deaths directly attributable to the operation itself, show it to be essentially benign and warrant its wider employment. All four of the fatal cases reacted well from the operation, and no death occurred under fourteen days. They were due to uremia, pulmonary embolism, double pyohydronephrosis, and double pneumonia respectively.

2. Restoration of voluntary micturition with absence of residual urine in almost all cases.

3. Continence of urine in all but one case, in which some diurnal incontinence still remains.

4. Preservation of sexual powers in a large proportion of cases as against almost constant loss of potency reported by those who make no attempt at conservation of the ejaculatory ducts.

5. Healing of fistula within two weeks in most cases. Persistent fistula in only two cases, one of which is carcinomatous.

6. No case of recto-urethral fistula since the suture of the levator ani has been practiced.

Dr. Young has used spinal cocainization in at least ten cases successfully, and calls attention to the fact that complete anesthesia for the perineal operation can be obtained in that way. This is not true of the suprapubic route. It should be noted also that spinal cocainization as practiced by him seems so far to be free from dangers of its own.

Tinker advocates perineal prostatectomy under local anesthesia as being far safer than under spinal cocainization. He employs a weak solution of B-eucaine with the addition of adrenalin chloride.

There is much truth and a wholesome suggestion in Squier's remark: "The choice of anesthetics is of but small moment compared with the choice of the anesthetist."

It is an open question whether the cystoscope should be used in the preliminary treatment. It is impossible in some cases, very unsatisfactory in others, and an added source of danger in still others.

In suitable selected cases its use may be of the greatest value. Journal of the American Medical Association, Feb. 11, 1905, p. 471.

It is our opinion that it should be restricted to cases evidently suitable, or in which suspected calculus or other condition renders it advisable.

It has been shown that good results can be obtained by a number of methods, much depending upon the skill of the operator. We must not therefore conclude that the choice of a method is a matter of indifference, a question of chance or prejudice.* The operation is one to be undertaken seriously, and should never be attempted by those without special surgical training. It must inevitably, however, in the future be done by the general surgeon in the majority of cases, and can no longer be limited to those who have cultivated special skill and dexterity in its performance. It becomes necessary, therefore, to select that operation which, in any given case, presents the least difficulty, entails the least danger to life, and offers the most in promptness and certainty of cure as measured by a return to relatively normal condition.

Conservative perineal prostatectomy undoubtedly fulfils these conditions more closely than any other operation in the majority of cases, since it offers (1) a lower mortality; (2) a shorter period in bed; (3) more complete approach to normal functions; (4) greater certainty of virility.

The technique of Young is unquestionably the best offered us thus far.

On the other hand, suprapubic prostatectomy should be the operation of choice in a minority of cases in which the prostatic hypertrophy shows itself in a large, pedunculated, intravesical middle lobe, or in which this condition coexists with stone, as shown by the cystoscope.

The Bottini is still applicable to cases which decline operation or cannot stand general anesthesia, but its field of usefulness is deservedly small.

It has been my hope in presenting this subject for discussion to-day to make it clear to you all that the surgery of hypertrophied prostate has reached a point of development where it is no longer sub judice; that it is our duty to lay before every

*Pitcher: Annals of Surgery, April, 1905, p. 565.

patient suffering from this cause the possibility of relief at the hands of the surgeon, and to impress upon him unceasingly the fact that in early operation, as soon as the condition has unmis takably declared itself and while the general health is still unimpaired, is to be found the surest road to health and happiness, and an escape from that nightmare, often worse than death itself -the catheter life.

Editorial.

ANNUAL COMMENCEMENT OF THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE SOUTH.

THE thirteenth annual commencement of the Medical Department of the University of the South (Sewanee Medical College) was held in St. Augustine's Chapel at Sewanee, Tenn., on Wednesday, Oct. 24, 1906, beginning at 9 A. M., a large audience filling the auditorium, the Faculty of the College and the vested choir occupying the chancel.

After devotional exercises under charge of Rev. Alex. Guerry, Chaplain of the University, and the hymn “America” by the choir, Prof. J. S. Cain, M. D., Dean of the Medical Department, made a short address, and certificates in the special schools and diplomas to the graduate nurses and the pharmacal students were conferred.

The charge to the graduates in medicine was then delivered by Prof. Deering J. Roberts, M. D., of Nashville, which will be found in the "Original Communications" of this number, and the graduates having been presented to the Vice-Chancellor by the Dean in an address in Latin. the degree of Doctoris Medicine was then conferred on the graduates by Vice-Chancellor B. L. Wiggins in the same language.

The honor medal was then presented to Dr. J. Lee Kirby-Smith by the Dean, who stated that Dr. O. N. Mayo was a close contestant, his grading being only two less, which was a higher grading than any previous recipient of this award of merit had attained.

The valedictory address on behalf of the class was then delivered by Dr. G. C. Kanelly, of Egypt, who acquitted himself in a most satisfactory, graceful, and eloquent manner.

Announcement of the next session then being made by the Dean, and the singing of “Onward, Christian Soldiers," by the choir, the benediction was pronounced by the chaplain, and the very pleasant exercises were closed.

The following is a list of the graduates: J. M. Atkins, Ala.; G. L. Austin, Ga.; J. C. Battle, Ga.; J. S. Beaty, N. C.; M. L. Bryant, Ky.; L. A. Caboche, La.; J. S. Carter, Texas; W. G. Casey, Ala.; Herbert Col

lins, Ala.; Elijah Curlee, Ala.; J. W. Darby, La.; L. W. Dart, Pa.; H. M. Divvens, Pa.; T. L. Driscoll, Va.; T. D. Fletcher, Ga.; J. Goldstein, Pa.; E. W. Hoylman, W. Va.; J. D. Jackson, Pa.; J. D. Jungmann, Pa.; W. R. Kelly, Miss.; G. C. Kanelly, Egypt; J. L. Kirby-Smith, Tenn.; T. F. Mack, N. Y.; Irby B. May, La.; S. J. Mayeaux, La.; O. N. Mayo, Texas; T. H. Nelson, Ga.; B. B. Owens, Ind. Ter.; G. A. Ozanne, La.; L. H. Paul, Fla.; J. K. Phares, La.; J. D. Phillips, Ky.; C. R. Reaves, Tenn.; T. E. Reeves, Ala.; C. A. Rogers, Tenn.; G. D. Walker, Pa.; T. B. Wilson, La.; W. C. Richardson, Tenn.

Graduate Nurses: Miss Bessie Octavia Brougher, Miss.; Miss Nellie Bell Martin, Ark.

PROSTATIC ENLARGEMENT.

UNTIL quite recent years this has been regarded as one of the opprobria of the "healing art;" and many earnest practitioners of medicine and surgery have been greatly annoyed at their inability to afford relief to elderly members of their clientele. Our "Selected Article" this month is a very able and comprehensive presentation by Dr. W. L. Munro of Providence, R. I., of the advances and progress, together with the methods and successes attained along this special line. From the St. Louis Medical Review of Oct. 11, ult., we quote the following from its report of the late meeting of the British Medical Association at Toronto, bearing on this subject:

"A discussion on Enlarged Prostate' was opened with a paper by Mr. J. Lynn Thomas, C. B., of Cardiff, who exhibited his instrument for raising the prostate to make a suprapubic operation possible. Short fing ered surgeons should not attempt the suprapubic route. Enucleation should not be practiced with a contracted urethral orifice or a fibrous prostate. If a suprarenal operation was done he advised a perineal incision for drainage. Dr. Robert F. Weir, of New York, pointed out that the earlier attempts at surgery of the prostate had been made only as a dernier ressort, with a correspondingly high mortality. Even now the mortality varied between nine and fourteen per cent. Dr. G. A. Bingham, of Toronto, read an exhaustive paper in which he said that the microscopical structure showed the prostate to lack a true capsule and definite lobes. It was embryologically purely sexual in origin. In the modern operation enucleation was always performed, through the outer part of the gland, and a portion was always left behind so that it was not a 'total' prostatectomy. He strongly favored the Bottini operation in cases too advanced for enucleation; in very early cases with obstruction as the only symptom, and in intermediate cases, enucleation was the proper treatWhen the middle lobe was alone affected, (which according to Mr. Lynn Thomas was most frequently the case) the suprapubic operation was

ment.

preferable; in other cases the perineal route. Septic cystitis called for treatment before enucleation according to both Thomas and Bingham.

"Dr. Arthur T. Cabot of Boston preferred the perineal route, and insisted that where uremic signs were present catheter drainage through the urethra until the tongue cleaned and the patient was in fit condition, should be practiced. Dr. Teskey, of Toronto, favored the perineal operation, as did also Dr. W. J. Mayo and Dr. Ochsner. The suprapubic route was preferred by Dr. E. F. King, of Toronto; Sir William Hingston, of Montreal; Dr. W. Alexander, of Liverpool; Dr. H. A. Bruce, of Toronto; Dr. D. J. Williams, of Dannelly, Wales; and Dr. Francis J. Shepherd, of Montreal. Sir Hector Cameron related a case of a man forty-six years of age on whom he had operated sixteen years ago, before there was any surgical literature on the subject. There was absolute retention, severe hemorrhage, and enormous distension of the bladder. Fetid gas followed the use of the knife, and thirteen stones, five of large size, were found, though the man had been sounded for stones without result. The patient was in perfect health sixteen years after the operation.

"Dr. Mayo gave greater rapidity of healing as one of his reasons for preferring the perineal route, fistula being a common complication with the suprapubic. The mortality, however, was the same. There was a large not less than fifteen per cent.- of malignancies.

percentage

"Dr. Ochsner exposed the prostate completely by a horseshoe incision. Sharp retractors drawing the prostate downward brought the field under control. The urethral venous plexus must be borne in mind. Ferguson's forceps were of use."

THE SOUTHERN MEDICAL ASSOCIATION.

AT the recent meeting of the Tri-State Medical Association of Alabama, Georgia, and Tennessee, held at Chattanooga, Oct. 3-5, ult., delegates who had been appointed by the presidents of the State Associations of Alabama, Georgia, Florida, Louisiana, Mississippi, and Tennessee, organized the above named association, which will be the Southern Branch or District Association of the American Medical Association.

A constitution and by-laws were adopted in accordance with the regulations of the National and State Associations. The officers elected were as follows: President, Dr. H. H. Martin, of Savannah, Ga.; Vice-Presidents. Dr. Mack Rogers, of Birmingham, Ala., J. B. Cowan, of Tullahoma, Tenn., and Dr. J. R. Tackert, of Meridian, Miss.; Secretary, Dr. Raymond Wallace, of Chattanooga, Tenn.; Treasurer, Dr. Y. L. Abernathy, of Chattanooga, Tenn. The Association will hold annual meetings on the first Tuesday in October, lasting three days. It is to be expected and hoped that the state of Kentucky and the Carolinas will be added. The Tri-State Medical Association, of Alabama, Georgia, and Tennessee, after a very successful existence of eighteen years passes out of existence, the new