next day. The tubes and gauze were removed on the 8th day. The patient was out of bed on the 14th day, but was weak and his appetite was poor. After the third week he improved slowly but steadily and was discharged on the S9th day. At that time patient was able to retain urine for four hours, voided freely, and had no incontinence. The wound was closed, and the bladder held 240 cc. The fistula afterwards reopened and did not close finally until three months after leaving hospital. study of 145 Cases of ■Perineal Prostatectomy. 209 March 15, 1904. — The patient voids twice during the night. There is still a slight leakage through the perineum. A silver catheter passes with ease and finds only 5 cc. residual urine. The bladder is contracted, holding only 1G5 cc. on forced distention. The perineal fistula will admit a fine probe. March 22, 1904. — The bladder has been forcibly distended by hydraulic pressure daily. Under this treatment the capacity has increased from 165 to 240 cc. in one week. He now voids eight times in 24 hours. The perineal fistula is healed and ho has complete control of urine which is quite purulent and contains numerous bacilli. May 20. 1904- Letter I can hold my urine six hours at night and four hours in the day. I have not used a catheter and urination is satisfactory. The fistula is not closed and a few drops escape at each urination. I suf- fer no pain, have no erections. My general health is good. February 1, 1905. Letter. I am cured. Can void urine naturally, gen- erally four times during the day and twice at night, half a pint at a time. November 30, 1905. — The wound is healed and the urination is normal. I am entirely cured. My general health is excellent and I work on the farm. I get up twice at night to urinate. May 20, 1900. I^etter. I void urine naturally, three or four times during the day and once or twice at night, and in normal quantities. I have no pain, no erections, and have had no complications nor treatment. My gen- eral health is good, and I consider myself cured. Pathological report. — The specimen, G. U. 68, consists of three lobes of the prostate which have been removed in seven pieces and weighs 91 gm. The left lateral lobe consists of four pieces and weighs 33 gm. It is fairly smooth, round, and on section shows considerable gland tissue with a fair number of dilated ducts, and a small amount of stroma. The right lateral lobe was removed in one piece, measuring 4x5x3 cm. in size, and is simi- lar in appearance to the left. The median lobe has been removed in two pieces and weighs 2G gm. It is more glandular and has more dilated acini than the lateral lobes. No mucous membrane, no ejaculatory ducts, no calculi. Microscopic examination. — The hypertrophy is a glandular one and much the same character in all three lobes. The amount of stroma varies in different portions, but as a whole the gland tissue is in excess. In the lateral lobes there are areas of marked cystic dilatation, and the majority of the acini are moderately dilated. In places there is the usual com- plexity of the alveoli and evidence of glandular proliferation. In the acini, which have undergone cystic degeneration, the epithelium is for the most part of a low cuoboidal type. In the middle lobe the alveoli do not show as much evidence of cystic degeneration as in the lateral lobes, but the ducts are considerably dilated. The stroma, which is rather dense in character, is composed mostly of fibrous tissue, although in areas the muscle predominates. No areas of prostatitis noted. 210 Eugli H. Young. Case 30. — Moderate enlargement of median and lateral lobes. Large di- verticulum, with small orifice on anterior wall of bladder. Excision of diverticulum. Perineal prostatectomy. Cure. Followed 27 months. No. 558. J. R. B., age 63, married, admitted February 18, 1904. Complaint. — " Difficulty and frequency of urination. Pressure in the lower abdomen." He lias never had gonorrhcea or previous urinary trouble. Present illness began about two years ago with slight difficulty, and fre- quency of urination. Since then there has been a gradual increase in the symptoms of obstruction and occasionally he has attacks of pain, dull in character, located in the perineum and neck of the bladder, and lasting only a short time. At times he voids three or four times an hour, but at other times goes as long as two hours without urinating. These attacks of great frequency are not associated -with pain, but seem to be due to a constant pressure in the lower abdomen and a desire to urinate which persists after micturition. Sexual powers are normal, but not entirely satisfactory. Examination. — Patient is a healthy looking man. Very slight arterio- sclerosis. The pulse is irregular and a presystolic murmur is present at the apex. Percussion of the abdomen shows considerably distended blad- der reaching almost to the umbilicus and an area of dulness extending up- ward and outward from the bladder into the right iliac fossa. The geni- talia are normal. The prostate is moderately enlarged, smooth, elastic, soft, without induration or nodules. The seminal vesicles are not palpable. The urine is clear and acid. Sp. gr. 1020. No albumin, no sugar. The prostatic secretion contains actively motile spermatozoa, lecithin bodies, a great number of large granule cells and no pus cells. Cystoscopic examination. — A coude catheter passes with ease and with- draws 1200 cc. residual urine. Study of the prostatic orifice shows a mod- erate hypertrophy of both lateral lobes and a small median bar. The blad- der is moderately trabeculated. On the anterior wall of the bladder about 2 cm. distance from the median line on the right side is the orifice 1 cm. in diameter of a large diverticulum. The cystoscope can easily be intro- duced through this opening and shows a large extra-vesical cavity lined with smooth mucous membrane and extending far backward along the right lateral wall of the bladder. There is no cystitis present. Note. — Owing to the position of the diverticulum and the small orifice it was thought best to remove it at the same time that prostatectomy was done. Operation, February 22, 1904. — Ether. With the patient in the Trendelen- berg position the anterior wall of the bladder was exposed in the median line. Diverticulum was found to be of great size filling the space between the bladder and right wall of the pelvis, the sacrum and the pelvic peri- toneum. Its walls were very thin and it contained probably 500 cc. of urine. It communicated with the bladder by a narrow orifice about 4 cm. above the prostato-vesical juncture and 2 cm. from the median line on the study of lJj.5 Cases of 'Perineal Prostatectomy. 211 right side of the anterior wall of the bladder. The neck of the sac was caught between two clamps, divided and then easily enucleated. The ori- fice was then inverted and closed by a purse string catgut suture. The bladder was not opened and the suprapubic muscular wound was closed with a small area for drainage. The patient was then placed in the litho- tomy position and the prostate enucleated by the usual technique. The lateral lobes measured 3x4x5 cm. in size and the median bar about 3 cm. in diameter. The ejaculatory ducts and urethra were preserved with the exception of a small tear that was made in removing the median bar through the left lateral cavity. The wound was closed as usual with double tube drainage. There was very little hemorrhage and the patient stood the operation well. Convalescence. — Patient reacted well. Evening temperature between 100° and 101° for seven days, after that normal. The gauze was removed from the perineal wound on the third day and the tubes on the fourth day. The suprapubic gauze was removed on the fifth day, and there was no leakage of urine through the suprapubic wound. On the tenth day urine was still coming through the perineal wound, but the patient had perfect control and could retain his urine for six hours. March 19, 1904- — Patient voids urine every three or four hours in the day and five to six hours at night. The perineal wound is healed (closed on the 26th day). Urine is cloudy and contains pus cells and bacilli. Pa- tient was treated actively by urotropin and intravesical irrigations of 1 : 5000 nitrate of silver with the hope of removing the vesical infection, but after one month's treatment the urine still contained bacilli. He was then discharged, 25th day. May 10, 1904- — (The patient has used intravesical irrigations of boric acid. Urotropin and helmatol internally. Urine passes freely, but still contains numerous bacilli. A catheter passes with ease. Residual urine 150 cc. The cystoscope shows a slight fold of mucous membrane at the vesical orifice in the median portion of the prostate. No prostatic lobes present. At the site of the diverticular orifice is a small scar. With the finger in the rectum and cystoscope in the urethra the amount of tissue is no greater than normal. May 31, 1904- — 'Urine is voided freely, a pint at a time. A catheter passes wihout meeting any obotruction and finds only 5 cc. residual urine. Decemher 12, 1905. — The patient voids urine freely at intervals of five or six hours. Often does not arise during the night to urinate. There is no incontinence, but occasionally a slight urgency. Erections and power of intercourse have returned. A catheter passes easily, residual urine 30 cc, bladder capacity 550 cc. Urine slightly cloudy, with pus and bacteria. May 8, 1906. — ^I void urine naturally at normal intervals, never more than once at night, as much as a pint at a time. I have no pain. Sexual inter- course is not entirely satisfactory, the power does not seem to be as strong. My general health is good and I consider myself cured. Vol. XIV.— 15. 212 Hugli H. Young. Case 31. — Moderate hypertrophy of lateral lobes. No stone. No catheter life. Cure. No. 565. R. W. B., age 65, admitted February 26, 1904. Complaint. — " Frequent and difficult micturition." He had gonorrhoea at the age of 20, but was thoroughly cured. The present illness began about five years ago with a sudden complete retention of urine which was relieved by a hot bath, his physician being unable to pass a catheter. For three days he had constant dribbling of urine, but then passed a small calculus and after that the urine came freely. His physician found the prostate enlarged at that time, and since then his symptoms have grown gradually worse. The catheter has only been used three times and always produced considerable hemorrhage. Pain has been very slight, and there has been very little loss of weight. Sexual powers have diminished considerably during the past two years, and he has had no erections for several months. He now urinates every hour during the night and every two hours during the day without hemorrhage and only slight pain. Examination. — ^A sturdy looking man with soft arteries and good pulse. The heart, lungs, genitalia and abdomen are negative. The prostate is moderately enlarged, smooth, slightly indurated and uniform in consist- ence. It is adherent laterally, and tender on pressure. The seminal vesi- cles are not palpable. A catheter passes with ease and finds 180 cc. residual urine. The bladder is irritable and contracted and will take only 195 cc. of fiuid. The cystoscope passed easily, but hemorrhage was produced, making the examination unsatisfactory. Urine acid, cloudy, albumen in considerable amount, no sugar. Microscopically, pus cells, no bacteria. Preliminary treatment. — Water in abundance, urotropin and catheteriza- tion three times daily. 800 cc. was withdrawn at one time. Operation, March 3, 1904- — Ether. Perineal prostatectomy by the usual technique. Two considerably enlarged lateral lobes were easily enucleated, a small tear being made in the urethra. There was no median lobe present and no calculus. The ejaculatory ducts were preserved. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient was infused on the table and stood the operation well. Pulse at the end 115. Continous irrigation on return to the ward. .Convalescence. — The patient's pulse was rather weak for several hours after the operation, but was good the next day. The temperature rose to 101° on the day after the operation, and during the next nine days there was an evening temperature generally between 100° and 101° and once reaching 103°, after that it was practically normal. On the third day the patient was stupid and slightly delirious and was infused. The gauze was removed on the third day and the tubes on the fourth day. Urine began to flow through the urethra on the sixth day, and on the 14th day the pa- tient was able to retain urine for four hours. He was discharged from the hospital on the 27th day in excellent condition with a pin-point fistula study of lJf.5 Cases of 'Perineal Prostatectomy. 213 in the perineum. An attempt was made to pass a catheter, but obstruction was met with in the region of the membranous urethra. Filiforms were then tried without success. The patient was able to void in a good stream, and there was no evidence of stricture. April 16, 190 Jf. (Seventh week later). — I have been improving daily. Only a few drops of urine pass through the fistula. I can hold urine for five hours, have no pain, sleep well and have a good appetite. May 11, 1904- — Letter. I can hold my urine five hours during the day, but void about every two hours at night. The wound is closed and I can empty my bladder. I pass one pint of urine at a time in a large stream and without pain. I have had no erections. My general health is good. February 1, 1905. — ^I can void urine normally and am cured. I void urine five times during the night, but only three times during the day and in large amounts, about 330 cc. at a time. I have no pain. Erections have been absent since several months before the operation. My general health is good. April 5, 1905. — 'Letter from physician. The patient died a few days ago of pneumonia. During his illness urine contained pus, red blood corpuscles and hyaline casts. His urinary trouble was relieved by the operation. Pathological report. — The specimen, G. U. 69, consists of the lateral lobes of the prostate, each removed in one piece and weighs in all 26 gm. The right lobe is the larger and measures 5 x 3 x 2. cm., weighs 18 gm., is encap- sulated, and on section shows numerous large spheroids with considerable cystic dilatation and moderate amount of stroma. The left lobe weighs 8 gm., and measures 2.5 x 2.3 x 2 cm. It is similar in character to the right, but is firmer and shows few dilated acini. A portion of the floor of the urethra has been removed with the right lateral lobe, but the ejacu- latory ducts are not present. No calculi. Microscopic examination. — The hypertrophy in both lobes is of the glandular type with dilatation of the acini, with numerous intraacinous off-shoots from the peripheral wall and occasional areas of cystic degen- eration. The adenomatous tissue is much in excess of the stroma which contains more connective tissue than muscle. A few small areas of pros- tatitis. Case 32. — Slight enlargement of lateral and median portions. Vesical calculus. Contraction of bladder. Restriction of normal urination. Con- traction of bladder persists. Followed two years. No. 569. W. P. R., age 64, widower, admitted March 5, 1904. Complaint. — " Frequency of urination and pain." Gonorrhoea at the age of 22, no gleet or stricture following. Present illness began 18 months ago with a slight smarting pain during urination. Two months later his bladder became very irritable and uri- nation frequent. Seven months ago he had hematuria for a week, and since then frequency and pain have been on the increase. /S. P. — Urination is very frequent, at times every half hour. During and 214: Hugh H. Young. at the end of urination there is a severe pain in the bladder and urethra. His general health is fairly good. His sexual desire has been absent for six months and previous to this he has only occasionally had intercourse. Examination. — Patient is a pale, rather feeble-looking man. The chest, abdomen and genitalia are negative. Rectal. — ^The prostate is very little enlarged, flat, indurated, but smooth. Seminal vesicles are palpable, enlarged and slightly indurated. Urinalysis. — Cloudy, acid, 1023, considerable albumin, microscopically, pus, epithelium, red-blood corpuscles and bacilli. Cystoscopic. — The catheter passes with ease and find very little residual urine. The bladder is very irritable, much contracted and holds only 65 cc. The cystoscope shows an irregular, chronically inflamed prostatic mar- gin with a verj' small rounded median enlargement. The lateral lobes are not at all intravesically enlarged. Just back of the prostatic orifice is a fairly large stone, rough and brownish in color. It was impossible to ex- amine the bladder satisfactorily. With finger in rectum and cystoscope in urethra the median portion of the prostate is slightly increased. Operation, March 7, 1904- — Ether. Perineal prostatectomy by the usual technique. Lithotomy through the wound. Both lateral lobes were little if at all enlarged, hard, very adherent and difficult to enucleate. The me- dian portion of the prostate was so small that it could not be engaged with the blade of the tractor, but was drawn by the index finger into the left lateral cavity and enucleated there after division of close adhesion to the mucous membrane. The left lateral wall of the urethra was then divided longitudinally, the vesical sphincter dilated, forceps introduced and a cal- culus 3 X 2 X 1^2 cm. in size removed. Double catheter drainage and light packing for the lateral cavities. No suture of the urethral incision, clos- ure of the skin as usual. Continuous irrigation and infusion. Patient stood the operation well. Pulse at end 116. Convalescence.— The patient had no fever until 11 days after the opera- tion He convalesced well. The continuous irrigation was kept up for 24 hours, the gauze was removed on the second day and the tubes on the third day. The patient was out of bed on the fourth day. The fistula closed on the 11th day. On the 13th day he was able to retain urine for three hours, but passed some blood. On the 14th day there was considerable hemor- rhage so that a retention catheter was inserted. Following this he had a chill, temperature reaching 103°. On the 18th day another hemorrhage occurred and the catheter again was inserted. After this he had no fur- ther bleeding and left the hospital on the 28th day. At that time the urine was clear, wound closed, general condition of the patient good. Micturi- tion at intervals of about two hours. April 20, 1904- — 'Urination is still frequent and examination shows that the bladder only holds 190 cc. June 1, 190Jf. — ^The patient has been treated by hydraulic dilatation of the bladder and its capacity is now 310 cc. Urine is voided in a large stream without difficulty, at intervals of two and one-half hours. July 9, 1904- — The bladder now contains 390 cc. study of IJfS Cases of 'Perineal Prostatectomy. 215 Septeynber 3, 1904- — A catheter passes with ease and finds no residual urine. The bladder capacity is 300 cc. He has used no intravesical irriga- tions or dilatations for several months. He is advised to begin again. February 1, 1905. — I void urine naturally five or six times during the day and three or four times during the night without pain. I am cured, but have had no erections. This disturbs me greatly. March 20, 1905. — A fine opportunity was afforded, and I found that my sexual powers were as good as ever. My youth has been renewed. I now believe in prostatectomy. February 17, 1906. — Letter. I void urine naturally, but quite often, ow- ing t -) contracture of the bladder. I generally urinate four or five times during the night, but I have no pain and sometimes pass a glass full of urine at a time. I have erections occasionally and have had very satisfac- tory sexual intercourse. I have not continued to dilate my bladder as you suggested. My general health is very good, and I have gained many pounds in weight. Pathological report. — iThe specimen, G. U. 72, consists of three pieces representing the lateral and median portions of the prostate, and weighs in all about 8 gm. The right lateral lobe measures 2.5x2x2 cm., is some- what irregular, but fairly smooth, and on section shows gland tissue with considerable intervening stroma, some dilated ducts, no spheroids and a fairly thick capsule. The left lobe is smaller than the right, measuring only 2x2x1.3 cm., but is similar to the right in character. The median bar is a small bit of tissue 1.5 x .8 x .6 cm. in size, and seems quite fibrous. No mucous membrane, no ejaculatory duct removed. An oval calculus about 3x2x1.5 cm. in size is present. Microscopic examination. — In both lateral lobes the hypertrophy is a richly glandular one, the stroma being comparatively small in amount. The acini are moderately dilated and in areas show cystic dilatation. There are the usual intra-acinous projections which in places assume a papillomatous type. There is present quite a marked prostatitis with numerous pus cells in the lumina of the ducts, and quite marked epithelial proliferation and desquamation. The stroma contains considerably more connective tissue than muscle, and there is quite extensive round cell and polynuclear cell infiltration with some areas of chronic inflammatory tissue formation. In the middle bar the glandular element is very much ex- ceeded by the stroma. The acini are filled with proliferating and desqua- mated epithelial cells. The microscopic picture seems to differ from the normal only in the fact that there is present quite a marked prostatitis. Case 33. — Small pedunculated median lobe. Vesical calculus. Con- tracted bladder. Catheter life. Result: Normal urination. Frequency and pain owing to contraction, possibly calculus. Lived one year after opera- tion. Death: Cause? No autopsy. No. 582. G. R. B., age 77, married. Seen in Rochester, New York, March 11, 1904. Complaint. — "Difficulty, frequency and painful urination." 216 Hugh H. Young. No history of gonorrhoea or previous urinary trouble. Present illness began six years ago with slight difficulty and frequency of urination which increased gradually until he began the use of a catheter two years ago. Since then he has been unable to void urine naturally, and he now has to use a catheter every hour. He suffers considerably from pain at the end of urination. Examination. — The patient is a very weak-looking man. He is pale and pulse is poor. Chest and abdomen negative. The prostate is only slightly hypertrophied, considerably indurated and tender. A catheter passes with ease. Retention of urine is complete. Bladder capacity small and bladder very irritable. The cystoscope shows a small pedunculated median lobe, a slight intravesical hypertrophy of both lateral lobes, and a vesical cal- culus of medium size. Operation, March 11. lOOJ/. — Spinal anesthesia with cocaine grains %. Prostatectomy by the usual technique. The lateral lobes w^ere only slightly enlarged. It was impossible to engage the middle lobe with the tractor or with the finger. As the urethra had to be dilated to remove the calculus, it was thought best to remove it through the dilated prostatic urethra, which was done by means of a clamp. It proved to be about 3 cm. long and 2 cm. in diameter. A stone 3x4x2 cm. in size was then removed through the urethra. The urethra and ejaculatory ducts were preserved intact. The usual closure was employed with double drainage tubes for the bladder. Patient did not suffer pain in the operation upon the pros- tate and his condition at the end was good. Continuous irrigation and a submammary infusion of salt solution were given on return to the room. Convalescence. — The patient reacted well. The tubes and gauze were removed on the third day. No complications. Letter from Dr. Howard, June 5, 1904- — The patient looks very well. The fistula has closed and he urinates freely. He walks about the ward and has a normal pulse and temperature. Sounds are passed occasionally. The pa- tient urinates every half an hour night and day, but the stream is large, and he thinks he can empty his bladder. His chief complaint is severe pain just back of the glans penis. He has no erections, but these were ab- sent before operation. Letter, Febriuiry 1, 1905. — I void every hour and about two ounces at a time. Pain is almost continually present in the penis. I do not use a catheter. I am physically very weak on account of the severe pain and frequency of urination. Note. — His physicians reported that there was no residual urine present and no stone, but the bladder was markedly contracted and markedly in- flamed. They were advised to try dilatation of the bladder by hydraulic pressure, but apparently very little success attended their efforts, and pa- tient died in the spring of 1905. No autopsy was obtained, but the obstruc- tion to urination had apparently been completely removed. Pathological report. — Specimen G. U. 97. The hypertrophy consists about equally of gland tissue and stroma, the relative amounts varying in dif- ferent areas. There seems but slight tendency to form spherical lobules. study of 1J/.0 Cases of 'Perineal Prostatectomy. 21T Microscopic examination. — The acini, as a rule, do not show the com- plexity which one sees in more glandular prostates. They are, however, for the most part dilated, and here and there show small cystic forma- tion. The stroma is rather compact, and contains more connective tissue than muscle. There are quite numerous areas of interstitial round cell and polynuclear cell infiltration. Case 34. — Slight enlargement of median and lateral loies. 200 cc. re- siduum. Diabetes m^ellitus. Complication: rectal necrosis, fistula. Sec- ondary closure of rectum. Cure. Folloiced 26 months. No. 581. J. K., age 65, married. Operated upon in Rochester, N. Y., March 11, 1904. Complaint. — "Difficulty and frequency of urination." No history of gonorrhoea. Present illness began 10 years ago with slight difficulty of urination. Since then there has been a gradual increase in the difficulty and frequency of micturition. He was catheterized first seven months ago and since then has used the instrument at least once daily, but has not had complete re- tention of urine. iS. P. — The patient catheterizes himself twice daily. After four or five hours he begins to void, the interval being every two hours until cathe- terized again. He has very little pain and his general health is good. Sexual powers are weakened. Erections are present occasionally and in- tercourse possible, but ejaculations are very premature. Examination. — The patient looks well, his lips are of good color, and the arteries are only slightly thickened. Chest, abdomen and genitalia negative. Rectal. — The prostate is slightly enlarged, does not bulge into the rec- tum, is smooth, but distinctly hard. The seminal vesicles are negative. Cystoscopic examination was not made. A coude catheter passes with ease and finds 200 cc. residual urine. Urinalysis. — Cloudy, acid, sp. gr. 1025, no albumin. Sugar in small but definite amount. Xote. — 'In view of the presence of sugar the operator would have put the patient upon anti-diabetic treatment before performing prostatectomy had the patient been in Baltimore. His general condition, however, was ex- cellent, there were no symptoms of diabetes and his physician considered the disease of slight import. Operation was therefore agreed to. Operation, March 11, 1904- — Chloroform. Perineal prostatectomy by the usual technique. The lateral lobes are very little larger than normal and quite adherent in the deeper portion, but were fairly easily enucleated each in one piece. The middle lobe could not be engaged with the blade of the tractor and that instrument was withdrawn. With a finger in the urethra a small pedunculated median lobe was pushed into the left lateral cavity and there enucleated without removing any of the mucous membrane cov- ering it. The middle lobe measured 1 x 1 x .5 cm. in size. The ejaculatory 218 Hugh H. Young. ducts were preserved and only one small tear was made In the urethra. The wound was closed with double tube drainage and light packs for the lateral cavities. Examination of the posterior portion of the wound with the finger showed that no tear had been made in the rectum (but the lev- ators were not drawn together as is now done). The patient stood the operation well. Continuous irrigation and infusion on return to room. Instructions were given to start the gauze on the next day, to remove them on the third day and the tubes on the fourth day. The operator left Rochester five hours after the operation. Convalescence. — Complete notes not obtained. When the tubes were re- moved on the fourth day a rectal fistula was discovered. March 25, 1904- — Letter. The patient is doing well, and the fistula is smaller, but there is quite a hole in the rectal wall just above the sphinc- ter. The urine escapes through the perineum, but no feces or gas escape through the urethra. The wound looks well. On April 7 an incision was made in the bulbous urethra and a rubber catheter inserted through it into the bladder for continuous drainage. It was removed after 12 days, and for one week there was no escape of urine through the original perineal wound, and the rectal fistula was greatly contracted. May 1, 1904- — The perineal fistula has opened again, but it is very small and does not leak until the bladder becomes distended. He voids urine every three hours and has no dribbling. October 6, 1904- — The patient presents himself for examination in Balti- more. He voids urine at normal intervals, arising only once during the night. There is no difliculty in urination, but the urine escapes partly through the penis, through the rectum and through the perineal fistula. Gas escapes through the urethra, but never any fecal matter. He has been on anti-diabetic diet for four months and his urine has been free from sugar. His general health is good. Examination. — At the apex of the perineal incision is a small urinary sinus. With finger in rectum a small rectal fistula is found just above the sphincter ani. The outlines of the prostate cannot be made out. The urine is acid, slightly purulent and contains 2% sugar. Preliminary treatment. — The urine contained very little sugar, the sp. gr. from 1020 to 1027. The patient was kept on anti-diabetic diet for 12 days previous to operation. The specific gravity varied from 1015 to 1020, there was no sugar or acetone present. For two days previous to the operation bicarbonate of soda, grains 15, was given every four hours. Operation, October 18, 1904.— Ether. Suprapubic cystotomy for drain- age. Closure of rectal and urethral fistula through perineal incision. A very small suprapubic incision was made. The finger showed a normal prostatic orifice and no foreign body. A large drainage tube was inserted, and the bladder closed round it. The patient was then placed in the litho- tomy position, and a probe passed through the fistula into the rectum and another into the urethra. Incisions were then made in the old scar and study of 145 Cases of ■Perineal Prostatectomy. 219 the flstulse excised. The urethral opening was found to be about 1 cm. long, that into the rectum was smaller. After excising all cicatricial tissue the rectal opening was closed with a double layer of mattress sutures of fine silk. The urethral opening, which was found to be in the membranous urethra, was similarly closed. The levator ani muscles were drawn to- gether over the rectum with interrupted sutures of catgut. The wound was lightly packed and partially closed with interrupted sutures of cat- gut. The patient was infused on the table and stood the operation well. Pulse at the end 95. Convalescence. — The patient reacted well. On the day after the opera- tion he was given an infusion 1000 cc. salt solution containing 40 grains of bicarbonate of soda. After that he received 30 grains of bicarbonate of soda every four hours and a lead and opium pill, and morphia in small amounts for seven days. The gauze was removed on the 4th day. There had been no escape of urine, all of which came through the suprapubic tube. The bowels were not moved until the 13th day, after he had re- ceived castor oil and Rochelle salts by mouth and high retained oil enema. The patient had been fairly comfortable up to the 12th day when he began to complain of pain. Some fecal matter came through the perineal wound and after that there was also an escape of urine through the perineum. The suprapubic drainage tube was not removed, and after nine days there was no further escape of feces or urine through the perineum, and the perineal wound healed by granulation. The suprapubic tube, however, was not removed until the 38th day. The patient left the hospital on the 55th day. At that time patient voided naturally, without pain. Rectal examination showed the closure of the rectal fistula, the suprapubic and perineal wounds were also closed. Silver catheter passed with ease, there was no residual urine present, no stone, the bladder was contracted, but its exact size not determined. Urine was clear, acid, con- tained no sugar, but pus cells and bacilli in moderate number. The pa- tient has been eating meat, eggs, onions, cabbage, and asparagus. February 1, 1905. — Letter. I void urine naturally at intervals of three hours, have no pain and consider myself cured. I have had no erections. Novem'ber 30, 1905. — I void urine once at night and about every two hours in the day, suffer no pain. I have erections at times, but have not had intercourse. The wounds have remained closed. My general health is excellent and I have gained in weight. May 10, 1906. — Letter. I void urine naturally at regular intervals, arise about once at night to urinate. Have no pain, no erections. My general health is good, I have gained in weight. The wounds have remained closed, and I consider myself cured. Pathological report. — The specimen, G. U. 71, consists of three lobes of the prostate each removed in one piece, and weighs in all about 10 gm. The median lobe is somewhat pear-shaped, and measures 1.2 x 1 xl.5 cm. One lateral lobe measures 2.5 x 2.5 x 1.5 cm. and the other about 2 cm. in diameter. Each of the lobes is globular in shape, encapsulated. 220 Hugh E. Young. and on section is fairly homogeneous with very little stroma in places; in other places it is more pronounced with spheroid formation. No areas of induration. No mucous membrane has been removed. The ejaculatory ducts are not present. Microscopic examination. — The gland tissue is very much in excess of the stroma and for the most part arranged in lobules. The acini are for the most part considerably dilated with occasional cystic degenera- tion of an acinus. The acini show the usual complexity and proliferation. The stroma is compact, the connective tissue being slightly in excess of the muscle. Some corpora amylacea are seen. A few small areas of pros- tatitis are present. The hypertrophy is of the same type in all three lobes. Case 35. — Moderate Jiypertrophy of median and lateral loies. Cured. No. 585. S. S., age 72, married, admitted March 21, 1904. Complaint. — " Difficulty of urination. Catheterism." No history of gonorrhoea. Present illness began four years ago with difficulty and frequency of urination which gradually increased until two years ago when complete retention of urine set in and patient had to be catheterized. For the next six months the catheter was used four or five times during the day. After that for a time he voided naturally, but during the past 18 months the catheter has been necessary. 8. P. — The patient uses the catheter five times in 24 hours, retention of urine being complete. He secretes about 10 pints of urine in 24 hours, and usually finds two pints each time with the catheter. He has not suffered pain nor hematuria and his general health has been good. Erections present, sexual powers normal. Examination. — The patient is a sturdy-looking man. Lips and mucous membranes of good color. Both lungs are emphysematous. The heart is difficult to outline, but the sounds are clear, though the rhythm is exceed- ingly irregular. Rectal examination. — The prostate is moderately hypertrophied, rounded, smooth, elastic, soft. The seminal vesicles cannot be reached. Cystoscopic examination. — 'A large coude catheter passes with ease. The bladder capacity is large, retention of urine is complete. The cystoscope encounters hemorrhage, making the examination unsatisfactory. The presence of a fairly large middle lobe and slight bilateral intravesical hy- pertrophy is made out. It is impossible to examine the bladder satis- factorily. Urinalysis. — Sp. gr. 1012, acid, albumin a trace, microscopically, pus and bacteria. Operation, March 22, 1904. — Ether. Perineal prostatectomy by the usual technique. The patient was a very large man and the perineum very thick and the prostate deep. Each lateral lobe was removed in two pieces. The middle lobe was drawn by the tractor into the left lateral cavity and enu- cleated without removing any mucous membrane. Examination with the study of lJf.5 Cases of ■Perineal Prostatectomy. 231 finger in the urethra showed no remaining hypertrophied tissue. The ure- thra was torn, but no mucous membrane was removed and the floor and ejaculatory ducts were preserved intact. An infusion was given on the table, the wound was closed as usual with double tube drainage and light packs for the lateral cavities. Condition at the end of the operation was excellent, pulse being 95. Continuous vesical irrigation was instituted on return to ward. Convalescence. — The patient reacted well, highest temperature was 100° on the day following the operation, and after that it was practically normal. The gauze was removed on the second day, and the tubes on the third day. There was fairly considerable bleeding for 24 hours after the operation and the patient was infused a second time. Pulse did not rise above 100, however. Urine passed through the urethra on the ninth day, interval uri- nation having been present for several days. The patient was up in a chair during the first week. He was discharged April 18 (27th day). He has not had instrumentation. His condition was excellent, could retain urine for three or four hours and only a small amount came through the fistula which was not yet closed. There had been no complications. May 20, 1904- — Letter. I urinate every hour during the day and five times at night. There is no fistula. I void half a pint at a time and feel that I can empty my bladder. Urination is satisfactory, I have no pain and I have not used a catheter. Urine is very foul. I have not had erec- tions. My general health is fairly good. Pathological report. — ^The specimen, G. U. 75, consists of the lateral and median lobes of the prostate removed in six pieces, and weighing in all 25 gm. The right lobe is composed of two pieces, the left of three pieces, and the median of one piece. All of the lobes are composed of large sphe- roids, loosely bound together. On section numerous small and enlarged spheroids are seen. The median lobe measures 2 x 2 x 1.5 cm., and con- sists of a globular mass about 1.5 cm. in diameter upon a flat base. The consistence is everywhere elastic, and the section shows numerous dilated acini. No calculi and no areas suggesting malignancy are present. Microscopic examination. — The hypertrophy is a glandular one with areas of considerable cystic dilatation and areas of rather marked glandu- lar proliferation. The stroma is formed mostly of fairly cellular con- nective tissue, although here and there is some embryonic tissue. The muscle is quite insignificant in amount. Some endoglandular prostatitis is present, with occasional infiltration of the periacinous stroma. The blood vessels show only slight thickening. Case 36. — Moderate enlargement of lateral lodes of prostate. Residual urine 10 cc. Bladder contracted, capacity 50. Vesical calculus. Cured. Followed two years. No. 106. J. W. L., age 72, married, admitted March 29, 1904. Complaint. — ■" Frequent and painful urination." No history of gonorrhoea. 223 Hugh H. Young. Present illness began about five years ago with increased frequency of urination. Shortly afterwards he passed a small calculus, and during the next six months 20 more calculi. In November, 1899, he came to the hos- pital complaining of painful and frequent urination which occurred at least four times every night, and often every 15 minutes. Examination showed a slightly enlarged prostate, but the catheter showed no residual urine. The bladder was irritable and held only 100 CO. He was carefully searched with a metal searcher, but no calculus was detected. Several days later the cystoscope showed a large oval calculus in a pouch back of the interureteral ligament. On December 24, 1899, lith- olapaxy was performed under chloroform anesthesia. Considerable diffi- culty was experienced in catching the fragments with the lithotrite and the operation required one hour and a half. January 15, 1901. — The patient has reacted well, voids urine without pain, at intervals of every two hours. He is discharged. March 29, 190Jf. — Eighteen months ago the patient began again to pass gravel. He now voids every hour in the night and every 15 minutes in the day. The stream is slow, and small, but he suffers no pain, no hema- turia. He has had no erections for four years, his general health is good. Examination. — Patient is well nourished, lips of good color. Heart, lungs and abdomen are negative. There is slight arterio-sclerosis. Rectal. — The prostate is considerably enlarged in both lateral lobes. The median furrow is deep and wide, and the notch is deep. The surface is smooth, consistence soft, no tenderness. The seminal vesicles cannot be felt. Urinalysis. — Cloudy, acid, sp. gr. 1018, no sugar, albumin slight, micro- scopically, pus cells and bacilli. Cystoscopic. — A coude catheter passes easily, residual urine 10 cc, blad- der capacity 50 cc. The lateral lobes of the prostate are moderately hyper- trophied, there is a deep cleft between them in front and be- hind. Resting on top of the two lateral lobes, with the cys- toscope looking upward, two stones are seen, as shown in A. In series U, when the handle of the cystoscope is depressed the anterior cleft becomes shallow and the calculi occupy the larger part of the field. When the handle of the cystoscope is elevated the calculi disappear from view and the anterior cleft becomes quite deep (2 and 3). In series D, with the handle depressed a deep cleft is seen posteriorly. On gradually elevating the handle of the cystoscope the lateral lobes are gradually sep- arated and a median fold of mucous membrane appears and finally in 4 is the only thing seen at the prostatic margin. Examination of the bladder was unsatisfactory. With finger in rectum and cystoscope in urethra there was very little increase in the median portion of the prostate. Operation, March 4, 190^. — Ether. Perineal prostatectomy by the usual technique. Removal of two calculi through wound. The lateral lobes were removed each in two pieces. After removal of the first piece on each side it seemed that all of the hypertrophied tissue had been removed. study of lJf5 Cases of 'Perineal Prostatectomy. 223 Careful examination, however, revealed an intravesical lobule higher up on each side, the blades of the tractor having slipped beneath them at the beginning v?hen traction was made. By pushing the tractor further into the bladder, depressing and rotating the handle, it was possible to draw down and enucleate these intravesical enlargements without tearing the urethra or the bladder. The median portion of the prostate was not re- moved, being very little hypertrophied. The tractor was then removed and the left lateral wall of the urethra divided longitudinally with scis- sors. The bladder orifice was dilated with a uterine dilator, a stone for- ceps inserted and two calculi easily extracted. The finger was inserted and showed a very small bladder and no remaining prostatic enlargement. The wound was closed as usual with double drainage tubes, and light gauze packs for the lateral cavities. Infusion and continuous irrigation. Patient stood the operation well, his pulse at the end being 90. Convalescence. — The highest temperature was 100.8° on the second day, after the third day it was practically normal. Continuous irrigation was kept up for 24 hours. The gauze was removed on the third and the tubes on the fourth day. The patient was out of bed on the sixth day. Urine came through the urethra on the eighth day and the perineal fistula closed on the eleventh day. There was scarcely any incontinence after the opera tion, and the patient was discharged on the 20th day, voiding urine in a large stream, every three hours during the day and with perfect control. May 20, 1904- — I void urine at intervals of three hours during the day, and four and one-half at night, half a pint at a time. The wound is closed and I feel well. February 1, 1905. — Letter. I void urine naturally, three or four times during the day and twice at night. I have no pain, no erections. Novem'ber 30, 1905. — Letter. I urinate three or four times during the day and twice at night. Half a pint at a time. Occasionally partial erec- tions occur, not suflicient for intercourse. My health is excellent and I consider myself cured. May 7, 1906. — Letter. I void naturally from four to six times a day, and once or twice at night when I drink much water. The largest amount voided at one time is about one-third of a pint. I have no pain, no erec- tions. I have had no complications, and my general health is good. I have gained in weight and consider myself cured. Pathological report. — The specimen, G. U. 76, consists of the two lateral lobes of the prostate, each removed in two pieces, and weighing in all 21 gm. The surfaces of the specimens are irregularly lobulated and of uni- form consistency. On section numerous spheroids are seen, but very few dilated ducts, the consistence being more homogeneous than usual. The right lateral lobe weighs 11 gm., and measures 4.5 x 2.5 x 2 cm. The left lobe weighs 10 gm. and measures 5x3x2 cm. Two smooth white calculi measuring each about 2.5 cm. in diameter have been removed. Microscopic examination. — The hypertrophy is of a rather glandular ap- pearance with arrangement in lobules and there is condensation of the 224 Hugh E. Young. perilobular tissue. The tissue presents nothing but the usual glandular hypertrophy except that there is quite extensive prostatitis present, with glandular proliferation and degeneration of the epithelial cells, and fairly extensive round cell and polynuclear cell infiltration of the stroma and the formation of some chronic inflammatory tissue. In many of the ducts quite numerous pus cells are present. Case 37. — Small hard prostate. Sligfit median enlargement. Multiple vesical septa and diverticula. Operation. Cure. Contracture of Madder, relieved ty hydraulic dilatation. No. 591. W. B. E., age 47, married, admitted March 31, 1904. Complaint. — " Irritable bladder." The patient had gonorrhoea at the age of IS and following it gleet and stricture. Was married at the age of 27 and his wife had no children. Present illness began 12 years ago with frequency and diflBculty of uri- nation and pain in the back. Four months later an encysted calculus was removed by Dr. Fenger of Chicago through a suprapubic incision. The suprapubic sinus did not heal for five months, but after that the patient was free from symptoms for six months. Another calculus was then found and removed by litholapaxy and the patient remained well for three years. He was then catheterized and five ounces of residual urine discov- ered. For three weeks his bladder was irrigated through a catheter with much improvement. After that he was treated by various men, and at times was quite well, and at others had considerable difficulty and fre- quency of urination. For the past two years he has been unable to work. Has treated himself off and on with intravesical irrigations through the catheter, usually finding three ounces of residual urine and a contracted bladder. For the past three months the patient has catheterized himself regularly at bed time, generally withdrawing seven ounces of residual urine, and in this way has been able to sleep four or five hours before arising to urinate. Urination is difficult and he often has to strain. He voids about every hour, but has no pain except when urination is particu- larly difficult. His general health is good. His sexual powers are normal with the exception that ejaculation is somewhat precocious. Examination. — The patient is a healthy looking man with lips of good color. The heart and lungs are negative. Abdomen negative with the ex- ception of an old suprapubic scar. Rectal examination. — The prostate is slightly emarged. The consistence is quite hard, particularly the right lateral lobe which is very hard, the surface is smooth and there are no nodules. The seminal vesicles are not palpable, and there is no induration in this region. A catheter passes with ease and finds 180 cc. residual urine. Bladder capacity is about 300 cc. The cystoscope shows a slight hypertrophy of the left lateral and median portions of the prostate with a deep cleft between. Th right lateral lobe is not enlarged and there is no cleft between the lateral lobes in front. The trigone is drawn behind the median bar so that it is impossible to study of 145 Cases of 'Perineal Prostatectomy. 225 see the ureters. Tlie bladder is markedly inflamed, trabeculated and sev- eral prominent irregular septa are present, and between these, deep pouches and three diverticula with large orifices are seen. The diverticula occupy the two lateral walls of the bladder, and there is apparently no danger of constriction of the orifices or of pressure upon the ureters. With the finger in the rectum and cystoscope in the urethra a definite increase in the median portion is found. Urinalysis. — Very cloudy, acid, albumin in small amount, no sugar. Microscopically, pus in considerable amount. Note. — The patient was treated by catheterization and intravesical irri- gation, prostatic massage and urethral dilatation from March 31 to April 19. Under this treatment the bladder became less irritable, but the amount of residual urine increased, at least 400 cc. being present. Perineal pros- tatectomy was decided upon, although there was very little enlargement present. Operation, April 19, IdOJf. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were very small, weighing about 7 gm. each. The median enlargement was even smaller, and was removed with the as- sistance of a finger in the urethra through the right lateral cavity. No other enlargement was present. Examination of the bladder with the fin- ger showed a broad shallow pouch behind the interureteral ligament, be- hind which there was a transverse septum; the diverticula were out of reach. The ejaculatory ducts, urethra and bladder were preserved intact. The lateral cavities were packed with gauze, double tube drainage for the bladder through the perineum was supplied and the wound closed as usual. There was very little hemorrhage and the patient's condition was excel- lent. Convalescence. — The patient reacted well. The gauze was removed on the fifth and the tubes on the sixth day. He was walking on the ninth day and on the thirteenth began to void through the penis. On the sixteenth day the perineal wound did not leak for a day. Temperature rose to 100.6" on the day after the operation, but after that it was practically normal. May 7, 1904. — The perineal wound is still open. The patient has not been instrumented since the operation. He voids his urine about every three and one-half hours. Has no dribbling and no pain. Is discharged from the hospital to-day (18th day). June 1, 1904-—^S'maU urinary fistula is still present in the perineum. Examination shows that it is extremely small and will not admit a probe. The small fistula gimlet can be screwed in with ease, and by this means the fistula is thoroughly curetted. June 7, 1904- — The fistula closed at once after the curettement with the gimlet and there has been no leakage for a week. The patient is drinking large amounts of water and is voiding 325 cc. of urine at a time. The stream is large and urination is entirely satisfactory. Erections have re- turned. A catheter passes with ease and finds 100 cc. residual urine. The bladder is slightly contracted. The patient is discharged. 226 Hugh H. Young. 'Note. — The residual urine in this case is probably due to the diverticula which have not the muscular power to empty themselves, but can be drained by a catheter. June 28, 1904. — I am feeling well, but the wound broke open on the way home. November 17, 190Jf. — My wound is completely healed, it closed two months ago. I have gained 30 pounds in weight. My urine is still quite cloudy and I am troubled sometimes with frequency of urination. February 1, 1905. — I can void urine normally, and consider myself cured. I have not used a catheter or sound since the operation. I suffer no pain. Erections have returned and intercourse is normal. I urinate three times during the night and five times during the day. My general health is ex- cellent. November 30, 1905. — I void urine naturally and consider myself cured. I do not arise at all at night to urinate as a rule, but sometimes once. I void about 250 cc. at a time. Suffer no pain. Erections and intercourse are normal. My fistula is closed and I have complete control. February 27, 1906. — ^The patient returns for examination. He has had no treatment since his discharge, and has not required catheterization. He has been able to void without difficulty or pain, but there has been a gradual shortening of the interval between urinations, and he now arises four or five times at night to urinate, and voids every two hours during the day. He has perfect control, and no dribbling at the end of urination. Sexual powers. — Erections and intercourse are normal. (Just as strong as before operation.) The patient looks well, and the wound is firmly closed. Rectal examination is negative. The urine is acid, very cloudy, sp. gr. 1011, and contains albumin in considerable amount, and bacilli and pus cells. Cystoscopic. — A silver catheter passes with ease and finds only 30 cc. residual urine. The bladder is contracted and admits only 150 cc. of fluid. (The patient is able to retain, however, over 200 cc. of urine.) There is no stricture present. The cystoscope shows no enlargement of the lateral lobes and no sulci between them. There is a slight, thin, but definitely ele- vated median fold or bar with a slight pouch behind it. Study of the bladder shows that the diverticula are still present, but apparently much smaller than before operation. The broad transverse ridge on the pos- terior wall with a pouch in front and with two diverticula on each side is seen. With finger in rectum and cystoscope in urethra the beak is easily felt, and there is no increase of the median portion of the prostate made out. The lateral lobes are much smaller. March 17, 1906. — The patient has been treated for three weeks, the blad- der being dilated twice daily by hydraulic pressure. The Kollmann dilator has been used about 10 times, although no stricture has been detected, and it has been easy to dilate the urethra up to No. 37-F. The bladder has gradually enlarged by hydraulic dilatations. At first it was possible to get in only about 150 cc. and the amount voided was never over 125 cc. The study of llj-o Cases of 'Perineal Prostatectomy. 237 patient is now able to void 325 cc. at one time, and urinates only about twice at night, and at intervals of four hours during the day. A cathetei finds 30 cc. residual urine. Urine is still quite cloudy and contains pus and bacteria. Patient is discharged and advised to continue irrigations. Remark. — This case is a good example of markedly increased frequency' of urination due to vesical contraction. May 8, 1906. — Letter. I void urine naturally about six times during the day and twice at night, about eight ounces at a time. I have erections and satisfactory sexual intercourse. My general health is excellent, and I con- sider myself cured. Case 38. — Considerable enlargement of median and less of lateral lohes. Catheterism. Pain, douMe epididymitis. Operation. Cure. Folloiced IS months. No. 613. G. T. C, age 65, married, admitted April 28, 1904. Complaint. — " Difficulty of urination and catheterism." The patient had gonorrhoea at the age of 19; a light attack of which was easily cured, without subsequent stricture or gleet. Present illness began about 10 years ago when he noticed for the first time a slight difficulty in urination. After that there was a slow but grad- ual increase in the difficulty and frequency, but he did not have complete retention until two years ago. He did not require the catheter again until one month ago, and since then has used it from two to five times every day, but occasionally has been able to void small amounts. Ten days ago both testicles became swollen. He still has erections, but his sexual powers are sorhewhat weakened. Examination. — The patient is a sturdy looking man with only slight ar- teriosclerosis. A marked aortic stenosis is present. Each epididymis is indurated and enlarged. On rectal examination the prostate is found markedly enlarged, being about the size of a medium-sized orange, smooth, elastic and soft, regular in contour with no nodules nor induration. The median furrow is shallow and the notch is replaced by a prominence, the upper end of which can just be reached. The seminal vesicles can not be palpated. Urine acid, cloudy, and contains albumin, pus and epithelial cells, and numerous bacilli. Cystoscopic examination. — A coude catheter passes with ease and finds 100 cc. residual urine (patient says he usually finds 500 cc. ). The cysto- scope shows a large median lobe with a deep sulcus on each side of it. The lateral lobes do not project far into the bladder, and there is no cleft between them in front. The bladder wall is considerably trabeculated and numerous pouches are seen. With the finger in the rectum and cystoscope in the urethra the beak could not be felt and the mass between the two was considerable. Preliminary treatment. — Frequent catheterization. Large amounts of water and urotropin by mouth. Vol. XIV.— 16. 228 Hugh H. Young. Operation, May 6, 1904. — Ether. Perineal prostatectomy by the usual technique. The prostate was enucleated in four pieces, the two lateral lobes each in one piece, and the median lobe in two pieces, one-half through each lateral cavity. The urethra, ejaculatory ducts and bladder were pre- ' served intact. There was only a moderate amount of hemorrhage. The wound was closed as usual with gauze packing for the lateral cavities and double drainage tube for the bladder. Submammary infusion was given on the table and a continuous irrigation for the bladder was given for about 48 hours after the operation. Convalescence. — ^The patient stood the operation well. The gauze was pulled out on the third day and the tubes on the fourth. The fistula closed three weeks after the operation, and the patient went home on the twenty- sixth day. Highest temperature 101.6° on the fourth day. June 5, 1904- — The patient voids at intervals of from four to six hours. He has no incontinence, and urination is normal. Erections have returned. June 29, 1904- — ^The patient reports urination normal. Sexual desire and erections have returned. September 22, 1904- — The patient goes to bed at 9 o'clock, arises to uri- nate at 9 a. m. Noveinher 30, 1905. — Urination is normal and the patient is able to retain urine for from six to nine hours. He has had no instrumentation since op- eration and voids urine in a large stream. Erections are the same as be- fore operation and intercourse is indulged in. Has had no complication since operation. Pathological report. — The specimen, G. U. 285, consists of five pieces of prostatic tissue representing the two lateral and the median lobe. Total weight about 25 gm. The tissue is lobulated, consistency firm, but elastic. On section the tissue is composed of spheroids in varying sizes with mod- erate-sized interlacing bands of denser tissue. The ejaculatory ducts have not been removed. No calculus. Microscopic examination. — 'The hypertrophy is a lobulated moderately glandular one in which the usual picture is greatly modified by infiamma- tory changes. Over extensive areas the acini are small, separated by con- siderable bands of stroma, and about the acini there is concentrically ar- ranged considerable fibrous tissue. The gland ducts are filled with pus cells, and degenerated and desquamated epithelial cells. In some lobules where the prostatitis is absent or small in amount the gland acini are moderately dilated with serrated margin and lined by tall cylindrical epithelium. The stroma is about equal in amount to the gland tissue, and it contains considerable excess of connective over muscle tissue. There is considerable infiammatory infiltration, and there has been consid- erable inflammatory hypoplasia. The microscopic picture has been much modified by the extensive prostatitis. The blood vessels for the most part seem practically normal. study of lJf.5 Cases of 'Perineal Prostatectomy. 229 Case 39. — Small round median lobe. No lateral enlargement. Residual urine JflO cc. Rectal fistula after operation. Closure at third operation. Cure. Followed two years. No. 630. S. M. G., age 62, widowed, admitted May 21, 1904. Complaint. — " Difficulty in urination. Catheterism." No history of gonorrhoea. Present illness began about eight years ago with slowness in starting urination. After voiding a small amount there would be a sudden stop- page accompanied by pain, but after a little while he would be able to void again. The difficulty and frequency of urination gradually increased and two years ago the difficulty was intense. In March, 1903, the patient had a severe attack of la grippe, and after that the difficulty of urination and frequency of urination were very great for two or three months. Then he began to improve and by November, 1903, he was able to void urine without pain at intervals of from six to eight hours. A month later, however, after a severe chill, urinary trouble again became very distressing, urination being very frequent, difficult and painful. About January 15, 1904, he was catheterized by his physician and 14 ounces residual urine obtained. Since then he has used the cath- eter about four times a day. Under this treatment he has improved con- siderably. S. P. — At present the patient uses the catheter night and morning. After catheterization he does not void for three hours, but thenceforth voids every hour or two until catheterized again. Urination is difficult, and he suffers pain which is located in the neck of the bladder, and is worse at the end of urination. Sexual powers. — Erections are present, but he has not had intercourse for 12 years. Examination. — The patient is a well nourished man with lips of good color. Heart, lungs and abdomen are negative. Genitalia negative. Rectal examination. — The prostate appears only slightly enlarged, left lobe being a little larger than the right. It is smooth, generally indurated, but not of stony hardness. No nodules are to be felt, and the seminal vesicles are soft. Urine cloudy, acid, sp. gr. 1010; trace of albumin, no sugar. Microscopically, pus cells and bacilli. Prostatic secretion contains many pus cells, few normal elements and no spermatozoa. Cystoscopic examination. — A catheter passes with ease and finds 470 cc. residual urine. The cystoscope shows a small median lobe with a shallow sulcus on each side, the lateral lobes are not intravesically hypertrophied and there are no clefts between them in front. The bladder is markedly trabeculated, showing numerous small cellules and deep pouches. There is no foreign body and a cystitis of moderate degree is present. With finger in rectum and cystoscope in urethra the beak can be easily felt, and the tissue in the median portion of the prostate seems only moderately thickened. 230 Hugh H. Young. Operation, May SI, 1904- — Ether. Perineal prostatectomy by the usual technique with the exception that the rectum was not examined and the levators were not approximated. The lateral lobes were only slightly en- larged, very adherent to the capsule and urethra, but were successfully re- moved each in one piece without injury of the mucous membrane or blad- der. Attempt was made to engage the median lobe with one blade of the tractor, but owing to its small size it was impossible, the tractor was then withdrawn and after dilatation of the urethra with a glove stretcher, the index finger of the left hand was inserted, and a very small, slightly rounded median lobe was found and carried with difficulty by the finger towards the left lateral cavity where it was removed with blunt and sharp periosteal elevators. A small bit of mucous membrane which covered its vesical surface was removed, but the urethra and ejaculatory ducts were left intact. The wound was closed with double drainage tubes for the blad- der; lateral cavities packed with gauze. It was not the custom then to examine the rectum at the end of the operation nor to approximate the levator muscles and neither of these was done, otherwise the closure was as usual. There was only a moderate amount of hemorrhage and the pa- tient stood the operation well. Continuous irrigation and submammary infusions were both given on the table. Convalescence. — The patient reacted well. Pulse at end of operation 70. Temperature on night following operation 98.4°. Continuous irrigation was discontinued after five hours, and the second day after the operation his temperature arose to 108.8°. The patient complained of a severe pain in the head and the abdomen. He was given an enema at 6 p. m. and shortly afterwards complained of severe pain in the wound. On the third day he continued to have pain in the abdomen and the wound and received codeia several times and calomel. His temperature was 104.4°. All gauze was removed on the third day (no evidence of fecal fistula then). June 3. — Fourth day. The patient had a large fluid stool to-day, there was a considerable discharge of feces from the wound when the bowels moved. The patient still complains of pain in the wound. The drainage tubes were removed to-day. At 9 p. m. the patient received a large enema through a rectal tube and had a large fluid stool, but continued to suffer a severe pain in the wound. June 9, 1904. — His general condition is improving, and the patient is on his feet every day. He has had several stools and is more comfortable. The urine still escapes through the perineum. June 11, 1904- — ^Night before last after an enema given with a large rec- tal tube, about half of the fluid expelled came through the perineal wound. The patient thought that gas had escaped through the wound on the day previous. July 1, 1904- — The recto-urethral perineal fistula persists. All the urine comes through the perineum and gas and feces also escape through it and sometimes through the urethra. Examination with the finger shows an study of lJf.5 Cases of 'Perineal Prostatectomy. 231 opening in the anterior wall of the rectum about one inch above the anus, and large enough to admit the end of the finger. Left sided epididymitis developed June 18, but subsided without operation. Note. — In reviewing the history it is evident that the rectum did not break down until four days after the operation, as previous to that time he had had numerous bowel movements without escape of either gas or feces through the wound. Whether the necrosis was due to the enema or the rectal tube or straining at stool, or to the unprotected condition of the rectum, owing to the levators not being drawn together over it, it is Impossible to say, but a tear was probably not made at the operation. Operation, July 2, 1904- — Ether. Separate closure of rectal and urethral openings. Incisions were made in the previous wound and the fistulae ex- cised. The rectum communicated with the wound by two fistulous open- ings, first close to the anus where the opening would admit a finger tip, and second 5 cm. up where it also communicated with the posterior ure- thra. These openings were joined and after excision of the edges closed with interrupted fine silk sutures, reinforcing sutures to cover in the first row were carefully placed, bringing together considerable amount of muscle in the line of suture. A urethrotomy wound was made in the bul- bous urethra and a catheter inserted through it into the bladder. It was found impracticable to close the urethral fistula. After packing the wound lightly the skin was approximated on each side with catgut. Convalescence. — July 9. Since operation the patient has had a great deal of pain, requiring removal of retention catheter last night. The gauze was removed on the third day. Last night feces came through the perineal wound as freely as before operation. July 13, 1904- — The catheter has been replaced with the hope of getting the rectal fistula to close. July 28, 1904- — Although causing considerable pain the catheter was re- tained until last night. The rectal opening is smaller, but liquid stools still escape through it. August 15, 1904- — 'The patient is discharged. He now voids urine at in- tervals of four hours without pain and in a large stream. Often all of the' urine comes through the meatus, at times there is an escape of urine into the rectum, and only a few drops come through the perineal fistula. Fecal matter does not come through the urethra or through the perineal fistula, but gas occasionally passes through both. Examination. — A silver catheter passes into the bladder with ease. There is no residual urine present. The vesical tonicity is good, but the bladder is somewhat contracted. Rectal examination shows a small opening in the anterior wall. The patient is instructed to use the catheter with the hope that the fistula will heal. December 7, 1904- — The patient's health has improved greatly. He re- tains his urine for five or six hours, and voids almost entirely through the penis. The recto-urethral fistula has not closed and when his bowels are loose a small amount of feces still escapes. He has had frequent re- currences of painful epididymitis on both sides. 232 Hugh H. Young. Third operation, February 6, 1905. — By Drs. Pitts and Smith, of Provi- dence, R. I. Perineal incision, exposure of rectal fistula, suture of edges; drainage of bladder by means of a catheter. Urethral fistula not closed. The catheter remained in place for several days. The patient was up on the 16th day, and left the hospital on the 19th. Examination at end of fourth week showed complete closure of the rectal wound, slight leakage of the perineal fistula. Bladder holds 12 ounces and the patient does not urinate for five or six hours. Noveml)er 12, 1905. — The patient voids urine without hesitation or difii- culty, has frequent erections and feels perfectly well. Examination shows that the rectal wound is healed and the perineal fistula closed. Epididy- mes indurated but painless. The urine is almost clear. Micturition nor- mal. No residual urine. May 8, 1906. — Letter. I void urine naturally, at intervals of about four hours, often 16 ounces at a time. I suffer pain in the scrotum. Do not have erections or intercourse. There is still a very small fistula in the perineum through which a few drops of urine escape. I am entirely cured of the obstruction to urination. May 19, 1906. — The patient returns for examination. In addition to above note he says that if he retains urine longer than four hours there is occasionally a slight escape of a very small amount of urine, perhaps a teaspoonful, but this is easily avoided by voiding urine at intervals of less than four hours. There is no nocturnal incontinence. Examination. — The perineal prostatectomy wound and the rectal wound are both firmly closed, and there is no evidence of prostatic enlargement present. A pin-point fistula at the site of the bulbous urethrotomy wound persists. A silver catheter passes with ease. There is no residual urine present, and the bladder capacity is 400 cc. There is no stricture present Urine is acid and contains only a few pus cells. The fistula in the bulbous urethra was almost completely excised, and no sutures introduced. Pathological report. — The specimen, G. U. 84, consists of the three lobes of the prostate each in one piece and weighs in all 7 gm. The right lobe is the largest; it is fairly smooth, and firm in consistence. On section it is pale with small white dots in a grayish stroma, and is fibrous in feel. It measures 2 x 1.7 x 1.3 cm. The left lateral lobe is somewhat smaller and is similar in character to the right. The median lobe has been torn into three pieces, to one of which a small bit of mucous membrane has been attached. One small lobule about 7 mm. in diameter represents most of the lobe. No ejaculatory ducts, no calculi removed. Microscopic examination. — The prostate is very interesting microscop- ically in that there is a very insignificant amount of gland tissue present. The acini present are grouped in a few small areas. The stroma contains considerably more muscle than connective tissue, the muscle fibers being often grouped together in bundles sur- rounded by a small band of connective tissue with small strands interlacing between the muscle fibers. The blood vessels do not seem to show any particular amount of arteriosclerotic changes. On gross study of 145 Cases of 'Perineal Prostatectomy. 233 appearance this prostate presented none of the typical appearance of benign hypertrophy, and microscopically there is no accumulation of gland tissue in lobules. Here and there one finds an area where there are rather numerous acini present which are somewhat dilated and present the intraacinous proliferation which one sees in ordinary hypertrophy cases. The median portion consists largely of fibrous tissue apparently of inflammatory origin. Numerous areas of prostatitis are also noted in the lateral lobes. Case 40. — Moderate enlargement of median and lateral lobes. Frequency and difficulty of urination. Occasional hematuria. Cured. No. 612. R. W., age 68, single, admitted April 28, 1904. Complaint. — 1" Frequency of urination." No history of gonorrhoea. Present illness began about four years ago with difliculty of urination. Since then there has been a slight increase in this trouble and a little burning at the neck of the bladder. Two weeks ago hematuria occurred, and the patient consulted a physician who advised prostatectomy. S. P. — Urination five or six times during 'the day and four times at night. No pain, but a slight burning during urination. Micturition slow, at times very difficult. Sexual powers. — (Erections are still present, has not had intercourse for years. Examination. — Patient is well nourished and his lips are of good color. The lungs are negative. There is a moderately intense systolic murmur at the apex and the area of cardiac dullness is increased. Sounds at the base are clear. The abdomen and genitalia are negative. Rectal. — The prostate is moderately hypertrophied, being about the size of a small orange. It is smooth, soft, elastic, there are no nodules, the median furrow and notch are obliterated. The seminal vesicles are nega- tive. Urinalysis. — Cloudy, acid, sp. gr. 1017, no sugar, a trace of albumin, urea 19 grams per liter. Microscopically, pus cells and bacilli. Cystoscopic examination.— A. catheter passes with ease and finds 75 cc. residual urine. The bladder capacity is diminished. The tonicity is ex- cellent. The cystoscope shows a fairly large left lateral lobe, a lesser right lateral lobe with a deep sulcus between them, a moderate sized me- dian lobe with a deep sulcus between it and the left lateral lobe and a shallow sulcus between it and the right lateral lobe. The bladder is trabeculated. There is a cystitis of moderate degree, no calculus. With finger in rectum and cystoscope in urethra, the beak can be easily felt, the median portion of the prostate being moderately increased. June 2, 1904. — Patient returns for operation. He has taken urotropin once daily and water in abundance. He has had no pain. Now voids urine about every two hours during the day and every three hours at night. His general health is excellent. 234 Bugh H. Young. June 3, 190Jf. — Operation. Ether. Perineal prostatectomy by the usual technique. The lateral lobes were easily enucleated, but in removing the left lateral, which was the larger, a tear was made in the vesical mucous membrane covering its deeper portion. The median bar was removed, a part with each lateral lobe. The tractor being withdrawn, a finger intro- duced through the urethra into the bladder showed a small median ridge which was very firmly adherent and less than 1 cm. high. It seemed un- necessary to remove this and nothing else was removed. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well, his pulse being 90 at the end. On return to ward an infusion and continuous irrigation were started. Convalescence. — The patient reacted well. Temperature 101° on the night after the operation, normal again after five days. The gauze was removed on the second day, and tEe drainage tubes on the fourth day. He began to walk on the sixth day, urine passed through the anterior urethra on the eighth day, and the fistula closed completely on the twelfth day. Control was established soon after removal of the tubes, and on the eighth day the patient was able to hold urine for several hours. He was discharged on the 19th day, the wound closed, able to hold urine all night, no dribbling, general condition excellent. October 1, 1904- — The patient has been treated by irrigations with the hope of curing the bacilluria, but without success. He can hold urine for six hours with comfort. The catheter meets no obstruction and finds no residual urine. The bladder capacity is 500 cc. The cystoscope shows a small bar in the median portion (which was intentionally not removed at operation), but this seems to cause no obstruction. February 1. 1905. — Letter. I am entirely cured. I void urine from three to five times during the day and once or twice at night, large amounts at a time. I have no pain. Erections have not returned. July 26, 1905. — 'Urine is retained from four to six hours during the day. Stream large and free, control perfect. Had one erection two months ago. Urine still contains bacilli. Pathological report. — The specimen, G. U. 85, consists of the two lateral lobes of the prostate, each removed in one piece and weighs in all 43 gm. The left lateral lobe weighs 25 gm., measures 4x3x3 cm.; presents a fairly smooth external surface with well pronounced capsule, and on section numerous spheroids with considerable stroma and few dilated ducts. The right lobe measures 3.5 x 3 x 2.3 cm. and weighs 18 gm. It is similar in character to the left. No mucous membrane, no ejaculatory ducts, no calculi. Microscopic examination. — The hypertrophy in both lateral lobes pre- sents the usual picture of glandular hypertrophy. The acini are quite dilated with complex lumina due to small inshoots in the periphery. These inshoots at first contained a thin septum of connective tissue form- ing a framework for the epithelium of which they are lined, and later on. study of 145 Cases of 'Perineal Prostatectomy. 235 as the septum increases in thickness, smooth muscle fibers are seen to be present. In areas there is rather marked cystic dilatation with flattening of the lining epithelium. The stroma seems to contain more glandular elements than muscular fibers. The adenomatous tissue sems to be ar- ranged largely in lobules. Few small areas of interstitial inflammatory infiltration are seen. Case 41. — Moderate hypertrophy of median and lateral lohes. Catheter- ism. Cured. Followed 22 months. No. 694. F. J. D., age 75, married, admitted June 28, 1904. Complaint. — " Enlarged prostate. Suprapubic fistula." The patient had never had gonorrhoea. Present illness began 14 years ago when he began to have slight diffi- culty in micturition which gradually increased. About four years ago he consulted a doctor who told him that he had an enlarged prostate and at- tempted to pass a catheter but without success. Three months ago mic- turition was very frequent and difiicult, and he was catheterized for the first time, and a large amount of urine withdrawn. After that he was catheterized once a day by his physician. One month ago he had an at- tack of severe pain in the region of the right kidney which lasted several hours and returned a week later. During the past two weeks he has suf- fered considerably with pain in the bladder and has been catheterized twice a day. Status prcesens. — The patient is now catheterized three times daily, about 500 cc. being withdrawn each time. About five hours later he be- gins to void and suffers considerable pain until he is relieved by catheter. He says that he occasionally has erections, but that he has not had sexual desire or intercourse for several years. Examination. — The patient is a well nourished man. Lips of good color, heart and lungs negative. No tenderness in the region of the kid- neys. On rectal examination the prostate is found to be moderately and sym- metrically enlarged, round, smooth and fairly soft; seminal vesicles not indurated. The urine is slightly cloudy, sp. gr. 1010, acid, no sugar, al- bumin a slight trace. Microscopically, pus and bacteria. Urea 27 grams daily. Preliminary treatment. — Catheterization three times a day, urotropin and water in large amounts by mouth. Total daily amount of urine 2500 cc. Operation, July 2, 1904- — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were of moderate size and the median lobe quite small. In removing the latter a small tear was made in the urethra. The wound was closed as usual with gauze packing in the lateral cavities and double drainage tube in the bladder. The patient was infused on the table, and his condition was good at the end of the operation. Pulse at end 80. 336 Hugh H. Young. Convalescence. — The patient reacted well and continuous irrigation was kept up for 24 hours when the gauze was removed. The catheters were removed on the next day. Urine began to flow through the penis on the sixth day, and the perineal fistula closed on the tenth day. The patient was out of bed on the fourth day and began to walk during the second week. Highest temperature 100.6° on the second day after the operation, after that normal. July 26, WO'f. — The patient can hold his urine for five hours. Catheter passes easily, shows no evidence of stricture and finds 40 cc. residual urine. Bladder capacity is 300 cc. Urine is voided in a large stream, is clear, acid, contains a few leucocytes and no bacteria. The patient dis- charged, 24th day. October 23, 190^. — Letter. I am a well man. I urinate once during the night and every six hours during the day. I have no incontinence, but if I do not promptly answer the call there may be a slight escape of urine, but this is improving. 1 have regained my normal weight. February 1, 1905. — Letter. I void urine three times during the day and once at night, about 250 cc. at a time, with a large stream and without pain. I have occasional erections. November 30, 1905. — Letter. The wound has remained closed. I void urine naturally three times during the day and once at night, about one- half pint at a time. I suffer no pain, erections have returned and my gen- eral health is excellent, and I think I am cured. May 8, 1906. — Letter. I void urine naturally four times during the day and once at night. I have no pain. Erections have returned. I have had no complications, my general health is very good. I have gained in weight and consider myself cured. Case 42. — Moderate enlargement of median and lateral lobes. Catheter life. Perineal prostatectomy : Incomplete operation; return of obstruction. Second perineal prostatectomy, tear into rectum, suture. Result: Recto- urethral fistula. Complete relief of urinary obstruction. Little discom- fort. No. 669. J. J. P., age 63, married, admitted July 14, 1904. Complaint. — " Enlarged prostate. Catheterism." No history of gonorrhoea. Present illness began about seven years ago with difficulty and frequency of urination and pain along the urethra. A year later he was catheterized and a large amount of residual urine discovered. Three years ago com- plete retention of urine came on, and since then he has catheterized him- self three times a day. S. P.-^The patient is unable to void and catheterizes himself four times a day. Of late he has suffered considerably from pain in the prostate and bladder. He has not lost weight, his general health is good. His sexual powers are normal. Examination. — ^The patient is a healthy looking man with lips of good color. There is no arteriosclerosis. Heart, lungs and abdomen are nega- tive. study of lJf.5 Cases of 'Perineal Prostatectomy. 237 Rectal examination. — The prostate is slightly enlarged in both lateral lobes. The contour is irregular, but the consistence is soft. The seminal vesicles could not be reached. Urinalysis. — Cloudy, slightly acid, sp. gr. 1016, no sugar, no albumin. Microscopically, a few pus cells and bacilli. Cystoscopic examination. — A large coude catheter passes with ease and finds 300 cc. urine present (retention of urine is complete). The bladder is large and the tonicity is good. The cystoscope shows only slight intra- vesical hypertrophy of the two lateral lobes, and a small rounded median lobe with a deep sulcus on both sides. The bladder is markedly trabecu- lated and inflamed, numerous septa and deep pouches being present. There are no calculi and no diverticula. With finger in rectum and cysto- scope in urethra the median portion of the prostate is moderately in- creased. Operation, July 15, 1904. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were only slightly enlarged and were very adherent and each was removed in two pieces. It was impossibe to en- gage the median lobe with the tractor which was then withdrawn and the finger inserted. A small sessile median lobe, the size of a pea, was discovered and carried into the left lateral cavity by means of the index finger of the left hand where it was enucleated by means of a sharp peri- ostal elevator, a small tear being made in the mucous membrane covering it. After removal it measured 1 cm. in diameter. The ejaculatory ducts and urethra were preserved intact. The wound was closed as usual with double drainage tubes and light packs for the lateral cavities. The pa- tient's condition at the end of the operation was good. Submammary in- fusion was given on return to ward and continuous vesical irrigation was instituted. Convalescence. — The patient reacted well, but had a slight temperature for five days after the operation, reaching 101.7° on the second day. The gauze was removed at the end of 30 hours, and the' tubes on the next day. The urine began to pass through the urethra on the 12th day. Epididy- mitis developed on the left side on the 18th day, and was accompanied by fever which reached 104° and persisted for a week. On August 5 phlebitis of the right saphenous vein developed. The patient left the hospital Aug- ust 14. The perineal fistula was not healed, and urine very purulent. October 8, 1904. — The patient has had a very unsatisfactory convales- cence. Both testicles have suppurated and had to be opened. He has had considerable trouble from phlebitis and the fistula has never healed. He voids urine in a fairly large stream, but has to arise three times during the night, and a catheter finds 500 cc. residual urine. Examination of the prostate by rectum shows a fairly considerable cicatrix, but no evidence of remaining prostatic lobes. The cystoscope shows a very small but rounded median bar, the lateral lobes are not at all enlarged. July 15, 1905. — From January until May the patient felt well, used a catheter at bed time and did not have to void during the night. Residual 238 Eugli H. Young. urine varied from 50 to 500 cc. During the day he voided at intervals of two hours. About one month ago catheterization bebcame very difficult and painful. For the past V^o Tveeks he has had to use the catheter three times a day to prevent incontinence. Cystoscopic examination again showed a small rounded median mass which evidently acted as an ob- struction. With finger in rectum and cystoscope in urethra, a hard ring surrounding the cystoscope was found in the region of the prostate. The following remark was made: It was evident that the first opera- tion did not completely remove the enlargement of the median portion of the prostate and that there is definite obstruction in this region of a sub- urethral rather than an intravesical character. A second perineal opera- tion is advised with the object of removing this portion of the prostate. July 11, 1905. — Operation. Ether. Inverted V-incision through the scar of previous operation. The prostate was very difficult to expose, ow- ing to the considerable amount of cicatricial tissue and its intimate adhe- sions to the rectum. In this dissection a small tear was made by the finger in the rectum. This was closed apparently satisfactorily with three layers of silk sutures. The urethra was opened through the left lateral wall and the median portion of the prostate with some mucous mem- brane was removed. This measured only 1x1x2 cm. in size, but very fibrous and had to be excised with knife and scissors. A mass of tissue measuring 2 x 1% x 1% cm. in size was removed from the left lateral lobe. The region of the right lateral lobe was not removed. The rectum was covered over with the levator and muscles which were drawn to- gether with catgut sutures. The wound was closed as usual with double tube drainage and light iodoform gauze packing. Convalescence. — The patient reacted well, but had a slight fever for four days. The gauze was removed on the ninth day and the tubes on the tenth day. July 30. — The patient is up in a wheel-chair. Urine has passed partly through the penis since the seventh day. No evidence of rectal suture breaking down. August 1. — Bowels moved for the first time to-day. No evidence of rectal suture giving way. August 5. — 'Bowels moving without pain. Urine passes through the wound. August 8. — Fecal matter passed through the penis with urine to-day. Recto-urethral fistula present. August 16. — 'No more fecal matter through the penis, but flatus escapes through it. Rectal examination discloses a small opening in the bowel, surrounded by considerable tissue. The perineal wound is healed except for a pin-point sinus. The patient voids urine at intervals of three to five hours and most of the urine comes through the penis. August 20. — Rectal and perineal fistula persist. The patient has an oc- casional severe pain in the urethra. He is discharged to-day. study of lJf-5 Cases of •Perineal Prostatectomy. 239 October 11, 1905. — Letter. I pass urine three times during the night and in the morning have a discharge of feces and urine from the rectum, and urine coming from the penis twice before breakfast and generally two or three times after breakfast. After the middle of the day the dis- charges are less frequent and more controllable. The passage of fecal matter through the penis is growing less. I have pain before, during and after the discharges, and constant soreness in perineum and testicles. December 17, 1905. — Letter. The perineal fistula is closed (Nov. 1). I void urine naturally about ten times during the day and four or five times during the night, four ounces at a time. I suffer pain before, during and after urination. I do not have erections. My general health is fair. February 6, 1906. — 'Letter. The perineal wound is closed, but there is still a communication through the perineum and urethra through which gas occasionally escapes into the urethra. About one-quarter of the urine passes through the rectum, the rest is voided through the meatus. I uri- nate seven times during the day and four times at night, from two to four ounces at a time. I suffer much pain before, during and after urination, but am comfortable when sitting still. April 21, 1906. — The recto-urethral fistula is still open, but no feces ever pass through the penis, and when the bowels are very loose there is only a very slight coloring of the urine. Frequently no urine passes into the rectum, but if he strains very hard (which he is in the habit of doing if the urine does not flow at once) a small portion of urine passes into the bowel, but this occurs very rarely. He voids urine in a good stream, with- out difficulty, and at intervals of about six hours during the day. He often does not get up at all during the night to urinate. He has practically no pain, only a slight one when the bladder is very full. He looks well and has gained in weight. Examination. — Patient voided 150 cc. of slightly cloudy, acid urine. With the finger in the rectum a small fistulous opening is felt 4 cm. above the anus. There is no urine in the rectum, although the patient has just voided. Remark. — The patient says he feels so comfortable, has so little trouble on account of the fistula that he does not wish to have an operation to close it. The prostatic obstruction seems to be completely relieved as a result of the second operation. Case 43. — Considerable enlargement of the lateral lobes. Catheterized twice daily. Cured. No complications. Followed 21 months. No. 689. J. S. T., age 72, widower, admitted August 5, 1904. Complaint. — " Incomplete retention of urine. Catheter ism." No history of gonorrhoea. Present illness began six years ago with intermittent attacks of fre- quency of urination. About four years ago he began to have hemorrhages from the urethra while asleep and occasionally during urination. These continued at intervals of three or four months. In December, 1903, he 240 Hugh E. Young. began to suffer for the first time with diflficulty and pain during urination. A catheter drew off one quart of residual urine. Since then the patient has been catheterized twice daily, but retention of urine has never been complete. S. P. — The patient is in good health, suffers no pain, is catheterized night and morning. After about eight hours he begins to void fre- quently and with difficulty. The residual urine is usually a pint. No note as to sexual powers. Examination. — The patient is a sturdy-looking man, lips of good color. The pulse is regular, 72 to the minute, and the arteries are not sclerotic. The chest and abdomen are negative. Rectal. — The prostate is considerably enlarged, the left lobe being the larger, and its upper end difficult to reach. The prostate is rounded, smooth, elastic, there are no nodules or areas of induration. The semi- nal vesicles are not palpable. Cystoscopic examination. — (19th day). The patient voids urine at intervals of two hours. He has good control, but there is slight dribbling at the end of urination. The stream is large and he suffers no pain. A cath- eter passes with ease and finds 10 cc. residual urine. The bladder ca- pacity is 250 cc. February 28, 1905. — The patient has gained 23 pounds since opera- tion. Retains urine for five hours during the day and arises twice dur- ing the night. A catheter enters with ease and there is no stricture present and no residual urine. The bladder capacity is 300 cc. The cystoscope shows a slightly irregular prostatic margin with a small al- most pedunculated redundant fold of mucous membrane in the anterior portion of the left lateral lobe. With finger in rectum and cystoscope in urethra the median portion of the prostate is about normal in size. November 30, 1905. — Letter. I void urine as well as I ever could, once during the night, a little more frequently during the day and about half a pint at a time. I suffer no pain, the wound is healed, and I am cured. I have had no erections. In August, 1905, the right testicle became swol- len. My general health is good and I have gained 45 pounds. May 8, 1906. — Letter. I void urine naturally, once during the night and six times during the day, about half a pint at a time. I suffer no pain. I have imperfect erections, but have not attempted intercourse. My gen- eral health is good and I consider myself cured. Pathological report. — The specimen, G. U. 119, consists of seven lobules, weighing in all 38 gm. The left lateral lobe is the larger and has been removed in two pieces. The median lobe measured about 2.5 cm. in diam- eter. The character of the prostatic lobes is about the same, irregularly lobulated, and the cut surface is fairly firm with two dilated ducts and little demarcation into spheroids. Two stones are also preserved, the larger measuring 3 x 2.5 x 2 cm. Microscopic examination. — ^The hypertrophy is a distinctly glandular one with a tendency to arrangement of the gland tissue in lobules. The acini study of lJf-5 Cases of Perineal Prostatectomy. 283 are for the most part slightly dilated, and are often closely set with but slender bands of stroma interlacing between them. Areas are seen where there is marked intraacinous proliferation in the shape of slender pedicles of connective tissue, occasionally containing some few muscle fibers, lijied by epithelium similar to the epithelium lining the acini. The stroma in places contains some young connective tissue even in areas where there is no prostatitis present. The stroma altogether contains much more con- nective tissue than muscle. Some areas of chronic prostatitis are present. The middle lobe is distinctly more fibrous than the lateral lobes, and there is present quite a marked prostatitis with partial atrophy in many areas of the gland tissue. Very few corpora amylacea are seen. Case 63. — Considerable enlargement of median and- lateral lobes. Sev- eral previous suprapubic operations for calculus and hemorrhages. Peri- neal prostatectomy. Natural urination established. Suprapubic fistula failed to close. Operation. Excision of suprapubic scar tissue and fistula. Excision of median portion of prostate. Still in hospital. No. 1326. C. R. P., age 75, widowed, admitted October 11, 1904. Complaint. — Bleeding from the bladder, and suprapubic fistula. The patient had gonorrhoea in 1875 with no complication. Present illness began 16 years ago with frequent urination, and during the next two years he had frequent attacks of gravel, often a dozen in quick succession. He had no pain or hematuria until 1891 when he passed blood for three days and urination was very frequent and difficult. He then catheterized himself and drew off two pints of bloody urine. After that he catheterized himself at various times, sometimes for complete re- tention of urine, at others to relieve a distended bladder. In August, 1897, he had considerable hemorrhage and catheterization was difficult on ac- count of clots. He then entered the Johns Hopkins Hospital. At that time he was catheterizing himself every two hours and was unable to void naturally. He was treated in the hospital for five weeks by catheterization and vesical irrigation. Examination showed a very large prostate, and a searcher detected calculi in the bladder. Operation, October 16, 1891. — Ether. Suprapubic cystotomy by Dr. Hal- sted. Two large stones were removed, and a large intravesical and pros- tatic hypertrophy discovered. A hard rubber drainage tube was sutured into the bladder. Convalescence. — The highest temperature after the operation was on the second day, 99.8°. All drainage was removed in 48 hours. For one week there was incontinence of urine, and after that the patient was able to void at intervals of two hours at first. Urine began to flow through the penis on the 13th day, and the perineal fistula closed on the 18th day. March 23, 1905. — 'Last night the patient slept five hours without urinat- ing. He voids urine in a large stream and without hesitation, and has no incontinence, except that when the desire to urinate comes on a few drops may escape before he can void. He suffers very little pain. A catheter passes with ease, and no residual urine is present. The bladder holds 320 cc. Urine is acid, sp. gr. 1015, and there is a small amount of albumin, some pus cells and bacilli. March 25, 1905. — -The patient is discharged to-day. His condition is ex- cellent. April 3, 1905. — .Letter. At times I can hold my urine for four hours, but when I become fatigued I have diflaculty in retaining it. 'November 30, 1905. — 'Letter. I void urine naturally, three times during the day and not at all during the night, about a pint at a time. The wound is closed, and I consider myself cured. I have had no erections. My general health is excellent. May 9, 1906. — 'Letter. I void two or three times during the day and once at night, and nearly a pint at a time. I have erections at night, but have not attempted intercourse. My general health is excellent. I have gained 20 pounds in weight and consider myself cured. 306 Hugh H. Young. Pathological report.— ^The specimen, G. U. 135, consists of prostate re- moved in seven pieces and weighs 145 gm. The median lobe measures about 7x4x3 cm. The intravesical portion of the right lateral lobe meas- ures 7x5x4 cm. The other masses are smaller, varying from 3 to 5 cm. in diameter. No mucous membrane has been removed with the intravesi- cal portions of the prostate, but portions of the lateral walls of the ure- thra have been removed along with the lateral lobes. The floor of the urethra and the ejaculatory ducts have not been removed. The lobes con- tain numerous spheroidal masses of various sizes more or less firmly bound together by fibrous stroma. The consistence is elastic. There are no areas of induration and no suggestion of malignancy. Microscopic examination. — fThe hypertrophy is a moderately glandular one, there being present a considerable amount of stroma. The acini are some small, others dilated, and some few show cystic degeneration and flattening of the epithelium which consists for the most part of a single layer of cells. One sees in the same section areas rather rich in gland tissue, and areas in which there is a marked hyperplasia of the connective tissue with only vestiges here and there of acini. The stroma is rather dense. There are numerous areas of chronic prostatitis with periacinous and interstitial inflammatory tissue formation. The stroma contains more connective tissue than muscle, although in places muscle fibers are fairly plentiful. The blood vessels seem practically normal. Case 73. — Considerable right lateral, small median and left lateral lodes. Recent complete retention. Residuum 80 cc. Cure. Sudden death after return home — lieart failure. No. 852. J. L. G., age 67, married, admitted February 25, 1905. Complaint. — ■" Difiiculty in urination." The patient has never had gonorrhoea. Present illness began 15 years ago with a slight difficulty and frequency of urination. Since then he has been subject to similar attacks which have gradually gotten worse. He suffers slight irritation, but never any pain. Three weeks ago complete retention of urine came on, and his phy- sician produced considerable hemorrhage in attempting to introduce a soft rubber catheter. A large silver prostatic catheter entered with ease and withdrew a pint of urine. He was catheterized for two days, but after that voided with little difficulty. At present he arises three times at night to void and has considerable difiiculty in urinating. He suffers very little, but he is afraid to leave his physician and his business requires that he take long trips. He therefore wishes to be cured. His sexual powers have been absent for three years. Examination. — The patient is a well nourished man, with lips of good color. Thorax: Expansion is fair and equal. Vocal fremitus present throughout, lungs are clear on auscultation and percussion. The heart sounds are best heard 9 cm. from the mid-line in the fifth interspace, and study of 145 Cases of Perineal Prostatectomy. 307 are clear. The heart is negative. The pulse is regular. The abdomen is negative. There is a right sided inguinal hernia for which the patient wears a truss. Rectal examination. — -Slight hemorrhoids are present. The prostate is moderately but distinctly enlarged, particularly in the right lateral lobe, which is more prominent, wider and longer than normal. The consistence is soft, contour rounded, and there is no induration. The left lateral lobe is only slightly enlarged, end soft. The seminal vesicles are not indurated. Cystoscopic eo:aniination. — A coude catheter passes after meeting an ob- struction in the median portion of the prostate and finds 80 cc. residual urine. The bladder capacity is 300 cc. and the tonicity good. The cysto- scope shows a small median bar and considerable intravesical enlargement of the right lateral lobe and a small left lateral lobe. The bladder was moderately trabeculated, but not inflamed. With the finger in the rectum and cystoscope in the urethra there was considerable thickness noted in the median portion of the prostate. Urinalysis. — Acid, sp. gr. 1016, no albumin, no sugar. Microscopically, a few leucocytes. Urea 17 grams to the liter. The secretion obtained by prostatic massage is composed of spermatozoa, a few hyaline and granular cells; no pus cell. Operation, February 28, 1905. — Ether. Perineal prostatectomy by the usual technique. The left lateral lobe was small, the median bar was only moderately large and was removed through one of the lateral cavities. The right lateral lobe was considerably enlarged and projected well into the bladder. It was easily enucleated without tearing the mucous membrane covering it. A slight linear tear was made in the urethra, but the floor and ejaculatory ducts were preserved intact. The wound was closed as usual with light gauze packs for the lateral cavities, but no tube drainage was supplied for the bladder. The amount of hemorrhage was slight, and the patient stood the operation well. An infusion was given before return to the ward. Convalescence. — On the day following the operation the temperature arose to 100.6°, but 36 hours later it was normal. The gauze packs were removed on the morning following the operation, and the patient was out of bed the next day. Forty-three hours after the operation the patient passed nearly all of his urine through his penis, and after the second day very little urine came through the perineum, and on the sixth day the fis- tula closed finally. Immediately after the operation the patient voided urine at intervals, at first every hour, on the seventh day every two hours, on the 14th day every three hours, and on the 21st day every five to six hours. For the first two weeks there was considerable urgency when the desire to urinate came on, but never any incontinence. March 21, 190-5. — iThe patient is discharged to-day (21st day). For the past week the patient has been walking about the hospital grounds. His strength normal, general condition excellent, and urination about every four hours without pain and with perfect control. His urine contains a few pus cells, but no bacteria. 308 Hugh E. Young. March 25. 1905. — Letter. I feel perfectly well. Void urine at intervals of from five to six hours without diflBculty or incontinence. March 29. 1905.— The patient died suddenly in his bed at 6 o'clock this morning. His physician, Dr. E. K. Root, writes as follows: After our patient's return, he felt perfectly well, passed urine easily without pain or dribbling, rose only once during the night and said he felt better than he had for two years. Examination showed a blood pressure of 180 mm., and I cautioned him against doing much work. On March 26 he com- plained of pain in his stomach and vomiting. There was no increase in pulse rate. I prescribed calomel, milk diet and vichy. On the evening of the 28th he felt so much better that he was up and about his room, saw som'^ personal friends and demanded more to eat, and said he would get downtown the next day. Urination was entirely normal. At 6 a. m., March 29, friends failed to arouse him, and sent for me. He was pulse- less, gasping for breath, and only lived five minutes. As the heart had always been unusually competent, my opinion was, in view of the arterial tension, that there was a sudden cerebral hemorrhage, probably basilar, that killed him. Pathological report. — The specimen, G. U. 134, consists of the three lobes of the prostate, each removed in one piece, and a sub-urethral nod- ule, total weight being 31 gm. The median lobe is the largest and meas- - ures 4x3x2 cm. The lateral lobes are about equal in size and measure 3x2x1.5 cm. A globular sub-urethral lobule about 1 cm. in diameter is present. The tissue removed is everywhere similar in character, lobu- lated and composed of gland tissue with a moderate amount of cystic di- latation, and fair amount of stroma. No mucous membrane, no ejacula- tory ducts, no calculi. Microscopic examination. — The tissue in all three lobes is of a rather glandular type, distinctly adenomatous portions varying with areas con- taining considerable stroma. There is the usual cystic degeneration, and intraacinous proliferation. The stroma is fairly equally composed of muscle and connective tissue. There is no prostatitis present. Case 74. — Moderate hypertrophy of lateral and median lobes. Cure. No. 881. J. R. G., age 61, married, admitted March 25, 1905. Complaint. — " Prostatic hypertrophy. Catheterism." Had gonorrhoea several times involving the testicles. Present illness began about two years ago with slight difficulty of urination. Since then this difficulty has gradually gotten worse. In June, 1904, the patient had a severe attack of hematuria lasting about 24 hours. For a month following he had a slight amount of blood often before and often after urination. The patient has only had to get up at night to urinate for the past six months, but of late his frequency has grown much worse, and unless he uses a catheter at bed time he has to arise six or seven times during the night. On March 16, 1905, he had a chill followed by fever and pain in the back and his physician made a diagnosis of pyelitis. study of lJf5 Cases of Perineal Prostatectomy. 309 Sexual powers.— Khovit two years ago erections were weak and inter- course very unsatisfactory, emissions often occurring before introitus. This condition remained for over a year. For the past eight months intercourse has been fairly normal. Examination.— TY^e patient is well nourished with lips of good color. Heart, lungs, and abdomen are negative. There is no hernia present. The right epididymis is indurated. Rectal examination.— Yi^terndil hemorrhoids are present in considerable mass. The prostate is markedly and symmetrically enlarged being approximately the size of a large lemon. The median furrow is shallow and the notch absent. It is smooth, soft. The seminal vesicles are pal- pable and not indurated and no enlarged glands are to be felt. The urine Fig. 46. — Case 74. is cloudy, acid. Sp. gr. 1012, there is no sugar, but considerable albu- min (5 per cent). Urea 14 gr. to the liter. Microscopically, pus cells and bacilli, no casts seen. Cystoscopic examination. — A coude catheter passes with ease and finds 100 cc. residual urine. This does not represent his residual as he was catheterized one hour before. (The true residual is 250 cc.) The bladder capacity is large and the tonicity is good. The cystoscope shows a fairly large middle lobe with a deep sulcus on each side of it, as shown in the accompanying chart. Fig. 46, R. and L. In series U' with the beak looking upward the handle is carried to the left so that as it is elevated it passes into the sulcus to the right of the middle lobe which becomes progressively prominent, as shown in 2, 3, and 4. A corresponding set of pictures is shown by carrying the cystoscope into the sulcus to the left of the lateral lobe, as shown in series U-2, by carrying the handle of the cystoscope to the right with the beak again looking upward. The bladder wall is markedly trabeculated with numerous small pouches, but with no definite diverticula and no foreign bodies. 310 Hugh H. Young. Preliminary treatment. — The patient was treated in ttie hospital one week before the operation, by hydrotherapy, urotropin, catheterization twice daily and vesical irrigation. During this time his highest tempera- ture was 99.5°. The urine contained urea 17 gr. to the liter. The daily amount voided was from 1000 to 1300 cc, sp. gr. 1012. Operation, March 30, 1905. — Perineal prostatectomy by the usual tech- nique. The lateral lobes, which were moderately enlarged, were easily enucleated, and with the right lateral lobe the middle lobe, about 3 cm. in diameter, was removed in one piece. The urethra and ejaculatory ducts were preserved, only a small linear tear being made in removing the median lobe. The wound was closed as usual with double drainage tubes and light packing for the lateral cavities. An infusion was given on the table and continuous irrigation of the bladder on the return to the ward. Convalescence. — The patient reacted well from the operation. Temper- ature on the day following was 100.8° and was fairly normal on the next day and remained so. The packing was pulled out on the day after the operation and the tubes on the following day. He was up in a wheel- chair on the fourth day and began to walk on the 10th. The urine began to flow through the urethra on the fourth day, and the fistula finally closed on the 23d day. Interval urination was established as soon as the drainage tubes were removed, and there was no period of incontinence. On the 20th day the temperature arose to 102.5° and did not reach normal for four days. There was nothing found to explain the temperature, no epididymitis, and no pain. The patient was treated by active hydro- therapy and soon regained his strength. He was discharged on the 30th day, able to retain his urine three hours, the wound closed and no incontinence present. A silver catheter passed with ease meeting no ob- struction and finding 10 cc. residual urine. Urinalysis showed pus, a small amount of albumin, and a few hyaline casts. May 6, 1905. — Letter. I void urine three or four times at night, and have a slight leakage when the desire to urinate comes on. I drink water freely and take urotropin. May 29, 1905. — I have gained nine pounds, sleep well, get up only once or twice at night and can retain my urine three and one-half hours during the day. jSJ'ovemlier 2, 1905. — Letter. I urinate on going to bed and do not void again until 6.30 in the morning. Erections have returned and I have had intercourse several times, twice fairly successfully with emissions. Kovember 30, 1905. — Letter. I void urine naturally, only once during the night, six to eight ounces at a time. I suffer no pain and consider myself cured. I have erections, but they are slight, and intercourse is not satisfactory as a rule. May 9, 1906. — Letter. I void urine naturally, every three or four time^ during the day, and am not disturbed from bed time until morning. The amount voided is about eight ounces each time. I suffer no pain. I have erections and sexual intercourse which is not entirely satisfactory, erec- tions as yet being somewhat imperfect. My general health is fine, I have gained 25 pounds and consider myself cured. study of lJf5 Cases of Perineal Prostatectomy. 311 Pathological report. — The specimen, G. U. 145, consists of two pieces. The larger measures 8x4x3 cm. and comprises the median and right lateral lobe which have been removed in one piece. The left lateral lobe measures 3.5 x 3 x 2 cm. in size. The surface of the lobes is somewhat irregular with numerous small lobules, and on section spheroids with intervening fibrous stroma and occasional dilated acini are seen. The specimen weighs about G-40. Microscopic examination. — The tissue is rather rich in stroma, moder- ately glandular areas alternating with areas containing mostly stroma. The acini are for the most part small, but occasionally areas where they are moderately dilated are seen. The epithelium lining the culs-de-sac usually consists of two layers, the superficial layer being cylindrical, and the deep layer on the basement membrane cuboidal type. There is considerable irregularity of the lumina of the acini. The stroma shows considerable young connective tissue, and there is a fair amount of muscle present. In some of the more fibrous areas the blood vessels show considerable arteriosclerotic change. There is present quite an extensive chronic glandular and interstitial prostatitis. Case 75. — Moderate enlargement of median and lateral lobes. Small suburethral lobe. Irritable bladder. Cystitis. Pyelitis. Relief of obstruc- tion. Cystitis persists. Examination IJf months after operation. Residual urine 20 cc. Contracted bladder. Small vesical calculus. Suprapubic lithotomy. Cured. No. 860. 0. T. S., age 69, married, admitted March 4, 1905. Complaint. — " Prostatic hypertrophy and difficulty in urination." No history of gonorrhoea. Present illness began five years ago with slight difficulty of urination and an intermittent frequency. After remaining the same for about two years the difficulty began to increase, but it did not become severe until November, 1904, when complete retention of urine came on. After one catheterization he was able to void, but he has been so uncomfortable that he has used a catheter three or four times a day since. Residual urine which at first was 11 ounces has recently been only three or four ounces. Two months ago he began to have a dull pain in the region of the right kidney which was very tender on pressure, and this condition persisted for four weeks. S. P. — The patient is voiding urine very frequently and suffers con- siderable pain in the bladder. He catheterizes himself three times a day and finds from two to four ounces of residual urine. When the bladder is emptied with the catheter he has a sharp pain which is sometimes so severe as to require morphia. Sexual powers. — Erections are still present, but sexual powers are unsatisfactory on account of pain on ejaculation. Examination. — Patient is a well nourished man with lips of good color. His lungs are somewhat emphysematous, but the heart is negative. There is no enlargement or tenderness in the region of either kidney. Genitalia. — The right globus major is somewhat indurated. 313 Hugh H. Young. Rectal. — The prostate is moderately hypertrophied, contour is rounded, smooth. The left lobe is soft and the right slightly indurated. The median furrow and notch are shallow. The prostate is not adherent to surrounding structures. The seminal vesicles are not palpable, no glands are to be felt. Urinalysis. — Urine is quite cloudy, acid, 1020, there is a small amount of sugar present, a trace of albumin, microscopically, a few pus cells and bacilli. Preliviinary treatment. — The patient was treated four days before oper- ation. Urotropin, lithia water in abundance, diabetic diet, catheterization. Fig. 47. — Median bar, small suburethral lobe, two lateral lobes, Case 75. and vesical irrigation twice daily. Sp. gr. of the urine varied from 1010 to 1020, the sugar was in very small amount. Urination was very frequent, about every 15 minutes night and day, and there was considerable pain in the bladder. Cystoscopic examination. — A catheter passes with ease and finds 50 cc. residual urine. Bladder is very small, holding only 175 cc. on forcible distention. Cystoscope shows a median bar and two slightly enlarged lateral lobes with a small sulcus in front. Cystoscopic examination was unsatisfactory on account of hemorrhage. No calculus was seen and using the cystoscope as a searcher it was impossible to feel one. With finger in study of IJfO Cases of Perineal Prostatectomy. 313 rectum and cystoscope in urethra the median portion of the prostate was thickened and lengthened. Note. — During the six days in the hospital very little residual urine was obtained with the catheter, the bladder was very small and irritable, and urination was painful. Prostatectomy to be followed by vesical dila- tation was advised. Operation, March 10, 1905. — Ether. Perineal prostatectomy by the usual technique. The right lateral lobe was larger than the left, measuring 6x3x3 cm. in size. The median bar was removed partly through each lateral cavity, Fig. 47. Examination then showed a globular suburethral mags about the size of a cherry, this was shelled out with great ease without tearing the mucous membrane covering it. This seemed to be an enlargement of the prespermatic group of glands and was entirely suburethral. The floor of the urethra and ejaculatory ducts were not disturbed, but a slight tear was made in the lateral wall of the urethra on each side. A finger, inserted after removal of the tractor, showed no remaining enlargement. The bladder was searched with a long spoon and no calculus found. The wound was closed as usual with double catheter drainage for the bladder and light gauze packs for the lateral cavities. Patient stood the operation well. His pulse at the end was 75. Sub- mammary infusion was given on the table, and intravesical irrigation after return to ward. Convalescence. — The patient reacted well, the highest temperature being on the day after the operation, 100.4°; after three days it was prac- tically normal. The gauze drain was removed in 18 hours and the tubes in 24 hours. He was out of bed in a wheel chair on the second day and began to walk on the third. Urine came through the penis on the second day and the fistula closed on the sixth day. Incontinence ceased on the fifth day, and at the end of two weeks the patient was holding his urine for two hours. The patient was discharged on the 23d day. At that time the wound was firmly healed, the urine was voided at intervals of two to three hours without hesitation or pain, a catheter passed with ease meeting no obstruction and finding no residual urine. The bladder capacity was 250 cc. No stone could be felt. Urine was slightly cloudy and contained pus and bacilli. November 30, 1905. — Letter. I have not used a catheter, can void urine naturally, but micturition is accompanied by a scalding pain and occurs every two hours night and day. The average amount voided was two ounces, the largest amount seven ounces. I have had no erections. February 5, 1906. — Urination is still frequent and accompanied by a burning pain. The amount voided is usually one and one-half to two ounces. A catheter passes easily, shows no evidence of obstruction and finds no residual urine. The bladder is very irritable, the capacity is small, holding only 150 cc. on forced distention. The wound is healed, and rectal examination shows no remaining prostatic enlargement. No evidence of malignancy. The urine is acid and very purulent. The Vol. XIV.— 21. 314 Hugh H. Young. patient's physician was advised to dilate the bladder forcibly by hydraulic with an idea of increasing the capacity and improving the cystitis. The frequency of urination is evidently due to irritable cystitis and contracture of the bladder. May 14, 1906. — Patient returns for examination. He says that he has no difficulty in urination, but that he voids very frequently almost every hour night and day. Since the operation he has had several attacks of pain in the region of the right kidney, and during the past two months has passed about 40 small calculi. He has pain at the end of urination and in the end of the penis. Examination. — The urine is cloudy and contains pus and bacilli. A coude catheter passes with ease and finds 20 cc. residual uriue, bladder capacity of 125 cc. and quite irritable. The cystoscope shows a small irregular white stone lying in the right half of the bladder but free. The vesical mucosa was markedly inflamed, trabeculated, and a shallow diverticulum was found in the left half. Study of the prostatic orifice shows a small but definite rounded median enlargement with a cleft on each side. Operation, May 18, 1906. — Ether. Suprapubic cystotomy. Two small calculi were found and rpmoved. Examination showed a large prostatic orifice which easily admitted the index finger. The lateral lobes were not at all enlarged. In the median portion there was a small transverse fold of mucous membrane about 8 mm. thick which was soft and flabby, but distinctly elevated above the trigone. Although the prostatic orifice was very large, and the presence of only 20 cc. of residual urine showed that there was very little obstruction, it was thought best to excise this median fold. It was accordingly caught between clamps and excised and a piece of tissue about 2 cm. wide and 1 cm. deep excised with the scissors coming away in two pieces. Examination showed mucous membrane and fibrous tissue, no evidence of prostatic glands. There was only a moderate amount of bleeding and the bladder was closed completely with interrupted catgut sutures. The recti muscles and skin were drawn together with interrupted sutures of silver wire, with a small gauze drain- age at the lower angle. Convalescence. — Immediately after the operation there was considerable intravesical hemorrhage with complete retention of urine. It was neces- sary to pass catheters several times to evacuate clots of blood. The patient suffered a great deal of pain and became quite weak. It was evident that the bladder should not have been completely closed as it broke down the following day. For a week the patient was very exhausted and his condi- tion was serious, but during the second week he rallied. On the 14th day a catheter was fastened in the urethra to hasten closure of the supra- pubic fistula. It was removed at the end of nine days, but the fistula did not heal until four days later, 26 days after the operation. June 15, 1906. — The patient is in good condition, the fistula has been closed for three days, he voids urine without pain, has no incontinence and can retain it for three hours. study of 14-5 Cases of Perineal Prostatectomy. 315 PatJiological report. — Tte specimen, G. U. 139. The prostate has been removed in four pieces and weighs 3 G. The right lateral lobe is the larger, and measures 5x3x2 cm., the left lateral measures 3x2x2 cm. The median bar is an irregular mass 3.5 x 2 x 1.5 cm. in size. A sub- urethral lobule measures 2 xl.5 x 1.5 cm. is smooth and has a smooth capsule. The relative arrangement of these lobes is shown in the accom- panying photograph. The lateral lobes are composed of irregular spher- oids, and the median bar is of similar structure. The sub-urethral lobule is much firmer, and almost homogeneous. Microscopic examination. — In the right lobe the hypertrophy is a rather lobulated glandular one with dilatation and cystic degeneration of the acini. The stroma is largely composed of fibrous tissue, and there has been a great deal of new inflammatory tissue formation. In areas the new formed fibrous tissue is leading to compression of the acini. The suburethral lobe is almost entirely fibrous, only occasionally does one encounter the vestige of an acinous. There is present very marked round cell and polynuclear infiltration with formation of new inflammatory tissue. The arteries are markedly sclerosed. In the right lobe the arteries show practically no thickening. Case 76. — Moderate enlargement of median and lateral lobes. Cathet- erism twice daily. Cure. Folloived 14 months. No. 853. F. H. W., age 63, married, admitted March 7, 1905. Complaint. — " Prostatic enlargement. Frequency of urination." Had chronic gonorrhcea for years in his youth.. Present illness began about 15 years ago with slight difficulty of urination, and dribbling at the end. Had very little trouble until five years ago after which there was a considerable increase in his urinary difficulty and! frequency. Has never had complete retention of urine, but three months ago on the advice of a physician he began the use of a catheter at bed time. Has had only slight amount of pain and entirely confined to the bladder. No hematuria. S. P. — The patient catheterizes himself at bed time and after that he does not void until morning, but then voids every hour until catheterized again. He has slight dribbling at the end of urination, but suffers no pain. Sexual powers. — Good. Examination. — The patient is a sturdy looking man with lips of good color. The chest and abdomen are negative. Rectal. — The prostate is moderately enlarged, smooth, firm, but not markedly indurated. The seminal vesicles are negative. Urinalysis. — Cloudy, alkaline, sp. gr. 1016, no albumin, no sugar, urea G-12 to liter. Microscopically, pus cells and bacilli. Cystoscopic. — A coude catheter passes with ease and finds 200 cc. residual urine. The bladder capacity is about 250 cc. The cystoscope shows very slightly hypertrophied lateral lobes with a shallow sulcus between them in front. There is a small but definite median bar with no sulci on either 316 Hugh H. Young. side behind which the ureters and most of the trigone can be easily seen. With finger in rectum and cystoscope in urethra the median portion of the prostate is found to be only moderately thicker than normal. Operation, March 11, 1905. — Ether. Perineal prostatectomy by the usual technique. The left lateral lobe was smaller than the right, but this was only moderately enlarged, both were easily enucleated. The median bar was removed in one piece with the right lateral lobe and left a cavity beneath the urethra which formed a communication between the two lateral cavities. The urethra above it and the ejaculatory ducts behind it were not injured. After removal of the tractor a finger in the bladder showed no remaining enlargement. The wound was closed as usual with double drainage tubes and light packs for the lateral cavities. The patient stood the operation well, pulse at the end 72. Continuous irrigation and infusion on return to ward. Convalescence. — On the second day after the operation the temperature arose to 103°, but fell to normal the next day, and afterwards did not rise above 100°. The irrigation was discontinued after 10 hours, the tubes removed in 18 hours and the gauze packing in 24 hours. The patient was out of bed on the fourth day, was walking on the sixth, began to pass urine through the anterior urethra on the fifth day, and the fistula closed on the 17th day. He had an erection five days after the operation. He was discharged from the hospital on the 20th day. At that time he retained his urine for four hours, had no incontinence, except a slight leakage when his bladder became very full. The wound was healed. A catheter passed with ease and found no residual urine and the bladder capacity 225 cc. May 19, 1905. — The wound opened slightly and a fistula formed after returning home. I can retain urine for six hours and am perfectly well. July 20, 1905. — Letter. The fistula healed after several curettements. His cystitis troubles him somewhat. November 30, 1905. — Letter. I void urine naturally, and often do not get up at night to urinate at all. The amount voided is about four ounces and I suffer no pain, the wound is healed and I consider myself cured. I have erections but seldom, and intercourse is not entirely satisfactory. My general health is excellent. May 8, 1906. — Letter. I void urine as well as I ever could, at intervals of four hours during the day and only occasionally rise at night. My general health is excellent, I have gained 16 pounds and am completely cured. Pathological report. — The specimen, G. U. 142, consists of the three lobes of the prostate each removed in one piece, and weighs about G-21. The median lobe is the largest and measures 2.5 cm. in diameter. The lateral lobes measure 2.5 x 2.5 x 2 cm. in size. The appearance of the three lobes is about the same, the external surface being irregular, and the cut surface showing considerable stroma. Very few dilated acini. No ejac- ulatory ducts. Microscopic examination. — The hypertrophy is a moderately glandular one, the usual characteristic appearance alternating with broad bands of study of lJi-5 Cases of Perineal Prostatectomy. 317 stroma in which the acini are small and rather compressed. The inter- stitial bands interlacing in the lobules are unusually broad, while in the areas outside, the stroma is, as a rule, in excess of the gland tissue. Fairly numerous areas of interstitial and glandular prostatitis are pres- ent. The stroma distinctly contains more muscle than connective tissue. Case 77. — Small sclerotic prostate. Vesiculitis. Residual urine 500 cc. Cured. No. 871. T. J. E., age 67, married, admitted March 14, 1905. Complaint. — " Frequency of urination and incontinence." Gonorrhoea 25 years ago, slight attack. Present illness began three years ago with frequency of urination. About the same time began to have slight incontinence. The trouble increased rapidly, and it soon became necessary to defecate in order to urinate. At present he urinates about every two hours, and has great difficulty in starting the flow of urine unless his bowels move at the same time so that he has practiced the habit of defecating at each urination. Urine escapes involuntarily in varying amounts both night and day so that it is necessary for him to wear a rubber receptacle. Pain has not been a prominent symptom and he has not lost weight. He has never had complete retention of urine, and no hematuria. Sexual powers.— Occasionally he has partial erections, but he has been unable to have intercourse for two years. Examination. — The patient is a large healthy looking man, his lips are of good color. The lungs are clear. There is a slight systolic murmur at the apex, but the pulse is good. Abdomen is negative. There is a right inguinal hernia present which is easily reduced. Rectal. — The prostate is not much larger than normal and does not bulge towards the rectum, but the outlines are difficult to make out, the surface being irregular, hard in places and soft in others, but there is no stony induration, and no periprostatic induration or glands. The seminal vesicles are both indurated and irregular. Above the prostate and running from one seminal vesicle to the other is an indurated band. Urinalysis. — Clear, amber. First glass contains a few shreds composed of epithelium. Second and third glasses are clear and contain no shreds. The urine is acid. 1012, no albumin, no sugar. Urea G-12.5 per liter. Microscopically negative for bacteria and pus cells. Cystoscopic. — A catheter passes with ease and finds 500 cc. residual urine. The cystoscope shows very little enlargement of the lateral lobes, and only a slightly enlarged median bar behind which the ureters and most of the trigone can be seen. Preliminary treatment. — The patient was catheterized twice daily and took urotropin 20 grains a day. Examination of reflexes showed no evi- dence of spinal cord disease, and although the prostate was very little enlarged, the amount of residual urine was considerable and perineal pros- tatectomy seemed advisable. 318 Hugh H. Young. Operation, March 18, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were very little enlarged, hard and very adherent. The median bar of the prostate was removed partly with each lateral lobe. It was found to be continuous with structures beneath the trigone and scissors were used to remove it. Examination with the finger in the urethra showed that the median bar had been completely removed, but the vesical orifice was still quite constricted, but dilated easily with the finger. Examination of the specimen showed that both ejaculatory ducts had been removed along with the median bar to which they were closely attached by firm fibrous adhesions. This was a second instance in which they were unintentionally removed and in no other specimens have the ducts been found. The wound was closed as usual, but the hem- orrhage was so slight that no drainage tube was inserted, the lateral cavi- ties being lightly packed with gauze. Infusion on return to ward. The patient stood the operation well, the pulse at the end being 96. Convalescence. — The patient reacted well. The temperature rose to 101° on the day after the operation, but on the next day it was normal. The gauze packing was removed within 24 hours and the patient was up in a wheel chair on the second day, his condition being excellent. On the eighth day slight epididymitis appeared on the right side, but under treatment with ice it rapidly disappeared, and in five days his condition was excellent. The urine did not come through the anterior urethra until the 19th day, and the perineal fistula did not close finally until the 44th day. From April 6th to the 21st, there was an evening rise of temperature, at times as high as 102° and during this time the patient was drowsy, hard to get out of bed and had very little appetite. After that he was free from temperature and improved rapidly in strength. He left the hospital on the 51st day in good condition, able to retain his urine four hours at night and three hours during the day, no dribbling, stream satisfactory. His bowels moved only once or twice during the day and he had good control of his rectal sphincter (which he had not had for five years). Examination. — Urine is voided in a good stream, but it is cloudy and contains bacilli in large number. The perineal wound is healed. Rectal examination shows the usual amount of scar tissue. The seminal vesicles are indurated, but there is nothing to suggest malignancy. May 25, 1905. — I can retain urine three or four hours and have perfect control. I do not have to evacuate my bowels during urination. Septemter 21, 1905. — I have not felt better for 30 years. I sleep well. Usually awake at 2 a. m. to urinate. Decemler 1, 1905. — I have gained 12 pounds in weight. I often sleep until 4 o'clock in the morning before urinating. I can void one pint at a time, have only a slight irritation in the morning, the wound is closed and I consider myself cured. February I4, 1906. — Letter. My frequency of urination depends upon my nervousness. If I know a urinal is not convenient I get nervous and the desire to urinate comes on much sooner than when I am at home where study of lJf5 Cases of Perineal Prostatectomy. 319 I am able to retain urine for two hours. At times the stream is almost perfect, at others spiral and forked.. I generally void urine at two and at five during the night. Sometimes I pass as much as eight ounces at a time. There is a sympathy between the bladder and rectum, and if I retain the urine beyond a certain point I must empty the rectum with the bladder. I suffer irritation but cannot call it pain, and it seems to depend upon my nervous condition. When quiet I have no irritation for hours. My general health is better, notwithstanding that I have been operated upon for cataract. May Ji, 1906. — The wound has remained healed, I void urine naturally, about three-quarters of a pint at a time. I do not use a catheter and have only a slight pain when the bladder becomes full. My general health is good and I consider myself very much improved. Pathological report. — The specimen, G. U. 141, consists of the lateral lobes of the prostate each in one piece. The right lobe measures 3x2.5x2 cm. in size. The surface is irregular, and at its upper end is a mass of tissue about 1 cm. in diameter containing the ejaculatory duet, which is very easily seen, being about 3 mm. in diameter and with a thick white wall. The left lobe measures 3x3x2 cm. in size and has a similar mass attached to its upper end which contains the ejaculatory duct. Section of the prostatic lobe shows spheroids, but more fibrous stroma than usual. The prostate weighs about 20 grams. Microscopic examination. — The hypertrophy is distinctly of the fibro- muscular type there being comparatively no gland acini present. In considerable areas almost pure bundles of muscle fibers are present while in other areas the fibrous tissue predominates. The few acini which are present are dilated, and lined by two layers of rather flat epithelium. Everywhere is present much embryonic connective tissue. As a whole the muscle element is considerably in excess of the connective tissue, al- though here and there one sees a rather fibrous nodule with some round cell infiltration, but even here distinct muscle fibers are present. The arteries show a moderate degree of arteriosclerosis, and at times, especially in the larger vessels, the thickening is marked. There is present every- where a well marked prostatitis. Case 78. — Moderate hypertrophy of median and lateral lobes. Complete retention of urine. Catheter life. Cured. Followed 14 months. No. 877. E. H. S., age 65, married, admitted March 24, 1905. Complaint. — " Enlarged prostate. Catheterism." No history of gonorrhoea. Present illness began five years ago with frequency and precipitancy of urination. Trouble gradually increased, and four months ago the patient found that his lower abdomen was enlarged. He was catheterized and a large amount of residual urine withdrawn. Since then the patient has been unable to void urine and has catheterized himself three times a day. Has never had pain nor hematuria. 320 Eugh H. Young. Sexual powers. — Erections are imperfect and as a rule not sufficient for entrance. Sexual intercourse very unsatisfactory. Examination. — Tlie patient is a healthy looking man. Chest, lungs, and abdomen negative. Rectal examination. — The prostate is only moderately enlarged, soft and does not suggest malignancy. Urinalysis. — Cloudy, acid, sp. gr. 1023, albumin in slight amount, no sugar, urea 24 gr. to the liter. Microscopically, pus cells, bacilli, and cocci. Cystoscopic examination. — A catheter passes with ease, the bladder is large, tonicity good, retention of urine complete. The cystoscope shows a moderately large median lobe and moderate intravesical hypertrophy of the lateral lobes. The bladder is trabeculated and there is a moderate cystitis. No stone present. Operation, March 27, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes which were moderately enlarged were re- moved each in one piece. The median bar and a pedunculated lobe, which was attached to it, were removed in one piece through the right lateral cavity. A small tear was made in the urethra but no mucous membrane was removed and the ejaculatory ducts were preserved. The finger was inserted into the bladder and showed no remaining prostatic enlargement. The wound was closed as usual with double catheter drainage and light gauze packs for the lateral cavities. The patient stood the operation well, the pulse at the end was 90. On return to ward an infusion was given and continuous intravesical irrigation was begun. Convalescence. — The patient reacted well. The temperature reached 101° on the day after the operation, but was normal after the second day. Gauze was removed in 24 hours and the irrigation stopped. The tubes were removed the next day, and the patient was up in a chair. He began to walk about the ward on the fourth day. Interval urination was established after the removal of the tubes, at first every hour, but the interval rapidly increased. On the seventh day urine came through the penis and the fistula closed on the 18th day. Broke open two days later. The patient was discharged on the 26th day. There was still a pin point fistula. Patient had no incontinence, was able to hold urine for five hours, and suffered no pain. A small silver catheter passed with ease and found 30 cc. residual urine. The fistula was curetted and the patient instructed to take urotropin, lithia water in abundance and to retain urine as long as possible to distend the bladder. (The fistula closed on the 46th day.) Novemier 30, 1905. — Letter. The fistula closed soon after my return. I have had no instrumentation. Void urine once at night and four times during the day. Micturition is normal, I have no pain and I consider myself cured. Erections occur occasionally and intercourse is satisfactory. May 8, 1906. — Letter. I void urine at natural intervals, suffer no pain. I have no erections. My general health is excellent. I consider myself cured. Pathological report. — The specimen, G. U. 144, consists of the median and lateral lobes of the prostate removed in three pieces, and weighing G-43. study of 14-5 Cases of Perineal Prostatectomy. 381 The median lobe is composed of irregular lobules and measures 5 x 2.5 x 1.5 cm. The right lobe measures 5 x 3 x 2.5 cm. The left lobe 5x3x2 cm. The consistence is everywhere elastic, and on section shows typical adeno- matous spheroids. Microscopic examination. — The hypertrophy is a lobulated glandular one. The acini show the usual dilatation with occasional cystic degeneration. The epithelium lining the acini is usually two layers in thickness al- though occasionally one sees solid epithelial cones many layers in depth, and again slender bands of connective tissue growing into other epithelial masses which would seem to represent new glands in the process of formation. This picture is frequently seen in these glandular prostates. The stroma is rather loose, and contains considerable new connective tissue, even in areas where there is no inflammatory infiltration and even where there is no prostatitis in the immediate neighborhood. There is a fair amount of muscle present, and some areas of chronic prostatitis. Case 79. — Considerable hypertrophy of lateral lobes. Small median bar. Intermittent attacks of great frequency and difficulty of urination. Cure. Followed 14 months. No. 879. A. H. L., age 68, widowed, admitted March 25, 1905. Complaint. — " Diflaculty in passing urine." No history of gonorrhoea. Present illness began about five years ago with slight difficulty and frequency of urination. This had gradually increased until the patient now voids every half hour during the morning, but during the rest of the day he is fairly comfortable and at times in the afternoon he will not urinate for three hours and as a rule only gets up once at night. Urine is passed only after considerable straining and the stream is small. He has been catheterized several times, but never on account of retention. Two years ago he had hematuria lasting 24 hours, and several months later a similar attack, but there was no pain in the kidney, bladder, or penis. He has not lost weight, his erections are fairly good, but he has not had intercourse for years. S. P. — The patient urinates at intervals varying from two to four hours, but occasionally there are periods during which urination is very frequent and the bladder very irritable. He usually arises only once at night. Examination. — The patient is sturdy in appearance and his lips are of good color. Chest and abdomen negative. A large right inguinal hernia is present. The testicles and epididymis are normal. Rectal examination. — The prostate is considerably enlarged particularly in its transverse diameter which is at least twice as great as normal. The median furrow is wide and the notch is fairly deep. The surface is smooth, rounded, elastic, the seminal vesicles are not indurated. Urine. — Cloudy, alkaline, 1020. Albumin moderate. Microscopically, pus cells, no bacteria seen. Cystoscopic examination. — A small coude catheter passes and meets with -considerable obstruction before entering the bladder. Only 25 cc. residual 322 Hugh H. Young. urine present. Bladder capacity is 240 cc, the tonicity is good. The cys- toscope shows a medium sized sessile middle lobe with a shallow sulcus on each side. The lateral do not project much into the bladder and there is no cleft between them in front. With the finger in the rectum and cystoscope in the urethra a considerable increase in the median portion of the prostate is made out. There was no foreign body present. Operation, March 30, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were of considerable size and easily enucle- ated. The median lobe was drawn down into the left lateral cavity without injury of the urethra, bladder or ejaculatory ducts. The middle lobe was about 2y2 cm. in diameter. Owing to the absence of cystitis the operator did not insert a catheter into the bladder, but packed the lateral cavities lightly ■ with gauze. The patient was infused, and the wound closed as usual. The patient stood the operation well. Convalescence. — There was more hemorrhage than usual during the night after the operation, but the pulse which was 74 at the end of the operation did not go above 84 during the night. The gauze was removed 16 hours after the operation, at that time hemorrhage had ceased and condition of the patient was excellent. The patient was up in a wheel chair on the fourth day and on this day the urine began to come through the penis, but the fistula did not close finally until the 20th day. Immediately after the operation the patient was able to retain urine for a definite interval. Since then the time between urinations has increased and on the 21st day he was voiding urine every five hours. There was no incontinence but urination was often urgent, and the sphincter weak, so that when he coughs a few drops may escape. Erections returned two weeks after the operation. He was discharged from the hospital on the 28th day. The wound healed. Voiding urine every five hours without pain and with good force. The urine before operation was clear, 1020, contained albumin and a few pus cells, but no bacteria. On the 15th day the patient developed fever without explainable cause. There was no epididymitis, no renal or lung complication. It began with a temperature of 102.5°, but after three days it was almost normal. July 20, 1905. — Report by his physician. This case has been eminently satisfactory. There is no cystitis, no fistula. November 30, 1905. — Letter. Urine passes without difficulty, several times during the day and once at night. I have no pain, but there is still sensitiveness in the bladder and occasionally I have to void urine three times at night on this account. Erections have returned. My general health is excellent and I have gained in weight. May 21, 1906. — Letter. I void urine naturally at intervals of from three to five hours, and frequently none at all at night. I suffer no pain, erections have returned. I have had no complications and no treat- ment. My general health is good, and I consider the operation entirely satisfactory. Pathological report. — The specimen, G. U. 146, consists of four pieces study of IJfO Cases of Perineal Prostatectomy. 323 and vreighs about G-55. The median lobe is in the shape of a globular mass about 2% cm. in diameter with a smooth outer surface. On section it shows considerable gland tissue with little stroma. The left lateral lobe has been removed in one piece, and measures about 4x4x3 cm. TTie surface is fairly smooth, encapsulated. On section there is considerable stroma and many dilated acini. The right lobe has been removed in two pieces, both of which are considerably torn. It presents a similar appear- ance to the left. No mucous membrane, no ejaculatory ducts are present, no calculus present. Microscopic examination. — Microscopically the tissue is a moderately glandular one with the formation of spherical lobules. There is a consid- erable, amount of stroma present. Within the lobulated areas the stroma is more evident than one sees in manj^ of these similar hypertrophies. The acini are moderately dilated and in areas there is fairly well marked cystic degeneration. The stroma contains much more fibrous tissue than muscle. In the interlobular areas the stroma is more abundant, but there is present a fair amount of glandular element. Some areas of small round cell infiltration are seen. Numerous corpora amylacea are present in the ducts. The arteries are apparently not undergoing any sclerotic changes. Case 80. — Large hypertrophy of median and lateral lobes. Emphysema of lungs, cardiac murmur. Casts in urine. Cure. Followed 13 months. No. 1331. J. M., age 65, single, admitted March 5, 1905. Complaint. — ^" Retention of urine." Patient had gonorrhoea at the age of 24 and again at the age of 34. No epididymitis with either attack. Present illness.— ^Fov 15 years the patient has had a slight increased fre- quency of urination, but no dysuria. In October, 1903, he had complete retention of urine requiring catheterization. After this he remained fairly well but for frequency of urination until one week ago. Since then he has been unable to void and has been catheterized twice a day with ex- treme difficulty. He is weak and has lost weight. Sexual powers. — ^Normal. Examination. — 'The patient is sturdy, his lips are of good color. Lungs. — Everywhere hyperresonant, mucous rales over both bases. Heart negative except slight presystolic rumble at apex. The abdomen is negative. Rectal. — iProstate is considerably and symmetrically enlarged, smooth, elastic. There is no induration in the region of the seminal vesicles, no tenderness. Cystoscopic. — ^The patient was able to void 15 cc. and was catheterized immediately afterward, residual urine 240 cc, bladder capacity 300 cc. The cystoscope shows a large globular median lobe with a deep sulcus on each side. The lateral lobes are very little intravesically hypertrophied and there is no sulcus between them in front. With finger in rectum and cystoscope in urethra there is considerable increase in the median portion. Preliminary treatment. — Continuous drainage through a permanent cath- 334 Hugh H. Young. eter, vesical irrigations, urotropin, large amounts of water by mouth. Under this treatment the urea increased from 28 gm. to 36 gm., and the total solids from 44 gm. to 52 gm. The urine contained pus cells, a few hyaline casts. Sp. gr. 1015 to 1025, albumin a trace. Operation, April 6, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes which measured 3x4x6 cm. in size were each removed in one piece without tearing the mucous membrane. A small portion of the median lobe was removed with the right lateral lobe. Most of the median lobe was found drawn well down along the urethra by the tractor by the rotation and traction on the instrument. It was very adherent to the mucous membrane and a small area of this was removed adherent to the lobe. Examination with the finger showed no remaining enlargement. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well, pulse at end 90. Continuous irrigation and infusion on return to the ward. Convalescence. — The patient reacted well. The highest temperature was on the fourth day after the operation, 102°, after that practically normal. The gauze and catheters were removed on the day after the operation, and the patient was up in a wheel chair the next day and walked on the third day. On the fifth day a very slight epididymitis developed on the right side which disappeared quickly under ice bag treatment. The temperature did not remain elevated for more than two days. The urine did not flow through the anterior urethra until the 17th day, and the patient was dis- charged on the 20th day. The wound had healed per primam, there was a pin point fistula through which only a few drops of urine escaped, and he was able to retain urine for four hours and suffered no pain. General con- dition excellent. The fistula finally closed on the 25th day. February 20, 1906. — Letter. The wound has remained healed, I void just like a boy, have no dribbling. Urinate at intervals of five or six hours in the day and six or seven hours in the night. I suffer no pain. Erec- tions have returned and sexual intercourse is normal and entirely satisfac- tory. Ejaculations profuse. I have had no complications and my health is fine. May 6, 1906. — Letter. I void urine naturally at normal intervals, about six ounces at a time. I have no pain. I have erections and satisfactory intercourse, the act being the same as before operation. My general health is good, I have gained 40 pounds and I consider myself cured. Pathological report. — -The specimen, G. U. 147, consists of the three lobes of the prostate removed each in one piece and weighs about 20 gm. The right lobe measures 4 x 2.5 x 2 cm., is fairly smooth, elastic, and on section shows a little capsule, fairly homogeneous surface with few spheroids, few dilated acini and little stroma. The left lobe is about the same size as the right, but seems to contain more stroma. The median lobe measures 3 x 2 X 1.5 cm., and is similar in appearance to the others. No mucous mem- brane, no ejaculatory ducts, no calculi. Microscopic examination. — In the right lateral the tissue contains very study of 145 Cases of Perineal Prostatectomy. 325 distinct lobules which are mostly composed of adenomatous tissue, and between these lobules are bands containing a fair number of glandular culs-de-sac. The acini within the lobules show considerably more dilata- tion and evidence of glandular proliferation than do the acini in the stroma outside. In the interstitial tissue between these glandular lobules there is a very marked prostatitis present, the lumina of the culs-de-sac being often filled with leucocytes and epithelial cells. The inflammatory infiltration in places is almost of sufficient density to suggest abscess formation. The prostatitis, however, does not seem to have invaded these glandular lobules, although they are surrounded on all sides by the in- flammatory processes. The left lobe is distinctly less glandular than the right, and there seems to be no formation of spherical lobules. There is everywhere present a diffuse prostatitis, the ducts being filled with leucocytes and epithelial cells and the interstitial tissue infiltrated. The picture in the left lobe is almost purely one of prostatitis with very little evidence of gland proiferation. Case 81. — Moderate hypertrophy. Two calculi. Incomplete retention. Cure. No. 888. C. A., age 62, married, admitted April 11, 1905. Complaint. — " Bladder trouble." Gonorrhoea at the age of 32, followed by gleet, no stricture. Present illness began 12 years ago with a sudden attack of retention of urine, requiring catheterization for two days. After that the course of the disease was characterized by gradual increase in difficulty and fre- quency which has been considerably worse during the past few years — ^no pain, but occasionally slight hematuria. 8. P. — ^Urination every hour during the night, every one and one-half hour during the day. For the past two months there has been a slight pain during urination, and occasionally hemorrhage. Sexual powers. — ^Erections, ejaculations and coitus normal. Examination. — Patient is a sturdy looking man. Chest and abdomen negative. Rectal. — The prostate is enlarged, but only moderately. It is smooth, elastic, fairly firm. The median furrow is shallow and the notch absent. At the upper end of the right lateral lobe is a small, hard, round mass which projects upward towards the seminal vesicle which is not indurated. The left seminal vesicle was also normal, and there are no adhesions. Urinalysis. — Very cloudy, alkaline, sp. gr. 1015, no sugar, albumin in moderate amount. Urea 10 gm. to the liter. Microscopically, bacilli, cocci and pus cells. Cystoscopic. — A coude catheter passes with ease and finds 150 cc. resid- ual urine. The bladder is contracted and holds only 250 cc. The cysto- scope shows very little enlargement of the lateral lobes, but a distinct, though small, median enlargement with a sulcus on each side. The mu- cous membrane covering the median lobe is extremely red and two large 326 Hugh H. Young. granulations are seen on its apex. Tlie bladder is markedly trabeculated, and contains two small oval, white calculi. No diverticula seen. With finger in rectum and cystoscope in urethra, the beak of the instrument is indistinctly felt, the median portion of the prostate is considerably in- creased. Operation, April 11, 1905. — Ether. Perineal prostatectomy by the usual technique. Removal of two calculi through wound. The lateral lobes which were easily enucleated were only moderately enlarged. A large me- dian lobe about the size of a walnut was enucleated through one of the lateral cavities. The urethra was then divided longitudinally along the left lateral wall, the neck of the bladder dilated, forceps inserted and two calculi removed without crushing; no additional calculi were found. The wound was closed as usual with double catheter drainage and light packs for the lateral cavities. Infusion and continuous irrigation on re- turn to ward. Pulse at end of operation was 95. Convalescence. — iThe patient reacted well, the temperature rising on the second day to 100.6°, but normal after the second day. The continuous irrigation was discontinued after 14 hours, gauze was removed in 24 hours, the tubes in 48. Urine passed through the anterior urethra on the third day, and the fistula closed on the 25th day. He left the hospital on the 30th day in good condition, able to retain urine for four hours during the day and voiding only twice during the night. No incontinence, stream large. Silver catheter passed with ease and found no residual urine. No complications after the operation. Letter from physician. — ^Our patient holds his water for six hours and is in excellent shape, but complains of considerable " smarting " at times. He passed concretions the size of a pea two or three weeks ago. Letter from physician. — Patient has continued to have pain at the end of urination, and on examination with the searcher I find a calculus. What operation would you advise? (Suprapubic lithotomy was advised.) August 15, 1905. — Operation by his physician. Suprapubic cystotomy, removal of a calculus one inch in diameter, closure of bladder with catgut. The prostatic orifice was examined with a finger in the bladder and pre- sented a normal appearance. Convalescence. — 'The suprapubic wound leaked slightly on the seventh day, but after the tenth day there was no leakage. He had no complica- tions. February 12, 1906. — 'Letter from physician. Both wounds are closed. Urine is voided naturally, he is able to retain it from six to eight hours and does not get up at night. He has no pain. Sexual powers are normal, and intercourse the same as before operation. His general health is good. May 10, 1906. — 'Letter. I void urine naturally three or four times a day and twice at night, half a pint at a time. I suffer no pain. Have erec- tions and satisfactory intercourse. My general health is excellent, and I consider myself cured. Pathological report. — The specimen, G. U. 148, consists of the three lobes of the prostate each removed in one piece and weighs about 30 gm. The study of lJf.5 Cases of Perineal Prostatectomy. 327 left lobe measures 5x1x3 cm., is somewhat irregular, and on section shows considerable stroma, and only a moderate amount of gland tissue. The right lobe measures 6 x 3 x 1.5 cm., and is similar in character to the left. The median lobe measures 6.5 x 3 x 3 cm., and in its lower portion presents a small round nodule about 1.5 cm. in diameter which was dis- tinctly suburethral. On section there is considerable gland tissue and a small amount of stroma. No mucous membrane, no ducts. Two stones, each measuring 6.5 x 3.5 x 1.5 cm. have been removed. Microscopic examination. — The middle and left lobes show stroma and gland tissue in about equal proportions. The gland tissue is aggregated in areas with rather broad bands of stroma intervening. Within the glandular areas the acini are moderately dilated with an occasional cystic degeneration of an acinus. As a rule the acini show considerable complexity due to intraacinous proliferation. The acini within the broad bands of stroma are as a rule much compressed. The stroma contains a fair amount of muscle. The right lobe has dis- tinctly less gland tissue than either of the other lobes, and there is present quite a marked prostatitis with the formation of considerable inflammatory tissue and atrophy of acini. The fibro-muscular type, as a whole, pre- dominates, although richly glandular areas are present. Case 82. — Severe stricture of urethra, involving prostate, complete re- tention of urine and catheter life for eight years. Multiple diverticula. Prostatectomy, urethrotomy. Cure. No. 848. J. P. C, age 54, married, admitted March 18, 1905. Complaint. — " Stricture of urethra. Complete retention of urine. Cath- eterism." Twelve years before, the patient had had gonorrhoea, which was fol- lowed by a stricture which gradually became worse, urination more diffi- cult, and eight years ago complete retention of urine. Under chloroform a sound was forcibly passed into his bladder and a false passage produced. Since then he has never been able to void urine and has had to lead a catheter life. During this time he has had several operations performed for the stricture. Internal urethrotomy, external urethrotomy and fre- quent dilatation, but at no time has he been able to void. S. P. — He now catheterizes himself with a small silver catheter every three hours night and day. Sexual powers are normal. General health good. Examination. — 'The patient is a well nourished man with lips of good color. Chest and abdomen negative. The right testicle is markedly atro- phic. Rectal. — ^Slight hemorrhoids are present. Prostate is normal in size and consistence, with exception of the upper portion of the left lateral lobe in which there is an induration which extends upward and involves the left seminal vesicle and vas. On the right side there is a small nodule at the junction of the vesicle and prostate. Urethral. — In the bulbo-membranous portion of the urethra there is a 338 Hugh H. Young. hard stricture whicli will not admit a No. 24 F. sound, a filiform and fol- lowers are passed, but are tightly grasped in the membranous and pros- tatic urethra. A small silver catheter now passes with ease, and finds a bladder capacity of 270 cc. The cystoscope shows an enlargement of each lateral lobe, but the enlargement is almost entirely intraurethral, pre- senting as two lateral intraurethral rounded lobules with a small trans- verse median fold behind them, as shown in the cystoscopic charts in ar- ticle on cystoscopy of the prostate. Case XXI. The bladder is markedly trabeculated and the orifices of five diverticula are seen. With finger in rectum and cystoscope in urethra there is very little increase in the median portion of the prostate. Urinalysis. — ^^Neutral, 1020, no sugar, trace of albumin, urea 15 gm. to liter. Microscopically, pus and bacilli. Remark. — -Urethral and rectal examination seem to show that the ob- struction was due to a stricture of the urethra, but internal and external urethrotomy and frequent dilatations of the urethra had failed to restore even temporarily the power of urination. It seemed evident therefore that the interurethral prostatic lobules were the cause of the complete reten- tion of urine, and perineal prostatectomy was therefore advised. Operation, April 12, 1905. — Ether. Perineal prostatectomy by the usual technique. Longitudinal division of extensive stricture of bulbo-mem- branous urethra. An inverted Y incision was made. The bulb of the ure- thra was exposed and found to be very greatly indurated and the mem- branous urethra was surrounded by a considerable amount of fibrous tis- sue, and the rectum was so closely adherent that it had to be dissected free with great care. The membranous urethra is opened upon a small staff, but it was impossible to insert a sound until it had been dilated with forceps. The lateral lobes were very little enlarged, very adherent, and the sharp periosteal elevator had to be used in freeing them from the vesical mucosa. The median bar was removed in two pieces through the left lateral cavity with scissors. Examination with the finger after re- moval of the tractor showed no remaining enlargement, and the large di- verticulum back of the left ureter easily admitted the finger. Double catheter drains and lateral gauze packs were then inserted and attention then directed to strictured membranous and bulbous urethra, which were opened longitudinally upon a grooved sound. The urethra was found to be surrounded by dense fibrous tissue from 5 to 8 mm. thick. The bulb was completely transformed to fibrous tissue, and did not bleed. The mu- cous membrane of the urethra was white and looked like skin. The su- perior wall of the urethra was also divided along the strictured region. Pack was then placed into the urethral wound and the lateral branches of the incision were closed with catgut. The patient stood the operation well. His pulse at the end was 105. His condition excellent. Salt solution and continuous irrigation on return to the ward. Convalescence. — The patient reacted well, but on the day after the op- eration the temperature rose to 104°, but two days later returned to nor- mal, and after that there was very little rise. The continuous irrigation study of lJ/5 Cases of Perineal Prostatectomy. 329 was stopped at the end of 12 hours, the gauze removed within 24 hours, and the tubes in 48 hours. Urine first passed through the anterior urethra on the 18th day and the fistula closed on the 30th day. Interval urination was established immediately after the removal of the tubes on the second day, and on his discharge from the hospital on the 40th day, he was able to retain urine for four hours, voided with a large strong stream, and had no pain. An attempt was made to pass a catheter, but it was caught in a pocket in the bulbous urethra. Filiforms were arrested in the prostatic urethra. May 26, 1905. — A filiform passed easily to-day and the urethra is dilated up to 22 F. June 6, 1905. — The patient was dilated several times with filiforms and followers. The Kollmann dilator passed with ease and can be dilated up to 27 F. Cystoseopic examination. — A catheter passes with ease and finds only 20 cc. residual urine. The cystoscope shows no prostatic enlargement. The diverticula are still present. The patient voids urine in a full stream, has no incontinence, partial erections have occurred. Novemher 30, 1905. — Letter. The wound has remained closed. I have had no dilatation or other treatment. I void urine naturally, four times during the day and twice at night, sometimes one pint at a time. Erections have returned and intercourse is entirely satisfactory. My general health is good and I consider myself cured. May 9, 1906. — Letter. I void urine normally at natural intervals and in normal quantities. I suffer no pain. I have erections and satisfactory in- tercourse. My general health is fine and I have gained in weight, and I consider myself cured. PatJiological report. — The specimen, G. U. 149, consists of three lobes of the prostate, and weighs about 12 gm. The right lobe measures 5 x 1.5 x 2 cm., is irregular in shape, and on section shows considerable stroma, and no dilated acini. The left lobe is more regular, measures 5 x 3.5 x 1.5 cm., and on section shows a great deal of stroma and is very fibrous in feel. The median portion is represented by a mass 8 mm. in diameter and seems very fibrous in character. No mu- cous membrane, no ejaculatory ducts, no calculus removed. Microscopic examination. — On microscopic examination the hyper- trophy in the right lobe is of a fibro-muscular type with a moderate amount of gland acini present. The acini are for the most part arranged in small aggregations, and the lumina are nearly all small. Only occasionally does one see any complexity of the lumina and scarcely any evidence of glandular proliferation is present. There is no evidence of compression due to formation of inflammatory tis- sue. The stroma is considerably in excess of the gland tissue, and seems to contain slightly, more muscle than connective tissue, the muscle and connective tissue interlacing in various ways. In the left lobe the stroma and gland tissue are present in the same proportion as in the right, but the acini in a few areas show more signs of glandular proliferation, and Vol. XIV.— 22. 330 Hugh H. Young. also have more complexity of their lumina. The stroma is very rich in muscle. There is present a well marked prostatitis, especially marked in the pei'iglandular tissue. Case 83. — Considerable enlargement of lateral lobes. Small median bar. Previous suprapubic prostatectomy. Vesical calculi. Old endocarditis. Reacted well. Hiccough, stupor. Hypostatic congestion of lungs. Death 21st day. No. 899. W. S. H., age 73, married, admitted April 17, 1905. Complaint. — " Inability to urinate. Catheterism." History of probable gonorrhoea at age of 17 years. Present illness began about 15 years ago with frequency and difficulty of urination. During the next three years there was a gradual increase in difficulty and frequency, and then complete retention of urine came on, re- quiring catheterization. After that urination was very frequent, but the catheter was not used until four years ago, but catheterization was very difficult, and suprapubic prostatectomy was performed by another surgeon. The suprapubic wound healed and micturition was improved, but still fre- quent for a time, but he soon had to begin the use of the catheter again, and during the past year has led a catheter life. 8. P. — The patient catheterizes himself five or six times in 24 hours. Of late he has had considerable pain in the region of the bladder, but no hematuria. His general health has been bad, and he has lost considerable weight, having lost 20 pounds during the past year. Sexual powers have been practically absent for several years. Examination. — (The patient is a well nourished old man. Radial arteries are moderately sclerotic. Pulse is regular and of good quality, about 80 to the minute. Chest. — iThe lungs are clear throughout, but hyperresonant. Heart. — 'The point of maximum impulse is in the fourth interspace about 1 cm. outside of the nipple line. A systolic murmur is present at the apex and transmitted to the axilla. There is a systolic murmur in the pulmonic area and the second pulmonic and second aortic are ringing in character. Abdomen. — ^Three hernise are present. A small ventral in the region of the suprapubic scar, a small incomplete right inguinal and a very large complete left inguinal. Kidneys negative. Rectal. — "The prostate is considerably enlarged in both lateral lobes, each of which forms a globular mass about the size of a hen's egg with a deep sulcus and notch between them. The prostate is smooth, symmetri- cal, elastic, but firm and not nodular. The seminal vesicles are negative. One small shotlike nodule is felt on the left side, but no enlarged gland. Cystoscope. — A coude catheter passes with ease, retention of urine is complete. Bladder capacity 370 cc. The cystoscope shows two large intra- vesical lateral lobes connected without intervening sulci by a median bar of slight degree. There is a deep cleft between the lateral lobes in front. The bladder is moderately trabeculated and considerably inflamed, and contains three small freely movable calculi. The ureters are easily seen study of lli-5 Cases of Perineal Prostatectomy. 331 and are apparently normal. With, finger in rectum and cystoscope in ure- thra the median portion of the prostate is found only moderately enlarged. Urinalysis. — Very cloudy, acid, 1012, albumin in small amount, no sugar. Urea 10.5 gm. to the liter. Microscopically, pus cells and numerous bac- teria. Preliminary treatment. — Regular catheterization, urotropin and water in abundance. The patient was evidently a poor surgical risk, but owing to the pain and the frequent necessity of catheterization and the calculi, op- eration was thought advisable. Operation, April 24, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were each enucleated easily in one piece and measur-ed each about 2 x 2V> x 2 cm. Examination showed very little me- dian enlargement and nothing was removed. In order to remove the cal- culi the urethra was divided along the left lateral wall, and the three cal- culi were removed, the largest measuring 1 x 1% cm. in size. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. Infusion and continuous irrigation on return to the ward. The patient stood the operation well. Pulse at the end 88. Convalescence. — The patient reacted well from the operation, the pulse varying between 76 and 84 during the next 24 hours. The temperature rose to 100.6°. There was practically no post-operative hemorrhage and ver5' little vomiting. April 25, 1905. — ^Highest temperature 100.6°, pulse 88 to 108. Respira- tions 20 to 24. Continuous irrigation discontinued, gauze removed, small amount of bleeding. April 26, 1905.— ^Highest temperature 100°, pulse 80 to 104, respirations 20 to 24. Fairly comfortable, soft diet, water in abundance, tubes removed. April 27, 1905. — Temperature 99°, pulse 88, respirations 20. Light diet and water in abundance. Complains of pain in wound. April 28. 1905. — Temperature 100.2°, pulse 96, respirations 24. Light diet, water in abundance. Urine secreted in large amount, Patient com- plains of pain in wound and discomfort in abdomen. April 29, 1905. — ^Highest temperature 101.2°, pulse 96, respirations 20. The patient is drowsy, weak and listless, has very little appetite. April 30, J905.— Highest temperature 100.6°, pulse 88 to 104, respirations 20 to 24. Drowsy, very little appetite, water 86 ounces by mouth. Infu- sion of 1000 cc. salt solution. May 1, 1905. — ^Patient had a chill followed by a temperature of 101.4°. Weak, drowsy, hiccoughing. Water 28 ounces by mouth, infusion 1000 cc. salt solution. May 2, i9i9.5.— 'Highest temperature 99.6°, condition improved, up in a chair. Hiccough at intervals, soft diet, water 30 ounces by mouth, 200 cc. by rectum. May 6, 1905.— ^he patient has had a daily temperature, generally reach- ing 101°, to-day 99°. He has been weak, at times irrational and hiccough- ing intermittently, his respirations have become weak and there is con- siderable expectoration. 332 Hugh H. Young. May 10, 1905. — iThe patient has had a slight temperature, has been irra- tional at times, complains of considerable pain in the wound. No nausea, vomiting or hiccough for several days. Soft diet and water in abundance. Infusion 1000 cc. salt solution two days ago. Examination of the chest showed many rales, and a condition of hypostatic congestion. May 12, 1905. — 'Patient is becoming weaker, at times in a heavy stupor. Respirations labored, coughs considerably, refuses nourishment and water. Temperature 101.6°, respirations 24. May 13, 1905. — The patient continues to secrete a large amount of urine and the wound looks well. There is still considerable mucus in the throat, the respirations are very labored, the patient is in a drowsy state and cannot be aroused and refuses nourishment. Salt solution per rectum. May IJ/, 1905. — The patient grew gradually weaker and more stupid and respirations more shallow and rapid, and he died at 9 p. m. During the last five days the temperature has only reached 102°, and the pulse has not been above 110. There has been no hiccough, nausea or vomiting and death has apparently been due to hypostatic congestion of the lungs. The kidneys continued to secret urine in abundance, and the wound and blad- der appeared to do well. No autopsy was allt)wed. Pathological report. — ^The specimen, G. U. 159, consists of the two lat- eral lobes of the prostate each removed in one piece and weighing in all about 12 gm. They are about equal in size, and measure 2.5 x 2 x 2 cm. Their external surfaces are fairly smooth, except where torn, and on sec- tion the surface is fairly homogeneous and there are very few dilated glands. A few pin-point calculi are scattered here and there. One vesical calculus is whole, and measures 1.5 x 1 x .8 cm., and is shaped like a beet. The other calculus is about the same size, but has been broken into several pieces. The outer surfaces are smooth, white and finely granular. The broken surfaces are yellowish and coarsely granular. Microscopic examination. — The hypertrophy is a glandular one with the arrangement of the acini in lobules. The acini are only moderately di- lated, and their lining epithelium shows considerable degeneration and desquamation. In the periphery of the lobule there is the usual condensa- tion of tissue with flattening and elongation of the acini. The stroma Is largely composed of fairly dense connective tissue, and contains a rather small amount of muscle. The arteries show but slight thickening. Case 84. — Moderate enlargement of median and lateral lobes. Induration. Pain, irritability. Cure. No. 943. M. L. L., age 72, married, admitted April 13, 1905. Complaint. — " Enlargement of the prostate. Frequency of urination." No history of gonorrhoea. Present illness began about 20 years ago, since which time he has had more or less difficulty in urination. About this time he had hematuria and pain in the back and diagnosis of congestion of the kidneys was made. He began to get up at night to urinate five years ago, and since then diffi- culty and frequency have gotten gradually worse. study of lJf5 Cases of Perineal Prostatectomy. 333 jS. p. — ^He now voids seven times during the nigM, and about every hour during the day. For the past month he has had severe pain in the bladder during urination, and occasionally there is considerable dribbling. He has no pain in the back, perineum or thighs. His sexual powers are very poor. Erections few and imperfect. Examination. — The patient is a fairly well nourished man. Chest and abdomen are negative. Rectal examination. — The prostate is moderately hypertrophied. The left lateral lobe is larger than the right which is small and contains about the middle of its outer surface a small, round, hard nodule about the size of a pea. The rest of the prostate is soft and there is no induration in the region of the seminal vesicles, no enlarged glands. The urine is very cloudy and contains a large amount of pus and cocci, considerable albu- min, no sugar, sp. gr. 1017. Urea 12 gm. to the liter. Cystoscopic examination. — A small coude silk catheter passes with ease and finds 250 cc. residual urine. The bladder is very irritable, rebelling at 200 cc. Examination of the prostatic orifice shows an unusually irregu- lar outline. The upper portions of the lateral lobes project quite far into the bladder, terminating in sharp points. The median lobe is small and separated from lateral lobes by deep sulci. The mucous membrane cover- ing the prostate is smooth, and there is nothing to suggest malignancy. The bladder wall is considerably trabeculated, the ureteral ridges are prominent and their orifices negative. A careful search failed to reveal any calculus. With the finger in the rectum and cystoscope in the urethra the amount of tissue between the two is slight. Preliminary treatment. — Catheterization twice daily, irrigation. Urotro- pin by mouth. Under this treatment the patient has been much more com- fortable. Operation, April 25, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes which were of moderate size were enucleated with ease, and the median lobe which was small was extracted through one of the lateral cavities. The ejaculatory ducts were preserved. The wound was closed as usual with double tube drainage for the bladder, and light gauze packing for the lateral cavities. The patient stood the opera- tion well. Infusion and intravesical irrigation. Pulse at end of opera- tion 85. Convalescence. — The patient reacted well. The highest temperature was on the day following the operation, 100.4°. It remained normal after the third day. Continuous irrigation was kept up for 12 hours when the gauze packing was removed. The tubes were removed on the second day. The patient was up in a chair on the third day. Interval urination was estab- lished immediately after removal of the tubes, urine coming through the penis on the fourth day and the perineal fistula closing on the 14th day. The patient walked about considerably after the first week, and was dis- charged on the 25th day, when the following note was made: The wound is closed, the patient voids urine every four hours, in a good stream, has no pain nor dribbling. He has already had several imperfect erections. 334 Hugh H. Young. His condition is excellent. A silver catheter passes with ease, no stricture, no residual urine. November 30, 1905. — Letter. I can void urine naturally, have had no in- strumentation, urinate five or six times during the day and three or four during the night. The amount voided is usually small, never as much as half a pint, but the bladder is irritable. Erections are present but imper- fect, and sexual intercourse is unsatisfactory, but was so before the opera- tion. My general health is excellent. "^Tien I void urine the stream is large and free enough at the beginning, then it becomes small and some- times in driblets. January 27, 1906. — .Letter. I void urine twice during the night and six times during the day. I void urine freely in a large stream unless I try to hold it too long. When the desire to urinate comes on I must attend to it at once, else there may be an escape of a small amount of urine. I have no other incontinence. I have no pain or irritation. May 5, 1906. — Letter. I void urine naturally and have not used a cath- eter. If I do not respond to the call promptly there is a slight escape of urine, but I have no definite incontinence. I retire at 10.30 and arise about 4 o'clock to urinate and again at 5.30 when I get up. The amount voided is never as much as half a pint. I suffer no pain. I have imperfect erec- tions, no worse than before operation. My general health is excellent and I have gained in weight. No one can dispute the wonderful success of the operation and the unspeakable relief. Pathological report. — The specimen, G. U. 152, consists of the three lobes of the prostate, each removed in one piece and weighing in all S^o gm. The lateral lobes are each about 2 cm. in diameter. Their surfaces are irregular, and on section considerable stroma and very little gland tissue is evident. No dilated glands are seen. The median lobe is very small, measuring 1.5xlx .8 cm. and presents the same characteristics as the lat- eral lobes. Microscopic examination. — The hypertrophy is only a moderately gland- ular one, there being present a large amount of stroma. Within the mod- erately glandular lobules the acini seem rather compressed and elongated. The epithelium lining the acini presents a great deal of degeneration, while the stroma seems to be undergoing a marked fibrous hyperplasia. The arteries show quite a marked thickening. Case 85. — Slight median and lateral hypertrophy. Vesical calculus. Cure. Followed 13 months. No. 929. A. S., age 64, married, admitted April 7, 1905. Complaint. — " Enlarged prostate." No history of gonorrhoea. Present illness began with a sudden attack of intense pain along the urethra four and one-half years ago. About the same time both testicles became swollen and painful. Since then patient has been troubled with frequent micturition with pain during and occasionally at the end of urination, and of late slight hematuria. Has recently passed several small study of 14^5 Cases of Perineal Prostatectomy. 335 calculi. There has never been complete retention of urine, but he has catheterized himself occasionally on advice of his physician. 8. P. — Urination every hour night and day with considerable difficulty, pain in urethra and occasionally slight hemorrhage. Sexual powers. — There has been a marked decrease in his sexual power, but erections still occur occasionally. His general health has remained good. Examination. — Fairly well nourished man with lips of good color. Chest, abdomen, negative. Genitalia. — The left epididymis is indurated. Rectal. — The left lobe of the prostate is about normal in size, smooth, fairly soft except at the upper end where it is slightly indurated and adherent to the seminal vesicle. The right lobe is about twice as large as the left, is prominent, indurated but compressible and not of stony hardness. Its contour is slightly irregular, and at its upper end is an oblong, smooth oval mass markedly indurated, projecting into the region of the right seminal vesicle for a distance of about 1.5 cm. The seminal vesicle above is not indurated, and there is no mass extending outward toward the pelvis, no periprostatic induration, no intravesicular mass, no enlarged glands. The rectal mucosa is soft and not adherent. Cystoscopic. — A small coude catheter passes with ease and finds 50 cc. residual urine. The bladder is small and irritable. The lateral lobes are apparently not at all intravesically enlarged and there are no clefts be- tween them in front. There is a small but definite median enlargement in the shape of a rounded bar, but there are no clefts on either side. The mucous membrane is smooth. A fairly large roughly granular, white calculus, freely movable in the bladder is seen. The bladder is moderately trabeculated, chronically inflamed. There are no diverticula present. Urinalysis. — Cloudy, alkaline, no sugar, albumin in small amounts. Microscopically pus and epithelial cells, cocci, and bacilli. Urea G-12 to liter. Total urine 1600 cc. The patient developed pleurisy soon after admission and operation was delayed on that account. Operation, April 25, 1905. — Ether. Perineal nrostatectomy by the usual technique. Extraction of a moderately large calculus through the wound. The lateral lobes were only slightly enlarged and were quite adherent, but each was removed in one piece. A small median lobe about 2 cm. in diameter was removed through one of the lateral cavities without tearing away any of the mucous membrane. The urethra was then incised along lateral wall to the neck of the bladder, and the calculus removed. The wound was closed as usual with double tube drainage and lateral gauze packs. The levators were drawn together with catgut. The patient stood the operation well, pulse at the end being 80. Infusion and continuous irrigation on return to room. The patient reacted well. His temperature rose to 101.2° on the day after the operation, but fell promptly and remained normal afterwards. The irrigation was dis- continued after 12 hours, the tubes were removed within 24 hours and the 336 Hugh E. Young. gauze within 48 hours. He was up in a chair on the third day and urine passed through the urethra on the fourth day. The perineal fistula closed finally on the tenth day, and at that time he was able to retain urine for five hours. He was discharged on the 15th day, voiding at intervals of about three hours with perfect control, size and force of stream good. A silver catheter passed with ease and found no residual urine. There were no complications. Xoveynber 30. 1905. — Letter. The wound has remained closed. I void urine two or three times during the night and six to nine times during the day. I suffer a slight pain at the end of urination, and if I procrastin- ate too long between urinations I have pain in the bladder. The urinary stream is full and free, but I do not void more than three and one-half ounces at a time. I have erections, but imperfect. My general health is good and I have gained 20 pounds. The urine is straw color and there is no sediment. Alay 15, 1906. — Letter. I void urine naturally, but not without some pain, about every two and one-half hours during the day and once at night. I sometimes pass a little over a half a pint at a time. I suffer no pain at the end of urination. I have erections and have had intercourse, but it is not very satisfactory. My general health is good, I have gained in weight, I am markedly improved but cannot say that I am cured. Pathological report. — The specimen, G. U. 151, consists of the three lobes of the prostate each removed in one piece. The weight is about G-13. The median lobe measures 1.6 x 1.5 x 1 cm. in size. The right lobe meas- ures 3 X 1.5 X 1 cm. The left measures 2 x 1.3 x 2 cm. The character of the three lobes is somewhat similar, the surface is irregular, and the cut surface is fairly homogeneous with few acini showing. Microscopic examination shows a moderately glandular hypertrophy. Lobulated areas rich in gland tissue, alternating with areas in which the acini are rather sparsely distributed, and in which the stroma pre- dominates. In some areas marked glandular proliferation is going on while in others hyperplasia of the stroma with atrophy of the parenchyma is taking place. The stroma contains rather more fibrous tissue than muscle. Some areas of chronic inflammatory infiltration. Case 86. — Moderate hypertrophy of median and lateral loies. Cathet- erism. Cured. Xo complications. No. 910. T. B., age 61, married, admitted April 25, 1905. Complaint. — " Difficulty of urination. Intermittent catheterism." The patient had gonorrhoea at the age of 16, and several times later. Since 1864, has had no urethral discharge, no evidence of stricture, and sexual powers have been normal. Present illness began six years ago with slight difficulty and frequency of urination. After that patient's symptoms gradually increased and two years ago had retention of urine for the first time. During the past 18 months the patient has used the catheter at least once a day, and of late three times a day. study of lJf5 Cases of Perineal Prostatectomy. 337 /S. P. — Urination is difficult, considerable straining being required. He uses a catheter three times at night, but none in the day. The only pain he has is slight and dull in character and located in the lumbar region. His sexual powers are satisfactory. Examination. — Patient is a sturdy looking man with mucous membranes of good color and slight arteriosclerosis. Chest and abdomen, notes lost. Both testicles are very small, but the genitalia are otherwise normal. The prostate is moderately hypertrophied, smooth, rounded, elastic but fairly firm. Slight induration at the base of the left seminal vesicle, but the right is normal. The prostatic secretion is composed almost entirely of pus cells, a few lecithins and large granule cells are present. The urine is acid, slightly cloudy and contains pus and bacilli in great number. A silver catheter passes with ease. 300 cc. residual urine present. The bladder capacity is slightly contracted. The cystoscope shows a fairly large median lobe bilobular in shape. The lateral lobes do not project into the bladder. Considerable trabeculation of the vesical wall and a moderate cystitis is present. The left ureter is secreting normal urine. The right ureter cannot be seen as it lies behind the median lobe of the prostate. Preliminary treatment. — Regular catheterization, intravesical irrigations and urotropin for three days. Operation, April 28, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were only moderately enlarged, but quite adherent and were removed with difficulty. The median lobe was removed through the right lateral cavity, a small tear being made in the lateral wall of the urethra, but no mucous membrane being removed. The rest of the urethra and ejaculatory ducts were preserved intact. A finger intro- duced through the urethra into the bladder showed no enlargement remain- ing. There was very little hemorrhage and the patient stood the operation well. The wound was closed as usual with double tube drainage for the bladder and continuous irrigation was supplied on the table and after his return to the ward, when a submammary infusion of salt solution was also given. Pulse at end of operation 80. May 24, 1905. — (26th day.) The patient has had an uninterrupted convalescence. The gauze was removed on the day after the operation and the tubes on the second day. After that there was constant leakage through the perineum for two days, but after that interval urination every two hours was established. The patient was out of bed on the third day. On the fourth day the urine began to pass through the penis, and the fistula finally closed on the 21st day. No epididymitis. The patient now does not arise at night to urinate (a period of eight hours). There is no urgency, no incontinence, no dribbling except a few drops at end of urination. He can hold his urine for five hours during the day, has no pain and " enjoys urinating." The wound was closed, there is no fistula, a catheter meets no obstruction and there is no residual urme present. He has had no instrumentation since operation. The urine is almost- clear and contains only a few bacilli. Patient was discharged 338 Hugh H. Young. from the hospital on the 27th day. The highest temperature was 100.5° on the day after the operation, after that normal. November 30, 1905. — Letter. I void urine naturally three times during the day and once or twice at night from one-half to three-quarters of a pint at a time. The wound has remained healed and I suffer only a very slight pain occasionally. I have only partial erections and intercourse is not satisfactory, the ejaculation being small in amount. My general health is excellent and I consider myself cured. May 8, 1906. — Letter. I void urine naturally, four or five times during the day and once or twice at night, about a pint at a time. I suffer no pain. Sexual intercourse is not satisfactory, erections being too weak and the ejaculation very slight. My general health is good, I have gained in weight and consider myself entirely well. Case 87. — Slight hypertrophy. Great frequency. Retention two weeks. Pain. Cure. Followed 19 months. No. 909. J. D. B., age 55, married, admitted April 21, 1905. Complaint. — " Difficulty and frequency of urination and pain." The patient had gonorrhoea 25 years ago, a severe attack, but not followed by gleet nor stricture. Urethritis a second time seven years ago, severe and followed by difficulty of urination. The present illness began with frequency and difficulty of urination during the attack of gonorrhoea seven years ago. Since then there has been a gradual increase in these symptoms, but at times they are worse than at others. Intermittent attacks of irritation with marked frequency of urination, often 10 to 12 times every night have occurred. At other times he can retain urine for three or four hours. Complete retention of urine came on for the first time in January, 1905, and the catheter was necessary for two weeks. Since then he has used the catheter once a day. For one year patient has had pain in the left lumbar region, inter- mittent, dull and lasting only for a short time. Occasionally this pain would radiate to the left groin and testicle, but it was never of a severe colicky character. jSf. P. — The patient voids urine about 12 times during the night, and every 15 to 30 minutes during the day. When the desire to urinate comes on there is a pain in the neck of the bladder and an urgency of urination. There is no pain in the urethra nor any hematuria. No pain in the rectum or thighs. The stream of urine is small, difficult to start and followed by dribbling. He has not lost weight. Erections are present; coitus causes pain. Examination. — Patient is a healthy looking man. Chest and abdomen negative. Rectal examination. — The lateral lobes of the prostate are moderately hypertrophied, smooth, soft. The seminal vesicles are not indurated and no enlarged glands are felt. The urine is slightly cloudy, acid, and contains numerous pus and epithelial cells and bacilli. A catheter passes easily and finds only 60 cc. residual urine. The bladder is contracted, holding only 300 cc. study of lJf5 Cases of Perineal Prostatectomy. 339 The cystoscopic examination is unsatisfactory owing to hemorrhage. The bladder wall was seen to be considerably trabeculated. No stone was present. The median portion of the prostate was slightly enlarged. With the finger in the rectum and cystoscope in the urethra the beak could be easily felt, but there is considerable increase in the median portion of the prostate. Operation, April 29, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were not greatly enlarged, but adherent in their deeper portions. The median lobe was so small that it could not be engaged with the tractor. The finger was then inserted and a median lobe about 1 cm. in diameter drawn into the left lateral cavity and enucleated. The right lateral wall, floor of the urethra, and ejaculatory ducts were preserved intact. A small tear was made in the left lateral wall in removing the middle lobe. There was considerable hemorrhage but the patient stood the operation well. Double tube drainage and closure as usual. Saline infusion and continuous irrigation on return to the ward. Convalescence. — The patient reacted well from the operation. The tubes were removed on the second day and the gauze on the third day. The urine began to flow from the urethra on the sixth day and the fistula healed on the 13th. Patient was up in a wheel chair on the third day and has been walking since the fourth day. Temperature rose to 101°, but was normal after the third day. May 18, 1905. — (20th day.) There has been no epididymitis nor other complications. He has perfect control and there is no dribbling. The wound is healed. A silver catheter passes with ease, no stricture encount- ered and no residual urine. The urine is almost clear, contains only a few pus cells and no bacteria. The patient is discharged from the hospital. Novemder 30, 1905. — Letter. I void urine naturally six or eight times during the day and two to four times at night, about one-half pint at a time. The perineal wound has remained closed, I suffer no pain. Have partial erections, but intercourse is not satisfactory. My general health is excellent and I consider myself cured. May 28, 1906. — Letter. I have not had to use a catheter and void urine naturally about eight times during the day and two to four times at night and as much as half a pint at a time. I have no pain. Erections and sexual intercourse is improving, but is not as yet entirely satisfactory. I have had no complications nor treatment. My general health is very good, and I consider myself cured. Pathological report. — The specimen, G. U. 157, consists of three lobes of the prostate removed each in one piece, and weighs probably not more than G-10. The median lobe measures 1.5 x .8 x .5. The right lobe meas- ures 3 X 1 x 1.5 cm. and the left 2.5 x 2.5 x 1.3 cm. No mucous membrane, no ejaculatory ducts, no calculi. Microscopic examination. — Microscopically the gland tissue is distrib- uted with slight tendency to lobulation. In areas the acini are fairly numerous while in other areas the stroma predominates. 340 Hugh H. Young. In the glandular areas the acini are small with a rather dense fibro-muscular frame work, and considerable endoglandular pro- liferation. The acini are rather closely set together and display but very little of the complexity so evident in some of the glandular hyper- trophies. The stroma in these glandular areas is largely composed of fibrous tissue with here and there some periacinous and interstitial in- flammatory infiltration. In the portions containing more stroma than gland tissue the alveoli are for the most part plugged with masses of proliferating and degenerating epithelial cells, and there is considerable excess of fibrous tissue over muscle in the stroma. Here and there are areas of interstitial infiltration, and some periacinous connective tissue formation. In this prostatic tissue the gland and stroma are present in about equal proportions; the relative amount of each varying in different areas, while the alveoli are small rather closely aggregated and with a rather dense interlacing stroma. No evidence of malignancy. The entire picture is simply one of prostatitis. Case 88. — Moderate hypertrophy of median and lateral lobes. Catheter life. Cured. Followed 13 months. No. 911. G. F., age 72, widowed, admitted April 26, 1905. Complaint. — " Complete retention of urine, catheterism." There is no history of gonorrhoea. Present illness began about 15 years ago with frequency and slight difficulty of urination. This gradually increased, but he did not have to be catheterized until three years ago, but chronic retention of urine has only been present for the past year and he now catheterizes himself every five hours and is unable to void naturally. He suffers no pain, has not lost weight. Occasionally has erections, but no desire, and has not had intercourse for about 10 years. Examination. — The patient is a sturdy looking man for his age. Rectal examination. — The prostate is considerably enlarged, globular in shape and about the size of an orange. The surface is smooth and regular, with the exception of the anterior portion of the right lateral lobe where a small lobule is felt. The consistence is firm, and there is distinct induration at the base of the right seminal vesicle. The prostatic secretion contains many pus cells, few granule cells and lecithins. The urine is cloudy, and no sugar, no albumin. Microscopically pus cells and bacteria, no casts. Urea, 27 gr. to the liter. Cystoscopic examination. — The patient is unable to void urine. A coude catheter enters with ease and finds a bladder capacity of 350 cc. The cystoscope shows hypertrophy of both lateral lobes, and a small round enlargement of the median lobe. There is a deep sulcus between the lateral lobes in front. The bladder is trabeculated. There is no stone present. The left ureter can be seen but the right cannot. Operation, April 29, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were moderately enlarged. The median study of lJf.5 Cases of Perineal Prostatectomy. 3-41 lobe measured 2x2x3 cm. in size, and was easily enucleated through the right lateral cavity, but in so doing a tear was made in the urethra. After removal of the tractor a finger was inserted and found that all hyper- trophied tissue had been removed. The lateral cavities were packed with gauze. Double catheter drainage was supplied and the wound was closed as usual. Saline infusion and continuous irrigation given on return to ward. There was very little hemorrhage and patient's condition at the end was good. Convalescence. — Gauze and catheters were removed 48 hours after the operation and the patient was at once gotten out of bed. The next day he began to walk. The fistula closed on the 16th day. May 18, 1905. — (20th day.) The fistula is closed and urine passes freely and in a large stream through the urethra. The patient can hold his urine for two hours. There is no incontinence, but a few drops dribble away at the end of urination. He has had no instrumentation and no complications. A silver catheter passes without obstruction through the membranous urethra, but it would not pass into the bladder owing to dilated pouch-like condition of the prostatic urethra in which it was impossible to find the prostatic orifice. The patient was discharged with instructions to take urotropin and to hold urine as long as possible in order to dilate bladder. Noveviber 30, 1905. — Letter. I void urine naturally and consider myself cured. The catheter has not been used since the operation. There is no fistula. I void urine once during the night and about three times during the day, 250 cc. at a time. I have no pain. Erections have re- turned and coitus would be possible if I were so inclined. I have had no complications and my general health is excellent. May 20, 1906. — Letter. I urinate naturally, four or five times during the day and once at night and about three-quarters of a pint at a time. I have no pain. Erections have returned, but I do not attempt inter- course. My general health is very good, and I consider myself entirely cured. Pathological report. The specimen, G. U. 156, consists of three pieces of tissue representing the three lobes. The lateral lobes are soft in consistency, lobulated, and weigh about 10 gr. The median portion is a small irregular mass distinctly firmer than either of the lateral lobes. A few small spheroids are present. The ejaculatory ducts have not been removed. No calculus is present. Microscopic examinati07i. — The hypertrophy is a moderately glandular one with arrangement in lobules. The acini are moderately dilated and in some areas show considerable cystic degeneration. There is present everywhere quite a marked prostatitis, and many of the acini are filled with desquamated epithelial cells and some leucocytes. There is present in the stroma considerable round and polynuclear infiltration with the formation of some inflammatory tissue. The stroma contains a moderate amount of muscle, although there is more connective tissue than muscle present. The arteries show in areas a moderate degree of thickening. 342 Hugh H. Young. Case 89. — Severe stricture of urethra, vesical ulcer, slight enlargement of prostate. Urethrotomy, prostatectomy, curettage of ulcer. Death eighth day. Hemorrhage. No. 685. H. C. B., age 53, married, admitted August 1, 1904. Complaint. — " Frequent and difficult urination." From his 16tli to his 35th year patient had gonorrhoea pretty constantly. Since then he has been free from the disease. In 1869, while under treatment for gonorrhoea he had difficulty in urination and an examination revealed two strictures which were treated by dilatation. After that the patient received no treatment for 10 years when the stricture had again closed down so that a filiform was passed with difficulty. After that he was treated by dilatation and electrolysis. At the end of two years his condition was fairly good, but soon the trouble recurred. In 1883, a peri- neal urethrotomy was performed and " the bladder which was found to be encrusted was curetted.". A little later he began to use a catheter and his condition gradually became worse until 1899, when an internal urethrotomy was performed, followed by dilatation to a 21 American sound. The treatment could not be continued, however, on account of the weak condi- tion of the patient, and micturition became so frequent that he had to wear a rubber urinal and suffered very greatly from pain. He has never passed gravel. 8. P. — Urine dribbles constantly into the rubber urinal. During the night he urinates as often as every 10 minutes. His conditon has become decidedly worse during the past year and he has suffered great pain. Examination. — The patient looks sick and weak. The mucous membrane is pale. He is very much concerned about himself, nervous and restless. The heart sounds are diminished in intensity. The lungs and abdomen are negative. Urethral. — A number 18 F. sound passes with difficulty through a very firm stricture of the deep urethra beginning in the posterior portion of the bulbous region. A small catheter is then passed and 50 cc. residual urine found. The bladder capacity is 100 cc. and this amount causes great pain. Rectal. — The prostate is only slightly enlarged. The contour is normal in shape, the consistence is slightly indurated. The seminal vesicles are palpable and indurated, but only moderately so. The bladder above feels very hard. Preliminary treatment. — Prostatic massage, urethral dilatation, vesical dilatation by hydraulic pressure. The stricture was very resistant and after 17 days treatment a filiform was necessary. The bladder was very irritable and dilatation difficult. Prostatic massage was followed by considerable relief of the pain and tenderness in this region and his condition improved, but urination was very frequent especially during the night. Patient discharged. Second admission, April 11, 1905.— The patient returns for further treatment. He still voids urine with difficulty and pain at very frequent intervals. A hard stricture of the deep urethra is still present, but it is study of lJf-5 Cases of Perineal Prostatectomy. 343 impossible to pass small sounds without flliforms. The prostate is very- little enlarged, moderately indurated, especially at the upper end. The seminal vesicles are palpable and slightly indurated and the bladder very hard. Urine. — Cloudy, alkaline, 1026, no sugar, albumin abundant. Micro- scopically pus, bacilli, and cocci. Cystoscopic examination. — A small silver catheter passes with difficulty into the bladder, considerable force being necessary to push it through the induration along the membranous and prostatic urethra. 100 cc. residual urine is found present. The bladder is very irritable and it is difficult to introduce 100 cc. of fluid. It is very difficult to wash the bladder . clean of pus and mucous. The cystoscope shows an irregular prostatic orifice covered by very red granular redundant mucous membrane. The lateral lobes are little if at all enlarged and there is only a slight increase in the median portion. The entire trigone and a portion of the adjacent lateral walls of the bladder are covered by a thin, white, shaggy exudate which cannot be dislodged so that it is impossible to see the conditions of the tissues beneath it. It appears to cover the right ureteral orifice, but the left ureter opened just at the edge of the exudate, the posterior limits of which are sharply defined and contrasted with fairly healthy mucous membrane of the posterior surface of the bladder. There was no intravesical tumor formation. The picture presented in the trigone suggests a malignant ulcer, but as it was impossible to see the base of it no positive diagnosis can be made. With finger in rectum and cj^stoscope in urethra the beak can be felt, but there is an increase in the thickness of the base of the bladder. The median portion of the prostate is also slightly thicker than normal. The cystoscope is tightly grasped by the urethra and prostate, so that it is difficult to manipulate. Treatment. — Another attempt was made to relieve patient by urethral dilatation, prostatic massage and hydraulic vesical dilatation, but with practically no success. The patient's condition was very weak, he suffered a great deal of pain in the bladder and urethra, was constantly depressed and slept very little. Micturition was extremely frequent and difficult. Perineal prostatectomy was advised and reluctantly accepted by the pa- tient, who said that he felt convinced that he was going to die. Operation, May 3, 190-5. — Ether. Perineal prostatectomy by the usual technique. Extensive perineal urethrotomy for stricture of urethra, vigor- ous curettage of vesical ulcer. The prostate itself was compartively small, very fibrous, but adherent to its surrounding capsule. The bulb of the urethra was very fibrous and the membranous urethra behind it surrounded by much irregular fibrous tissue. The membranous urethra was then opened upon a grooved sound and examination showed that the prostatic urethra was dilated and contained several valve-like folds and false pass- ages, two of which were large enough to admit a good sized sound and apparently entered the substance of the prostate. The lateral lobes, which were verv small and fibrous were excised with scissors, and the median 34:4: Hugh H. Young. portion was removed in ttie same way. Considerable amount of the dilated prostatic urethra was excised. The bladder was then thoroughly curetted in the region in which the ulcer had been seen. Attention was then turned to the strictured urethra, the walls of which wer-e found to be greatly increased and very fibrous, and on account of induration of the anterior portion of the bulbous urethra internal urethrotomy was performed from the wound with a blunt pointed bistoury. One catheter was placed in the urethra and the other placed in the perineal wound in the bladder. The lateral cavities and the urethrotomy wound were packed with gauze and the skin wound partially closed with catgut. Patient stood the oper- ation well, pulse at the end being 110. Infusion and continuous irrigation after return to ward. Convalescence. — The highest temperature was on the day after the operation 100.6°. The pulse was never good, reaching 120 during the first three days after the operation and 140 on the fourth day. The continuous irrigation was discontinued after 12 hours, the gauze was removed at the end of 30 hours and was followed by a slight hemorrhage which led to repacking of the wound. The catheter in the penile urethra drained well. May 7, 1905. — The patient has been weak, nauseated and vomited several times. To-day his temperature dropped and could not be registered. There was an immense blood clot in the perineal wound which was dislodged by the patient's straining to urinate, and this was followed by considerable bleeding. The urethra, bladder, and wound were irrigated and packed. The pulse is irregular, 140 to the minute. May S, 1905. — Pulse 120, temperature 100°, patient much more comfort- able. The dressings are soaked with urine and only slightly tinged with blood. Some urine passes through the penis. The patient is very nervous and concerned about himself. P. M. There has been considerable bleeding in the perineal wound this afternoon. May 9, 1905. — The pulse is 120, the temperature normal. There has been less bleeding but the patient has had two or three attacks of intense pain in the bladder followed by passage of clots through penis and perineal wound. May 11, 1905. — Yesterday the patient was generally weaker, felt cold, was nervous and restless. Temperature 96. The dressings were soaked with urine which was tinged with blood. Strichnine was administered. During the afternoon he had two rather profuse hemorrhages from the perineal wound, and he was infused. Packing the perineal wound did not control the hemorrhage. At midnight the patient was catheterized, and suprapubic cystotomy performed. A large blood clot was found in the bladder which was packed with gauze. A clot of blood was evacuated from the perineal wound which was also firmly packed. The patient was transfused on the table and seemed to stand the operation well, but shortly afterward his pulse became weak and irregular and his respiration shallow. At 7 a. m. to-day he was restless and in a stupor and the pads were soaked with urine. There has been no fresh hemorrhage. His hands and feet were cold and cynosed. Pulse was irregular, weak, 116. After study of H5 Cases of Perineal Prostatectomy. 345 that the pulse and respiration gradually grew worse, did not respond to stimulants or infusions and the patient died at eleven o'clock. A vigorous attempt was made to get an autopsy, but without success. Pathological report. — The specimen, G. U. 154, consists of the three lobes of the prostate removed in one piece and weighs G-7. The right lobe weighs G-3.5, measures 2.5 x 2 x 1.5 cm., is fairly smooth, oval, and on section shows considerable stroma and a small amount of gland tissue. The left lobe weighs G-3, and measures 2.5x2x1.5 cm.; it is very irregular and considerably torn and on section is similar to right. The median lobe is a small mass, weighing G-.5 and measuring 1.5 x 1.3 x .5 cm. No mucus membrane, no ducts, no calculi. The scrapings from the vesical ulcer have been lost. Microscopic examination. — Microscopically the sections contain very few glandular alveoli. About nearly all of the ducts there is a polynuclear and round cell infiltration with formation of new connective tissue and within many areas compresion of the glands. The infiltration is, for the most part, periacinous, and within the lumina of the ducts there is endoglandular proliferation and degeneration of the epithelial cells. A few leucocytes are seen in the culs-de-sac. The stroma, as was said above, is greatly in excess of the gland tissue, is quite dense and compact, and seems for the most part fibrous tissue although there is present a fair amount of smooth muscle. It is distinctly a fibro-muscular prostate with predominance of the fibrous tissue, and diminution in the gland elements, and the whole picture is that of prostatitis rather than prostatic hypertrophy. Case 90. — Small rounded median lohes. Contracted, Madder. Occasional complete retention. Cure. No. 916. E. P. E., age 50, married, admitted April 29, 1905. Complaint. — " Bladder trouble." No history of gonorrhoea. Present illness began 10 years ago with an attack of burning in the urethra and frequency of urination. During the next three years had similar attacks at intervals of two to four weeks. About seven years ago began to have slight difficulty of urination, and one year later complete retention of urine requiring catheterization. Since then has had to catheterize himself on numerous occasions, but as a rule has voided naturally, but very frequently. Has had no hematuria nor severe pain. S. P. — The patient urinates every two hours and from two to four times at night. Occasionally he is unable to void and has to pass a catheter, usually finding about five ounces of urine. Occasionally there is a slight pain in the urethra extending to the end of the penis, and a spasm in the bladder at the end of urination. He has never passed a calculus and has had no pain in rectum, perineum, or thighs. Sexual powers. — Present. Examination. — The patient is a well nourished man with lips and mucous membranes of good color. Chest and abdomen are negative. Vol. XIV.— 23, 346 Hugli H. Young. Rectal. — The prostate is only slightly hypertrophied. The right lobe being a little larger and more prominent than the left. It is soft and smooth. The seminal vesicles are negative. Gystoscopic. — A catheter enters with ease and finds only 15 cc. residual urine. The bladder capacity on forced distention is only 225 cc, the patient complaining of pain before that amount is injected. The cystoscope shows a small rounded median lobe with a deep sulcus on each side. The lateral lobes are not enlarged and there are no clefts between them in front. The bladder is very little trabeculated, there is no inflammation and the ureters appear normal. With finger in rectum and cystoscope in urethra very little enlargement is to be felt (the cystoscope evidently in one of the clefts). Note. — The absence of residual urine, cystitis and vesical trabeculation would seem at first sight to show that an operation was unnecessary. The frequency and difl&cult of urination and occasional attacks of retention of urine, however, made patient demand an operation. Urinalysis. — Cloudy, 1014, acid, no sugar, a trace of albumin, micro- scopically pus cells and bacilli. Urea, G-16 to liter. Operation, May 3, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were easily enucleated, the left being small, the right moderately hypertrophied. The median lobe was drawn into the right lateral cavity by means of the tractor and easily enucleated. The urethra and ejaculatory ducts were preserved. The wound was closed as usual with double drainage tubes and light packs for the lateral cavites. The patient stood the operation well, the pulse at the end being 100. No infusion, no irrigation. Convalescence. — The highest rise of temperature was on the evening after the operation 99.7°, after that the patient's temperature was practic- ally normal. There was considerable blood in the urine for the first 30 hours, and when the gauze was removed at the end of 24 hours there was considerable hemorrhage so that the wound was repacked. During the next four days, the patient complained of severe pain in the urethra which was relieved by urethral irrigation. On the fourth day urine came through the penis, the tubes having been removed on the second day. On the sixth day the patient was able to retain urine for three or four hours. The perineal fistula closed on the 15th day. Three weeks after the operation there was very slight pain and tenderness in the left epididymis which subsided in 24 hours after application of ice. On discharge from hospital on the 28th day the patient was able to hold urine for five hours, stream was large, there was no incontinence, the wound was closed, a silver catheter showed no obstruction and found no residual urine. November SO, 1905. — Letter. I void urine naturally four or five times during the day, usually not at all during the night, often one-half pint at a time. The wound is healed and I consider myself cured. Erections are satisfactory, and intercourse normal. My general health is good. May 9, 1906. — Letter. I void urine naturally every four or five hours study of llf5 Cases of Perineal Prostatectomy. 347 during the day and none at night, about half a pint or more at a time. I have no pain. Erections and intercourse are satisfactory. My general health is good, and I consider myself cured. Pathological report. — The specimen, G. U. 153, consists of the three lobes of the prostate and weighs G-7.5. The right lobe 2.5 x 2 x 1.2 cm. weighs G-3.5. The left 2.5x2x1 cm. weighs G-3.5. The median lxlx.6 cm. in size, weighs G-.5. The surface of the lobes is irregular, in places torn, the consistence is firm and the section shows very little spheroid formation and few dilated ducts. The consistence is homogeneous. Microscopic examination. — The hypertrophy is a moderately glandular one. The acini are only slightly dilated although occasionally one sees acini of considerable size with numerous intraacinous off-shoots. The acini contain numerous corpora amylacea and are lined by epithelium which is usually two layers in thickness. The stroma is rather dense, and contains an unusually large amount of muscle which is irregularly intermixed with the connective tissue. The arteries show practically no thickening. No prostatitis was noted in the sections. Case 91. — Moderate enlargement of median and lateral lobes. Catheter life. Attack of hemiplegia previously. Cure. Followed 12 months. No. 934. C. E R, age 66, married, admitted May 13, 1905. Complaint — >" Enlarged prostate." Had gonorrhoea when a young man. Present illness began about nine years ago with a slight frequency of urination. He did not have to get up at night, had no straining, and at in- tervals was entirely comfortable. These periods of increased frequency gradually grew worse until four years ago he began to have pain and one day a severe hemorrhage into the bladder followed by complete retention of urine. After that slight hemorrhage occurred at intervals, but he did not have to use a catheter until 18 months ago, since which time he has used it every day, at first only at bed time. In February, 1903, hemi- phlegia of the left side came on, but he subsequently made a complete re- covery. During the past two months the patient has had to use the cath- eter from three to five times a day. Last month, while in Italy, catheter- ization became much more diificult and painful, and he went at once to London to see a surgeon, who advised an immediate suprapubic prostatec- tomy. His son who is a physician cabled him to wait and went over and brought him to Baltimore. S. P. — Patient catheterized himself every four hours, and on account of a dull pain takes one-fourth to one-half of a grain of morphia daily. Re- tention of urine is practically complete. Sexual powers. — Are still satisfactory. Examination. — *Patient is a weak looking man of sallow complexion, but lips are of good color. The pulse is regular and of good volume. Very little arteriosclerosis is present. Chest and abdomen are negative. Rectal examination. — ^Prostate Is moderately enlarged, bulges slightly towards the rectum, contour is rounded, surface smooth, consistence is 348 Hugh H. Young. elastic, with a little induration at the upper end of the right lobe which does not extend into the region of the seminal vesicles, both of which are soft. No indurated lymphatics or glands are to be felt, and the prostate is not tender. Prostatic secretion is composed largely of pus cells. Some large granule cells are present, but no spermatozoa. Cysioscopic examination. — A catheter passed with ease. Complete reten- tion of urine is present. The vesical capacity is large. The cystoscope shows a fairly large median lobe with a deep sulcus to the left of it. The lateral lobes are only slightly hypertrophied intravesically. The bladder is markedly trabeculated with numerous pouches and one diverticula. In the trigone in front of the interureteral bar is a succession of bullse cov- ered with smooth mucous membrane and in places almost papillary in character. At first sight they suggest neoplastic growth, but on further study they are shown to be similar in appearance to the picture obtained in bullous cystitis. With finger in rectum and cystoscope in urethra the beak can be felt, showing no induration in the region of the trigone, and a considerable increase in the median portion of the prostate. Urinalysis. — Total quantity in 24 hours 1100 cc. Urea 15 gm. to liter. Urine acid, sp. gr. 1016, no sugar, albumin in slight amount, pus cells and bacilli. Preliminary treatment. — Patient was catheterized regularly, given water in great abundance and urotropin for four days. The blood pressure was taken on the day before the operation and registered 165. Owing to the fact that he had had one apoplectic stroke he was put upon sodium nitrite to reduce the blood pressure. Operation, May 17, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were moderately enlarged and easily enu- cleated. The middle lobe was removed partly with the left lateral and partly through the right lateral cavity after removal of the left lateral lobe. The urethra was torn on both sides, but the floor and ejaculatory ducts were preserved intact. After removal of the tractor a finger was inserted into the bladder and showed that the enlargements had been com- pletely removed. The blood pressure was taken before ether was adminis- tered and registered 175. Under ether it rapidly rose to 200, and when the patient was put in the lithotomy position with the hips elevated and the thighs flexed the blood pressure rose to 220. In order to reduce the blood pressure no vessels were ligated and fairly free hemorrhage con- tinued, during the operation, but the blood pressure remained between 200 and 225 all through the operation which lasted 18 minutes. As soon as the patient was removed from the table the blood pressure fell to 170. The patient showed no evil effects from the high blood pressure and stood the operation well. The woimd was closed as usual with double rubber tube drainage for the bladder, light gauze packs for the lateral cavities. An infusion was started before he left the operating room, and continuous irrigation of the bladder begun on his return to the ward. During the op- eration the pulse varied from 80 to 110, being 90 at the end. study of 1J/-5 Cases of Perineal Prostatectomy. 349 Convalescence. — The patient reacted well. For two days the temperature rose to 100.5°, but after that remained practically normal for six days. The gauze drains were removed in 30 hours. On the first and second days the drainage tubes became plugged with blood several times, causing the bladder to fill up and producing intense pain. Boric irrigations would give instant relief each time. The tubes were removed in 48 hours and patient was up on the third day. The urine began to flow through the ure- thra on the seventh day, and the perineal fistula closed on the 14th day. The right epididymis became inflamed on the ninth day, but subsided un- der ice caps in a few days. On the 14th the patient was able to hold his urine as long as five hours and had no dribbling. On the 18th day the right epididymis became slightly swollen and tender, but subsided after a few days. The patient took nitrites and the blood pressure remained between 130 and 140. The patient was kept fairly quiet, not being allowed to take as much exercise as usual. He was discharged on the 27th day. He was then able to retain his urine four or five hours, had not been in- strumented and his general health excellent, the wound completely closed. July 5, 1905. — Letter. Last night I only urinated twice, my bladder holds eight ounces, my urine is clear, acid, and contains no pus. Novemher 30, 1005. — Letter. I void urine naturally, usually once at night and two or three times during the day, eight or nine ounces at a time. I suffer no pain, have had no use for catheters and consider myself cured. I have erections, and have had intercourse many times. May 15, 1906. — 'Letter. I void urine naturally, 250 cc. at a time, two or three times during the day and usually once at night. I have erections and satisfactory intercourse. I have had no complications nor treatment. The wound has remained healed, and I consider myself cured. Case 92. — Considerable enlargement of median and lateral lobes. Large vesical calculus. Contracted bladder. Result: Removal of obstruction. Frequency of urination due to contraction of bladder. No. 938. D. M. I., age 67, widowed, admitted May 18, 1905. Complaint. — " Enlarged prostate." No history of gonorrhoea. Present illness began five years ago with frequency of urination and hesitation at the beginning. One year later he began to have pain during urination and diagnosis of vesical calculus was made, but he did not sub- mit to operation. He has never had retention and does not use a catheter. S. P. — Micturition every 15 minutes during the night, and about every hour during the day. Very little pain on voiding, but considerable pain after micturition, referred to the middle of the penis, no hematuria, no pain in hips, thighs or rectum. Has not lost weight. Sexual powers have been absent for several years. General health good. Examination. — The patient is emaciated and his lips are pale. Lungs negative. Heart. — Soft systolic murmur at apex, not transmitted to axilla, systolic murmur heard over the vessels in the neck. 350 Hugh H. Young. Rectal examination. — The prostate is considerably enlarged, forming a mass about the size of a large lemon. The contour is rather irregular, especially on the left side where it is continuous with an induration ex- tending upward and outward along the pelvic wall. The right lateral lobe is smooth and soft in consistence, and tender near its apex. The left lat- eral lobe is also smooth, fairly soft, but not tender. At the upper end running outward are several hard cords adjacent to the induration de- scribed above. Indurated cords are also felt, extending upward and out- ward from the upper end of the right lateral lobe and forming a bundle about 1% cm. in diameter. The notch at the upper end of the prostate is replaced by a transverse firm band of tissue, but it is not of stony hard- ness and has no sharp concave border as in certain cases of carcinoma. No enlarged glands are to be felt in the pelvis. Urinalysis. — Slightly cloudy, acid, sp. gr. 1010, no sugar, albumin a slight trace, urea 12 gm. to the liter. Microscopically, pus cells, bacilli and cocci. Gystoscopic examination. — The catheter passes with ease and finds about 100 CO. residual urine. The bladder is very irritable and will not admit 100 cc. of irrigating fluid. Lavage caused hemorrhage and cystoscopic study was unsatisfactory It was possible, however, to make out a large globu- lar median lobe, and a large, dark, irregular mass lying in front of it against the anterior wall of the bladder. Owing to hemorrhage it was im- possible to say whether it was stone or neoplasm. Palpation of the hypo- gastric region shows that the bladder is small, and markedly indurated and thickened. Operation, May 22, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes which were fairly large were removed in two pieces. The middle lobe, which measured 3x4x5 cm. in size was drawn down by the tractor and enucleated through the right lateral cav- ity. In these manipulations the urethra was not torn, but the vesical mucous membrane covering the apex of the middle lobe was removed. A stone forceps was then inserted through this opening and a calculus meas- uring 2 X 214 X 3 cm. in size was extracted. The wound was closed as usual with double catheter drainage and light gauze packs for the lateral cavi- ties. There was very little hemorrhage and the patient stood the operation well. A submammary infusion was given on return to the ward and con- tinuous irrigation begun. The pulse at the end of the operation was 100, and half an hour later 72. Convalescence. — 'The patient reacted well. On the day following the operation the temperature rose to 101.8°, but fell to normal the next day, and after four days remained normal. The irrigation was discontinued after 12 hours. The gauze packing was removed without causing hemor- rhage after 24 hours, and the tubes were removed the next day. The pa- tient was up in a chair on the third day, and walked at the end of a week. The urine did not pass through the penis until the 13th day, but the fis- tula closed completely on the 18th day. He began to have control on the tenth day, and was discharged from the hospital on the 22d day. At that study of lJf5 Cases of Perineal Prostatectomy. 351 time he was able to retain his urine for three hours, voided in a large stream without pain, and his general health was excellent. Novem'ber 30, 1905. — Letter. I void urine naturally, four or five times during the day and three or four times at night, from one-half to one pint at a time. The wound is closed and I consider myself cured. I have had no erections. (These were absent before operation). My general health is good. May 9, 1906. — Letter. I am cured. I void urine naturally and at normal intervals during the day, but often three or four times at night. My general health is good, and I have gained in weight. Pathological report. — ;The specimen, G. U. 165, consists of the three lobes of the prostate removed in five pieces, and weighs about 65 gm. The me- dian lobe is the largest, has been removed in one piece, and measures 6x5 X 2.5 cm. in size. It is smooth, globular, has no mucous membrane attached to it, and on section shows gland tissue with little intervening stroma. The lateral lobes have been removed, each in two pieces, and are each about 3 cm. in diameter. They are fairly smooth and on section show more stroma than the median lobe. No mucous membrane, no ejac- ulatory ducts, no calculi. Microscopic examination. — The picture in all three lobes is that of a very glandular tissue arranged in spherical lobules. The acini are for the most part small, with occasionally very regular lumina, and here and there is seen one considerably dilated. The epithelium lining the acini is of the usual tall cylindrical type, in places growing out into the lumina of the ducts in solid tufts of cells. The stroma is for the most part very compact, although here and there seems rather loosely bound. It is composed of muscle and fibrous tissue in varying proportions. Quite frequently one sees well marked concentric bands of muscle fibers closely encircling the acini. Here and there in the stroma are areas of round cell and polynuclear infiltration with occasional evidence of peri glandular and interstitial inflammatory tissue. Occasionally one sees quite numerous pus cells in the lumen of an acinus and not infrequently some in acini which show no inflammatory process either in the the parenchyma or its immediate vicinity. The hypertrophy is of a distinctly adenomatous type with practically no cystic degeneration, and with a comparatively small amount of flbro-mus- cular stroma. Case 93. — Fairly large hypertrophy. Catheter life seven years. Cured. Followed one year. No. 908. W. H. B., widowed, age 76, admitted April 25, 1905. Complaint. — " Prostatic hypertrophy. Catheterism." No history of gonorrhoea or previous urinary trouble. Onset 13 years ago with slight increased frequency of urination. In 1896 began to use a catheter occasionally. Retention of urine has been complete for the past 10 months and the catheter employed two to four times during the day. 352 Hugh H. Young. He has no pain, but finds the catheter an unbearable nuisance, and at times difficult to introduce. Pain is not a marked symptom. Erections have been absent for the past two years. Examination. — ^A vigorous looking man for his age. There is slight ar- teriosclerosis. Pulse regular and 80 to the minute. A slight systolic murmur at apex of heart. Lungs and abdomen negative. Rectal examination.— 'The prostate is considerably hypertrophied, form- ing a globular mass the size of an orange. It is round, smooth, elastic and without induration or tenderness. No enlarged glands are present. Both epididymes are indurated. Urinalysis. — Slightly cloudy, sp. gr. 1024. Albumin considerable, no sugar, acid, pus cells and cocci in large numbers. Urea 21 gm. to the liter. Cystoscopic examination. — A silver ca,theter enters with ease. The blad- der capacity is large, tonicity is good, retention of urine is complete. The cystoscope shows a slight enlargement of the right lateral lobe, a very prominent intravesical hypertrophy of the left lobe, projecting anteriorly, and small rounded median lobe. The bladder is considerably trabeculated with small pouches, but no diverticula. The ureters cannot be seen on account of the middle lobe. No calculus is present. With the finger in the rectum and cystoscope in the urethra the beak is easily felt, and the thickness of the posterior commisure is only slightly greater than nor- mal (cystoscope in sulcus to one side of middle lobe). Preliminary treatment. -^The patient was instructed to take urotropin and to drink water in abundance, and to return later for operation. Nitro glycerine and nitrites for two days previous to operation on account of high blood pressure, 210 mm. Operation, May 22, 1905. — Ether. Perineal prostatectomy by the regular technique. The median lobe was removed through one of the lateral cavi- ties and was about the size of a cherry. The lateral lobes were moder- ately enlarged. The ejaculatory bridge and floor of the urethra were pre- served intact, and only a small linear tear was made in the lateral walls of the urethra, the bladder was not torn. There was very little hemor- rhage, and the patient stood the operation well. Closure, as usual, with double tube drainage and continuous intravesical irrigation before leaving the table and after return to the ward. Submammary infusion was given after the operation. At beginning of operation pulse 85, blood pressure 180, at end of operation pulse 65, blood pressure 125. Convalescence. — ^The patient reacted well. The gauze drainage was re- moved on the next day and the tubes on the second day, continuous irriga- tion having been maintained over night. The perineal fistula closed on the twenty-first day. No epididymitis or other complications occurred. Highest temperature 100.8° on second day after operation. June 20, 1905. — -Patient drinks two quarts of water a day and voids from 11 to 24 times. Has no incontinence, but when bladder becomes full the sphincter is a little weak. The wound is tightly healed. The urine Is clear, acid, and contains only a few pus cells and bacteria. A silver cath- study of 14-5 Cases of Perineal Prostatectomy. 353 eter passes with ease and finds 22 cc. residual urine. There is no evidence of stricture and patient has not been instrumented since the operation. Patient left the hospital on the 33d day. Septem'ber 23, 1905. — 'Letter. It is now four months since the operation. All has gone well in every way. I have satisfactory retention of urine, only occasionally the merest dribble of a few drops, apparently due to nervtjus causes. I am riding my bicycle. iJVovem&er 21, 1905. — 'I have satisfactory control of my urine. There has been a slight return of erections and my general health is excellent. I have perfect freedom from a load of discomfort under which I had been for years, and have a new lease on life. November 30, 1905. — 'Letter. I void urine naturally about 10 times in the day and once or twice at night, rarely over 325 cc. at a time, occasion- ally 400 cc. I suffer no pain, the wound has remained healed. I have in- complete erections. My general health is excellent. Last night I slept seven and one-half hours without urinating. May 7, 1906. — The wound has remained closed. I void urine naturally, and at normal- intervals, from 300 to 350 cc. at a time. I have no pain, have semi-erections, have not attempted intercourse. I have had no com- plications nor medical treatment. My general health is excellent and I con- sider myself cured. May 22, 1906. — Letter. It is a year since the operation. I pass my urine naturally, have satisfactory control, and only dribble occasionally (at in- tervals of days) when convenient opportunity of relief is poor and when the bladder gets too full. The intervals are between four and five and one-half hours, and the amounts voided from 200 to 300 cc. Pathological report. — The specimen, G. U. 166, consists of the three lobes of the prostate removed in five pieces, and weighing about 30 gm. The left lateral lobe measures 3 x 3 x 1.7 cm., is fairly smooth and on section shows gland tissue and a considerable amount of stroma. The right lobe measures 3.5 x 2.5 x 1.7 cm., and has been removed in two pieces, is some- what torn and irregular, and is apparently more fibrous than the left. One dilated cyst seen. The median lobe forms a globular mass about 2 cm. in diameter and has been removed in two pieces. It is apparently more glandular than the lateral lobes. No mucous membrane, no ducts, no cal- culi removed. Microscopic examination. — This shows in the middle and left lateral lobe an adenomatous hypertrophy in which the gland tissue is largely arranged in lobules. In areas many of the acini are very much dilated and lined with a single layer of flattened epithelium. In areas they are about normal in size, and again in other areas somewhat dilated with irregular lumina. The gland tissue is very much in excess of the stroma, which is of a fairly compact nature. Surrounding the glandular lobules the stroma is fairly compact, and its contained ducts are very much compressed. The stroma is composed of both muscle and fibrous tissue; the fibrous tissue somewhat predominating. Here and there is some round cell infiltration. The right lobe is also 354 Hugli H. Young. distinctly adenomatous in nature, but its ducts show practically no cystic degeneration, and there are distinct areas of connective tissue hypoplasia. It contains more stroma than either the middle or left lobe. Case 94. — Slight enlargement of lateral lobes. Cystin calculus. Con- tracted bladder. Cured. No. 913. W. B. E., age 67, married, admitted April 27, 1905. Complaint. — " Enlarged prostate." The patient never had gonorrhoea. Present illness began about one year ago with slight increase in the fre- quency of urination. About six months ago he began to have a sharp pain in the glans penis at the end of micturition. He has never had retention of urine and no catheter has been introduced. He has been unable to have sexual intercourse for one and one-half years. S. P. — 'Voids once or twice at night and six or eight times during the day. Micturition accompanied by pain at the end of the penis, and slight tenesmus. Examination. — The patient is a sturdy looking man. Heart, lungs, and abdomen are negative. The prostate is enlarged in both lateral lobes, the left being the larger. The median furrow and notch are wide and deep. The general contour is rounded, smooth, fairly hard, but no nodules are present and there is no induration in the region of the seminal vesicles. The prostatic secretion contains a few pus cells, a large number of gran- ule cells and very few lecithins. The urine is slightly cloudy, acid, albu- min present, no sugar. Urea 13 gm. to the liter. Microscopically pus cells and a few bacteria. Cystoscopic exam,ination. — Coude catheter passes with ease and finds 15 cc. residual urine. The bladder is contracted, holding only 160 cc. The cystoscope shows a slight hypertrophy of the median portion in the shape of a small, rounded lobe. The lateral lobes are only slightly enlarged. In the bladder is seen a small oval calculus with a coarsely granular surface composed of yellowish crystals. Operation, May 22, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were only slightly enlarged, measuring 2 x 2% X 3 cm. in size. The urethra and bladder were not torn in their removal. The tractor was then removed and the urethra split along its left lateral wall, the vesical orifice dilated, the stone forceps introduced and an oval calculus 1.0 X 2 X 3 cm. in size removed. It is roughly granular, its sur- face being composed of numerous crystalline spicules, amber in color and very hard (chemical examination showed it to be composed of pure cys- tin). Insertion of the finger after the removal of the calculus showed no enlargement of the median portion of the prostate. It had apparently been sufficiently removed with the lateral lobes. The lateral cavities were packed with gauze. Double catheter was inserted into the bladder through the perineum and the wound closed as usual. Submammary infusion and continuous irrigation on return to ward. Convalescence. — The patient reacted well. The gauze was removed in study of 145 Cases of Perineal Prostatectomy. 355 36 hours and the tubes in 48. Urine began to come through the penis on the fifth day and the fistula closed on the 18th. He was out of bed on the fifth day, but did not walk until the eighth. Highest temperature 100.2° on third day after operation, after that normal. June 14, 1905. — -The patient voids urine freely in a good stream at inter- vals of from three to five hours during the day and only once at night. Has good control, no dribbling, slight precipitancy at times. A coude catheter passes easily, there is no residual arine. The urine is cloudy and contains a few pus cells and bacteria. Discharged from the hospital on the 24th day. July 5, 1905. — Letter. Yesterday I passed a small calculus without pain or hemorrhage. November 30, 1905. — Letter. I void urine naturally and consider myself cured. I have no pain and often void a pint at a time. I urinate two or three times at night and six or seven times during the day. I have no erections, but these were absent before the operation. May 8, 1906. — Letter. I void urine naturally, once during the night and at normal intervals during the day, and occasionally void a pint of urine at a time. I have no pain. . Erections are partial. I have not attempted sexual intercourse. My general health is good. I have gained in weight and consider myself cured. Pathological report. — The specimen, G. U. 163, consists of the two lateral lobes of the prostate, each in one piece and weighing all about 15 gm. The right lobe measures 3 x 2.5 x 2 cm. is fairly smooth, encapsulated, and on section shows considerable gland tissue with dilated acini. The left lobe measures 2.5 x 2.3 x 2 cm., and contains a cavity about 5 mm. in diam- eter from which a calculus has been removed. The cut surface shows gland tissue with very little stroma, no cystic dilatations, and one or two seed calculi. No mucous membrane or ejaculatory ducts have been re- moved. Microscopic exaviination. — The hypertrophy is of the glandular type with some arrangement in lobules. The gland acini show the usual dila- tation with complexity of the lumina and areas of cystic degeneration. There is present much endoglandular sprouting. The stroma contains very much more fibrous tissue than muscle. Some areas of prostatitis and numerous corpora amylacea are seen. Case 95. — Moderate hypertrophy of median and lateral lobes. Complete retention. Catheter life. Cured. Followed 12 months. No. 937. T. S. N., age 59, married, admitted May 5, 1905. Complaint. — •" Enlarged prostate." No history of gonorrhoea. Present illness began three years ago with burning pain on urina- tion, slight hesitation and some straining. He had no particular incon- venience until two years ago when urination became quite frequent and difficult. In a few weeks he was voiding every hour night and day. He had no acute retention of urine, but on the advice of a physician he began 356 Hugh H. Young. the use of a catheter now almost two years ago, and since then has been unable to void naturally except small amounts very occasionally. About nine months ago he had epididymitis on the left side, and since then three other attacks on this side and one on the right. He has never had hema- turia nor passed a calculus. His general health is excellent, his sexual powers are good. )S. P. — A catheter is used three or four times a day. He suffers no pain, has no hematuria, and his general health is excellent and he begs to be relieved of the catheter life. Examination. — The patient is well nourished with mucous membranes of good color. His chest and abdomen are negative. Genitalia: Both epi- didymes are hard and tender. Rectal examination. — >The prostate is only moderately enlarged. It is smooth, soft, globular in shape and is not tender. Extending upward and outward from the upper end of the prostate on each side is a smooth, hard cord about the size of a small lead pencil, the upper limits of which are impossible to reach. The diagnosis of indurated vasa deferentia is made. Seminal vesicles are not palpable; there are no glands to be felt. Urinalysis. — Slightly cloudy, acid, sp. gr. 1016, no albumin, no sugar. Urea 15 gm. to the liter. Microscopically pus cells and bacilli. Cystoscopic examination. — The patient has complete retention of urine. Bladder capacity 600 cc. Tonicity good. A stricture of large caliber is present one inch from the meatus, which grips the cystoscope. The cysto- scope shows a small round median lobe with a deep sulcus on each side and very little intravesical hypertrophy of the lateral lobes. A small polyp is seen attached to the right lateral lobe, the mucous membrane elsewhere is smooth and regular. The bladder is markedly trabeculated, but only slightly inflamed. There are numerous cellules and diverticula on the pos- terior and lateral walls, but no foreign bodies are present. The ureters cannot be seen on account of the middle lobe. With the finger in the rec- tum and cystoscope in the urethra the amount of the tissue is not greatly increased. (Cystoscope in one of the sulci.) Operation, May 22, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes which were only moderately hypertrophied were easily enucleated, each in one piece. The median bar was removed in two pieces, one through each lateral cavity. It was impossible to engage the small median lobe with the blade of the tractor which was therefore withdrawn and the finger inserted through the urethra to push the middle lobe into the left lateral cavity where it was easily enucleated. Urethra was torn on each side, but no mucous membrane was removed, and the floor of the urethra and ejaculatory ducts were preserved intact. The wound was closed as usual with double catheter drains and light packs for the lateral cavities. An infusion was given on return to the ward and continuous vesical irrigation begun. The patient stood the operation well. Pulse varying from 95 to 115, 110 on return to the ward. Convalescence. — The patient convalesced rapidly. The temperature did study of lJf5 Cases of Perineal Prostatectomy. 357 not rise above 100°. The gauze was removed after 24 hours and the tubes in 48 hours. Urine began to come through the penis on the fifth day. He had good control on the eighth and by the twelfth day could retain urine for several hours. The perineal fistula closed on the fifteenth day. He was out of bed on the third day, and began to walk in the first week. Erections returned on the fourteenth day. On the twentieth day a catheter was in- troduced and found 40 cc. residual urine. He was discharged from the hospital on the twentieth day. June 19, 1905. — The patient is in excellent condition. Retains urine for five hours during the night and four hours during the day. The stream is large, there is no hesitation and no incontinence. The perineal wound is closed. A large silver catheter passes with ease, no obstruction is pres- ent, residual urine 10 cc. Novem'ber 30, 1905. — Letter. I void urine naturally three or four times during the day and rarely ever more than once at night, from 12 to 16 ounces at a time. Occasionally I have a slight pain when urinating. The fistula is closed. Erections have returned but are only partial. I have had sexual intercourse, but the ejaculation is slight and not entirely satis- factory. My general health is excellent. May 10, 1906. — Letter. I void urine naturally as much so as when a boy, at normal intervals and very rarely have to get up at night. I have no pain, no incontinence, no fistula. Erections have returned and I have sexual intercourse, not quite as satisfactory as before. I consider myself perfectly cured. My recovery seems like a miracle. Pathological report. — The specimen, G. U. 167, consists of the three lobes of the prostate removed in four pieces and weighs about Gr-20. The left lobe measures 2.5 x 2.5 x 1.5 cm., is fairly smooth with considerable capsule, and on section shows an abundance of gland tissue and a small amount of stroma. The right lobe measures 3.5 x 2 x 1.5 cm., and is similar in character to the left. The median lobe has been removed in two pieces each about 2.5 x 1.5 x 1 cm. in size, one of which formed a pedunculated intravesical lobe, oval in shape, but contains no mucous membrane. No ejaculatory ducts or calculi removed. Microscopic examination. — Both lateral lobes and the middle lobe show practically the same type of hypertrophy, which is a distinctly adenoma- tous one. The gland tissue is arranged somewhat in lobules, and there is considerable dilatation of the culs-de-sac. The majority of the acini show a considerable complexity due to the folding and papillomatous out- growth of the lining walls. The epithelium is of a tall cylindrical type, in places of one layer deep, and others many layers, and again growing out in apparently solid epithelial masses into the lumen. The stroma is fairly compact, and composed of more fibrous than muscle tissue. The gland tissue is very much more in excess than the stroma. There is con- siderable round cell infiltration in various areas. This infiltration is mostly limited to the interstitial tissue, although in a few areas being most marked about the acini. 358 Hugh H. Young. Case 96. — Very large prostate with great median lobe, with villous sur- face. Diagnosis, malignant. Suprapubic drainage. Later perineal pros- tatectomy. Cure. No. 944. J. C, age 68, married, admitted September 29, 1904. Complaint. — " Prostatic hypertrophy, catheterism." The patient had never had gonorrhoea. Present illness began 14 years ago when the patient noticed a slight difficulty and increased frequency of urination. The first retention of urine came on 12 years ago. Since then the catheter has been used at irregular intervals, but the patient has always been able to void a small amount naturally. Of late he has been suffering pain and severe spasm in the bladder which frequently comes on 10 or 12 times a day. He usually passes the catheter as soon as the spasm has subsided, and finds urine, but sometimes the bladder is completely empty. He has had no pain in the back, buttocks, or groins, but he frequently has a severe pain in both legs from which he only can find relief in the kneeling posture. Two months ago he had a considerable hemorrhage from the bladder which continued for a week. There has been none since. He has lost considerably in weight. 8. P. — The frequency of urination is very variable, at times every half hour at others every two hours. "When the desire to urinate comes on he has a severe pain and a spasm at the neck of his bladder. He catheter- izes himself from three to six times a day, but usually finds only two or three ounces of residual urine. Sexual powers. — ^Normal. Examination. — The patient is a rather pale looking man. Heart, lungs, and abdomen negative. The right testicle and epididymis are enlarged and indurated. There is no hernia present. Rectal examination. — The prostate is considerably enlarged about the size of a medium sized orange. Smooth, rounded, soft, elastic, no nodules, no induration. The median furrow and notch are shallow. Seminal vesicles not palpable nor enlarged, but there is no induration above the prostate, and the rectal wall is soft and not adherent and no glands are to be felt. Cystoscopic examination. — A coude catheter cannot be passed owing to obstruction in the prostatic urethra. A silver catheter passes with some difficulty and produces hemorrhage which requires the use of adrenalin. Residual urine 250 cc. is present. The cystoscope shows a very extensive outgrowth from the prostate on all sides. The surface is irregular, in places villous in type, in others fissured, and in places frayed out and white. On the left side the growth extends far out into the bladder and has the appearance of a large vesical tumor, but examination shows that it springs from the left lobe of the prostate. It is difficult to see more than a small portion of the bladder which is found to be greatly trabeculated with numerous diverticula. With the finger in the rectum study of 145 Cases of Perineal Prostatectomy. 359 and cystoscope in the urethra it is impossible to feel the beak of the instrument, the amount of tissue in the median portion being very- extensive. Urinalysis. — ^Very purulent. Microscopically red blood cells, pus, bacilli, and cocci. Slightly acid, no sugar, small amount of albumin. Remark. — The diagnosis of carcinoma of the prostate with extensive intravesical tumor outgrowth was made upon the appearance of the intravesical mass, pain and the loss of weight. Rectal examination did not suggest malignant disease. Operation, September 30, 1904. — Ether. Suprapubic cystostomy for drainage. Examination of the bladder with the finger showed an extensive outgrowth of the prostate which filled the base of the bladder. Its surface was very irregular, fissured, villous, and in places granular and quite firm. The diagnosis of carcinoma seemed entirely confirmed, and ex- tirpation not attempted. Convalescence. — The patient improved rapidly after the operation, was up in a wheel chair on the 11th day and discharged on the 28th day. He then had a healthy suprapubic fistula in which he wore a hard rubber tube connected with a Bloodgood bag. May 19, 1905. — The patient returns for examination. He has worn the Bloodgood drainage apparatus since leaving the hospital. He has had no pain, but there has been considerable leakage around the tube and he is uncomfortable. Hemorrhage occurred for the first time last week. He has gained 15 pounds in weight and his health is excellent. Rectal examination. — The prostate is in the form of a smooth globular mass about the size of a medium sized orange, elastic, fairly soft, and without induration. The cystoscope shows an entirely different picture around the prostatic orifice. The villi and fissures have completely dis- appeared and there are present now two large lateral lobes connected by a fairly large median bar. The mucous membrane covering them is granular, but not irregular, and the appearance is that of an ordinary hypertrophy and does not suggest malignancy. Perineal prostatectomy is advised. Operation, May 22, 1905. — Ether. Perineal prostatectomy by the usual technique. The left lateral lobe, the median bar and the right lateral lobe were removed in one piece without destroying the fioor of the urethra, the right lobe having been drawn after the median bar beneath the urethra into the left lateral cavity. The tractor was then removed and a finger inserted into the bladder, and a fairly large rounded median lobe, which had dropped well back on the tractor was found. It was drawn up by the finger until it presented into the left lateral cavity and enucle- ated, but in doing so a small tear was made in the mucous membrane cov- ering it. The ejaculatory ducts and fioor of the urethra were preserved intact. The usual closure was employed, lateral cavities being packed with gauze and double catheter drainage for the bladder. There was mod- erate amount of hemorrhage and the patient stood the operation well. Continuous irrigation and a submammary infusion were given on return to the ward. Pulse at the end 110. 360 Hugh H. Young. Convalescence. — The patient reacted well, the temperature rose to 101.4^ on the day after the operation, but after the fourth day was practically normal. The gauze was removed on the day after the operation and the tubes on the next day. The patient was up in a wheel chair on the second day. Urine flowed through the urethra on the fifth day. The supra- pubic fistula closed on the seventh day, and the patient was discharged on the 32d day. His general condition then was excellent, nearly all of the urine passed through the meatus, a small fistula was present in the perineum. The perineal fistula closed on August 1, 1905, 70 days after operation. November 30, 1905. — Letter. I urinate seven or eight times during the day and once or twice at night and often pass 250 cc. at a time. I am free from pain and my general health is excellent. The wound is completely closed, but there is a slight rupture in the suprapubic scar. I have no erections. I have had a swelling of the left testicle. May 7, 1906. — Letter. I void urine naturally, in large amounts, but more frequently than normal, seven or eight times during the day and two or three at night, and about half a pint at a time. I suffer no pain and consider myself cured. I have erections but they are not perfect, and have not attempted intercourse. I passed two calculi last month. My health is excellent. Pathological report. — The specimen, G. U. 168, consists of three lobes of the prostate, and weighs about G-85. The right and left lobes and the median bar have been removed in one piece. The right lobe measures 5x4x3 cm. The left measures 6 x 3.5 x 3.5 cm. and the median bar joining them is 3 cm. wide and 2 cm. thick. There is no mucous membrane attached to these lobes which are irregular along the urethra, but smooth externally. The median lobe has been removed separately in two pieces, measuring 5x3x3 cm. and 2 x 2 x 1.5 cm. in size respectively. On section there is considerable glandular tissue with small amount of stroma. No induration or areas suggesting malignancy. No mucous membrane, no ejaculatory ducts and no calculi have been removed. Microscopic examination. — The lateral lobes show an adenomatous type of hypertrophy. The ducts in many lobules show much cystic degenera- tion with flattening of the epithelium. In other areas the ducts are not so much dilated, but there is very marked complexity of the gland. The stroma is in places fairly thick, and in other areas, where the gland tissue is particularly abundant, is composed of slender bands. The stroma is rather dense, and composed for the most part of muscle and fibrous tissue in fairly equal parts. In a few limited areas there is some round cell and polynuclear infiltration. The middle lobe contains distinctly less gland tissue than the lateral lobes, and there is considerable connective tissue hyperplasia. The ducts, which are present, are for the most part undilated although here and there one finds a few acini which have undergone cystic degeneration. This is distinctly an adenomatous type of hypertrophy in the lateral lobes, while the middle lobe is less adenomatous, and contains considerably more fibrous tissue than the lateral lobes. study of lJi.5 Cases of Perineal Prostatectomy. 361 Case 97. — Moderate hypertrophy of median and right lateral lohes. Great hypertrophy of the left lateral lobe, with intravesical villi suggesting malignancy. Suprapubic exploration. Perineal prostatectomy. Cure. No.. 894. J. L. McW., age 61, married, admitted April 24, 1905. Complaint. — " Prostatic trouble." No history of gonorrhoea. Present illness began six years ago with difficulty of urination which gradually increased and five years ago complete retention of urine set in and he had to be catheterized. After that the patient was able to void, but urinated frequently and in a small stream. On January 29, 1905, retention of urine came on a second time, and as his physician was unable to pass a catheter, suprapubic aspiration was performed. Later a silver catheter with a large curve was passed, but in a short time the patient was able to void again and has not been catheterized since. S. P. — Urination three times during the night, four times during the day. Urine difficult to start, stream small and slow, slight dribbling at end. No blood, no pain, general health excellent. Sexual powers are weak. Erections imperfect. Sexual desire about normal. Examination. — Patient is a well nourished man, lips and mucous membranes of good color. Heart, lungs, and abdomen negative. Rectal examination. — The prostate is considerably enlarged, being about the size of a medium-sized orange. It is smooth, rounded, soft, there are no areas of induration and no nodules, and the upper end is reached with difficulty. Seminal vesicles are not palpable, but there is no induration in this region. The prostatic secretion contains a few pus cells, granule cells, spermatozoa and a few lecithin bodies. Urinalysis. — Clear, acid, sp. gr. 1022, no albumin, no sugar, urea 13 gr. to th6 liter. Microscopically red-blood corpuscles, no pus cells, no bacteria. Cystoscopie examination. — A coude catheter passes with ease and finds 40 cc. residual urine and a bladder capacity 320 cc. The cystoscope shows a moderate enlargement of the median lobe and a fairly considerable intra- vesical enlargement of the left lateral lobe. The right lateral lobe is only slightly enlarged intravesically. The surface of the median lobe is irregular and one large polypoid mass is seen attached to its posterior surface. Looking upward and to the left several irregular fissures are seen. There are no definite villi and no ulcerations, and the bladder wall is trabeculated and shov/s no evidence of infiltration. The cystoscopie examination suggests malignancy owing to the irregularly lobulated and fissured condition of the intravesical portion and the adherent polyps, but rectal examination does not at all suggest malignancy. The history is also against malignancy, but in order to be certain it is thought best to perform a suprapubic cystostomy for exploration previous to prostat- ectomy through the perineum. Operation, April 28, 1905. — Suprapubic cystotomy for vesical examination. Diagnosis, benign hypertrophy. Closure of the bladder with three inter- rupted sutures. Partial closure of the abdominal wound with catgut. The Vol. XIV.— 24. 362 Hugh H. Young. patient was then placed in the lithotomy position and perineal prostat- ectomy performed by the usual technique. The left lateral lobe was found to be greatly hypertrophied measuring 5x6x8 cm. in size. It was quite adherent to the urethra and to the bladder, but was enucleated without removing any of the mucous membrane. The right lateral lobe was much smaller measuring 2x3x4 cm. in size, and attached to it was the median lobe which was enucleated in one piece with it. A small tear was made in the urethra but no mucous membrane was removed and the ejaculatory ducts were preserved. The wound was closed as usual with double catheter drainage and light packs for the lateral cavities. Saline infusion on return to ward, no continuous irrigation on account of suprapubic suture of vesical wound. The patient stood the operation well. The hemorrhage was slight. Pulse at the end 95, one hour later 88. Convalescence. — Patient reacted well and the temperature rose to 106.6° the day after the operation, but was normal on the third day. The gauze packs were removed from the perineal and suprapubic wounds in 48 hours and the tubes the same day. The suprapubic vesical wound did not leak, the abdominal wound healing nicely by granulation. No urine came through the penis until the 15th day. After that the perineal fistula closed slowly, but a few drops escaped through it on his discharge on the 24th day. Interval urination, however, had been present since the removal of the perineal tubes, and he was able to retain his urine three hours and had no incontinence. A silver catheter passed with ease, no stricture or other obstruction, no residual urine present. The fistula was curetted and the patient was discharged. Urine contained a few pus cells and bacilli. Before leaving patient reported that he had several erections. Owing to suprapubic wound the patient was confined to his bed for two weeks. The perineal fistula closed on the 30th day. February 8, 1906. — Urination is entirely satisfactory, three times during day and twice at night, four or five ounces at a time, entirely without pain. I have erections but very seldom and rather weak. I have sexual inter- course occasionally, but the ejaculation is slow and the emission scant. May 7, 1906. — Letter. I void urine naturally three times during the day and about twice at night, about six ounces at a time. I have no pain. I have erections, but not as firm as normal and the ejaculation is slow. I have had intercourse occasionally. My general health is excellent, I have gained in weight and consider myself cured. September 14, 1906. — Letter. The perineal wound has remained closed. I void urine naturally five times in 24 hours and consider myself cured. I have erections and sexual intercourse. My general health is excellent. Pathological report. — The specimen, G. U. 150, consists of two pieces, the two lateral lobes and weighs about G-60. The left lateral lobe is smooth, oval, slightly lobulated mass 7 x 5 x 4.5 cm. in size, and on section shows a very thin capsule, moderate amount of gland tissue and considerable stroma with few dilated ducts. The right lateral lobe is much smaller, measuring 6x3x3 cm. in size, and is similar in appearance to the left. No mucous membrane, no ducts, no calculi. study of lJf5 Cases of Perineal Prostatectomy. 363 Microscopic examination. — This hypertrophy is of the usual glandular type with areas of gland aggregation. The acini are for the most part dilated, and there is present a considerable amount of endoglandular papil- lomatous growth. Some glandular and interstitial prostatitis is present with small accumulations of inflammatory cells at several points almost suggesting small abscesses. The stroma is about two-thirds fibrous tissue although there are areas where the muscle element is equal to, if not in excess of, the connective tissue. Case 98. — Moderate hypertrophy of median and lateral lobes Cure. Followed 11 months. No. 1001. M. S., age 60, married, admitted June 3, 1905, St. Francis Hospital, La Crosse, Wisconsin. Complaint. — " Frequent urination." No history of gonorrhcea. Present illness began eight years ago with hesitation at beginning of urination, and straining. Urination gradually became more frequent, and he now urinates about 10 times at night and every hour during the day. There is an occasional burning sensation at the end of the penis, but no definite pain. Sexual powers. — No note made. Examination. — Patient is a sturdy looking man. Chest and abdomen are negative. Rectal. — Prostate is moderately enlarged, smooth, elastic, no induration, no nodules. Cystoscopy was not performed. There was considerable residual urine, but no note has been made as to the amount. Operation, June 9, 1905. — Ether. Perineal prostatectomy by the usual technique. Two fairly enlarged lateral and a small median lobe were easily enucleated without removing any of the mucous membrane of the urethra, and the ejaculatory duets were preserved intact. The patient stood the operation well. The wound was closed as usual with double drainage tubes and light packs for the lateral cavities. The patient stood the operation well. Infusion and continuous irrigation on return to room. Convalescence. — Continuous irrigation discontinued after 14 hours. The gauze and tubes were removed on the second day and soon after the urine came through the anterior urethra. The patient had no temperature above 99°, was up on the second day, and on the 14th day could retain urine for five hours. The perineal fistula closed completely on the 17th day, and the patient was discharged on the 18th. At that time he could retain urine five hours. Had no pain, fistula had reopened and a few drops of urine had escaped through it. His condition was excellent and the urine apparently normal. The fistula finally closed. November 30, 1905. — Letter. The wound has remained closed, I void urine naturally, about one-half pint at a time about four or five times dur- ing the day and twice at night. I suffer no pain, have not been instru- 364 Eugli H. Young. mented since operation and consider myself cured. I have erections and satisfactory sexual intercourse. I have had no complications and my general health is good. May 5, 1906. — Letter. I void urine naturally at fairly normal intervals, one-half a pint at a time. I suffer no pain. Sexual intercourse is satis- factory. I have had no complications or treatment, and consider myself cured. Pathological report. — The specimen, G. U. 264, consists of three pieces, two lateral lohes and a small median lobe, whole weighing about 25 gr. The median lobe measures only 1.5 x 1.3 x .8 cm. is irregular and on section looks fibrous. The lateral lobes are about equal in size, measuring about 3.5 x 3 x 2.5 cm., covered by fairly smooth capsule, and on section show numerous spheroids. A number of dilated acini are seen. The consistence is uniformly elastic. No mucous membrane or ejaculatory ducts have been removed. Microscopic examination. — The hypertrophy is a lobulated glandular one. The acini are for the most part only moderately dilated, and present a rather marked papillomatous proliferation. The stroma is rather dense, almost entirely composed of fibrous tissue. There is present considerable interstitial and periglandular prostatitis. In the middle lobe the prostatitis is more intense, and almost leads to the formation of abscesses about many groups of acini. The arteries show practically no thickening. Case 99. — Moderate hypertrophy of lateral and median loies. Occasional catheterism. Cured. Followed 11 months. No. 1002. C. M. M., age 56, admitted June 3, 1905, at St. Francis Hospital, La Crosse, Wisconsin. Complaint. — " Frequent and painful urination." No history of gonorrhoea. Present illness began five years ago with pain in the perineum and difficulty of urination which lasted only a few days, but returned six months later when retention became complete and catheterization neces- sary. During the next three years he had to be catheterized about 10 times, and for the past 18 months has had to use the catheter four or five times every month. S. P. — Urine is voided four or five times during the day and 15 times at night. The amount passed is small, and there is a severe pain in the bladder and perineum before urination. His phj'sical condition is good. Sexual powers. — No note made. Examination. — The patient is a strong, sturdj' looking man with lips of good color. Chest and abdomen are negative. Reclal. — The prostate is considerably enlarged, smooth, elastic, no induration in the region of the seminal vesicles. Urine of good quality. Operation, June 9, 1905. — Ether. Prostatectomy by the usual technique. study of 145 Cases of Perineal Prostatectomy. 365 The lateral lobes wMcli were considerably enlarged were easily enucleated. The median lobe was enucleated through one of the lateral cavities without difficulty, no mucous membrane being removed and only a small tear being made. Search of the bladder failed to reveal any calculus. Closure as usual with double tube drainage and light packs for the lateral cavities. Continuous irrigation and infusion on return to room, condition of patient excellent. Convalescence. — Patient reacted well. The irrigation was discontinued after 14 hours, the packing was removed within 24 hours and the drainage tubes within 48 hours. Immediately afterwards urine was voided through the urethra, and the patient was gotten out of bed. On the fourth day nearly all of the urine came through the anterior urethra. On the sixth day the patient had a chill and temperature of 105°, but after that the temperature remained normal. The patient was discharged on the 18th day. His condition was excellent, urination three times during the day and twice at night, without pain and in a large stream, only a few drops of urine escaped through the perineal fistula. July 11. — The perineal fistula closed, 31st day. December S, 1905. — Letter of physician. The wound has remained closed. Urine is voided naturally, about one-half pint at a time without pain, about five times during the day and five times at night. He has erections, but has not attempted intercourse. He has recently been troubled with a nervous disorder of the stomach. I consider him entirely cured by the operation. May 7, 1906. — Letter. I void urine naturally, six times during the day and twice at night, about four ounces at a time. I have no pain except a burning sensation when I urinate. I have erections, but rarely, have not attempted sexual intercourse. Eight months ago I had pain in the peri- neum and fever followed by a discharge of pus from the urethra after which I slowly got better. I also had epididymitis on the left side. My general health is good, and I have gained in weight. I consider myself cured apart from what I have described. September 11, 1906. — Letter. The perineal fistula closed 32 days after the operation. I void urine naturally, six or seven times a day and five times at night. The amount voided is natural. I suffer no pain, have erections and consider myself cured. Pathological report. — The specimen, G. U. 265, consists of three lobes of the prostate removed each in one piece and weighs about G-20. The lateral and median portions of the prostate are about equal in size, each being about 3x2.5x2 cm. They are smooth, slightly lobulated, and on section show considerable gland tissue, but also a good amount of stroma. No mucous membrane, no ejaculatory ducts, no calculi removed. Microscopic examination. — The hypertrophy is a moderately glandular one with less dilatation of the acini than one usually sees, but the off-shoots into the lumina of the acini from the lining wall are present in considerable degree. The stroma is fairly dense, but there are numerous areas where young connective tissue has been formed. Connective tissue is in excess of the muscle elements. The blood vessels seem practically normal. 366 Hugh II. Young. Case 100. — Large hypertrophy of median and lateral lobes. Compli- cations: Suppuration in wound. Cholecystitis. Cured. No. 965. G. W. H., age 64, married, admitted June 20, 1905. Complaint. — " Enlarged prostate." No history of gonorrhoea. Present illness began about eight years ago with diflBculty of urination, pain and incontinence which continued for several weeks. One year later he had retention of urine for the first time, and after that with increasing frequency until three years ago when the retention became complete and chronic and he has led a catheter life. Two years ago he had epididymitis on the left side. He has had a dull aching pain in the bladder, but none elsewhere. No hematuria, no calculus. S. P. — The catheter is used at bed time and he voids first at 4 a. m. He uses the catheter again in the morning and does not void then for four hours, after which he voids every two hours. Catheterization is often very difficult and sometimes produces hemorrhage. His general health is good. Sexual powers. — Erections and coitus satisfactory. Examination. — The patient is a well nourished, healthy looking man. Chest and abdomen negative. Rectal. — Prostate is considerably enlarged, smooth, soft, no nodules or induration, the upper end can be passed with difficulty. The seminal vesicles are negative. Cystoscopic. — A catheter passes with ease and finds 360 cc. residual urine. The bladder capacity is large. The cystoscope shows a fairly large median lobe and considerable intravesical enlargement of the lateral lobes. The bladder is trabeculated, cystitis moderate, no calculus. With cysto- scope in urethra and finger in rectum, the median portion appeared quite thick and the beak could not be felt owing to the length of the prostate. Urinalysis. — Cloudy, 1022, acid, no sugar, no albumin, pus cells and bacteria. Operation, June 21, 1905. — Ether. Perineal prostatectomy by the usual technique. Both lateral lobes were quite large. While enucleating the left lateral lobe it was found possible by directing one blade of the tractor so as to engage the summit of the middle lobe to draw it down and enucleate it in one piece with the left lateral. A median bar was left and this was removed in two pieces also through the left lateral cavity. A tear was made in the mucous membrane of the median portion, but none removed. The ejaculatory ducts were apparently preserved. Usual closure with double drainage tubes and light packs for the lateral cavities. The patient stood the operation well, infusion, pulse at the end 70. Continuous irrigation on return to the ward. Convalescence. — The patient reacted well, and had a practically normal temperature and for three weeks the temperature was normal except on the fifth day when it reached to 100.5°. The tubes and gauze were removed on the third day, and interval urination was established almost at once. Urine did not flow through the anterior urethra until the 13th day. study of lJj.5 Cases of Perineal Prostatectomy. 367 The sutured wound did not heal per primam and left a large wound to granulate. On the 25th day there was a sudden rise of temperature to 102.9 at 6 p. m. and examination showed a distended tender gall bladder. This attack persisted for two 'weeks during which the patient was con- fined to bed.. The perineal fistula healed completely on the 40th day and he left the hospital on the 44th day in good condition, voiding urine in a free stream at intervals of three hours or more. November 30, 1905. — Letter. The wound has remained closed. I have had no instrumentation. I void urine at normal intervals, about three- quarters of a pint at a time. Have no pain and am perfectly cured. I have had several erections, but have practically no sexual desire. May 8, 1906. — Letter. I am perfectly cured, there is no fistula, I do not use a catheter. I have nb pain. Have not had erections or intercourse. My general health is excellent. I have gained 25 pounds. Pathological report.- — The specimen, G. U. 173, consists of the prostate removed in three pieces, weighing about G-60. The left lobe is the larger, weighs G-30 and measures 5x4x3 cm. It is irregular, lobulated and on section shows many spheroids, considerable dilatation of the ducts and also considerable stroma. The right lobe weighs G-22, and measures 5x3x4 cm. It is more regular than the left and is similar in appearance. The median lobe weighs G-8, and is about 2.5 cm. in diameter, is consider- ably torn. No mucous membrane is attached, no ejaculatory ducts, no calculi. Microscopic examination.— iThe sections show a tissue which is largely arranged in lobules. Within these lobules the acini are very much dilated and the epithelium for the most part is flattened. There is some intracystic outgrowth in many of the di- lated acini, but most of them are smooth walled, and show very little of the complexity of the wall which is present in many of the small acini. The stroma in places is quite dense, and in other places slender bands only are present between the acini. There is a very marked inflammation throughout the greatest part, and there are some areas in the denser stroma where the ducts are compressed, and chronic inflammatory tissue has been formed in quite thick bands about these acini. The amount of muscle varies in different portions, in some places being fairly abundant, while in others the connective tissue predominates. The tissue is that of a fibro-myoadenoma in which the adenomatous tissue is very abundant especially in the lobulated areas, and has under- gone quite a marked cystic degeneration. There is a very marked in- flammatory change present with the formation of considerable perigland- ular and interstitial inflammatory tissue. Some corpora amylacea are seen. Case 101. — ^Moderate enlargement of median and lateral lobes. Calculus in bladder. Seed calculi in prostate. Cured. Followed 11 months. No. 954. R. W. M., age 65, married, admitted June 8, 1905. Complaint. — " Enlarged prostate and stricture." Patient had gonorrhcea 30 years ago. 368 Hugh H. Young. Present illness. — The patient has had some urinary difficulty for 20 years, beginning with a burning in the deep urethra and frequency of uri- nation. This condition persisted for about 10 years when he was examined by a physician who told him that he had two strictures and passed instru- ments. This did not cure him of his trouble which has persisted up to the present time. S. P. — His condition is now about the same as 10 years ago. He voids urine every two hours night and day, and suffers burning pain in the neck of the bladder during and after urination. Sexual poxcers. — Occasionally has normal erections.. Has had no inter- course for two years. Examination. — ^The patient is well nourished. Has not lost weight. Heart, lungs, and abdomen are negative. Rectal. — The prostate is only slightly enlarged, symmetrical, distinctly harder than normal, but not of stony hardness. Smooth with no nodules. The right seminal vesicle is distinctly palpable and slightly indurated, but the left vesical is not indurated. The prostate does not extend up into the region of either vesicle, and there is no intravesicular mass. Oystoscopic. — A catheter passes with ease and finds 450 cc. residual urine (yesterday it was 200 cc). The cystoscope shows a slight intravesi- cal enlargement all around the orifice in the shape of a collarette with no intervening sulci. The bladder is considerably inflamed, markedly trabeculated with several small and one large diverticula. On the trigone rests a large oval, freely movable calculus. With finger in rectum and cystoscope in urethra the prostate feels like a hard collar around the shaft, and the beak is easily felt. Urinalysis. — Cloudy, alkaline, sp. gr. 1010, albumin a trace, no sugar. Microscopically, a few pus cells, bacilli and cocci. Operation. June 21, 1905. — Ether. Perineal prostatectomy by the usual technique. The rectum was found very adherent to membranous urethra and apex of the prostate, and in freeing it a small tear was made into the rectum. It was not, however, until the completion of the prostatectomy. The bilateral capsular incision exposed at once multiple seed calculi in the prostatic substance on each side. These varied from 1 to 4 mm. in size. The lateral lobes were only slightly enlarged, and owing to adhesions were removed with difficulty. The urethra was then divided along the left lateral wall, the neck of the bladder dilated, stone forceps introduced and a fairly large oval calculus removed. Examination showed no further calculi. A finger in the urethra then showed a slight median enlargement which was excised. Double catheter drains were placed in the urethra which was not closed by sutures. The lateral cavities were packed with gauze. Glove finger was then inserted in the rectum and palpation with the finger of the other hand in the wound showed a tear in the anterior part of the rec- tum. This was closed by interrupted sutures of fine silk, two rows which were in turn covered in by a row of catgut sutures. The levator muscles were then approximated and the cutaneous wound partially closed on each side as usual. The patient stood the operation well, the pulse at the end being 95. Infusion and continuous irrigation on return to ward. study of IJj-o Cases of Perineal Prostatectomy. 369 Convalescence. — The temperature arose to 101 en the day after the op- eration, but after that remained 100 for a week before returning to normal. On account of the wound in the rectum the bowels were not opened for six days, during which time the diet was very limited and a lead and opium pill was administered. Caster oil by mouth and an oil enema were used to move bowels. The irrigation was discontinued after 24 hours, the gauze and tubes were removed after 36 hours. He had a slight epididymitis five days after the operation, but after a few days the swelling and pain dis- appeared. The rectal wound healed per primam. He was discharged from the hospital on the 25th day. At that time he was able to retain urine for six or seven hours, voided in a large stream without pain, difficulty or incontinence. His condition was excellent. A pin point fistula was pres- ent which was curetted. A silver catheter passed with ease, meeting no obstruction and finding no residual. The urine contains pus cells and bacilli. The fistula finally closed on the 27th day. July 20, 1905. — 'The wound is healed. The patient arose once last night to urinate, has perfect control. Has already had several partial erections. February 19, 1906. — -I void urine naturally twice at night, and sometimes a pint at a time. There is no fistula present, but the wound is a little sore. I do not have erections. My general health is good, and I have gained in weight. May 23, 1906. — Letter. I void urine naturally and at fairly normal in- tervals, and from one-half to one pint at a time. I do not suffer much pain. I do not have erections. My general health is quite good. The wound has remained closed and I am very much improved by the opera- tion. Pathological report. — >The specimen, G. U. 172, consists of two small pieces of prostatic tissue and weighs less than 10 gm. The left lobe meas- ures 3 X 1.5 x 1 cm. and the right lobe 2.5 x 2 x .8 cm. The external surfaces are rough, irregular, torn. On section there is considerable fibrous stroma, a moderate amount of gland tissue, and no dilatation of the ducts, no mu- cous membrane, no ejaculatory ducts present. An oval calculus 3.5 x 2.5 x 2 cm. has been removed, is yellowish in color and finely granular. Microscopic examination. — The section shows the tissue mostly composed of stroma. There are some areas in which the gland tissue is grouped together in fair amounts. The glands are for the most part rather small, and everywhere is present quite a marked prostatitis. About the individual acini, and those grouped in lobules, there is a very marked periglandular infiltration of round cells and polynuclears. The infiltration often extends out into the interstitial tissue for a considerable distance, but is distinctly much more pronounced immediately about the acini. About some of the glands there has been formed apparently considerable amounts of inflammatory tissue. The epi- thelium lining some of the ducts is, in places, thickened, and in other parts desquamated. Numerous polynuclears are present in many of the acini. The stroma as a whole is rather dense; is composed in large part of fibrous tissue, although considerable smooth muscle tissue is present. The pic- ture is almost purely one of chronic prostatitis. 370 Hugh H. Young. Case 102. — 'Slight enlargement of median and lateral lobes. Consider- able pain. Cured. Followed 11 months. No. 950. C. M. H., age 52, married, admitted May 25, 1905. Complaint. — ■" Enlarged prostate." No tiistory of gonorrhcea. Present illness began seven years ago with slight burning in the urethra and frequent urination. The condition gradually grew worse and nine months ago the patient was voiding urine every hour, night and day, and there was severe burning sensation in the urethra. Five months ago urina- tion occurred about every 15 minutes, and he was catheterized by a physi- cian and 15 ounces of urine was withdrawn, after that the catheter was passed several times and his condition improved considerably, but he suf- fered so much pain in the urethra that he began the use of morphine which he has not used for some time. The patient urinates about every two and one-half hours night and day. There is no hesitation and the stream is large, but there is considerable burning and straining at the end of urina- tion. He has never had hematuria or passed a stone. His sexual powers are impaired. He has not had intercourse for six months, but he still has erections. Eo:ar,iination.~^Th.e patient is thin, emaciated. Mucous membranes are pale. Lungs are negative. The heart is enlarged and a soft, systolic mur- mur is present at the ape'x and in the tricuspid area. The abdomen is negative. Inguinal glands are not enlarged. Examination of the blood shows 76% hemoglobin, reds 3,550,000. Rectal examination. — The prostate is moderately enlarged in both lat- eral lobes, the left being the larger. It is rounded, smooth, soft, and not tender. The right seminal vesicle is slightly indurated, but the left is soft. No enlarged glands are to be felt. June 12, 1905. — 'The patient returns for operation. He has considerable pain in voiding and urinates about every 15 minutes with marked strain- ing. A catheter is passed and 180 cc. cloudy urine is withdrawn. Urinalysis. — Cloudy, acid. Sp. gr. 1025, albumin a trace. Microscopic- ally, pus cells. He is put on urotropin, 30 grains a day, and instructed to return for catheterization once daily. June 17. — 'The patient has improved, but he has been taking morphine in considerable quantity. He suffers greatly from pain in urethra and bladder. Cystoscopic examination. — *A catheter passes with ease and withdraws 250 cc. residual urine. The bladder is very irritable and it is impossible to get its correct capacity. Cystoscope showed two fairly large lateral lobes with a deep sulcus in front and a shallow sulcus behind and a small median bar connecting the two. Both ureters were visible and normal in appearance. The bladder is slightly trabeculated and acutely inflamed. With the finger in the rectum and cystoscope iu the urethra the beak can be felt, the trigone is soft, and there is very little increase in the median portion of the prostate. The urine contains pus cells and bacilli in large numbers. study of lJf-5 Cases of Perineal Prostatectomy. 371 Note. — IFollowing cystoscopy the patient had a rise of temperature to 104°. There was no evidence of pneumonia nor renal infection, but five days later he still had a temperature of 103°, and it was thought probable that the fever was due to absorption from the bladder and operation was therefore performed at once. Operation, June 21, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were moderately enlarged, soft and easily enucleable. The median portion, which was very small, was removed through the left lateral cavity, a small tear being made in the urethra. The rest of the urethra and ejaculatory ducts were preserved intact. The wound was closed with double drainage tubes for the bladder and the late- ral cavities packed lightly with gauze. Continuous irrigation was begun at the operating table, infusion on return to the ward. His pulse re- mained high throughout the operation, being 135 at the end, but his condi- tion was otherwise good. Convalescence. — Condition of the patient improved rapidly after the op- eration. The temperature fell to normal the next morning and remained so after the third day for ten days. The gauze and catheters were re- moved on the second day. The patient suffered considerable from vesical and urethral irritability and the urine did not begin to iiow through the urethra until the 15th day, but the fistula closed completely on the 25th day. On the tenth day epididymitis developed on the left side, and about two weeks later upon the right side. During this time the temperature which had been normal arose and for two weeks varied from 100° to 102.5°, when it again became normal. A week later, however, the fever returned and he continued to have a daily temperature of 103° for several days. The patient was a very weak subject and convalesced poorly. He complained severely of the need of morphine. After August 3 he was free from fever, but did not leave the hospital until August 13, when he was discharged, 49 days after the operation. At that time he was able to main- tain his urine from four to five hours, stream was large, a catheter passed with ease and found no residual urine. At times, when moving around, a few drops of urine escaped, but as a rule he had perfect control. Both epididymes were indurated, but neither had gone on to suppuration. His general condition was much improved. November 30, 1905. — Letter. The perineal wound is closed. I void urine naturally, once or twice at night, four or five times during the day, often as much as a pint at a time, and I consider myself cured. Erections have returned and sexual intercourse is entirely satisfactory. I have gained 35 pounds in weight, and my health is excellent. May 9, 1906. — (Letter. I void urine naturally three or four times a day and once at night, from 12 to 16 ounces at a time. I suffer no pain. Erec- tions and intercourse are entirely satisfactory. My general health has never been better. I have gained in weight, and I consider myself cured. September 15, 1906. — Letter. I void urine naturally three or four times during the day and once at night, about 10 or 12 ounces at a time. Sexual intercourse is normal and entirely satisfactory. I am entirely cured. 372 Hugli H. Young. Pathological report. — ^The specimen, G. U. 171, consists of three pieces of prostatic tissue comprising the three lobes. The total weight is about 18 grams. The left lobe is a lobulated mass, typical of benign hypertrophy and weighs about nine grams. The right lobe is composed of a number of spheroids, elastic in consistency, and weighs about seven grams. The middle lobe is a small, irregular mass, weighing two grams, is much more fibrous than either of the lateral lobes, but a few small spheroids are pres- ent. The ejacuatory ducts have not been removed. No calculus present. Microscopical examination. — The tissue of the lateral lobes contains very little gland tissue, while in the section from the middle lobe there is scarcely any gland tissue at all. In the lateral lobes one finds small areas where there is some gland tissue grouped together in lobules, but the acini are not dilated. The epithelium is cylindrical in type, in places one layer thick, in other ducts part of the wall has an epithelium many layers thick. Throughout the greater part, the gland tissue is atrophied and the ducts are compressed, the epithelium in many instances being entirely absent. Everywhere throughout the section there is marked round cell in- filtration with extensive formation of inflammatory tissue. In areas there is a fair amount of muscle tissue present, but in the majority of the areas the fibrous tissue is distinctly more abundant. The middle lobe contains practically no gland tissue, and the ducts, which are present, are for the most part compressed and atrophied. Everywhere very extensive round cell infiltration with formation of new connective tissue is present. This is a distinctly fibrous type of hypertrophy, the gland and myoma- tous tissue being comparatively small in amount. Case 103. — Moderate hypertrophy of median and lateral lobes. Catheter three months. Cured. No. 969. J. S. A., age 61, married, admitted June 22, 1905. Complaint. — " Prostatic obstruction. Catheterism." No history of gonorrhcea. Present illness began seven years ago with frequency, difficult urina- tion and slight pain. Course of disease. — 'Gradual increase in frequency and difficulty until March, 1905, when he was urinating every two hours and suffered consid- erable pain at end of penis. Had no complete retention of urine. Began the use of a catheter three months ago. Since then has used it twice daily, has been free from pain, has never had hematuria, has lost no weight. S. P. — (He catheterizes himself at bedtime, and withdraws about five ounces of residual urine. Does not rise to urinate until 7 a. m. Uses the catheter again at 10 a. m., and voids again at 5 p. m. and again about 8 p. m., passing five or six ounces each time. Suffers no pain, but finds the catheter an " infernal nuisance." Sexual powers. — 'Considerably weakened, but is still able to have inter- course. Erections infrequent, but fairlj' good. General health excellent. Examination. — ^Patient is a sturdy looking man. Chest and abdomen negative. study of lJf5 Cases of Perineal Prostatectomy. 373 Genitalia. — ^The corona of the glans penis is congenitally obliterated, owing to adhesion of prepuce to anterior portion and glans at a point 1 cm. distant. Rectal. — Small silk catheter passes with ease, finding 340 cc. re- sidual urine. Bladder capacity is large and tonicity is good. The cysto- scope shows very little enlargement of the lateral lobes, but no cleft be- tween them anteriorly. The median portion of the prostate is slightly enlarged with a shallow sulcus between it and the lateral lobes on each side. In front of the median lobe, the lateral lobes are seen to come to- gether and compress the prostatic urethra, both ureters are easily seen, and are apparently normal. The bladder is trabeculated with numerous shallow pouches. There is slight cystitis, no foreign bodies. With finger in rectum and cystoscope in urethra the beak is easily felt, and the thick- ness in the median portion is only slightly increased. Operation, June 2If, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were moderately enlarged, measuring each about 3x4x5 cm. The median portion of the prostate was removed through one of the lateral cavities and measured 2 x 2% x 3 cm. A small tear was made in the urethra, but the ejaculatory ducts were preserved. The rectum was very adherent to the posterior capsule of the prostate, and a small tear was made into it with the finger. After completion of the operation the hole was closed with several layers of fine silk sutures. The levator muscles were drawn together with catgut. The rest of the wound was closed as usual with double catheter drainage and light packs for the lateral cavities. Patient stood the operation well, pulse at the end 75. In- fusion and continuous irrigation on return to the ward. Convalescence. — ^Patient reacted well, and during the first six days the highest temperature was 100.5°. The irrigation was discontinued after 12 hours, the gauze was removed in 24 hours and the tubes in 48 hours. The urine came through the anterior urethra on the fourth day, and he was able to retain it for two or three hours. The patient was kept on milk diet and the bowels were not moved until seventh day with calomel. The rectal sutures did not break down. Epididymitis set in on the ninth day, and was accompanied by a temperature of 104°, which rapidly fell to nor- mal. After eight days the epididymitis had completely disappeared under treatment with ice. The perineal fistula closed on the 19th day, and the patient was ready to go home, but on July 14 he had a slight fever and phlebitis came on on the left side. For five days the jpatient had a tem- perature which reached 101° to 102°, after that it remained practically 374 Hugh H. Young. normal, but his leg was tender and he was not discharged from the hospital until the 34th day. At that time his condition was excellent, he voided urine freely, at intervals of three hours, the wound was closed, a cath- eter showed 55 cc. residual urine, and no stricture. The rectal and peri- neal wounds were tightly closed. December 30, 1905. — ^Letter. I void urine once during the night and four times during the day, about 10 ounces at a time, suffer no pain. The wound is closed, I have not been instrumented and I consider myself cured. I have had no erections, but before operation intercourse was very unsatisfactory. My general health is excellent. May 7, 1906. — ^Letter. The wound has remained healed. I void urine naturally, only once during the night, and as much as 15 ounces at a time. I have a slight pain at the end of urination and have not had erections. My general health is excellent, and I consider myself cured. September 14, 1906. — Letter. Urination is normal, three or four times during the day, often not at all during the night, 12 ounces or more in amount. I have erections, but my sexual capacity is weak. I am cured. Pathological report. — The specimen, G. U. 175, consists of the median, right and left lobes removed in four pieces, the whole forming a small mass which weighs not more than 15 gm. The lateral lobes are about equal in size and measure 3x2.5x2 cm. The median bar measures 2x1 X 1 cm. The surfaces of the lateral lobes are smooth, soft, and on section show the typical picture of adenomatous hypertrophy. Fibrous tissue is more abundant in the right than in the left. The median bar shows glandular tissue with considerable fibrous stroma. Microscopic examination. — The tissue contains more stroma than gland- ular elements. The acini occur oftentimes in small aggregations, and there seems only a small tendency to formation of lobules. The stroma is composed mostly of fibrous tissue, the muscular fibers being compara- tively few in number. There is a tendency in this hypertrophy towards the fibrous type. There are very numerous corpora amylacea in the culs- de-sac. Case 104. — Anterior lobe, growing out from right lateral. Small median. Three calculi. Cure. No. 969. E. G. C, age 55, married, admitted June 22, 1905. Complaint. — " Enlarged prostate." Gonorrhoea at the age of 20, mild attack without complication. Present illness began six years ago with difficulty of urination. The course of the disease was gradual up to January, 1904, when complete retention of urine came on. He was then catheterized for two weeks. Since then has not used a catheter except when urination was unusually difficult. S. P. — At present voids urine three times during the night, 15 times during the day. Urination painful, but never radiates to end of penis, but sometimes to back. No hematuria. Micturition is slow and difficult. One month ago the residual was 10 ounces. Sexual powers. — Good. General health excellent. study of IJfO Cases of Perineal Prostatectomy. 375 Examination. — A well nourished man, lips of good color, no arterio- sclerosis. Chest and abdomen negative. Rectal. — Prostate is slightly enlarged, the posterior surface being flat, outlines difficult to make out. It is soft, smooth, not tender, and there are no nodules, seminal vesicles are negative.. The prostatic secretion contains numerous lecithins, moderate number of granule cells and a few pus cells, actively motile spermatozoa. Urinalysis. — Cloudy, alkaline, sp. gr. 1022, albumin a slight trace, mi- croscopically, pus cells and staphylococci. Cystoscopic. — A coude catheter passes with ease. Residual urine 100 cc. bladder capacity 250 cc. The cystoscope shows a small rounded median lobe, very little enlargement of the left lateral lobe, considerable intra- vesical enlargement of the right lateral lobe which presents upward so Fig. 48.— Case 104. that it is seen in front of the urethral orifice as a prominent overhanging mass, as seen in the accompanying cystoscopic pictures. Fig. 48. In the series A. L. with the cystoscope looking upward and to the left, the side of this anterior lobe is seen, and the sulcus is shown to become deeper as the handle of the cystoscope is elevated in No. 2 and 3. In Fig. X. the apex of this anteriorly projecting lobe is seen. This condition is an unusual finding. In R. the deep sulcus between the middle lobe and right lateral lobe is seen. The bladder is slightly trabeculated and contains two calculi, one smaller than the other. "With finger in rectum and cystoscope in urethra the median enlargement appeared only moderate. Operation, June 24, 1905. — Ether. Perineal prostatectomy by the usual technique. Removal of three calculi through the wound after division of lateral wall of the urethra and dilatation of the neck of the bladder. The larger stone measured 3 x 2^^ x 2 cm., the others were much smaller. The lateral lobes were only slightly enlarged. The median lobe was small and removed through one of the lateral cavities. The operator had 376 Hugh H. Young. forgotten the cystoscopic findings and thought the operation was complete, after removal of the calculi the finger was inserted in the bladder and showed at once a prominent overhanging anterior lobe, which had been seen with the cystoscope. It was easily drawn into the right lateral cavity, and enucleated. It was about 2 cm. in diameter. The wound was closed as usual with double tube drainage and slight packs for the lateral cavities. Pulse at the end of the operation was 76. Infusion and continuous irrigation on return to the ward. Convalescence. — For four days the patient had temperature varying between 99° and 100.7°, after that practically normal. The irrigation was discontinued after 12 hours, and the gauze and tubes were removed within 24 hours. On the fifth day most of the urine came through the anterior urethra. On the 10th day he had perfect control and very little urine came through the fistula which finally closed on the 18th day. He was up in a chair on the third day, and began to walk on the fourth day. Was discharged on the 26th day, wound closed, voiding urine at intervals of four hours, no incontinence, no pain. General condition excellent, has had no compli- cations. A silver catheter caught in a pouch in the prostatic urethra and no further attempt was made to obtain the residual urine. Urinalysis. — Acid, slightly cloudy, pus cells and bacilli. Novemder 30, 1905. — Letter. I void urine naturally, about every three hours during the day and five hours at night. I have had no instrumenta- tion, the wound has remained closed. I sometimes void 10 ounces at a time, have only a slight pain at end of urination. Erections have not returned. My general health is good with the exception of paralysis agitans. May 8, 1906. — The wound has remained healed. I void urine normally at intervals of four hours during the day. I do not rise at night to urinate. The amount voided is sometimes 12 ounces. I suffer no pain. Do not have erections. My general health is excellent and I consider myself cured. September i-J, 1906. — Letter. I void urine naturally at intervals of three or four hours and not at all at night, 12 ounces in amount. I have erec- tions and intercourse, but imperfectly, owing to lateral curvature of the penis. I consider myself cured. Pathological report. — The specimen, G. U. 174, consists of three lobes of the prostate removed in four pieces, and weighs (j-25. The lateral lobes are about equal in size and measure 4 x 2.5 x 2 cm. and each has been removed in one piece. The outer surfaces are smooth, but the inner surfaces are somewhat torn and lobulated, and there is considerable stroma, and little gland tissue. The median lobe was very small and has been lost. The anterior lobe forms a globular mass about 2 cm. in diameter, and is similar in character to the rest of the prostate. There is no suggestion of malignancy. No mucous membrane, no ejaculatory ducts. Three calculi have been removed as described in the operation. Microscopic examination. — Section from the left lobe, which ap- study of 145 Cases of Perineal Prostatectomy. 3T7 parently macroscopically contains most fibrous tissue, sho^vs on microscopic examination a rather less amount of glandular tissue than normal. The acini are very irregular in outline, and the epithelium is absent from a great number of them. There is no marked dilatation of the ducts although here and there one is seen which is somewhat larger than normal. Many of the ducts are small and compressed. There are quite a number of corpora amylacea seen. The stroma is largely fibrous in character although a fair amount of smooth muscle fibers is present. There are several areas of chronic prostatitis. Prostatitis is evidently of long standing in these areas as there is con- siderable chronic inflammatory tissue formed, especially periglandular. The areas of prostatitis are comparatively few and small. The hypertrophy is of the flbro-myomatous type, there being compar- atively no glandular increase, and the fibrous tissue predominating. Case 105. — Moderate enlargement of median and lateral lobes. Indura- tion and enlarged glands suggesting cancer. Symptoms not. Perineal enucleation. Cure. Followed 12 months. No. 967. H. D. P.,. age 69, married, admitted June 22, 1905. Complaint. — " Enlarged prostate." No history of gonorrhoea. Present illness began 15 years ago with frequency of urination, hesitation and straining. He came then to the hospital where he was irrigated once a day for two weeks with considerable improvement. Urination, however, remained frequent, generally three or four times at night and every two hours during the day, and at times there were attacks of irritability, associated with very frequent urination which was relieved by catheter- ization and irrigation of the bladder. He has not had complete retention of urine and during the last two years has been unable to pass a catheter to irrigate the bladder. Five weeks ago epididymitis of left side came on. He has never had hematuria nor pronounced pain, and has passed no calculus. S. P. — The patient voids four times during the night, and about every one and one-half hours during the day. He suffers no pain, no hematuria, no straining, has lost very little weight. Sexual powers. — Erections present, intercourse fairly normal. Examination. — The patient is a sparely nourished man, with lips of good color, slight arteriosclerosis. Heart and lungs are negative. Ab- domen negative. Genitalia. — The globus minor of left side is considerably indurated, and there is a varicocele present. Rectal. — The prostate is moderately enlarged, the left lateral lobe being larger than the right. The surface is smooth, the consistence firmer than normal, but not of stony hardness. It is slightly elastic and not tender. There is slight induration at the junction of the prostate and seminal vesicles on both sides and several firm fibrous cords are felt extending from the middle and upper end of the prostate to the pelvic wall. The out- Vol. XIV.— 25. 378 Hugh H. Young. lines of the seminal vesicles are difficult to make out and there is no marked induration. There is no intervesicular mass. The outer borders of the seminal vesicles are adherent to the lateral structures on both sides, but not to the rectum which is soft and movable. Several enlarged glands are felt far up on the left side next to the pelvic wall, and in the sacral fossa several small glands are felt. Prostatic secretion contains a few lecithin cells, granule cells, and a moderate number of pus cells. Urinalysis. — Clear, amber, acid, very few pus cells, and a few short bacilli. Cystoscopic. — A small coude catheter passes with ease and finds 25 cc. residual urine and a contracted bladder which will hold only 150 cc. on forced distention. The cystoscope enters easily and is not grasped by the prostatic urethra. It shows a small sessile rounded median lobe with a fairly deep sulcus on each side. The lateral lobes are not at all intra- vesically enlarged. Both ureters are easily seen and are apparently normal. With finger in rectum and cystoscope in urethra the beak is easily felt, there is no subtrigonal thickening, the median portion of the prostate is considerably enlarged, and the prostate feels quite hard around the cysto- scope. Remark. — The history did not suggest carcinoma, but the finding of enlarged glands and induration, while not of stony hardness, made us suspicious of carcinoma. The cystoscope did not, however, present the picture of carcinoma. It was decided to do the conservative operation on the ground that if the disease was carcinomatous the case was hopeless on account of the involvement of the glands in the sacral fossa. Operation, June 27, 1905. — Ether. Perineal prostatectomy by the usual technique. The prostate was easily separated from rectum leaving a fairly smooth posterior capsule. Palpation showed considerable induration in both lobes, but in the region of the seminal vesicle there was very little induration. The usual bilateral capsular incisions were made and a thin piece of tissue excised for examination. It had a roughly granular appear- ance with small white and yellow specks in a fibrous stroma and suggested carcinoma. A frozen section made at once, showed many areas of appar- ently benign adenomatous hypertrophy, in a few places there were large masses of epithelial cells packed together in spaces of tissue and with no appearance of normal glandular structure. The picture was not typical of carcinoma, but all who saw it thought it was probably malignant. Owing to the presence of enlarged pelvic and sacral glands the radical operation was not at- tempted. The lateral lobes were easily enucleated, were only moderately enlarged, measuring 3x4x4 cm. in size. The middle lobe was enucleated through the left lateral cavity, was smooth, round and measured 2 cm. in diameter. The wound was closed as usual with double tube drainage and light gauze packs for the lateral cavities. The patient stood the operation well, pulse at the end being 110. Infusion and irrigation on return to ward. study of llf-5 Cases of Perineal Prostatectomy. 375) Convalescence. — The patient reacted well, and had an uninterrupted convalescence, the highest temperature being 100°. The irrigation was discontinued after 12 hours, the gauze and tubes removed at the end of 24 hours. The patient was up in a chair on the second day. Urine came through the anterior urethra on the ninth day, and the perineal fistula closed on the 16th day. On the fourth day the left epididymis, which had been swollen before operation again became enlarged and tender. He was discharged from the hospital on the 29th day, able to retain urine for four hours, with no incontinence but with considerable precipit- ancy. He was free from pain and the perineal wound tightly healed. Rectal examination showed slight induration in the region of the seminal vesicles, but nothing suggesting carcinoma. A silver catheter passed with ease, no strictures present, no residual urine. Patient advised to take urotropin, drink water in abundance and dilate bladder by retaining urine as long as possible. Novemlter 30, 1905. — Letter. The wound has remained closed, but is somewhat tender. I void urine naturally, about once in two hours, and three to five times at night. Generally three ounces at a time, occasionally four and one-half. I have no pain. No erections. Have had no treatment. Have gained in weight and my health is fairly good. May 21, 1906. — Letter. I void urine naturally, three times during the night and at intervals of two hours during the day, and about three and one-half ounces at a time. I suffer no pain, my general health is fair. I have gained a little in weight, the wound has remained closed and I consider myself cured. September 15, 1906. — Letter returned with a report that patient is trav- eling in Europe and enjoying good health. Pathological report. — The specimen, G. U. 177, consists of the three lobes of the prostate removed in three pieces, and weighing about G-10. During operation an incision was made through the prostatic capsule, and a piece removed for examination. The cut surface showed many fibrous bands, with intervening areas yellowish in color, and it was thought to be suspicious of carcinoma. Yellowish dots were granular, raised above the surface and the intervening tissue was very hard and fibrous. A frozen section showed a very peculiar picture. There was only a small amount of normal gland structure, considerable fibrous stroma with intervening round cell infiltration, and a few areas with peculiar epithelial cells, apparently infiltrating the stroma. This was thought to be carcinoma although the picture was very unusual. The right lobe of the specimen removed measures 2.5 x 2 x 2 cm., is fairly smooth, encapsulated externally, and internally where incised by the scalpel shows numerous yellowish dots in a fibrous stroma; it does not grit under the knife, but suggests somewhat carcinoma. The left lobe is about 2.5 X 1.5 X 1 cm. in size and is similar to the right. The median lobe measures about 2 cm. in diameter, and on section the yellowish mottling is quite marked. No mucous membrane, no ejaculatory ducts, no calculi. 380 Hngh H. Young. Microscopic examination. — The section is largely composed of fibrous and smooth muscle tissue. There is very little gland tissue present. Many of the acini are dilated and show intracystic growth. In areas the acini are flattened and giving evidence of compression; some being almost entirely obliterated. In these areas of compressed acini there is consid- erable fibrous hypoplasia. In one angle of the section there is quite an extensive prostatitis, probably most marked about the acini, but extending over a considerable area in the interstitial tissue. The inflammatory pro- cess here gives evidence of long standing as there is considerable fibrous tissue formation. This section is that of a fibro-myoma with compara- tively little adenomatous tissue. Case 106. — Considerable hypertrophy of lateral lobes. Small median bar. Catheter life. Cured of obstruction. No residual urine present. Frequent urination due to cystitis and vesical contracture. Followed 11 months. No. 956. C. K. D., age 64, widowed, admitted June 8, 1905. Complaint. — " Catheterism." No history of gonorrhoea. Present illness began seven years ago v/ith frequency and difficulty of urination, this gradually increased until he was voiding urine every 15 minutes at night, and every hour during the day four years ago. Complete retention of urine then came on and he was catheterized. For the next three years he was catheterized at bed time but was able to void in small amounts. During the past year retention of urine has been complete and the catheter has been necessary. 8. P. — The patient is unable to void and catheterizes himself about six times a day, often with considerable difficulty. He suffers no pain except when the bladder becomes full; no hematuria. He has been unable to have sexual intercourse for two years, but on rare occasions has an erection "When the desire to urinate comes on. Examination. — The patient is well nourished, lips of good color. Chest and abdomen are negative. Rectal. — The prostate is quite large, apparently about the size of a small orange, smooth, elastic, no areas of induration, no nodules. The upper end is reached with difficulty, and the seminal vesicles cannot be reached. Cystoscopic. — The retention of urine is complete. The cystoscope shows a median bar and two very large lateral lobes with a deep sulcus in front. There are no sulci between the lateral lobes and the median bar. The bladder is trabeculated and one small diverticulum is seen. No stone present. With finger in rectum and cystoscope in urethra the beak is easily felt and the median portion of prostate is moderately increased. Urinalysis. — Cloudy, acid, 1030, no albumin, no sugar, microscopically, pus cells and bacteria. Prostatic secretion contains few lecithins, many large granule cells, a few pus cells, no spermatozoa. Operation, June 30, 1905. — Ether. Perineal prostatectomy by the usual study of 1J/.5 Cases of Perineal Prostatectomy. 381 technique. The lateral lobes which were quite large, were easily enucle- ated. A small median lobe was enucleated through the left lateral cavity, a slight tear being made in the urethra, but no mucous membrane being removed. The ejaculatory ducts were preserved. The wound was closed as usual with double drainage and light packs for the lateral cavities. Submammary infusion and continuous irrigation on return to the ward. The patient stood the operation well and the pulse at the end was 95. Convalescence. — The patient reacted well. The irrigation was continued for eight hours, and the gauze and tubes were removed at the end of 24 hours. Considerable bleeding followed this, and a few hours later the urethra became plugged with blood clots so that a catheter had to be passed. The catheter was removed on the following day and there was no more hemorrhage. Interval urination was established immediately after removal of the catheter. On the fourth day urine came through the anterior urethra, but the fistula did not close until the 15th day. On the 17th day the patient complained of pain in the bladder, and he was catheterized, about 150 cc. urine being withdrawn. He was catheterized again on the following day. The patient had a slight temperature until July 20. The evening rise being between 100 and 100.5° each day. He had no epididymitis or other complications to explain this. He was dis- charged on the 22d day in good condition, able to retain urine for three hours, and voiding in a free stream with no incontinence. A silver catheter then passed with ease and found 18 cc. residual urine. The bladder was slightly contracted and patient was advised to drink water in abundance and to retain urine as long as possible in order to dilate the bladder. September 30, 1905. — The patient has enjoyed good health since the operation three months ago, has had no complications and no treatment except urotropin. Urine is voided every two hours during the day and three or four times at night. Examination.- — The urinary stream is large and free, silver catheter meets no obstruction and finds 15 cc. residual urine and the bladder capacity is 360 cc. The wound is closed. November 30, 1905. — Letter. I void urine naturally and freely, but too frequently viz., about every two hours night and day, about four or six ounces at a time. I have a slight pain just before urinating. The wound is closed and my general health is good. I have had no erections. May 10, 1906. — Letter. I void naturally but often during the day and night, the largest amount at a time is about two ounces. I suffer pain when I hold my urine too long. I do not have erections. I have had no complications or treatment since operation. September 12, 1906. — Letter. I void urine naturally, three or four times during the day and once at night, in normal amounts. Erections and sexual intercourse are satisfactory. My general health is splendid and I am entirely cured. 383. Hugh H. Young. Case 107. — Moderate hypertrophy of the median and lateral portions of the prostate. Residuum 1150 cc. Nephritis. Operative cure. Later dropsy. Accidental death six ynonths after operation. Folloxoed 10 months. No. 983. J. M. M., age 65, married, admitted July 7, 1905. Complaint. — " Frequency of urination and incontinence." Gonorrhcea once as a young man. Preset illness began two and one-half years ago with increased fre- quency of urination. His condition gradually grew worse until one year ago he began to dribble and would void every half hour night and day. Four months ago he had considerable hematuria, no pain, no gravel. Six weeks ago a catheter was passed and one quart of urine withdrawn. S. P. — Urine is voided about every half hour during the day and seven or eight times at night in small quantities. There is considerable precipit- ancy, never any hesitation. During the night there is almost constant dribbling. His appetite has not been good and he has lost 27 pounds. Sexual powers. — Has not had erections for two years. Examination. — Patient looks well and his lips are of good color. The pulse is full, regular, and there is very little arteriosclerosis. Genitalia. — Negative. Rectal. — The prostate is only slightly enlarged, smooth, fairly soft at apex, slightly indurated at the base particularly on the left side. The left seminal vesicle is indurated slightly and there is a small nodule at its junction with the prostate. The right seminal vesicle and vas are not indurated. There is nowhere induration of marked degree, no enlarged glands, no intravesicular mass and the posterior wall of the bladder feels soft. Cystoscopic. — A coude catheter passes with ease and finds 1150 cc. residual urine. The cystoscope shows a moderate intravesical enlargement of the lateral lobes and a slightly rounded median lobe with a shallow sulcus on each side. The ureters are easily seen and appear normal. The bladder is trabeculated ; there is a slight cystitis, no calculus. With finger In rectum and cystoscope in urethra the trigone feels soft, the median portion of the prostate is slightly increased. Urinalysis. — Cloudy, alkaline, 1006, albumin a trace, no sugar, micro- scopically, pus cells and a few casts. Urea G-16 to liter. Total solids G-23 to the liter. Preliminary treatment. — The patient was sent to the hospital and cathe- terized two or three times daily. He was able to void a small amount, but the catheter frequently withdrew 800 or 900 cc. residual urine, and on the day before operation 1100 cc. Catheterization produced considerable ure- thral irritation, but the patient's condition improved, the sp. gr. increased from 1006 to 1010, but the granular casts and moderate amount of albumin were still present. Operation, July 21, 190 5. ^Ether. Perineal prostatectomy by the usual technique. Both lateral lobes were moderately enlarged and easily enucle- ated. A median lobe of moderate size, a part of which was suburethral. study of lJf5 Cases of Perineal Prostatectomy. 383 was removed through one of the lateral cavities without removing any of the urethra or vesical mucosa. Two small linear tears were made, but the floor of the urethra and ejaculatory ducts were preserved intact. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well, but his pulse was quite rapid, being 140 at the end and 156 on return to the ward. Infusion and continuous irrigation on return to ward. Two hours after the operation the pulse was 100 and the patient's condition excellent. The gauze was removed on the day after the operation, the irrigation was discontinued on the second day and the tubes removed on the fourth day. There was no post-operative rise of temperature. The patient was up on the sixth day. Urine began to flow through the anterior urethra on the 13th day, the patient was able to retain urine for four or five hours, and his condition was good. He was discharged from the hospital on the 40th day. The fistula was not quite closed, but practically all of the urine came through the urethra in a large stream, at intervals of four hours without pain or hesitation. There was a slight terminal dribbling but no incontinence. Silver catheter meets no obstruction and finds 75 cc. residual urine. October 14, 1905. — The fistula persists, but only a few drops come through it. He voids urine freely without pain, at intervals of three or four hours. Gets up only twice at night. Novemher 30, 1905. — Letter. I void urine naturally, but it comes with little force. The largest amount at one time is four ounces. I urinate three times during the day and four or five times during the night. The fistula is still open and about one-half ounce comes through each time. There is a burning and scalding during urination. December 28, 1905. — I am very weak, my breathing is short, I am dropsical, my stomach and feet are very much swollen. I have lost my appetite, my kidneys are not doing their duty. The fistula is still open. January 27, 1906. — My condition is very bad and I am confined to my room, I am dropsical, my feet and scrotum are swollen, and I measure 47 inches around my bladder. My wound has not closed yet, a portion of the urine still comes through it. February 19, 1906. — The patient was killed to-day by being thrown out of a buggy. Pathological report. — The specimen, G. U. 182, consists of the three lobes of the prostate removed in four pieces. The lobes were not labeled and it is impossible to say what the pieces represent. The entire weight is about G-20, and the entire mass measures about 5x3x3 cm., more than half of it being in one piece. The surface is fairly smooth, and on section shows considerable gland tissue and a small amount of stroma. No induration nor suggestion of malignancy. No ejaculatory ducts, no mucous membrane. Microscopic examination. — Section from the large lobe. In this section the gland tissue is very abundant, and arranged mostly 384 Hugli H. Young. in lobules. The acini within the lobules are only slightly di- lated, but there is considerable papillomatous outgrowth in the lumina of the ducts. The stroma within the lobules consists mostly of slender bands interlacing between the various acini. The epithelium lining the acini is of a cylindrical type sometimes one layer deep, and in other places growing out in epithelial tufts many layers deep. One sees occasionally a few leucocytes in the lumina of the acini with occasional areas of round cell and polynuclear cell infiltration in the stroma. Oc- casionally one sees an acinus which is considerably dilated, and the epi- thelium is considerably flattened. The stroma is composed of smooth muscle and connective tissue; the smooth muscle fibers apparently being largely concentrically arranged about the acini while the center of the stroma is largely connective tissue. The stroma in the glandular areas seems for the most part loosely bound together, but is much more dense in the less glandular areas. This is a section of a distinctly adenomatous type of hypertrophy with some glandular dilatation, and a stroma composed about equally of muscle fibers and connective tissue. Some mild chronic prostatitis present, evidently of not very long standing as in the areas of infiltration there is no formation of inflammatory tissue. Case 108. — Considerable enlargement of median and lateral lobes. Cath- eter life for nine years. Cure. No. 163. J. M. C, age 68, married, admitted July 5, 1905. Complaint. — " Prostatic hypertrophy. Catheterism." No history of gonorrhoea. Present illness began 13 years ago with difficulty in urination. This gradually increased until complete retention of urine came on nine years ago, and since then patient has led a catheter life. On September 19, 1901, a Bottini operation was performed under cocaine. Only one cut was made owing to the breaking down of the transformer. The patient was unable to void after the operation and nine days later a second attempt was made to perform a Bottini operation, but again the apparatus failed to work. After that the patient continued to lead a catheter life, but has been able to void voluntarily a few drops of urine. 8. P. — Catheterization four to six times daily, very little voluntary urination, no pain in rectum, bladder or perineum. He suffers from re- current epididymitis brought on by the use of the catheter. Sexual powers. — Satisfactory. Examination. — The patient is a healthy looking man, with lips of good color. The lungs are slightly emphysematous and the heart is somewhat enlarged, but otherwise negative. The abdomen is negative. Genitalia. — The right globus major is indurated and enlarged and there is a varicocele of moderate size on the left side and the epididymis is slightly indurated. Rectal. — The prostate is considerably enlarged, about the size of a small study of 145 Cases of Perineal Prostatectomy. 385 orange, smooth, rounded, elastic, no tenderness, no nodules, no marked induration. There is a slight induration of the seminal vesicles, no enlarged glands are to be felt. The prostatic secretion is composed almost entirely of pus cells. Gystoscopic. — The catheter passes with ease, there is complete retention of urine, the bladder is large. The cystoscope shows a very large median lobe, a portion of which is directed downward and backward and lies upon the trigone obscuring the right ureter. It is covered by rough granular, in places papillary mucous membrane, and at first suggested an intra- vesical tumor, but its connection with the median lobe was easily made out and the bladder around seemed perfectly healthy. The lateral lobes are moderately intravesically enlarged. The bladder is markedly trabeculated with numerous intervening pouches. There is considerable cystitis, but no calculus. With finger in rectum and cystoscope in urethra the beak cannot be felt owing to the great length of the prostate and the consider- able size of the median portion. Urinalysis. — Cloudy, acid, 1020, no sugar, albumin in considerable amount. Microscopically, pus cells and a few casts and bacilli. Operation. July 24, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were of considerable size but were easily enucleated. The median lobe was very large measuring about 5 cm. in diameter. It was removed through the right lateral cavity, a small portion of the mucous membrane covering it was very adherent to it, and was removed with it. A small tear was also made in the urethra but none was removed and the ejaculatory ducts were preserved. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. Patient stood the operation well, his pulse at the end being 80. Infusion and continuous irrigation on return to the ward. Convalescence. — The patient reacted well, but on the day after the operation the temperature rose to 104.3°. The pulse, however, was only 100° and after four days the temperature remained normal. The irrigation continued for 18 hours, the gauze was removed in 24 hours and the tubes in 48 hours. The patient was out of bed in a week. The urine came through the anterior urethra on the seventh day, and on the 12th day he was able to hold urine for four hours. The perineal fistula closed on the 16th day and the patient was discharged from the hospital on the 19th day, the wound healed, and voiding urine without pain or dribbling, at intervals of from two to five hours. General condition excellent. A silver catheter passed with ease and showed no obstruction or stricture, no residual urine. November 30, 1905.- — Letter. The wound has remained closed, I void iirine naturally at intervals of four to five hours night and day, in normal amounts. I suffer no pain, have had no erections as yet. My general health is excellent. May 1, 1906. — The patient voids urine at intervals of six hours. Does not void during the night. There is no incontinence and no pain. Erec- tions have returned but are still weak. The urine is almost clear. 386 Uugh H. Young. Pathological report. — The specimen, G. U. 184, consists of three lobes of the prostate each removed in one piece and weighs about G-55. The lateral lobes are about equal in size and measure 3.5 x 2.5 x 2.5 cm. ; they are fairly smooth, encapsulated, slightly lobulated and on section show considerable glandular tissue and also considerable amount of stroma. There is no dilatation of the ducts. The middle lobe is larger than the two lateral combined and measures 6 x 4.5 x 4 cm. It is irregularly torn and a small area of mucous membrane is attached to it. On section there is apparently more gland tissue than in the lateral lobes. No ejaculatory ducts, no calculi present. Microscopic examination. — Section from the right lobe shows tissue in which there is a large amount of stroma. Here and there are areas in which the gland tissue is fairly abundant. The acini, as a rule, are small, and even in places compressed, although occasionally one sees an acinus which is considerably dilated, with convolutions of its lining wall. There is quite marked evidence of chronic inflammation in the stroma with con- siderable formation of areas of inflammatory tissue. This new tissue is often concentrically arranged about the acini and interlacing in different directions through the interstitial stroma. About a few of the acini there is considerable round and polynuclear cell infiltration with quite numer- ous leucocytes in the lumina of the acini. There is quite a fair amount of smooth muscle present in the stroma, but the connective tissue would seem to predominate. This section is a fibro-myo-adenoma in which the adenomatous tissue is only moderate in amount, the tissue being to a large extent composed of stroma in which the connective tissue predominates. Case 109. — Yery large hypertrophy of median and lateral lobes. Des- perate condition before operation. Uremia. Operation to supply perineal drainage. Continuation of uremia. Death twenty-seventh day. No. 992. J. S. O., age 73, widowed, admitted July 20, 1905. Complaint. — " Prostatic enlargement. Catheter life." No history of gonorrhoea. Present illness. — About 10 years ago the patient began to have great difficulty in urination which increased for two years when he began the use of a catheter and has been unable to void since. He has suffered greatly with pain in the back but has not lost much weight. Of late he has had great difficulty in passing his catheter and has suffered a great deal and become very weak. 8. P. — He is now being catheterized by his physician two or three times daily. He is very weak and sick. Examination. — The patient looks sick, has been quite prostrated by his trip. His lips are of fair color and pulse 80, volume good, slight nodular arteriosclerosis. The heart, lungs, and abdomen are negative. There is tenderness over the kidneys which are not palpable. Genitalia. — Left epididymis is considerably indurated. The glands in both groins are enlarged. study of 145 Cases of Perineal Prostatectomy. 387 Rectal. — The prostate is considerably enlarged, tlie left lobe being the greater. The contour is rounded, in places a little irregular, elastic, fairly soft, except at the upper end of right lobe where it is slightly indurated, and continuous with a small indurated mass which runs off towards the pelvis. Neither seminal vesicle is palpable and there is no intervesicular mass. The patient is unable to void urine. A coude catheter passes easily and finds 500 cc. of urine. The patient is too sick for cystoscopic exam- ination and is sent to the hospital for preliminary treatment. July 23, 1905. — The patient has been catheterized three times a day. The total amount of urine to-day was 1050 cc. Sp. gr. 1005, albumin considerable, urea G-l-l per liter. The patient has been drowsy and often very irrational and difficult to manage. To-day he had a severe chill, temperature of 102.6°. The patient seems to be going down and operation seems advisable to supply better drainage. Operation, July 2Jf, 1905. — Ether. Perineal prostatectomy by the usual technique. The prostate was enormous. Two very large lateral lobes were removed with ease, each in one piece, Fig. 49. The median lobe, which projected at least three inches into the bladder was removed in two pieces, one through each lateral cavity. The mucous membrane was very adher- ent to it, and a small portion was removed. There was very little hemor- rhage and the patient stood the operation well. The wound was closed with double tube drainage and light packs for the lateral cavities as usual. ■A submammary infusion was given on the table and continuous irrigation on return to the ward. Convalescence. — The patient reacted well from the operation, had no rise of temperature and the highest pulse during the next 24 hours was 94. A second infusion was given during the night, considerable urine was secreted. About two hours after the operation the patient pulled out the tubes, and they were inserted again with difficulty. July 26, 1905. — The temperature has ranged between 97° and 100°, the pulse between 67 and 80. His general condition is good, he has taken much water and voided considerable urine, but his mental condition is bad and not at all improved. Patient is up in a wheel chair to-day and the tubes have been withdrawn. August 1, 1905. — The patient has been up in a wheel chair daily. His condition improved for a while, but to-day he is more stupid. Plenty of urine is voided through the perineal wound, and he has drank considerable water and been infused every other day. His temperature has varied between 80° and 100.5° and his pulse between 65 and 85. August 6, 1905. — Since last note the patient has been irrational, extremely restless, has refused everything by mouth. He has been fed through a stomach tube and infused twice daily (too often). His temperature has risen slightly, was 102° last night. His general condition is growing worse. August 13, 1905. — The patient has been fed through a stomach tube two or three times a day and given two infusions daily. Large quantities of urine are passed through the perineal wound which is clean and healing 388 Hugh H. Young. nicely. His mental condition is bad, at times very stupid. He has had Cheyne-Stokes respirations for one week, and his temperature has varied between 100° and 103°, has not been over 100.5° during the past three days. August 16, 1905. — Patient has not been infused for several days. He has refused nourishment and has been fed through the stomach tube three Fig. 49. — Large coalescent median and lateral lobes. Case 109. times a day. For the past two days there has been a marked oedema of the hands and feet. He has been very stupid and it has been almost impossible to arouse him. Temperature this morning 104.3°. August 17, 1905. — The patient grew steadily worse. Respirations were bad, and at 4.30 this morning he died. No autopsy could be obtained. Pathological report. — The specimen, G. U. 183, consists of five pieces, and weighs about G-150. The lateral lobes have each been removed in two pieces, the smaller portion in each case being intravesical. The right lateral lobe (two pieces together) forms a mass about 7x4x3.5 cm., is study of IJf-S Cases of Perineal Prostatectomy. 389 fairly smooth, and on section shows numerous spheroids and a small amount of connective tissue. The left lateral lobe is larger, measuring about 9x6x4 cm., but is similar in character. The median lobe is the largest and measures 9x5x4 cm., and has been removed in one piece, it is similar in character to the other lobes. No ejaculatory ducts, no calculus. Microscopic examination. — The stroma and gland tissue are pres- ent in about equal proportions, the gland tissue being somewhat more abundant than stroma, especially in the areas of lobulation, while outside of the lobules the gland tissue and stroma are about equal in proportion. Within the lobules the ducts are con- siderably dilated, the stroma in many instances being but thin bands interlacing between the various acini. In the areas outside of the lobules the gland ducts are about normal in size with comparatively regular lumina. There is some round cell and polynuclear cell interstitial infiltration, with formation about many of the acini of a fair amount of new connective tissue. The stroma is made up in varying proportions of muscle fibers and connective tissue, the latter in many areas predominating. This is a rather adenomatous type of hypertrophy with a fair amount of stroma and a moderate amount of interstitial and peri-glandular inflammatory tissue formation. Case 110. — Moderate hypertrophy of median and lateral lobes. Complete retention two weeks. Cure. No. 1114. C. M. F., age 76, married, seen in Buffalo, N. Y., August 1, 1905. Complaint. — " Complete retention of urine. Catheterism." No history of gonorrhoea. Present illness began three years ago with frequency and difficulty of urination. This gradually increased until two months ago, when retention of urine became complete, but after 24 hours he was able to void without catheterization. During the past month he has had to urinate three or four times every night, and incontinence has been present. His only pain has been an occasional one in the epigastrium. A second retention of urine came on one week ago, and since then he has required catheteriza- tion three or four times daily. The patient suffers considerable pain dur- ing catheterization. Sexual powers absent for some time. Examination. — (The patient is a robust looking man with lips of good color. The heart and lungs are negative. The abdomen is large, and there is considerable over-fatness. Rectal. — ;The prostate is moderately hypertrophied, forming a soft, rounded bulging mass, not tender on pressure. There is no induration in the region of the seminal vesicles. Cystoscopic. — A coude silk catheter passes with ease and finds about 500 cc. residual urine. Introduction of the cystoscope was followed by con- siderable hemorrhage, and it was impossible to determine the condition of the intravesical portion of the prostate or to see whether a stone was present. 390 Hugh H. Young. Urinalysis. — Acid, cloudy, microscopically, pus cells and bacilli. Urea in good amount. No evidence of poor renal function. Operation, August 2, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were enucleated and measured each 5x4x3 cm. The median lobe was removed through one of the lateral cavities and measured o x 3 x 2 cm. The ejaculatory ducts were preserved and only a slight tear was made in the urethra. Examination showed no stone in the bladder and that the prostatic enlargement had been completely re- moved. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient was given an infusion during the operation and continuous vesical irrigation afterward. The amount of hemorrhage was slight and his condition was excellent at the end. Convalescence. — The patient reacted well. Continuous irrigation was maintained for 12 hours, and the gauze was removed on the day after the operation, and the tubes on the next day. On the third day the patient was in excellent condition, propped up in bed, suffering very little pain. I then left Buffalo. IiCtter. — The highest temperature after the operation was 101°. Fourteen days after the operation epididymitis set in and delayed his convalescence. The perineal fistula closed on the 42d day. The patient was out-of-doors in four weeks, voiding urine naturally at intervals of about two hours. On October 6 the other testicle began to swell, this followed the passage of sounds through the urethra. February 19, 1906. — iThe wound has remained closed, I void urine natu- rally once during the night and every three hours during the day, about six ounces at a time. I suffer no pain, do not have erections. My general health is good, and I consider myself cured. May 8, 1906. — 'Letter. I think I am entirely cured. I void urine natu- rally about five times during the day and about once or twice at night. During the day when the desire to urinate comes on I must attend to it at once or there may be a slight leakage. I have never wet the bed at night. I suffer no pain. Erections which were absent before operation have not returned. My health is good. I could not be much better at my age. Pathological report. — The specimen, G. U. 204, consists of the three lat- eral lobes of the prostate removed each in one piece, and weighs in all about 40 gm. The lateral lobes are about equal in size, encapsulated, coarsely lobulated, and on section show considerable gland tissue and little stroma, the picture in places being rather homogeneous, in others showing considerable spheroid formation. Some of these spheroids are quite yellow in color, and have dilated acini. The median portion of the prostate meas- ures 3 X 3 X 1.5 cm., and has apparently more stroma than the lateral lobes, which measure each about 4 x 4 x 2.3 cm. No mucous membrane, no ejac- ulatory ducts present, no calculi. Microscopic examination. — Microscopically the hypertrophy is a mod- erately glandular one, the gland tissue at times being arranged in spher- study of lIf-5 Cases of Perineal Prostatectomij. 391 ical lobules, at other times it is rather diffuse. In the spherical lobule the gland tissue is distinctly in excess of the stroma, but in the areas outside, the gland tissue and stroma are present in varying proportions. The al- veoli are, as a whole, moderately dilated, although there are many areas where the alveoli are rather small. The usual complexity of acini noticed in these cases is also present, and corpora amylacea are seen. The stroma contains more fibrous than muscle tissue, and throughout the various por- tions of the gland there is seen considerable round cell infiltration of the stroma together with formation of a fair amount of inflammatory tissue interlacing in different directions. Case 111. — Moderate hypertrophy of median and lateral lohes. Catheter life. Residual urine 600 cc. Cured. Followed 10 months. No. 933. S. L., age 65, married, admitted May 15, 1905. Complaint. — '' Frequency of urination and dribbling at night." No history of gonorrhea. Present illness began two years ago with frequency of urination, but no diflBculty and no pain. Since then there has been a gradual increase in the frequency and four months ago patient consulted a physician who passed a sound and gave him medicinal treatment without relief. Incontinence of urine has been present at night for the past three months. S. P. — The patient voids urine every hour during the day and three or four times at night, and, despite this, wets the bed almost every night. The patient voids urine in very large amounts without hesitation, no pain and with very little difficulty. His general health is fairly good, but he feels uncomfortable in his abdomen. Sexual poicers. — Has no sexual power. Imperfect erections in the morning. Examination. — The patient is well nourished with lips of good color. The lungs are negative. There is a soft presystolic murmur at apex and systolic and diastolic murmur at aortic area. Pulse is good. Slight arterio- sclerosis. Abdomen is negative with the exception of a distended bladder. Genitalia. — ^There is a large varicocele with an atrophic testicle on the left side. Rectal. — -The prostate is moderately hypertrophied, globular, smooth, soft, no nodules, no induration in region of the seminal vesicles, no tender- ness, rectal mucosa soft, no glands present. Cystoscopic. — A coude catheter passes with ease and finds 600 cc. residual urine. The cystoscope shows a fairly large median lobe with a sulcus on each side. The lateral lobes are very little intravesically hypertrophied. The bladder is markedly trabeculated with numerous pouches and one fairly large diverticulum on the right side. No cystitis, no calculus. Subsequent treatment. — The patient was given urotropin and advised to go into the hospital at once, but would not consent. Complete retention of urine came on during the night, following cystoscopy and -cEtheteriza- tion was necessary. After that he was catheterized onc^more and left the city, promising to return for operation. After thaj/he did not have 392 Hugli H. Young. complete retention, but urination became gradually more frequent, and he had considerable irritation along the urethra. After May, on account of the difficulty of urination, he began using a catheter at first three times a week and recently twice daily. His general health remained good. On August 9, 1905, he returned for operation. Urinalysis. — Cloudy, 1010, acid, no sugar, trace of albumin, numerous pus cells, no casts. Urea 15 gm. to the liter. Operation. August i '/. 190.'/. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were only moderately enlarged, being about 4 cm. in diameter and rather firmly adherent. A pedunculated middle lobe of moderate size was removed through one of the lateral cavities along with a small area of mucous membrane which was attached to it. Closure as usual. The patient stood the operation well. Pulse at end 90. Infusion and continuous irrigation on return to ward. Convalescence. — The patient convalesced well. The highest temperature 100.7° on the day following the operation, after that practically normal. Continuous irrigation was discontinued after 12 hours, gauze removed in 24 hours and the tubes in 48. The patient was up on the third day, in ex- cellent condition. The urine came through the anterior urethra on the 12th day, and the fistula closed on the 16th day. He was discharged on the 36th day in excellent condition, able to retain urine four or five hours with no dribbling, perfect control, stream large, no pain. Urine. — Sp. gr. 1010, pus cells, cocci, no casts. A catheter passed with ease and found no residual urine. November 30, 1905. — Letter. The wound has remained closed. I void urine naturally every three or four hours during the day and twice at night in large quantity without pain or irritation. My general health is excellent, and I consider myself cured. Have had no erections. February 12, 1906. — The patient says he feels well, voids urine at normal intervals, gets up once at night, has no pain and feels perfectly well. Urine is still cloudy and contains bacteria. March 10, 1906. — The patient reports for examination. Wound has remained closed, and he has had no treatment except urotropin since op- eration. He drinks water in considerable amount and voids large quanti- ties of urine at intervals of four hours night and day. (Arising at 2 and 6 a. m. to urinate.) He has no pain or irritation. Has had no erections. His general health is excellent. May 8, 1906.— I void urine naturally at intervals of four hours during the day and at 2 a. m. and 6 a. m. at night. I suffer no pain. I do not have erections. My general health is fairly good. I have gained 11 pounds since the operation. The wound has remained healed, and I consider my- self cured. September 1.5. 1906. — Patient reports that he is perfectly well and en- joying good health. Pathological report. — The specimen, G. U. 206, consists of five pieces, comprising both lateral and middle lobes. Total weight about 18 gm. It is study of llt-o Cases of Perineal Prostatectomy. 393 soft and elastic in consistence and on section is made up of numerous sptieroids. The ejaculatory ducts have not been removed. No calculus present. Microscopic examination. — The hypertrophy is a lobulated, moderately glandular one. Some of the acini are dilated with quite extensive intra- acinous proliferation. The epithelium lining the acini is often many layers thick, and the lumina are frequently filled with degenerated epithelial cells. The stroma shows some polynuclear and round cell infiltration with, in areas, marked periacinous inflammatory tissue formation. There is a considerable amount of muscle present in the stroma. The arteries show quite marked thickening, especially in the fibrous areas. Case 112. — Moderate hypertrophy of median and lateral lobes. Cured. Folloiced seven months. No. 1021. J. R. R., age 71, single, admitted September 24, 1905. Complaint. — " Catheterism. Prostatic trouble." No history of gonorrhoea. Present illness began 10 years ago with slight difficulty and frequency of urination. Condition remained about the same until one year ago when complete retention of urine came on, after which he was catheterized for two weeks. After that frequent and difficult urination. During the past month the patient has been catheterized twice daily. 8. P. — About five hours after catheterization the patient is able to void urine in small amount and afterwards every hour with great difficulty until catheterized. His only pain is in the bladder when it becomes full, no hematuria, no gravel, has not lost weight. Sexual powers normal. Examination. — The patient is well nourished with lips of good color. The arteries are slightly thickened, but his pulse is good. Chest, abdo- men and genitalia are negative. Rectal. — The prostate is considerably and equilaterally enlarged, about the size of a small orange. It is slightly irregular, generally soft, in places slightly indurated. There is no induration in the region of the seminal glands or between them, and there are no glands to be felt. Prostate is not tender. Cystoscopic. — 'A catheter passes with ease and finds 170 cc. residual urine. The bladder is irritable and contracted and retaining only 200 cc. The cystoscope shows a fairly large median lobe with slight intravesical lateral hypertrophy. There is a deep sulcus on each side of the middle lobe. Both ureteral orifices are apparently normal, the bladder is slightly trabeculated, considerably inflamed, there is no stone present. With finger in rectum and cystoscope in urethra, there is no subtrigonal induration, and the tissues beneath the cystoscope in the median portion are only mod- erately increased (cystoscope probably in the lateral cleft). Urinalysis. — Cloudy, acid, 1020, albumin in small amount, no sugar. Pus cells and bacteria numerous. Operation, September 25, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were easily enucleated and measured 394 Hugli H. Young. about 2x3x5 cm. in size. The middle lobe was extracted in one piece with the right lateral lobe by means of the tractor and measured 3x4x5 cm. in size. A 'portion of the urethra on the right side was torn and re- moved. The floor of the urethra and ejaculatory ducts were preserved intact. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well, pulse at the end 112. Submammary infusion and continuous irrigation on return to the ward. Convalescence. — The patient reacted well, but had more fever than usual, viz., 102° on the second and third days, between 99° and 100° for the next 12 days, and between 101° and 102° for a week. He was very comfortable, however, and his condition was good and there was no ex- planation for the late rise in temperature. There were no epididymitis or other complications. The irrigation continued for 12 hours, the gauze was removed on the day after the operation and the tubes on the follow- ing day. On the third day the patient was up, urine came through the an- terior urethra shortly after the removal of the tubes, and the perineal fis- tula closed finally on the 18th day. Interval urination was established early, but there was slight incontinence for three weeks. The patient was discharged from the hospital on the 31st day. At that time he could re- tain urine for five hours, voided in a large stream without hesitation, was free from pain and had had several firm erections. The wound was found healed, a silver catheter met no obstruction, residual urine 5 cc. Urine still contained pus and a small amount of albumin. November 30, 1905. — Letter. The wound has remained closed, and I void urine as freely as I ever did, three or four times during the day and once or twice at night, often a pint at a time. I have no pain and consider my- self cured. 1 do not have erections. My general health is good. May 7, 1906. — 'Letter. I void urine as naturally as I ever did and a pint or more at a time. I suffer no pain, I have some erections, but not as satisfactory as before operation. My general health is very good. I have gained in weight, and I consider myself cured. September 13. 1906. — Letter. I void urine naturally three or four times during the day and none at night, about a pint at a time. Erections have returned. General health excellent. I am cured. Pathological report. — The specimen, G. U. 186, consists of two pieces and weighs about 32 gm. The right lateral and median lobes have been removed in one piece, and are about equal in size, each measuring 4 x 3 x 2.5 cm. in size. They are formed of many spheroids more or less loosely bound together. The section shows the usual adenomatous picture with considerable fibrous stroma in the median portion. The left lobe measures 5x3x2 cm.; it is similar in appearance, but apparently more glandular than the rest of the prostate. Portion of the mucous membrane has been removed with the left lateral lobe. Microscopic examination. — All three lobes present microscopically the same picture. The alveoli are for the most part arranged in lobules, and the gland tissue is very much in excess of the stroma. There is con- study of 14.0 Cases of Perineal Prostatectomy. 395 siderable cystic degeneration present in areas, while in others there is only moderate dilatation with rather marked invagination and complexity of the gland lumina, with papillomatous outgrowth. There seems to be marked glandular proliferation going on. The stroma in many areas is insignificant in amount, comprising but slender bands of muscular and fibrous tissue. In other portions, especially surrounding the lobules, the stroma is much more evident. Here and there small areas of interstitial and occasionally periacinous polynuclear and round cell infiltration are seen. The hypertrophy is of the glandular type with slight cystic degenera- tion and considerable gland proliferation. Case 113. — Considerahle hypertrophy, particuJarly of left lobe, tcith in- duration, pain and other symptoms suggesting cancer. Cure. Followed nine months. No. 1325. H. H. M., age 64, married, admitted September 5, 1905. Complaint. — ■" Prostatic trouble." No history of gonorrhoea. Present illness began with slight frequency of urination four years ago, but he had very little trouble until three and one-half years ago when complete retention of urine came on, and he had to be catheterized for three weeks. One year later he was again unable to void and has had to use a catheter ever since. He is able to pass small amounts, but with great difficulty, straining, pain and burning along the entire urethra and at times in the thighs and testicles. Hematuria has been considerable at times and patient has found catheter life very disagreeable. ;S. P. — The patient catheterized himself without regard to asepsis two or three times during the day and once or twice at night. Micturition is very painful and difficult. Erections have not been present for five years. Both testicles have been swollen. Examination. — The patient is well nourished, mucous membranes of good color. The lungs, heart and abdomen are negative. Rectal. — rThe prostate is considerably enlarged, particularly in the left lateral lobe which extends far upward in the region of the seminal vesicle, but the contour is oval, the surface smooth. In places it is slightly indu- rated, in others soft. The seminal vesicle cannot be palpated, but two small cordlike masses are felt extending jpward and outward from its upper portion. The right lateral lobe is only moderately hypertrophied, smooth, elastic, and does not extend upward into the region of the seminal vesicle, which is not indurated. Both lobes are distinctly more tender than usual. The rectum is not adherent and no enlarged glands are to be felt. Cystoscopic. — The catheter passes with ease. Retention of urine is com- plete. Vesical capacity is somewhat contracted. The cystoscope shows a moderate enlargement of the left lateral lobe, greater enlargement of the right lateral lobe and a median bar of moderate size continuous with the right lateral lobe, but separated from the left by a fairly deep sulcus. Vol. XIV.— 26. 396 Hugh H. Young. The mucous membrane covering the prostate is smooth. The trigone and ureters are easily seen. The bladder wall is markedly trabeculated, and two small diverticula are present. Considerable inflammation is present. No foreign body. With finger in rectum and cystoscope in urethra there is no increase in the subtrigonal tissues and the median portion of the prostate is only moderately thickened. Urinalysis. — Cloudy, alkaline, 1019, no sugar, albumin a trace, urea 8 gm. to liter. Total quantity in 24 hours 1500 cc. Microscopically, numer- ous pus cells. Operation. September 6, 1905. — Ether. Perineal prostatectomy by the usual technique. The right lateral lobe was only moderately enlarged, the left was much larger and projected well up into the region of the seminal vesicle. It was smooth, rounded, encapsulated and easily enucleated. The urethra, ejaculatory bridge and bladder were not disturbed. Frozen sections of the left lateral lobe during the operation showed benign ade- noma. The wound was closed as usual. Submanimary infusion and con- tinuous irrigation on return to the ward. Patient stood the operation well, the pulse being 95 at the end. Convalescence. — The temperature rose to 101.1° on the day after the operation, and for a week there was a temperature every evening between 100° and 101°. The patient was comfortable and had an excellent con- valescence. Continuous irrigation was discontinued after 12 hours, gauze was removed 24 hours without bleeding, tubes in 30 hours. Urine began to come through the anterior urethra on the second day. The patient was up in a chair on the third day and walking on the fifth. The perineal fistula closed on the ninth day, and he was discharged from the hospital on the twelfth day. His condition was excellent, urination every three to four hours with no incontinence, good stream, only a slight burning at times. He had had one erection after the operation. Xovemier 30, 1905. — -Letter. The wound has remained healed. I void urine as well as I ever could, about four or five times during the day and two or three times at night, often a pint at a time. I have no pain and think I am cured. I do not have erections, have had no complications, no treatment, have gained 10 pounds, and I feel like a two-year-old. May 7, 1906. — ^Letter. Urination is entirely normal. I void twice dur- ing the night, almost a pint at a time. I have no pain nor erections. Have had no complications nor treatment. My general health is good, I am gaining in weight and strength, and consider myself entirely cured. Case 114. — 'Considerable enlargement of median and lateral lobes. Large stone seen with cystoscope, but not found at operation. Result: Relief of obstruction, frequency of urination and pain. Examination eight months later. Stone seen and removed by suprapubic lithotomy . No. 1025. E. S., age 70, widowed, admitted September 8, 1905. Complaint. — " Enlarged prostate, catheterism." No history of gonorrhoea. Present illness began three years ago with marked precipitancy and fre- study of lJi-5 Cases of Perineal Prostatectomy. 397 quency of urination during the day. Very soon after his physician was called, passed a catheter and drew off over two quarts of urine, since then patient has not voided and has used a catheter. He has never had hema- turia, never passed gravel. His only pain has been an occasional sharp pain at the neck of the bladder and in the rectum during defecation. 8. P. — 'He catheterizes himself about every six hours. Cannot void at all, occasionally has slight pain in the bladder. Sexual powers. — ^No erections for one year. General health fairly good. Examination. — The patient is emaciated, lips of good color, pulse regu- lar, but considerable arteriosclerosis is present. The heart, lungs and ab- domen are negative. The glands of both groins are enlarged, indurated but discreet. Genitalia. — The left epididymis is slightly indurated and enlarged. There is a varicocele present. Rectal. — 'Prostate is moderately enlarged, somewhat irregular in shape, particularly along the outer border of the right lateral lobe where a large hard nodule can be felt. At the upper end of this lobe is an indurated mass one and one-half cm. wide, extending upward and outward into the region of the seminal vesicle for a distance of about 2 cm. It is hard, smooth and not tender, and no indurated cords are to be felt above it. The seminal vesicles cannot be made out. The left lateral lobe is larger than the right and regular in contour. Its consistence is elastic, and al- though it extends farther upward than the right lobe, there is no prolonga- tion into the region of the seminal vesicle, which is soft. In the intravesi- cular region nothing abnormal is made out. No enlarged glands can be felt in the sacral fossa or left side of the pelvis. On the right lateral wall of the pelvis one hard gland is felt about 2 cm. above the induration of the prostate. The rectal wall is soft and not adherent. Cystoscopic. — A No. 17 coude catheter passes with ease. There is no roughness in the posterior urethra and the catheter is not grasped. Reten- tion of urine is complete and the bladder capacity is small, admitting only 150 cc. The cystoscope shows a considerable enlargement of both lateral lobes with a deep sulcus between them anteriorly, and a median lobe of moderate size with a deep sulcus between it and the left lateral lobe. Be- hind the median portion of the prostate is a long, oval, white, slightly gran- ular calculus, freely movable in the bladder. When the patient is turned to the left side it rolls into the left half of the bladder (see cystoscopic chart. Case XV, "Use of Cystoscope, etc."). The bladder is considerably trabeculated and inflamed, and considerable mucus is present. With the finger in the rectum and cystoscope in the urethra the subtrigonal tissues are apparently not much increased. To the right of the cystoscope the oval induration continuous with the right lateral lobe is felt. This indura- tion is not of stony hardness and is smooth in contour. The median por- tion is moderately increased. Operation, September 11, 1905. — Ether. Perineal prostatectomy by the usual technique. The posterior surface of the prostate was smooth and not of stony hardness and did not suggest carcinoma. The lateral lobes 398 Hugh H. Young. were quite large and easily enucleated. On section they appear benign and a frozen section shows benign adenoma. At the upper end of the right lateral lobe a small oval lobule was found separately encapsulated and dis- tinct from the main body of the right lateral lobe. It was evidently a lobule which had broken through the capsule at this point and projected into the region of the seminal vesicle, the frozen section showed it to be benign. The middle lobe was enucleated through the right lateral cavity without tearing the urethra or the mucous membrane of the bladder. The lateral walls of the urethra were very adherent to the lateral lobes and a portion was removed on each side. Every effort was made to And the cal- culus which had been seen with the cystoscope, forceps, spoons and search- ers were used, but it could not be detected. The operator, convinced that he had mistaken a mass of mucous for a stone, finally desisted and closed the wound, as usual, with double tube drainage and light packs for the lateral cavities. The patient stood the operation well. Pulse at the end 100. Submammary infusion and continuous irrigation on return to the ward. Convalescence. — The patient reacted well, the temperature rose to 103.6" five hours after the operation, but rapidly fell, rose to 100.8° the next day and after that remained practically normal. Continuous irrigation was discontinued after 12 hours, the gauze was removed in 24 hours and the tubes in 48 hours. For two days the urine came entirely through the wound, the patient having no control. On the fourth day it began to flow through the anterior urethra in small, but rapidly increasing amounts. The patient was up on the third day and left the hospital on the 14th day in excellent condition. The perineal fistula was not completely closed. Urine was voided about every three hours in a large stream, there was con- siderable urgency of urination but no incontinence. He was free from pain and had no complications. A silver catheter passed with ease, meet- ing no obstruction, found 40 cc. residual urine, bladder capacity of 230 cc. Careful search failed to detect a calculus. The urine was acid, quite puru- lent. The patient was advised to take urotropin and to distend bladder by retaining urine as long as possible, and to return in a month for cys- toscopic examination. November 30. 1905. — 'Letter. The fistula finally closed on 35th day. The wound is firmly closed, I void urine naturally, but frequently, about every two hours during the night, and every time I get up after sitting down during the day. I only pass about one-quarter pint at a time and have considerable pain during urination. My general health is excellent, and I have gained considerably in weight. May 8. 1906. — Letter. I void urine about every hour during the day. I suffer a great deal of pain during urination, particularly in walking down hill. At night I use the catheter three times, and have about three hours rest between catheterization. I have had no erections since the operation. My general health is good and I have gained 20 pounds. I am benefited, but not cured. May 19, 1906.— The patient returns for examination. The wound has study of 1J/.5 Cases of Perineal Prostatectomy. 399 remained closed, but he still voids urine at intervals of an hour and with pain. He catheterizes himself at bedtime, and is then able to sleep for three or four hours. Has had no erections since operation. Examination. — ^The patient looks well. Rectal. — In the region of the prostate is a small cicatrix, no evidence of remaining hypertrophy. Cystoscopic. — The catheter passes with ease and finds 60 cc. residual urine. The bladder is small and irritable and will retain only 160 cc. The cystoscope shows a large, oval, white vesical calculus free in the vesical cavity. The bladder is trabeculated, no diverticula seen. Study of the prostatic orifice shows a somewhat irregular margin, and in the median portion a small tentlike fold of mucous membrane. There is no definite enlargement present. With the finger in rectum and cystoscope in urethra there is no enlargement of the median portion made out. May 22, 1906. — -Operation. Ether. Suprapubic lithotomy. A large soft calculus about 4x6x3 cm. in size was removed. Examination of the blad- der showed no remaining calculus. The wall contained a few cellules, but the stone was not encysted. Examination of the prostatic orifice showed a smooth mucous membrane, no intravesical lobes, a small transverse fold in the median portion about 1 cm. high and 7 mm. thick. The prostatic orifice was large and apparently no obstruction was present. It was thought easy, however, to excise this median fold and it was caught be- tween two clamps and excised. A piece of tissue about 1 cm. in diameter being removed. The bladder was drained suprapubically through a large rubber tube which was fastened in place. The patient stood the operation well. Pulse at the end 85. Infusion on return to the ward. The tempera- ture arose to 100.8° on the second day and the patient was nauseated and hiccoughed frequently. The suprapubic tube was removed on the third day and the patient was up in a wheel-chair on the sixth day. On the 10th day a catheter was inserted into the urethra with the hope of closing the suprapubic fistula. On the 12th day the urine was still coming through the suprapubic fistula, but the patient asked to be discharged to save ex- pense. June 9, 1906. — Eighteenth day. The urine comes through the suprapubic fistula. The patient is comfortable, but finds the suprapubic dressings gen- erally wet and disagreeable. He is in good condition and leaves for home to-day. September 14, 1906. — Letter. I void urine naturally at intervals of from two to three hours, about a gill at a time. I have no pain. My general health is good and I feel that I am cured. Pathological report. — The specimen, G. U. 187, consists of the three lobes of the prostate which have been removed in four pieces and weighs about 80 gm. The right lobe measures 5 x 4.5 x 3.5 cm. Adherent to it is a small area of urethral mucous membrane. It is firm, but elastic and shows con- siderable gland tissue and little stroma on section. The left lateral lobe measures 6 x 4.5 x 2 cm., is lobulated, elastic, and on section shows consid- erable gland tissue separated by a fibrous stroma. The middle lobe meas-; 400 Hugh H. Young. ures 3.5 X 2 X 1.5 cm., is covered by a smooth capsule, is elastic and glandu- lar in character. A small round lobe 1.5 cm. in diameter, which projected beyond the capsule at the upper end of the right lobe is smooth and on section presents an adenomatous appearance. Frozen section from this at operation showed benign adenoma. Microscopic examination. — Sections from all three lobes show a very glandular tissue. The acini are for the most part very much dilated and lined with somewhat flattened epithelium. In occasional areas the acini are very slightly, if at all dilated, but the lumina are very irregular in outline. Many of the smaller acini show proliferation of the epithelium, often growing out in solid tufts into the lumen. The stroma is com- paratively small in amount, fairly compact and made up in fairly equal amounts of muscle and fibrous tissue. It is an adenomatous type of hy- pertrophy with considerable cystic degeneration, and rather small amount of stroma. Case 115. — ■Considerahle hypertrophy of median and lateral lohes. Small calculus. Cure. Followed seven months. No. 1082. W. H. P., age 65, married, admitted October 21, 1905. Complaint. — •" Retention of urine." No history of gonorrhoea. Present illness began eight months ago with frequency of urination. Several months later began to have pain during ufination and sometimes a burning at the end of the penis. Occasionally there was considerable dribbling after urination. Six days ago complete retention of urination requiring catheterization came on, and since then he has been catheterized every six or seven hours. Sexual powers have been considerably weakened since onset of trouble, but intercourse is still possible. Examination. — The patient is a sturdy looking man with lips of good color. Heart. — Enlarged and there is a soft blowing systolic murmur at apex. The lungs and abdomen are negative. Genitalia negative, with the excep- tion of a profuse urethral discharge which contains pus cells and cocci, mostly round. (This has been present only since catheterization.) Ar- teries are sclerotic. Rectal. — The prostate is considerably hypertrophied, forming a mass w^hich projects well toward the rectum. It is smooth, rounded, elastic, seminal vesicles are palpable but not indurated. There is very little tenderness, no enlarged glands. Urinalysis. — -Cloudy, acid, 1024, trace of albumin^ no sugar, no casts, very little pus. Cysioscopic. — A coude catheter passes with ease and finds 460 cc. re- sidual urine. The cystoscope shows considerable enlargement of both lat- eral lobes with a deep cleft between them anteriorly and a fairly large median bar which is continuous with the lateral lobes on each side with- out intervening sulci. The bladder wall is moderately trabeculated, with shallow pouches and no definite diverticula. Very little cystitis. A very study of lJf.5 Cases of Perineal Prostatectomy. 401 small oval, dark brown, moderately rough calculus is present behind the interureteral bar. The ureters are visible, and apparently normal. With finger in rectum and cystoscope in urethra the beak can be felt, there is no subtrigonal thickening. The median portion is thicker than normal and the prostatic length is greatly increased. Preliminary treatment. — ^The patient remained in the hospital for two days and was catheterized at intervals of from four to six hours. The re- sidual urine varied from 300 to 500 cc. A few hours after catheterization the patient begins to pass water with considerable straining and in small quantities. Urotropin and water in abundance prescribed. Operation, October 2, 1905. — Ether. Perineal prostatectomy by the usual technique. Lithotomy. The lateral lobes were considerably enlarged, but easily enucleated. A fairly large median bar was easily removed through the right lateral cavity. The floor of the urethra and ejaculatory ducts were preserved intact, no mucous membrane was removed. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The calculus was not found, although a prolonged search was made. Patient stood the operation well, pulse at the end being 120. Infusion and continuous irrigation on return to ward. Convalescence. — Patient reacted well. Temperature rose to 100.8° on the day after the operation, but after that was normal. Continuous irrigation was stopped after 18 hours. Gauze was removed in 24 hours, and tubes in 48. The patient was up on the third day. At the end of the week almost all of the urine came through the penis, and the fistula finally closed on the 15th day. Patient was discharged on the 16th day, voiding at intervals of three to four hours, good stream without pain, with no incontinence. General condition excellent. It is possible that the little calculus was re- moved in a clot of blood and not detected. December 1, 190-5. — Letter. I am getting along very well. The wound has remained healed and urine comes as freely as when I was a boy. I am gaining in flesh and strength. February 17, 1906. — Letter. The wound has remained closed. I void urine three times during the day and twice at night, sometimes a pint at a time. I suffer no pain, have had no complications, have not had erec- tions. My general health is not good on account of my stomach. May 7, 1906. — Letter. I void urine naturally at normal intervals during the day and about once at night, and one pint at a time. I have no pain, no erections. My general health is excellent and I consider myself cured. September 13, 1906. — Letter. I void urine naturally three or four times during the day and once at night. I suffer no pain. Erections and inter- course are fairly satisfactory but somewhat weakened. General health good, am cured. Pathological report. — The specimen, G. U. 191, consists of three lobes of the prostate removed in four pieces, and weighs about 40 gm. The right lateral lobe is lobulated, 3 x 2 x 1.5 cm. The cut surface Is irregular, ow- ing to the protrusion of yellowish lobules with trabeculated fibrous stroma intervening. One small encapsulated abscess is seen. The left lobe con- 403 Hugh H. Young. sists of two pieces, and measures in all about 4x2x2 cm. A small piece of mucous membrane is attached to it. On section it is similar to the right lobe. The median lobe is an irregular mass, 2.5 x 2 x 1 cm. It is soft, elastic, and on section is granular with considerable fibrous stroma. No ejaculatory ducts. Microscopic examination of the left lateral lohe. — The section contains a fair sized lobule which is rich in gland tissue. Ihe stroma between the acini is fairly thick, and is composed about equally of muscle and con- nective tissue. The epithelial lining of most of the acini shows a redupli- cation and folding, in places assuming a papillomatous type Many of the acini are moderately dilated. Towards the periphery of the lobule some of the acini show a periacinous round cell infiltration. The tissue outside of the lobule contains comparatively few tubules. Some of the tubules are dilated, while there are other areas where the acini are compressed and undergoing atrophy. The stroma is composed of smooth muscle fibers of considerable extent, but in many areas the connective tissue hyperplasia is very abundant. There is considerable round cell infiltration. The con- nective tissue hyperplasia is especially marked about the acini which are compressed. This section may be called a fibro-myo-adenoma, the adeno- matous tissue predominating in areas; and a fibro-myoma in other por- tions. Right lateral. — The adenomatous tissue predominates in this section. Many of the ducts are dilated and the lining epithelium is flattened, in other dilated ducts there is some papillomatous outgrowth. The stroma is apparently composed about equally of muscle and connective tissue. In a few limited areas there is some chronic prostatitis present, the infiltration being most marked about the acini and also extending somewhat into the interstitial tissue. In this section the adenomatous tissue distinctly pre- dominates. The "middle lobe. — The tissue here distinctly contains more stroma than the lateral lobes. Many of the acini are quite markedly dilated with fiat- tened epithelium, in other acini there are some solid masses of epithelial cells growing into the lumina of the acini. In areas there has been con- siderable connective tissue hyperplasia which has almost completely replaced the acini. Here and there is well marked round cell infiltra- tion in the stroma. In this section the fibrous tissue is more abundant, and there is comparatively small amount of gland tissue present except in limited areas. * Case 116. — Previous suprapubic prostatectomy. Considerable enlarge- ment of the left lateral lobe. Vesical calculi. Cured. Followed eight months. No. 1160. H. J., age 65, married, admitted October 6, 1905. Complaint. — •" Frequency and painful urination." No history of gonorrhoea. Present illness began about two and one-half years ago with frequent and difficult urination. During the next year he suffered considerably Study of lJj-5 Cases of Perineal Prostatectomy. 403 from straining during urination, and 16 months ago complete retention of urine came on. All attempts to catheterize him were unsuccessful, and he was aspirated suprapubically for five days, when a suprapubic cystot- omy was performed for drainage. Two months later a suprapubic pros- tatectomy was performed in Canada. His convalescence was slow, he suf- fered with phlebitis and epididymitis, but ultimately left the hospital in good condition, and has not required catheterization since. Urination has been frequent and for the last two months there has been considerable pain in the neck of the bladder and radiating to the end of the penis. S. P. — Urine is voided every hour during the day and three times at night. The act is painful, the pain radiating to the end of the penis. Sexual powers. — iHas had no erections since suprapubic prostatectomy. Examination.- — The patient is a well nourished man with lips of good color, no arteriosclerosis. The chest is negative, and the abdomen also with the exception of a small suprapubic scar. Genitalia. — 'No epididymitis, no hernia. Rectal. — There is a definite prostatic enlargement present, particularly of the left lateral lobe, the upper end of which is difficult to reach. The right lateral lobe is definitely enlarged. The general contour of the pros- tate is round, surface smooth, consistence elastic, and fairly soft. The seminal vesicles are negative and no enlarged glands to be felt. Uri?ialysis. — 'Cloudy, 1021, acid, no sugar, trace of albumin, pus cells, no casts seen. Cystoscopic. — A coude catheter passes with ease and finds a small amount of residual urine. The bladder capacity is somewhat contracted and very irritable. The cystoscope shows a fairly considerable intravesical enlargement of the prostate consisting of a large left lateral lobe, a small right lateral lobe, and a small median bar connecting the two without in- tervening sulci. The bladder was trabeculated, inflamed, and in a pouch immediately behind the median portion of the prostate five small oval calculi are seen. With finger in rectum and cystoscope in urethra there is a definite enlargement in the median portion of the prostate. Operation, October 6. 1905. — Ether. Perineal prostatectomy by the usual technique. The right lateral lobe of the prostate was very small, about 21/0 cm. in diameter. The left lateral lobe was considerably enlarged, and after its removal another large lobe, probably the intravesical portion of the left lateral lobe was removed. At first it seemed that this was a middle lobe about 5 cm. in diameter. Exploration with the finger then showed no remaining prostatic hypertrophy. The lateral wall of the urethra was then incised longitudinally, a stone forceps inserted and several small, soft, round calculi and some detritus and fragments were removed. Care- ful examination with forceps and spoon show no remaining fragments. The wound was closed as usual with double catheter drainage tubes and light gauze packs for the lateral cavities. Patient stood the operation well, his temperature at the end being 85. Infusion and continuous irri- gation on return to ward. Convalescence. — ^The patient reacted well, but on the day following the 404 Hugh H. Young. operation the temperature rose to 102.4°; after the third day it remained practically normal. The continuous irrigation was discontinued after 16 hours, the gauze removed after 24 hours and the tubes after 48 hours. On the second day the patient complained of a slight dull pain in the left testicle. There was no swelling and the pain disappeared after two days. The urine continued to come entirely through the perineal wound until the 14th day, when after urethral irrigation some urine came through the an- terior urethra. On the 18th day the perineal fistula closed completely. The patient was discharged on the 21st day, in good condition, voiding at intervals of two or three hours with a good stream and only a slight burning. December 26, 1905. — The patient has had no instrumentation since opera- tion. He urinates without hesitation and in a large stream, at intervals of three hours during the day and five hours at night. He has perfect con- trol, no incontinence of any sort, the wound is healed. A catheter passes with ease, meets no stricture or other evidence of obstruction, and finds no residual urine. Urine still contains pus cells and bacilli. March S, 1906. — The patient urinates about every three hours during the day and once or twice at night, usually with a good full stream, but occa- sionally rather small. Examination. — The patient voids with a good stream. Urine is almost clear. A silver catheter passes with ease ,and finds 5 cc. residual urine. Bladder capacity 250 cc. A Kollmann dilator passes into the bladder with ease and is dilated up to 35 F. ; there is no stricture present. March 22, 1906. — The patient thinks urination is more free since dilata- tion. He is able to retain urine seven hours at night and has no inconti- nence, but during the day when the desire comes on it is imperative, and if patient is very much fatigued a few drops may escape involuntarily. May 15, 1906. — Letter. I void urine naturally, about six times during the day and once at night, about four or five ounces at a time. I have only occasionally a slight pain. I have erections and satisfactory sexual intercourse, my general health is improving. I have gained in weight and consider myself cured. September 25, 1906. — Letter. I void urine naturallj^ six or seven times during the day and once or twice at night, in normal amounts. I suffer no pain. Sexual intercourse is satisfactory. I am cured. Pathological report. — The specimen, G. U. 290, consists of three pieces representing right, left and median lobes and weighs about 25 gm. The left lateral measures 5x4x3 cm., surface is lobulated, consistency some- what firm but elastic. On section it is seen that the tissue is made up of lobules of varying size separated by small denser bands of tissue. The right lateral lobe measures 3x2x1.5 cm. and is similar in character to the left. The median lobe is a somewhat rounded mass measuring 2.5 x 2 cm., and is also made up of lobules. Microscopic examination. — The hypertrophy is a glandular one with con- siderable cystic dilatation of the acini in certain lobules. In areas the acini show considerable intraacinous budding. About the periphery of Study of 145 Cases of Perineal Prostatectomy. 405 the lobule there is the usual condensation and compression of acini. In some lobules the acini are rather regular in outline, while in others the acini are serrated and present evidence of activity. The stroma is fairly- compact, and contains a moderate amount of muscle. Some few areas of prostatitis are present, but these are comparatively insignificant. The ar- teries show very little change from the normal. Case 117. — Moderate hypertrophy of viedian and lateral lobes. Consid- erable pain. Cure. No. 1073. C. K., age 75, married, admitted October 21, 1905. Coinplaint. — '' Enlarged prostate." No history of gonorrhoea. Present illness began 18 months ago with slight increase in frequency of urination. A little later he had pain in the urethra during urination, but soon recovered from both these symptoms. Four months ago he had chills and fever, of malarial character, associated with frequent, difficult and painful urination, during which he was catheterized, and since then he has had gradually increasing difficulty. He has had no pain in the re- gion of the kidneys, no nausea or vomiting. 8. P. — Urination occurs about every half to one hour. The stream is small, urination difficult and slow and accompanied by pain, no hemor- rhage. Sexual powers. — No note made. Examination. — 'The patient is well nourished, but looks weak and his lips are pale. The heart is slightly enlarged, but the sounds are clear. The lungs are negative. The pulse is of good volume and tension. There is slight arteriosclerosis. The abdomen is negative. Genitalia. — Complete inguinal hernia on right side well retained by truss. Rectal. — 'The prostate is considerably enlarged, rounded, smooth, soft, and slightly tender. There is no induration in the region of the seminal vesicles nor in the intervesicular space. No enlarged glands. Urinalysis. — Cloudy, slightly alkaline, 1014, albumin in moderate amount, no sugar. Microscopically, pus cells, no casts seen. Cystoscopic. — A coude catheter passes with ease and finds SO cc. residual urine, bladder capacity of 200 cc. and considerable iiritability. The cysto- scope shows a small sessile rounded median lobe. The lateral lobes are very little enlarged intravesically, and there are no clefts between them in front. The bladder is considerably trabeculated with numerous small pouches and cellules. The ureters cannot be seen. Preliminary treatment. — The patient remained in the hospital six days before operation, during which he was catheterized three times daily, the residual urine varying from 150 to 400 cc. Catheterization was very pain- ful and the bladder very irritable. Catheterization afforded very little re- lief and he frequently voided, every half hour night and day. Operation. October 21, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were easily enucleated and measured 406 Hugli H. Young. 4x5x6 cm. in size. The median lobe was about 2 cm. in diameter and came away in one piece with the lateral lobe. A tear was made in the urethra on each side, but the floor and ejaculatory bridge were preserved. Frozen section showed the benign nature of the hypertrophy. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well, the pulse at the end being 100. Infusion and continuous irrigation in ward. Convalescence. — The patient reacted well. On the day before the opera- tion he had a temperature of 101.7°, on the day after the operation his temperature rose to 101.8°, and on the third day to 102.8°, but it rapidly returned to normal and remained so during the rest of his stay in the hospital. The irrigation was discontinued after 12 hours, the gauze was removed at the end of 24 hours and the tubes 48 hours. Patient was up in a chair on the third day, his general condition excellent. Urine passed through the penis on the ninth day and the perineal fistula closed com- pletely on the 14th day. At that time he was able to retain urine for three hours and voided urine in a good stream and had perfect control. He was discharged from the hospital on the 18th day, voiding urine at in- tervals of from two to four hours without pam, in a good stream. The catheter passed easily and showed no residual urine. His general health excellent. May 9, 1906. — ^Letter. I void urine naturally at normal intervals during the day and once at night, a pint at a time. I have no pain, no inconti- nence, no erections. My general health is good and I consider myself cured. September 15, 1906. — Letter. I void urine naturally at intervals of three or four hours during the day and once at night, one pint at a time. No pain, no erections. My general health is good. Cured. Pathological report. — The specimen, G. U. 189, consists of the middle and two lateral lobes of the prostate and weighs about 35 gm. The left lateral lobe is a lobulated elastic mass, measuring 4 x 3.5 x 3 cm. Attached to it is a small bit of urethral mucous membrane. On section it has a somewhat granular appearance with yellowish areas in a whiter, more fibrous stroma. The median lobe has been removed in one piece with the right lateral, and measures 4x3x2 cm. in size. The right lateral is about the same size as the left and also has a tag of mucous membrane attached to it. On section it appears to be more fibrous than the right. No calculi, no ejacu- latory ducts. Microscopic examination. — The tissue is of much the same character in all three lobes, being almost entirely composed of stroma. Here and there are seen occasional acini, some of which seem fairly normal, while about others there has been considerable connective tissue formation with com- pression and at times almost complete disappearance of the acini. The stroma is for the most part smooth muscle fibers with a very small amount of interlacing connective tissue, except in the limited areas about acini where an excess in the connective tissue elements is present. The arteries show rather a marked endarteritis. study of 145 Cases of Perineal Prostatedomy. 407 This is a hypertrophy in which the muscular element predominates, bundles of pure muscle fiber often being present, and in which the fibrous tissue is comparatively small in amount except in areas as above stated. Case 118. — Considerable hypertrophy of median and lateral lobes. Com- plication: Epididymitis slight. Cure. No. 1080. L. T. D., age 70, married, admitted October 30, 1905. Complaint. — " Frequency of urination." No history of gonorrhoea. Present illness began about two years ago with dribbling after urina- tion. No new symptoms developed until six months ago when the fre- quency of urination rapidly increased. ;S. P. — The patient urinates every hour and there is considerable drib- bling, requiring the use of absorbent dressings. His only pain is a slight burning pain near the end of the penis and in the neck of the bladder on urination. There seems to be little difliculty of urination and only some hesitation in starting the flow. There has never been complete retention of urine. Sexual powers began to decline about 12 months ago, no intercourse for four months, no erections for two months. His general health has been good. Examination. — /The patient is a sparely built but healthy looking man with lips of good color and only moderate arteriosclerosis. The lungs are negative. Heart. — There is a soft systolic murmur at the base, but the heart is not enlarged. Genitalia. — The left epididymis is enlarged, irregularly indurated. The right vas deferens and epididymis are indurated, but smooth and not tender. Rectal. — The prostate is moderately and equilaterally enlarged. The posterior surface is flat, elastic, in places firmer than others, but nowhere of stony induration. The contour is slightly irregular, but generally of an oval shape. The seminal vesicles are negative and there is no inter- vesicular mass. One enlarged gland is felt along the lateral pelvic wall. The inguinal and deep iliac glands are not palpable. Cystoscopic. — A large coude catheter passes with ease and finds 660 cc. residual urine. The cystoscope shows a broad median bar continuous with- out intervening sulci with large intravesical lateral lobes, the right being the larger. The cleft in front between these lobes is wide and the lobes are not closely approximated (possibly accounting for the dribbling). The bladder is moderately trabeculated, very slightly inflamed. Numerous pouches and small cellules are present. The left ureter is seen and is ap- parently normal. The right ureter cannot be seen, owing to numerous pouches in the region of its orifice. With finger in rectum and cystoscope in urethra, it is impossible to feel the beak, owing to the considerable in- crease in the median portion. Urinalysis. — Cloudy, acid. 1003, no sugar, albumin in small amount. Mi- croscopically, pus cells and bacilli. Urea 8 gm. to liter. 408 Hugh H. Young. Preliminary treatment. — Catheterization three times daily, urotropin, water in abundance. Before catheterization the bladder forms a definite abdominal tumor, and the patient voids urine in small amounts. From 200 to 400 cc. of residual urine was found. Operation, November 2, 1905. — Ether. Perineal prostatectomy by the usual technique. As soon as the bilateral capsular incisions were made numerous seed calculi were encountered. The lateral lobes were quite ad- herent, firm, only moderately enlarged, and each was removed in one piece. The median lobe about 3 cm. in diameter was removed through one of the lateral cavities, a small piece of mucous membrane being excised with it. Most of the urethra, including the floor of the urethra and ducts, preserved intact. Wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well. Pulse at the end 80. Infusion and continuous irrigation on return to the ward. Convalescence. — The patient reacted well. The temperature rose to 101° on the day after the operation, and after that varied from 99= to 100°. The irrigation was discontinued after 12 hours, and the gauze and tubes re- moved 30 hours after the operatipn. The patient was out of bed on the third day. On the 12th day the right side epididymitis began and two days later the temperature rose to 104.2°, and the patient complained of nausea and headache. He was infused and on the next day the tempera- ture was normal and remained practically so thereafter. The epididymitis was slight in character and disappeared after six days. The urine began to flow through the anterior urethra on the 14th day, and the perineal fistula was apparently closed on the 18th, but after two days slight leak- age again occurred. Discharged 23 days after the operation in excellent condition. Voiding urine at intervals of two to three hours without pain. Pin point fistula present in perineum. Epididymitis gone. February 27, 1906. — Letter. The wound has remained healed. I void urine naturally, three times during the day and once or twice at night, three or four ounces at a time. I have had no erections. My general health is very good, I have gained in weight and consider myself cured. May 7, 1906. — Letter. I void urine naturally, three times during the day and twice at night, about half a pint at a time. I suffer no pain, the wound has remained healed, my general health is excellent. I have no erections. I consider myself perfectly cured. Pathological report. — The specimen, G. U. 193, consists of three lobes of the prostate, each removed in one piece and weighs about 30 gm. The left lobe measures 3 x 2 x 1.5 cm., is lobulated, elastic, and on section numerous small seed-like calculi are seen in the substance of the gland; these vary in size from a small grain of sand to a millet seed, and 50 are seen in a section through the center of the gland. The tissue is yellowish in color with streaks of grayish fibrous tissue between. The right lobe is slightly smaller than the left, lobulated and soft. At its upper end there is a small portion of tissue which is distinctly firmer, and on section is hemorrhagic and granular. Frozen sections were made from this during Study of lJf5 Cases of Perineal Prostatectomy. 409 operation and it showed much fibrous tissue with inflammatory infiltra- tion. A small piece of mucous membrane is attached to the inner surface of the right lobe. The middle lobe is irregular, and about 3 cm. in diame- ter. The surface is lobulated, and on its anterior aspect is a piece of mu- cous membrane 2x1 cm. in size. Bjaculatory ducts are not present. Microscopic examination.— The tissue from all three lobes as a whole contains gland tissue considerably in excess of stroma. The glands are arranged somewhat in lobules about which the stroma is somewhat thickened and compact. Within the lobules the acini are moderately dilated with rather flattened epithelium and a thin stroma, while in others the ducts are not dilated, the stroma is considerably more evident and the lumina of the ducts quite irregular. In the interlobular tissue the acini are compressed and rather infrequent. In several good-sized areas from the right lobe there is considerable in- flammatory interstitial infiltration, evidently of long standing in places, as there is considerable new connective tissue formation. The stroma, as a whole, contains more fibrous than muscle tissue. This is an adenomatous type of hypertrophy with moderate cystic degeneration, and some chronic interstitial prostatitis. Case 119. — Slight enlargement of median and lateral lobes. Catheter life. Occasional incontinence and severe pains in legs. Perineal prosta- tectomy. Removal of obstruction. Natural urination at night. Inconti- nence (partial) in the day. Followed seven months. No. 1091. H. N. H., age 55, married, admitted November 4, 1905. Complaint. — >•' Prostatic enlargement. Catheterism." Gonorrhoga 36 years ago — ^was perfectly cured. Present illness began about two years ago with a feeling of pressure in the bladder and occasional incontinence of urine. He was examined by a physician who diagnosed prostatic hypertrophy. Following this he had inflammation of the bladder, very difficult urination and has had to use a catheter, although retention of urine has never been complete. He has never had any pain in the bladder other than a slight one, has not lost weight. Severe lightning pains in legs for two years. 8. P. — The catheter is used three times a day, withdrawing usually 12 ounces of urine. Retention of urine is generally complete, but occasionally he may void small amounts while at stool. The catheter life is extremely disagreeable to him. Sexual powers. — His desire is practically gone, has erections at night when the bladder becomes full and occasionally has intercourse, but it is very unsatisfactory. Examination. — Patient is a strong, well nourished man with lips of good color. The chest and abdomen are negative. The pulse is intermit- tent, but the volume and tension are good. Moderate arteriosclerosis. Rectal. — iThe prostate is only slightly hypertrophied, smooth, regular, elastic, but fairly flrm. There are no nodules. The lobes extend some- what into the region of the seminal vesicles, and there is considerable in- 410 Hugh H. Young. duration at this point, but it is not prominent and does not suggest malig- nancy. No enlarged glands are felt and there is no tenderness. Urinalysis. — Cloudy, 1012, neutral, no sugar, albumin a trace. Micro- scopically, pus cells, red blood corpuscles. Cystoscopic. — The retention of urine is complete. A coude catheter passes with ease and finds the bladder large. The cystoscope shows a moderate hypertrophy of both lateral lobes with a shallow sulcus between them in front, connected by a thin median bar. On depressing the handle of the cystoscope with the beak looking downward the lateral lobes come together forming a deep cleft, behind which only a small portion of the median bar is seen. On the left side a second lobule is seen projecting into the urethra external to the lobule which appears at the prostatic ori- fice, so that it is distinctly intraurethral. The bladder is considerably trabeculated, moderately inflamed, no calculus present. The ureteral ori- fices are normal. With the finger in the rectum and cystoscope in the urethra the beak is easily felt, there is no subtrigonal induration, no in- crease in the median portion. Operation. Xoveiader 9, 1905. — Ether. Perineal prostatectomy by the usual technique. Lateral lobes were onlj" slightly enlarged, hard and ad- herent. A small median bar was enucleated along with the right lateral lobe. There was no definite middle lobe present as shown by insertion of the finger through the urethra. Small tear was made in the urethra, but the ejaculatory ducts and floor of the urethra were preserved intact. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well. His pulse at the end was 110. Infusion and continuous irrigation on return to the ward. Convalescence. — The patient reacted well. On the second night after the operation the temperature arose to 101.5°, but immediately fell and re- mained practically, normal. The irrigation was discontinued after 28 hours and the gauze and tubes after 40 hours. On the third day he had several attacks of pain in the bladder and urethra which were relieved by urethral irrigation, several clots being dislodged from the wound. No subsequent discomfort. On the third day the patient was up in a wheel- chair and in six days was walking about the ward. On the fifth day all the urine came through the anterior urethra, but subsequently the perineal wound opened again. The perineal fistula closed on the lAth. day, and the patient was discharged on the ISth day. He was then able to retain urine for six hours, and had no nocturnal incontinence. During the day there was a slight incontinence. No epididymitis. The wound was closed. A silver catheter passed without meeting any obstruction and found no re- sidual urine. The urine was acid and contained pus cells. He was in- structed to take urotropin and to drink water in abundance and to retain the urine as long as possible. Fetruary 20. 1906. — The patient returns for examination, complaining of incontinence of urine. He says that he has had no retention of urine since the operation, and no pain, but he is unable to retain urine more study of lJf.5 Cases of Perineal Prostatectomy. 411 than an hour or so when involuntary leakage begins. While walking about there is almost constant dribbling of urine. During the night he does not get up to urinate and has no incontinence. "When he arises in the morning he voids a large amount of urine in a good stream. He has had no sharp shooting pains in the front of thighs which were present before operation. Rectal. — In the region of the prostate is a small moderately indurated mass, but no prostatic enlargement. A silver catheter passes with ease. No stricture present, no residual urine. The bladder capacity is large — 380 cc. The tonicity is excellent. The cystoscope shows a dilated irregular prostatic orifice so that in places there is no well defined margin. The urethra is apparently dilated, thrown into folds. No intravesical prostatic hypertrophy is seen, but sev- eral irregular protrusions of the urethral mucous membrane, possibly small spheroid prostatic masses, are seen in the interior of the urethra. There is no median lobe or bar present, and with finger in rectum and cystoscope in urethra the tissue between the two is less than normal. The bladder is very little trabeculated, no diverticula, no stone present. Examination by Dr. Thomas. — -Pains: Has been subject to pains in legs since bladder began to trouble him, intermittent and in various places, felt as if a knife were thrust about and then withdrawn. Does not think the skin was sensitive after them. Since operation has been much better. Sexual power decreasing for two years. The optic nerves are normal, pupils somewhat eccentric and irregular in outline. They react to light and during accommodation. The muscular strength and movements of the arms are normal. Triceps and biceps reflexes are present on both sides. The walk is firm and station good with feet together and eyes open. When the eyes are closed there is some swaying, but no tendency to fall. No disturbance of sensation over sacral segment. Gluteal, cre- masteric, and abdominal reflexes are present. Knee kicks present on both sides but somewhat subnormal. Ankle reflexes only obtained upon reinforcement. No abnormality of sensation. The case is, I believe, one of local trouble of the bladder. There are, however, things that suggest the possibility of tabes, i. e., the pains, which although not perfectly char- acteristic, make one think of those in tabes. The deep reflexes in the legs are decreased, but other than this there are no other objective findings indicative of spinal cord diseases. February 24, 1906. — The dribbling continues when the patient is on his feet, but after sitting he voids 150 cc. in a good stream. The bladder holds 300 cc. on forced distention. The urine is almost clear and contains a little pus. The patient is advised to dilate the bladder by hydraulic press- ure twice daily, to keep quiet and wear a jock-strap to hold the penis up against the abdomen. May 8, 1906. — 'Letter. My condition is improved somewhat. The bowels are somewhat torpid and require purgatives. The severe nightly recur- rent pains have let up and there seems now to be a girdle or section of skin about eight inches wide around the abdomen and back that is ex- Vol. XIV.— 27. 413 Hugh H. Young. tremely sensitive to the touch, chafing of underclothes and exposure to the air. The feeling in a way is like that of a burn from which a dress- ing was suddenly removed. The incontinence of urine is gradually lessen- ing, and is 50% better than when I saw you. May S, 1906.— hettev from physician. The patient has been improved in a general way. The severe pain which came on at 12 p. m. or 1 a. m. every night for a considerable period, gradually subsided, and now has entirely ceased to occur. As this pain gradually disappeared a new symp- tom came on, viz., a hypersensitive condition of the skin around the lower abdomen corresponding to the region supplied by the lumbar nerves. The obstinate constipation has disappeared and his control of the bladder has perceptibly improved. He certainly shows more symptoms of mcipient tabes now. He is losing in weight and is not able to work, and is men- tally exceedingly irritable. May 21, i906.--Letter. I void urine naturally once in three or four hours, and get up not more than once at night, and sometimes not at all, to urinate. The largest amount voided at one time is nine ounces. I have never had any incontinence at night, and the occasional dribbling of urine which has been present during the day is improving. September 11, i906.— Letter. I void urine naturally about four times during the day and once at night, as much as 10 ounces at a time. No pain no erections. Incontinence during the day, but none at night. His phys'ician reports that the hypersensitive condition which was present around the abdomen has increased and now involves the chest as far as the second dorsal vertebra and the patient says he feels as if there were a constricting band over this entire area. Lightning pains have been present once. There is a marked swaying when the eyes are closed, diffi- culty in walking at night and ataxic symptoms have increased consid- erably. Pathological report.^The specimen, G. U. 194, consists of the two lateral lobes of the. prostate gland and one Cowper's gland. The right lobe meas- ures 2x3x1.5 cm., is firm, but elastic, and on section numerous small black calculi are seen in the peripheral portion. It is moderately glandu- lar and has considerable fibrous stroma. There are some nodules which are firm and smooth and apparently entirely fibrous tissue. The left lat- eral lobe consists of two parts connected by a narrow neck of tissue. The intravesical portion is quite lobulated and succulent, and on section very glandular. The extravesical portion seems to be fibrous. No mucous membrane, no ejaculatory ducts, no calculi removed. Cowper's gland is a small globular mass about 8 mm. in diameter and is normal in appearance. Microscopic examination.— The section shows a rather fibro-mus- cular type of hypertrophy with small accumulation of gland ducts here and there. In the intravesical portion of the left lateral lobe, however, there is present a fair amount of gland tissue. The stroma in this latter tissue is very dense, contains a large amount of muscle, and about numerous acini there is considerable accumulation of round and polynuclear cells. In the right lateral lobe study of 145 Cases of Perineal Prostatectomy. 413 and extravesical portion of the left, ttie tissue is largely made up of a stroma composed of muscle. The acini are not at all dilated, but about the majority of them there is a round cell and polynuclear cell infiltration which invades only to a slight extent the interstitial stroma. Some evi- dence of new connective tissue formation about a few of the acini is seen. This is distinctly a myomatous type of hypertrophy, there being a very small amount of fibrous tissue present, and except in one small portion of the left lateral, the gland tissue is rather sparse. Some corpora amyl- acea are present in the ducts. Case 120. — ■Considerable enlargement of right lateral lohe. Very little residuum. Contracture of bladder. Painful erections. Cure of obstruc- tion, and improvement of pain in posterior urethra. Followed six months. No. 1090. J. R. M., age 59, married, admitted November 4, 1905. Complaint. — " Slight frequency of urination. Frequent painful erections at night." The patient had gonorrhoea at the age of 20, was apparently perfectly cured, had no further trouble until 19 years ago when he began to have painful erections at night. He would wake up with pain in the perineum and find the penis erect. Urination will relieve the erection and the pain, but in an hour or two he would be awakened again and find the same con- dition present. He was treated by a physician and sounds were passed twice a week for a year without relief of his symptoms. He has continued to suffer as above described for 19 years. /S. P. — The patient is wakened from one to three times every night with painful erections and has to urinate to relieve the condition. Occasionally a night passes without having erections, and he then may not have to urinate at all during the night. Micturition is normal during the day. Sexual potcers are fairly normal, intercourse satisfactory. There is hesitancy at the beginning of urination and the stream is usually small. He often has difficulty in urinating while in the standing position and usually sits down. Examination. — Patient is a well nourished man, lips of good color. Chest and abdomen negative. Rectal. — ^The prostate is distinctly broader than normal and the right lobe is larger than the left. The surface is smooth, firmer than normal, but not markedly indurated nor very tender. There are no nodules. The seminal vesicles are not enlarged but are indurated at their juncture with the prostate. There is no intervesicular mass, no enlarged glands to be felt. The prostatic secretion contains some pus cells, many lecithins, few granule cells and spermatozoa. Urinalysis. — Clear, acid, 1018, no sugar, no albumin, no pus cells or bac- teria. Urea 16 gm. to the liter. Cystoscopic. — A coude catheter passes with ease and finds 35 cc. residual urine. The bladder capacity is contracted, holding 300 cc. on forced dis- tention. The cystoscope shows considerable intravesical enlargement of the right lateral lobe, no intravesical hypertrophy of the left lateral lobe 414 Hugli H. Young. and very little median enlargement, the bar being replaced by a cleft, as shown in the cystoscopic pictures which are reproduced in the article on cystoscopy of the prostate (Fig. 25). The bladder is very little trabecu- lated. There is no pouch formation and no diverticula, no cystitis, no calculus. With finger in rectum and cystoscope in urethra the beak is easily felt, the median portion is very slightly greater than normal Operation, November 15, 1905. — Ether. Perineal prostatectomy by the usual technique. The left lateral lobe, as predicted, was very little en- larged, but it was easily enuclated in one piece. The right lateral lobe was removed in two pieces, the first being about the size of the left lat- eral lobe, and superficial examination seemed to show that everything had been removed. On rotating the tractor and directing one of the blades upward a large intravesically projecting portion of the right lateral lobe was found, engaged with the tractor, and drawn down into the right lat- eral cavity. It was evident that the blade of the tractor had slipped be- neath the anteriorly projecting right lateral lobe, as shown in Fig. 36. It was very easily enucleated without removing any mucous membrane which covered it, and measured about 214 x 3 x 5 cm. in size. There was only a moderate amount of hemorrhage and no tubes were inserted in the bladder, as the operator was anxious not to infect it. The lateral cavities were lightly packed and the wound closed as usual. The patient stood the operation well, the pulse at the end being 100. Infusion on return to the ward. Convalescence. — The patient reacted well and had an uninterrupted convalescence. Temperature on the night after the operation was 100.4°, but after that was practically normal. There was very little hemorrhage and urine passed through the penile urethra on the night after the opera- tion. The gauze drains were removed on the next day and the fistula closed on the eleventh day. On the third day after the operation the pa- tient was walking about his room, and he left the hospital on the eight- eenth day. Interval urination was established immediately after the opera- tion, being at first two hours between urinations. After that the interval gradually increased, and on discharge he was voiding urine in a large stream at intervals of three hours with no incontinence and no pain. The catheter passed with ease, meeting no obstruction and found 85 cc. re- sidual urine. The wound is tightly healed. The urine contains no pus cells, no bacteria. December 24, 1905. — -Letter. I void urine naturally at 2 a. m. and 6 a. m. and about every three hours during the day, half a pint at a time. I have no pain. Erections have returned. January 10, 1906. — [ can go all night without urinating, stream is free and I have no pain. Erections seem to come when the bladder is full. I have not had intercourse as yet. February 16, 1906. — Letter. During the last week I have had no painful erections, in fact my pain has entirely subsided, and I now think it is due to gout. May 6, 1906. — ^Letter. I pass urine freely, which I did not do before the study of 145 Cases of Perineal Prostatectomy. 415 operation, but I have a constant uneasy feeling in a sore spot in the deep urethra, the same as before operation. I void urine twice during the night, about half a pint at a time. I have no pain except the constant uneasiness spoken of above. I have erections and intercourse, but it is not very satisfactory. The seminal ducts feel sore. The operation has not relieved the tendency to erections at night which keep me from sleep- ing, and seems as though I had neuralgia in that region. The irritation does not come on until after midnight. September 13, 1906. — Letter. I void urine naturally four times during the day and twice at night. I still have painful erections which awaken me during the night. Intercourse is not very satisfactory, being some- what painful. I have no urinary trouble, and, although I am improved by the operation, as regards painful erections I am not entirely cured. Pathological report.— The specimen, G. U. 199, consists of three portions, a small left lateral 3.5 x 1 x 2 cm., a right lateral about the same size and an oval lobule, the intravesical portion of the right lateral lobe, 3 x 2.5 x 2 cm. in size. On section all three portions are succulent and juicy, soft and elastic, and seem exceptionally cellular. The surface has a rather granular appearance, is yellowish in color with very small intervening trabeculse of fibrous tissue. No mucous membrane, no ducts, no calculi removed. Microscopic examination. — The prostate shows in different places a mixed type of hypertrophy. There are certain portions where the gland tissue is very abundant, arranged in lobules, and the acini in some of the lobules quite dilated. In others the dila- tation is moderate, but the lumina of the ducts are quite ir- regular and complex. About the lumina of the ducts very distinct mus- cular bands are noticed, while the intervening stroma is mostly fibrous. The stroma in the areas where the gland tissue is not so markedly ar- ranged in lobules, is composed about equally of muscle and fibrous tissue, and the concentric arrangement of the muscle fibers about the acini is not so marked. Here and there one sees acini about which there has been considerable connective tissue formation. There are occasional areas of round cell and polynuclear cell infiltration. In other parts of the pros- tate the gland tissue is very sparse, and the stroma is largely composed of muscle, in places grouped together in almost pure bundles of muscle. Some of the acini which are present in this muscular portion are dilated, while others are compressed. Here and there are areas of round cell and polynuclear cell infiltration with some formation of new connective tissue. We have in this prostate a distinctly adenomatous type with a relatively small amount of flbro-muscular stroma and a myomatous type in which the glands and connective tissue elements are insignificant. Case 121. — Moderate enlargement of median and lateral lobes. Cure. No complications. Followed six months. No. 1100. J. L., age 58, married, admitted November 16, 1905. Complaint. — ^"Prostatic trouble." No history of gonorrhoea. 416 Hug}i R. Young. Present illness began tv/o years ago with slight difficulty and frequency of urination which gradually increased until January, 1904, when he had complete retention of urine, requiring catheterization. Six months later a second retention after which he was catheterized for a week. Since then urination has been more difficult and he has catheterized himself fre- quently on account of complete retention of urine. For one month the catheter has been used once daily and micturition about every hour. There has been a slight pain in the bladder, none elsewhere. Hemorrhage only once. No loss of weight. General health excellent. S. P. — »The patient catheterizes himself at bedtime and withdraws about a pint of residual urine, after that does not void until morning, but dur- ing the day voids urine about every hour 'Vith difficulty and occasionally slight pain. Sexual powers were normal up to a month ago. Fig. 50.— Case 121. Examination. — Patient is sparely built, but a healthy looking man, with lips of good color. No arteriosclerosis. Pulse regular and of good vol- ume. The chest and abdomen are negative. Genitalia. — Negative. Rectal.— Th-Q prostate is slightly enlarged, smooth, in places slightly ir- regular, elastic but firmer than normal, and at the upper end near the juncture with the seminal vesicles there is a slight induration. The semi- nal vesicles are soft and not distended. No enlarged glands are to be felt. Massage of the prostate shows a moderate amount of tenderness, there is no intervesicular mass, no induration in the region of the trigone. Urinalysis. — Cloudy, acid, 1027, albumin a trace, no sugar, microscopic- ally, pus, no casts, no bacteria. Cystoscopic. — A coude catheter passes with ease and finds only 100 cc. I study of lJi.5 Cases of Perineal Prostatectomy . 417 residual urine. The bladder is irritable, rebels at 300 cc. and is evidently slightly contracted. The cystoscope shows (Fig. 50) a slight intravesical hypertrophy of the lateral lobes, and a fairly large median lobe with a sulcus between it and the lateral lobe on each side, and seen unusually high up, in RA and LA respectively, as shown in the accompanying chart. In Series U the small size of the anterior sulcus is seen. In the pictures shown in the top row of circles progressive views by rotating the instrument from L. through LA, A, RA, to R are shown. As seen here, the commissure between the median lobe and lateral lobe occurs very far forward. The bladder wall is only slightly trabeculated and there are no diverticula present. No calculus seen. The trigone and ureters cannot be made out with certainty. Operation, November 22, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were moderately hypertrophied and easily enucleated. The median lobe was about 2i/^ cm. in diameter and was easily removed through the right lateral cavity, only a small tear being made in the lateral wall of the urethra in extracting it. Examina- tion with the finger afterward showed no remaining obstruction. Owing to the fact that the bladder was sterile it was thought best not to insert rubber drainage tubes. The lateral cavities were packed with gauze and the skin wound was partially closed as usual. The patient stood the op- eration well, pulse at the end being 100. Infusion on return to ward. Convalescence. — ^The patient reacted well. During the night following the operation the bladder became distended with urine, the gauze drains were removed, but the patient was still unable to urinate and had to be catheterized. On the following day he was nauseated and vomited and was given a submammary infusion and salt solution per rectum. On the night of the third day retention of urine again came on and the patient was catheterized. After that there was no further retention. He was up in a wheel chair on the third day and began to walk on the fourth day. Urine came through the anterior urethra on the fifth day and in a few days most of it came through the meatus. The perineal fistula healed on the 20th day, and he left hospital on the 21st day, able to retain urine for four hours, voided freely in a large stream without incontinence or pain. Examination of the urine showed no bacteria, but numerous pus cells were present. April 4, 1906. — I void urine at normal intervals during the day and do not rise at night. I have perfect control, no pain. Urination is entirely normal. Erections have returned, and sexual intercourse has been in- dulged in. Ejaculations are about normal. June 5, 1906. — ^Letter. My condition remains excellent. Urination is normal. Sexual intercourse is entirely satisfactory. Pathological report. — The specimen, G. U. 202, consists of three lobes of the prostate, each of the three lobes having been removed in one piece, and weighs in all 15 gm. The lateral lobes are equal in size and measure 4.5x4x2 cm. The external surfaces are encapsulated and fairly smooth, they are elastic, and on section show a moderate amount of gland tissue 418 Hugh H. Young. and a definite amount of stroma. The median portion of the prostate measures 2 x 1.5 x 1.3 cm., and is somewhat similar in appearance to the lateral lobes. No mucous membrane, no ejaculatory ducts, no calculi re- moved. Microscopically both lateral lobes contain about the same amount of gland tissue which is much in excess of the stroma. The middle lobe contains distinctly more stroma than either of the lateral lobes, and the gland tissue and stroma are present in about equal amounts. The gland tissue is rather diffusely distributed with here and there considerable ag- gregations of alveoli. There is moderate dilatation of the majority of the acini with here and there some cystic dilatation with flattening of the lining epithelium. There are occasional areas in which the alveoli show invagination and proliferation. The stroma contains rather more fibrous than muscle tissue with here and there points of rather dense accumula- tion of some round but more polynuclear cells. About some of the acini, in circumscribed areas, there is rather dense infiammatory infiltration with endoglandular proliferation and epithelial degeneration. Case 122. — Yery large hypertrophy of median and lateral lobes. Oxa- late calculus. Cure. Followed six months. No. 1122. D. M., age 71, married, admitted December 19, 1905. Complaint. — " Frequent painful urination." Gonorrhcea in early youth, no gleet or stricture subsequently. Present illness began 10 years ago with a severe sharp pain in the left side and back which radiated to the left groin and testicle. About a month later he had a similar attack and shortly afterwards three other attacks. Since then he has been free from pain in his side and back, but has had irritation in the bladder and pain at the end of urination referred to the head of the penis, and urination has been more frequent than normal. Eight years ago he had complete retention of urine requiring catheteriza- tion, and since then has been catheterized about 20 times for this reason. ;S. P. — Urination every half hour night and day, imperative and associ- ated with considerable pain at the end of urination and located in the head of the penis. Urination difficult, stream small, amounts voided little. His general health is excellent. No hematuria. Sexual powers.— -There has been no sexual desire and no erections for the past two years. Examination. — The patient is a ruddy, healthy looking man. There is no arteriosclerosis. The chest and abdomen are negative. Genitalia. — The left testicle is small and indurated, globus major large and indurated, the minor soft. On the right side there is a hydrocele present and the entire epididymis is considerably enlarged and indurated. Rectal. — The prostate is markedly enlarged, forming a globular mass about as large as a good sized orange. It is elastic, not tender, and gen- erally smooth. Lying on the posterior surface about its middle are two peculiar irregular lobulations which seem to project through the posterior capsule, and are so close to the rectum that they almost seem to be in study of lJj.5 Cases of Perineal Prostatectomy. 419 the rectal wall. But the rectal mucosa is not adherent to them. The con- sistence o:^ these small lobulations is firmer than that of the prostate, but not extremely hard. The seminal vesicles cannot be reached. No en- larged glands are palpable, prostate not tender. Cystoscopic. — Coude catheter passes with ease and finds 200 cc. residual urine. The bladder is very irritable, apparently contracted and will not admit more than 250 cc. The cystoscope shows a large, irregular oxalate calculus, freely movable in the bladder. Owing to hemorrhage it is im- possible to make out the intravesical portion of the prostate, but a large median lobe was made out. Urinalysis. — Slightly cloudy, acid, 1016, albumin a trace, no sugar, few pus cells, many bacilli, some micrococci, no casts. Preliminary treatment.- — Catheterization three times daily, urotropin, hydrotherapy. Operation, December 27, 1905. — Ether. Perineal prostatectomy by the usual technique. The posterior surface of the prostate and rectum were very adherent, and had to be dissected apart. The irregular lobules, felt on rectal examination, were not seen, evidently being dissected off with the rectum. An orderly holding the urethral staff punctured the urethra at tho beginning of the membranous portion and considerable diflaculty was experienced in finding the membranous urethra and introducing the tractor. The lateral lobes were enucleated very easily, each in one piece, and were very much enlarged (Fig. 51). Quite a large median lobe was drawn down and removed through the right lateral cavity. The calculus was extracted through the dilated prostatic urethra. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well; infusions and continuous irrigation on return to ward. Convalescence. — The" patient reacted well. The gauze and tubes were removed on the following day and he began to walk on the fourth day. The urine began to flow through the urethra on the third day, and the patient was discharged from the hospital on the 30th day. At that time he was able to retain urine for four or six hours, had perfect control, no pain, and felt well. February 21, 1906. — Small amount of urine escapes through a perineal fistula with each urination which occurs at intervals of four to five hours. Sounds meet an obstruction in the membranous urethra, but a filiform passes with ease, and a dilating follower. No. 29-P., passes into the bladder. (In this case rupture of the urethra was produced at operation by an orderly who was holding the urethral staff.) March 3, 1906. — Patient voids with a better stream and the fistula is much smaller. There is still slight dribbling after urination. May 14, 1906. — The fistula is almost closed, only a few drops of urine escape. There is no incontinence, but the end of urination is accompanied . by a slight dribbling. May 17, 1906. — ^There is a pin point fistula in the perineum. Only a few drops of urine escape through it and the patient voids twice at night and 420 Rugli H. Young. at intervals of four hours during the day. Has no incontinence of urine at night, but during the day occasionally, while walking, there is a slight involuntary escape of urine, hut this is improving. Exaviination. — 'Silver catheter passed with ease. There is a slight hitch at the membranous urethra, but after manipulation the catheter passes Fig. 51. — Large median and lateral lobes. Case 122. with ease and withdraws 25 cc. residual urine, bladder capacity 450 cc. Voided urine is almost clear and contains microscopically only a few pus cells and bacilli. June 16, 1906. — Patient returns for examination. He says that the in- continence has ceased. He is able to retain urine for three or four hours, and the perineal fistula is now very small. His condition is excellent. study of Ho Cases of Perineal Prostatectomy. 421 September 18, 1906. — Ttie patient voids urine naturally, five times dur- ing the day and twice at night, about half a pint at a time, no pain, no erections. There is a pin-point perineal fistula through which a few drops of urine escape during urination. A catheter passes but detects a stricture of large caliber at the membranous urethra. There is no residual urine present. The stricture is dilated up to 35-F. with the Kollmann dilator, and the fistula partially excised and curetted. Pathological report. — The specimen, G. U. 222, consists of the three lobes of the prostate which have been removed in four pieces and weighs about 90 gm. The left lobe is a globular mass measuring 5x3.5x3 cm.; it is smooth ^ and encapsulated, and on section shows many dilated ducts and considerable stroma. The right lateral lobe is in two pieces forming a mass about as large as the left and similar in character. A piece of the lateral wall of the urethra is attached to one of the pieces. The middle lobe is a rounded mass, 4.5 x 3.5 x 3 cm. in size, fairly smooth, and on sec- tion shows more gland tissue and less stroma than the lateral lobes. No ejaculatory ducts removed. An oxalate calculus about 2 cm. in diameter with a very nodular surface was removed. Microscopic exainination. — ^The hypertrophy is a lobulated glandular one. The acini are dilated, with many areas of cystic degeneration. There is considerable endoglandular proliferation and degeneration of the epithe- lial cells. The stroma is rather dense, is mostly composed of fibrous tissue, and there is present some inflammatory infiltration. The arteries show a moderate degree of arteriosclerosis. Case 123. — Moderate enlargement of median and lateral lobes. Residimm 325 cc. Cure. Followed five months. No. 1121. A. W. F., age 57, married, admitted December 19, 1905. Complaint. — " Frequency and difficulty of urination." No history of gonorrhoea. Present illness began three years ago with hesitation and slight diffi- culty in urination. Since then there has been a gradual increase in the difficulty and frequency of urination, but he has had no pain except when the bladder becomes full. No hematuria. His general health has re- mained good. S. P. — Urination two or three times at night. Micturition difficult, slow, stream small, painless. Sexual powers normal. Rectal. — The prostate is moderately enlarged, bulging towards the rec- tum, rounded, smooth, very soft, not tender. The seminal vesicles are palpable and not indurated. Prostatic secretion contains a few pus cells, lecithin, and a few granule cells. Urinalysis. — Slightly cloudy, acid, 1012, no albumin, no sugar, pus cells, a few epithelial cells, many micrococci. Cystoscopic. — A catheter passes with ease and finds 325 cc. residual urine. The bladder capacity is large. The cystoscope shows a very small rounded, slightly elevated median lobe with very small sulci on either side. The lateral lobes are only slightly enlarged intravesically. The bladder 433 Hugh H. Young. is trabeculated and there are numerous pouches and cellules, but no defi- nite diverticula. The vesical mucosa is only slightly inflamed. With finger in rectum and cystoscope in urethra the beak is easily felt, and the median portion of the prostate shows a slight but definite enlarge- ment. Preliminary treatment. — Catheterization two or three times daily, uro- tropin, hydrotherapy. Operation, December 21, 1905. — Ether. Perineal prostatectomy by the usual technique. The lateral lobes were quite adherent to the capsule and urethra, and in removing the deeper portions it was necessary to em- ploy the sharp periosteal elevator. A portion of the median bar was re- moved in one piece with the right lateral lobe. The tractor was then removed and the finger inserted in the urethra, and showed a circular constriction of the prostatic orifice which was difficult to dilate with the finger. Examination showed very little remaining prostatic tissue in the median portion, so that it was not thought necessary to remove anything further. The wound was closed as usual with double tube drainage and light packs for the lateral cavities. The patient stood the operation well. No infusion was given. Continuous irrigation was given on return to the ward. Convalescence. — The patient reacted well. The tubes and gauze were removed on the day after the operation, and he Avas out of bed the next day. Urine came through the penis on the fourth day, interval urination was established within a week, the fistula closed on the 14th day, and he was discharged on the 22d day after the operation, voiding urine at inter- vals of four to six hours with perfect control and the perineal wound healed. May 26, 1906. —