Journal of Medicine and Surgery

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TORONTO, JANUARY, 1905.

Editorials.

THE INDICATIONS AND THERAPEUTIC VALUE OF

PROSTATECTOMY.

THE indications and therapeutic value of the principal operations practised for the relief of prostatic enlargement was the subject of a masterly report, presented by Dr. R. Proust, at the eighth Congress of the French Association of Urology, held at Paris, Oct. 2022, 1904. The reporter, who is a master surgeon in prostatectomy, showed that ablations of the prostate are performed by two

routes, the suprapubic and the perineal. Partial prostatectomies are, and ought to be, abandoned.

Removal of the entire prostate by the perineal route shows a mortality of 7.13 per cent,, which places this operation in the position of one of the most favorable in the surgery of the urinary

organs.

Its special post-operative complications are: lesions of the rectum (recto-urethral fistula), urinary complications (uroperineal fistulæ, incontinence of urine), lesions of the genital organs (orchitis, impotency).

The best results are obtained in complete chronic retention of urine. Patients who had been unable to urinate for years, pass their urine easily and spontaneously. In recent complete retention, the results obtained are quite as good, but not so striking.

In incomplete chronic retention, the results are not so good, and sometimes are negative. The therapeutic feature of prostatectomy in those cases is explained by the bad state of the bladder and the condition of the lesions arising from their long standing. When calculi are present, their removal is easy during a prostatectomy, and the latter operation makes a relapse unlikely. Prostatectomy exercises a happy influence on micturition and the state of the kidneys; the patients progressively get rid of their toxic condition, and their general condition of health is completely changed.

Suprapubic prostatectomy, or Freyer's operation, may be done in two ways: in one there is a total enucleation of the prostate, with a portion of the prostatic urethra (Fenwick's); in the other (Freyer's) there is a partial or paraurethral enucleation of the prostate, the prostatic urethra not being removed The latter operation is to be chosen when possible. From a statistic of 244 operations by the suprapubic method, the mortality is found to be 12 per cent., which is, of course, much higher than that from perineal prostatectomy. In looking for the causes of death traceable to this operation, Dr. Proust finds accidents manifestly due to infection; on the other hand, post-operative complications are much less frequent than in perineal prostatectomy. The therapeutic results seem to show that suprapubie prostatectomy is equally efficacious with, if not superior to, perineal prostatectomy.

In the first part of his report, Dr. Proust showed

the results of prostatectomy as applied to the treatment of the hypertrophied prostate gland; in the second part he showed the results obtained in the treatment of malignant tumors of the prostate (cancers and sarcomas). The results in the latter, though bad, are not quite desperate, for the mortality from the operation in such cases, which at first was 55 per cent., has fallen to 30.4 per cent. (Pousson.)

The chief indication for prostatectomy is hypertrophy of the prostate gland. It is during the second period of prostatism, when congestive disorders have been succeeded by mechanical difficulties and retention has occurred, that prostatectomy should be done. In fact, retention of urine is a sufficient indication for prostatectomy, but not a necessary one. The patient ought to have a choice between "catheter life," with which he is threatened, and the operation, which can free him from such a condition. But the indication may become more pressing, owing to the difficulties of catheterism in complete retention, and the increase of the residue in incomplete retention, and prove necessary, owing to the presence of toxemia and progressive infection. Another element which should be remembered in establishing the operative indications is the size of the prostate and the extent to which its shape is altered.

With regard to the choice of route in prostatectomy, Dr. Proust simply says that "If the perineal method is better regulated, has more cases to its credit, and has a lower mortality than the suprapubic one, we must look to the future to learn which is the better of the two operations."

In the matter of malignant growths of the prostate, the fact that their mortality has been lowered by 25 per cent. by prostatectomy should give encouragement in the future, even if the survival in such cases should be small, owing to the fact that the methods by which an early diagnosis is secured still remain imperfect.

The paper was discussed by Drs. Desnos, Heresco, Reboul, Harmonic, Veerhogen, Pauchet, Paul Delert, Rafin, Malherbe, Loumeau, Brin, Reynés, Leguen and Albarran, who mentioned the results of their prostatectomies, and, in a general way, confirmed Dr. Proust's conclusions. Dr. Nicolich (Trieste), however, declared himself a supporter of the suprapubic method,

because that operation is done "more easily, more quickly, and is less dangerous."

The statistics of prostatectomy, given by American surgeons, are still more favorable than Dr. Proust's.

In a paper published in the Journal of the American Medical Association, November 12th, 1904, Dr. Eugene Fuller, of New York, says: "My experience to date with prostatectomy is somewhat over three hundred cases. I feel that, if cases complicated with very marked uremia are excluded, I can operate with an average risk to the patient of not more than probably under 5 per cent. Death from the operation itself is. practically nil." Dr. Fuller selects the route most suitable for the case in hand.

Dr. Parker Syms, of New York, who is opposed to the suprapubic route in prostatectomy, said, in the discussion which followed the reading of Dr. Fuller's paper: "There are 78 cases of prostatectomy reported by Goodfellow, 58 by Young, and 33 by myself, being a total of 169 cases, with only 4 deaths. This certainly speaks well for perineal prostatectomy, showing a mortality of only 2.33 per cent."

The statistics given by Fuller and Syms speak well for the American surgeon, the American patient and the American nurse. It is about time for Canadian surgeons to begin to publish their statistics of prostatectomy.

J. J. C.

SOMETHING ABOUT THE ETIOLOGY OF BERI-BERI.

ISOLATED facts fall into groups and may be crystallized into general conclusions.

From a study of the summer and winter outfit of the Japanese infantry soldier (Brit. Med. Journal, November 12th, 1904) it appears that the greatest care and ingenuity are exercised by the military authorities of Japan to secure the health and comfort of the men serving in Manchuria, which is in summer very hot and in winter very cold.

Further, at the International Congress of Military Surgeons, held at St. Louis, October, 1904, Major Seaman, U. S. Army, declared that the medical forces of the Japanese army, in addition to the care of the sick and wounded, have to granole with the greater problem of preventing disease by the careful super

vision of the details of subsistence, clothing and shelter. The medical officer was to be found in the front of the army and in the rear. He tested and labelled wells, so that the army which followed would drink no contaminated water; he examined the sanitary conditions of a town, and, if cases of contagious or infectious diseases were discovered, he placed a cordon around the quarter where they were found. A medical officer accompanied foraging parties, and, with the commissariat officers, sampled the various foods, fruits and vegetables sold by the natives before the arrival of the army.

The medical officer also taught the men how to cook, bathe and live in general a healthy life, and it was a part of the soldier's routine to carry out these instructions in every particular. As a result of this system, cases of fevers and dysentery that follow the use of improper food and polluted water were not brought to the notice of the medical officer. During six months of war in a foreign country the Japanese army lost only a fraction of one per cent. from preventable disease. Major Seaman stated that up to August 1st, 1904, 9,802 patients had been received at the hospital at Hiroshima, of whom 6,636 were wounded, and that of the entire number only 34 had died.

So far so good. Another bit of evidence is not so satisfactory. Richard Harding Davis, Collier's special war correspondent with the Japanese Second Army, writes as follows, in Collier's, November 5th, 1904: "The next morning, as the camp woke, a company of soldiers came towards us on foot. That they were going to the base, instead of to the front; that they were without arms would have made them conspicuous; but, added to this, the gray light gave to them a touch of the weird and uncanny. They were not wounded, at least they wore no bandages; apparently they were not ill, for they were able to walk. But, as they passed us, we saw that they moved only with infinite effort, that their glazed eyes were unseeing. Thy neither joked nor spoke. Before they had passed we knew that all of these were the latest victims of that scourge of the Japanese army, the beri-beri, or the sleeping sickness. In the morning mists, as the long, sad column moved in utter silence, it resembled a procession of ghosts."

The name beri-beri" is that given by the Malabars to this disease. Beri is the Singalese for weakness, and by iteration.