lowers report.

Indeed, Goodfellow's are better. He reports that he has questioned every one of his patients after operation, and they all stated. that they had sexual power. But replies of patients to questions on this point must always be notoriously unreliable and little dependence can be placed on any of these reports. This whole question seems to me to be a fanciful and unimportant one. The vast majority of prostatics as they come to the surgeon at the present time, are in such a condition that they have long since lost all sexual power and appetite. And it is manifestly absurd to expect any prostatic operation to rejuvenate these old men. In the future, when the laity have been impressed with the advantages of early operation for prostatic trouble, I fancy that it will be found that the operation does not materially affect the sexual powers.

On this point Horwitz says:

"We believe that those who affirm that they can resect the prostate gland by any known method without injury to the ejaculatory ducts should be classified as well meaning but misguided enthusiasts. It is well known that the course pursued by the ejaculatory ducts in the normal prostate gland is by no means uniform; varying very considerably in different specimens. Hence no definite rule can be given to the surgeon, which will serve as a guide to prevent his injuring those organs during operation. When the gland is distorted by hypertrophy it will be observed that in most instances the position of the ducts deviates very materially from the normal position, so that it is impossible to locate them, consequently injury to these structures is bound to occur when the organ is enucleated.

"It is believed that impotence following prostatectomy is not caused by either wounding or resecting the ejaculatory ducts; but that it is due to the injury inflicted on the glandular structure of the prostate, thereby destroying its intimate relations with the entire nervous system.

"When we reflect that the prostate gland is supplied by large nerves derived from the hypogastric plexus of the sympathetic, the sacral plexus of the spinal nerves, and through the lumbosacral trunk with the lumbar plexus, the conclusion is readily reached that the organ is in intimate connection not only with the component parts of the genitalia, but through the agency of the free interchange of fibres between the sympathetic and the cerebro-spinal system of nerves, with remote parts as well. It is easy to comprehend how the severing of the connection of such an important nervous mechanism could easily result in sexual debility."

Statistics of the operators who do the perineal prostatectomy through a small median incision show by far the best results. Indeed, Goodfellow's statistics give the best results that up to the present time have been reported by anyone. He reports 78 operations with two deaths, one from sepsis and one from shock, no cases of permanent urethral fistula, no case of permanent incontinence, or loss of bladder control, and a good functional result in every case.

One of the greatest advances that has been recently made in the treatment of prostatics has been the introduction of spinal anesthesia. By this means patients very infirm, septic, and suffering with advanced renal disease, on whom ether or chloroform would be fatal, can now be successfully operated on. The method used is the one devised by Morton of San Francisco, which Goodfellow recommends, and which has been so successful in his hands. Four-tenths of a grain of dry sterile cocaine is allowed to dissolve in the spinal fluid, which has been drawn into the barrel of a Luer syringe, and then reinjected into the spinal canal. There are none of the unpleasant sequelæ which follow the injection of an aqueous solution into the canal.

Sometimes there is a slight nausea and vomiting on the table, but this is all, and the anesthesia is perfect, lasting an hour and even longer. Through spinal anesthesia perineal prostatectomy has been made a much safer procedure. and the Bottini operation has been robbed of the strongest argument in its favor, viz., that it alone could be done without a general anesthetic.

My personal experience with the surgical treatment of prostatic hypertrophy embraces five cases, which I desire to take this occasion to report.

The first case I operated on before I had become acquainted with the technic of the median perineal operation. The patient was a man 70 years of age, who had been confined to his bed for six months. His entire urinary tract was septic to the last degree. The power of voluntary micturition had been lost a year before. He suffered from constant tenesmus and bladder

hemorrhage. He had had a catheter continuously in his bladder for two months.

Prostatectomy was done by the combined method. The suprapubic method was attempted but failed, when an additional incision was made in the perineum. The patient died on the fourth day of uremia.

The four subsequent cases were all operated on by the method described by Good fellow. Their ages were respectively 74. 70, 68, and 59. All were of long standing and had septic bladders. The two oldest cases (74 and 70) were in a wretched physical condition. All recovered.

in the habit of using the ordinary antiseptics, and I find urotropin very useful, more so than boric acid or salol.

DR. MORTON: I have listened with much interest to this paper, as the doctor has discussed the matter so fully as to include all that we know about the operations and other procedures that have been in use, and has carried it up to date; and the literature he has so carefully reviewed makes it all the more interesting to us. He did not say much in regard to the diagnosis of this condition, but these cases are, as a rule, easily diagnosed, both from the history of the case as well as from the examinations.

There is one point I would like to consider for a moment, and that is as to what we are able to learn by palpation. If this is properly done, you can outline the prostate gland exactly, and upon this I always rely in making a diagnosis. I recently had a case sent me, and it was sent for operation. The patient was an old man, and had experienced trouble for ten years or so, and it was constantly growing worse and more and more troublesome. I passed my finger into the rectum and found an ordinary-sized prostate. A closer examination showed that all we had to deal with was a stricture, and although this is a very simple thing, it had been overlooked, because there was no adequate examination made of the urethra or the rectum.

As to the treatment. When the patient passes to catheter life, when the catheter becomes indispensable, that is the time to operate. There are a great number of physicians and surgeons who think that when a man reaches that state, and gets to that age, to give him a catheter and tell him to follow out certain instructions as to the minor details of cleanliness, and to use a catheter, is about all that is required. Now, I believe that it is a dangerous thing to give a man a catheter and a little knowledge, for the simple reason that he is not able to carry out the principles of asepsis; and I do not care how you try to educate him, he will soon become negligent and infection will follow; and when once established it soon travels up to the kidneys. It is in these cases that you have such a large fatality. Now, it does not matter which one of the three operations you use, but I do not think it is ever wise to allow a man to remain a slave to catheter life. In selecting any one of the three perineal incisions, I think the doctor's remarks and conclusions are very sound. I have used the Bottini method in a great number of cases, and the results in the great majority of cases were happy ones, but there have been so many cases of sepsis reported that it has fallen somewhat into doubt. I think his conclusions that the practice is being discarded, are true; but there are statistics to show that the Bottini operation is followed by very little mortality, ranging from 4 to 10 per cent, and the statistics as to prostatectomies are about the same, I believe, possibly a little less, but statistics vary, and they are often selected, and there is much disparity in the reports from different sources. The doctor perhaps reports the better ones, and you might be led to infer that the operations mentioned are very simple ones; but I want to say that none of these operations are so very simple to the patient, and if the patient you are dealing with is an old man, which is commonly the case, you will find him in a weak and debilitated condition, and with this state of adynamia, you will possibly have atheroma of the vessels, crippled kidneys, and all conditions that are associated with a lowered state of vitality in general; consequently none of these operations are to be regarded as simple procedures.

The method that I usually follow is that of Dr. Goodfellow of San Francisco, which I consider a most excellent operation, but we all practice essentially the

same thing, and the only difference between the Goodfellow operation and the Young operation is that one uses the retractor through the urethra and the other uses his finger to bring the prostate out. The operation of Zukerkandle. which Dr., Behle referred to, is practically what Murphy follows, and he also uses the cat's-paw retractor. Whichever one of these operations you employ, you will produce about the same amount of trauma to the parts, and in all of them there is bound to be considerable trauma. I do not believe there is much trouble resulting from the tearing away of the urethra; but the least amount of trauma inflicted the better. In Young's operation he opens the urethra to insert the prostate retractor to put it through, and Goodfellow opens it on a lithotomy staff, and enucleates the prostate from the urethra through the incision. There often seems to be an undue amount of cutting, which can be done away with, and in my early work in this line I pushed the prostate down and made an incision in the median line to the prostate, but not upon the urethra. After you get to the prostate all that is necessary to do is to support the septum between the prostate and the bladder and the rectum, so as not to injure the rectum, and then you can push the prostate out in good view. The only advantage in the use of the segregator I have is that it is about the size of an American No. 18 sound, and has the general appearance of an ordinary sound. which is passed into the bladder and separates. I use this to press the prostate down, and to act as a guide to the illumination of the urethra so as to avoid cutting the urethra. I have tried to enucleate the prostate so as to save the vesicles, but I do not know that I have accomplished much in this direction, and I believe it is quite immaterial whether you protect them or not. The essential thing to remember is to produce as little trauma as possible, and it is by using these instruments that I am able to preserve the urethra.

Sometimes there are very severe complications. I have found severe hemorrhage occasionally, and for that reason I have always packed the region of the prostate thoroughly, by rolling up a piece of gauze and placing it in position. At first I tried the catheter and drain, but I found very serious inconvenience, and there is danger of fistula in it; but now I leave a drain for 24 hours, and then remove it. Then I give as much water as the patient desires to drink, and get him out of bed as soon as possible.

Out of all the cases I have operated upon, I remember one case of fistula that lasted about twelve months. I finally determined that this was due to a very small piece of gauze, and as soon as that was removed he made a complete and prompt recovery. In another case I recall there was inability on the part of the bladder to retain the urine. There was a constant dribbling, which lasted many months. He was obliged to use a rubber urinal to hold the urine. I believe this was a result of injuring the muscular tissue around the neck of the bladder. If too much force is made with the finger in tearing out the prostate, it is more likely to occur. If you are dealing with a very large prostate and the muscles around the neck of the bladder, and there is more or less intimate union, this may occur. With the exception of two, all my cases have made good recovery. One that died resulted fom embolism and the other from uremia.

In regard to the preference in the way of an anesthetic, I have always used cocaine by medullary narcosis, as the doctor described in his paper, and I believe that this is the ideal method, especially when the operation is to be performed on old people, and it is particularly adapted to prostatic work in general.

DR. E. O. JONES: I have very little to say in conclusion. In regard to what Dr. Viko had to say in

the way of objections raised to the median perineal operation and the unnecessary degree of traumatism that results, as I said, that objection is very material. The amount of injury done by the finger does not show up in final results.

In regard to the larger incisions that Dr. Behle spoke about, I must say that my own experience and observation of other operations in which this was done, has very much prejudiced me against it. I do not like the results. I made no mention of various other operations as I considered them only slightly different from the ones mentioned, and so did not think it worth while to enumerate them. The transverse inci

sion is perhaps 2,000 years old, and is in no way original.

I am glad that this paper has been the means of bringing the views of Dr. Morton before this association, and I feel that this is ample recompense for its preparation. I personally feel that I have been very much instructed by listening to his discussion of it, especially as regards the diagnosis. I did not enter this field, for it was not contemplated in the title of the article; however, I should have said that I rely mainly on the rectal examination in making a diagnosis. Furthermore, I nnd that the use of the cystoscope in these cases is a bad practice.

Cysts of the mesentery are comparatively rare as I should infer from my inability to find but little literature on the subject in books at my command. Much, however, is written on tubercular peritonitis; in fact the symptoms are very much the same, and the condition is identical save its localization. Huntington Richards, in the "Reference Hand-Book," under the head of abdominal tumors, includes cysts of the mesentery, but says that they are so rare that they need no consideration, and, in fact, are seldom diagnosed except by the aid of an exploratory laparotomy. Warren and Gould say: "Cysts of the mesentery are of rare occurence, but nearly one hundred cases have been reported. They are generally movable, and on this account are apt to be diagnosed as ovarian cysts." Osler says that a striking peculiarity of tuberculous peritonitis is the frequency with which either the condition simulates or is associated with tumor, and that the effusion may be limited and confined by adhesions between the coils of the intestines, the parietal peritoneum, the mesentery, and the abdominal or pelvic organs. Under the head of cysts of the mesentery, he says that they occur at any portion of the mesentery, and range from a few inches in diameter to large masses occupying the whole abdomen, and that the diagnosis is extremely uncertain, and no sign is in any way distinctive.

An extensive and valuable article on "Surgical Tuberculosis of the Abdominal Cavity" by W. J. Mayo, appeared in one of the April numbers of the Journal of the A. M. A. He says that "Tuberculous peritonitis has its origin in a local focus in practically every case, the Fallopian tubes and

*Read before the Southwestern Minnesota Medical Society, June 27, 1903.

the appendix being more often the seat of the disease."

CASE

The case I wish to report occurred in the fiveyear-old son of J. J, Martin Township, Rock County, Minn. No tubercular history could be elicited from his father. He claimed that at the age of three months he noticed that the child's abdomen was larger than that of any of the other six children in the family. The growth was slow, and until a few months before I saw the child no attention had been paid to it. The child becoming fretful, they took him to Dr. Froshaug, of Hills, who immediately sent for me to see the case. This was on October 11, 1904. He presented a picture I shall never forget; pale, emaciated, weak, tottering as he walked, whining almost constantly, a rapid, shallow respiration. and a frequent desire to defecate, accompanied with the passage of small mucous stools. His abdomen was greatly distended, and his appearance not unlike that of an old, emaciated woman with a neglected ovarian tumor. How such a case could have been allowed to go on to such an extreme and unpromising condition, I am unable to comprehend. Operation was advised, and the child was immediately brought to Luverne. He was placed on the operating-table in a sitting posture, and ether was administered while in that position, as he was unable to lie down owing to the great dyspnea produced by the pressure on the diaphragm. As soon as he lost consciousness he was placed in the recumbent position, and an incision made in the median line between the umbilicus and the pubes. The incision was a perpendicular one. as the abdominal wall extended in a vertical line from the pubes.

I must admit that I thought I was dealing with a case of tubercuiar peritonitis, and expected to see the fluid gush out as soon as the peritoneum was opened, but this did not occur. A shiny cyst appeared, which I surrounded with gauze, grasped the sack with forceps, punctured, and let out two gallons of dark straw-colored fluid. Large veins coursed over the exterior surface of the cyst, while the interior was completely studded with the characteristic rice bodies.

After drawing the greater part of the cyst out of the abdominal cavity, its connection with the mesentry was easily discerned; and the question then confronted me as to what disposition should be made of the cyst. There was no small pedicle to ligate, but a broad flat sack, with rice bodies.

at what might be termed its base, many of which would necessarily be left behind. Again, to ligate might mean the cutting off of the blood supply to the intestine, and consequent death of that part. I proceeded therefore as follows: the cyst was evenly drawn out and stitched to the peritoneum with catgut sutures, using sufficient force in tying to stop all hemorrhage. The sack was excised half an inch from the abdominal wall, and the inside was then packed with iodoform gauze, and a large dressing applied.

The outcome of this case was all that could be desired. The child began immediately to gain in flesh and strength and is today the picture of health.

ST. BARNABAS HOSPITAL

MINNEAPOLIS

PATIENT'S CONDITION.-The rectum opened into the vagina just inside the vulva. The opening was very small, adraitting only a No. 16 F. urethral sound, and could not be seen unless feces were being forced out. The edges of the

ANUS (ATRESIA ANI)

IN THE SERVICE OF DR. W. E. ROCHFORD

Elsie H, one year old. Entered the hospital September 8th, and was discharged October 2nd.

FAMILY HISTORY.-Father, 50 years old; mother 26, Scandinavian. Mother had two children by a former husband, one still-born, the other now three and a half years old. Both

tough inelastic tissue. The mother gave the child castor oil every day to keep bowel movements soft. Sometimes the bowels moved eight and ten times during the day, but always caused the child to cry with pain, and most frequently to double up and turn blue in the face and sometimes to go into spasms, the whole body being in a tremor. The baby was artifically fed. The general nutrition of child appeared fairly good.

At the time of operation, when I first saw the child, a slight, non-pigmented depression (not