ary symptoms for six years. Two years previously he had had great difficulty in urinating, and later complete retention. He had experienced a number of uremic attacks, and once lost consciousness and was not expected to live. At the time of consultation he was using the catheter three times, and voiding urine eleven or twelve times in twenty-four hours. He had suffered with six attacks of orchitis, both testicles being affected, and there had been several severe hemorrhages from the urethra. He had eight or ten ounces of residual urine. There was moderate enlarge. ment of both lateral lobes, and the cystoscope showed large intra-vesical middle lobe, with beginning sacculation of the bladder. prostatectomy was done through a median incision (2, Fig. A). Convalescence was prompt and steady. The record shows the patient's ability to completely empty his bladder and to retain urine. He is now living and enjoying health and strength, free from urinary troubles and passing water as well as when a boy, as he expresses it. His health has been re established for nearly five years. The transition from chronic urinary retention and impending uremic attacks to his existing condition has been striking, to say the least. CASE 3.-Complete retention; supra pubic lithotomy; Bottini operation, failure; perineal prostatectomy; rectal fistula; plastic operation; recovery. cision (1, Fig. A), and the bladder-neck dilated. Patient sat up in ten days, and was able to empty his bladder in a short time thereafter, urinating only four times in twenty-four hours. For some months afterwards he found it necessary to urinate promptly when the desire was felt, because of a little insecurity in the retentive power of the sphincters, but later this was regained. general health has been excellent. Sexual desire, he says, is lessened; but when it is considered that his age is now seventy-three, this is not unexpected. cure His CASE 5.-Obstruction and complete retention, following attempt at Perineal by electricity (an "electric cure"); dangerous septic infection; perineal prostatectomy; recovery. Henry H., forty-nine years, Nashville, Ill.; referred by Dr. Goodner, of Nashville, Ill., April 29, 1903. Úrinary obstruction for one year, gradually increasing. Patient had eighteen and onehalf ounces of residual urine. He was advised to undergo operation, which he deferred, choosing to consult some advertising physicians who used electricity on him. There was rapid increase of symptoms, infection and fever, so that when called into consultation by Drs. Little, of East St. Louis, the patient was found in a deplorable condition. He was treated with retained catheter for a week. On May 25, through an inverted Y incision, perineal prostatectomy was done, after forcible dilatation of a contracted vesical neck. A soft rubber catheter was left in position; recovery was prompt. The chills and fever did not return, and the patient's ability to empty his bladder returned completely. In one month he was able to return to his farm work, which he has continued since. Captain O. G. H., Missouri, aged sixty-six years; referred by Dr. Safford, September, 1902. Urinary symptoms for three years. Retention had been sudden. After straining all night, he had been catheterized, and had continued the use of the catheter after that time. No voluntary urination for one year previous to operation. The passage of the catheter had been painful and frequently followed by swelled testicles, so that he had used hypodermics of morphine of from one to two grains daily. He had mitral regurgitation and intermittent pulse, and his urine was loaded with albumin and pus. The prostate felt large and globular per rectum. Palliative treatment did no good, so on September 13, 1902, suprapubic cystotomy was done and two stones removed, weighing 70 and 400 grains respectively. When his general condition had been improved by continued drainage of the bladder, a Bottini incision was made, without improving his ability to urinate. On November 3 perineal prostatectomy was done, in the course of which a retractor was pressed through the rectal wall, causing a subsequent urethro-rectal fistula. This was later repaired by the operation of Ziembieki, after which the patient made an excellent recovery. He has since been able to void urine in a full stream and to empty his bladder completely. CASE 4.-Complete retention of long duration; perineal prostatectomy; recovery. A. E.W., Salisbury, Mo., aged sixty-nine years, referred by Dr. Geiger, in May, 1902. Urinary symptoms for twenty years. Catheter life for six years; complete retention, using catheter four times daily and once at night. Prostate considerably enlarged to rectal palpation. Cystoscope showed intra-vesical enlargement of right side, sacculation and moderate inflammation of the bladder wall.. May 16, 1902, perineal prostatectomy was done through a median in CASE 6.-Septic retention in a corpulent individual; perineal prostatectomy; relief. J. B. C., of Mississippi, aged sixty nine years, referred by Dr. Pinkney French, May 5, 1903. Weight, 230 pounds, but he had lost fourteen pounds in the previous few months. Complained of obstructive symptoms of six years' standing. Four to six ounces of residual urine, regular catheterization necessary six weeks before coming to St. Louis. Moderate hypertrophy felt per rectum, especially marked on left side. He had been having repeated chills and fever. Perineal prostatectomy was done in May, 1903. covery was rapid, and he was soon able to urinate easily and empty his bladder completely. He has since carried on his farm duties, and reports yearly that he keeps well. Re CASE 7-Obstruction causing pyelitis; perineal prostatectomy; recovery. J. W. D., of Mississippi, aged fifty-seven; referred by Dr. French, July 3, 1903. This patient, a close friend of the one last mentioned, came with him and underwent the same operation at the same time. While twelve years younger in actual age, he appeared as much older, because of the debility produced by the extension of infection into the renal pelves. Symptoms of obstruction of four years' standing He had suffered from chills and fever, had lost much flesh, and was extremely depressed. There were seven ounces of residual urine, quite cloudy, and infected with colon bacilli. Left side of the prostate was only moderately enlarged per rec tum. Enucleation was done through the invertedY perineal incision. He was very nervous and over-anxious about himself, but made a rapid recovery, emptying his bladder voluntarily in two weeks. Both patients went home completely recovered, and report from time to time that they are able to carry on their respective occupations. CASE 8.-Complete retention; perineal prostatectomy; recovery. J. A. M., Missouri, aged fifty-six years; referred by Dr. Robert Haire, June, 1903. Urinary symptoms of sixteen years' standing (that is, since his fortieth year of age). Five years before operation he had begun to use the catheter, and had kept it up ever since. For two weeks previous to his arrival he had complete retention, relieved only by catheter. Perineal prostatectomy was done through the inverted-Y incision. Convalescence was not as prompt as in other cases, because of some re-contraction of the structures at the vesical neck, requiring several dilatations of the deep urethra. The perineal wound was closed within a month, and the patient was urinating freely when he went home. He said afterwards that he believed the operation had lessened his sexual vitality, although it gave him the ability to urinate and empty his bladder completely. CASE 9-Prostatic obstruction; perineal prostatectomy; recovery. Alois W., Keokuk, Iowa, aged sixty-nine. For five years he had had some urinary obstruction, the symptoms of which were prominent and followed the usual course of severe straining, etc. October 24, 1903, perineal prostatectomy was done through the inverted Y incision. The prostate was large and friable, and was removed in several pieces. The bladder was very little disturbed by the operation, as the early urine drained was clear. The patient made an uneventful recovery, and has since been able to void urine freely and to empty his bladder completely. CASE 10.-Complete retention; perineal prostatectomy; complete and prompt recovery. Dr. Alex. M., St. Louis, aged sixty-nine years, came September 4, 1903. Although obstructive symptoms had existed but one month, the retention of urine was complete, requiring the use of the catheter to evacuate the bladder. Perineal prostatectomy was done, the wound being partly closed with sutures, leaving a large rubber drainage tube in the bladder. The patient suffered no shock and was perfectly comfortable within an hour after it. There was complete and prompt recovery from all symptoms, and he was practically a well man within three weeks, returning to his employment in the City Health Department in a month after the time of operation. CASE 11.-Catheter life; perineal prostatectomy; complete recovery. E. B., Hot Springs, Ark., aged sixty-five years; referred by Dr. S. P. Collings. Had symptoms of obstruction for eight years, gradually increasing up to the time of his arrival in St. Louis, September 7, 1903. There had been partial incontinence from overflow for four years. He was making use of the catheter about six times in twenty four hours. Rectal examination revealed only moderate amount of prostatic enlargement, not enough, apparently, to account for the large amount of obstruction present. This was found to be very deceptive during the operation, the finger then determining that there was marked bulging together of the lateral lobes, compressing the urethra into a narrow slit. The perineal enucleation was done through the inverted-Y incision. The floor of the urethra was broken, but the roof remained intact. Recovery was uneventful and prompt. The patient has reported at times since that he has been able to empty his bladder with the ease of childhood and has suffered no inconvenience from the operation. CASE 12.-Prostatic hypertrophy and vesical calculus; patient in extremis; perineal lithotomy and prostatectomy; death from uremia. Lewis P., of Missouri, aged sixty-eight years, referred by Drs. Geiger, of St. Joseph, and Boehm, of St. Louis. The patient had suffered from urinary obstruction and inflammation for two years; he was semi-comatose from uremia when he was brought to St. Louis. He had passed bloody urine a number of times, and suffered much pain in the left renal region; had had chills, and fever of 104°. Through an inverted-Y incision, October 31, 1903, the neck of the bladder was found firmly contracted, and was dilated with the uterine dilator; a vesical stone, biscuit. shaped, the size of a silver half dollar, was removed, together with the median lobe of the prostate. Double tube and continuous-stream drainage. The patient seemed to improve for the first five days, but did not recover from his uremic condition; suppression of urine occurred with rise of temperature to 104°; convulsions and death ensued. No post-mortem examination was permitted. CASE 13.-Obstructive hypertrophy (intravesical); perineal prostatectomy; recovery. S. T. W., Arkansas, aged fifty-five years, referred by Dr. C. Travis Drennen, of Hot Springs. The patient first complained of slowness of the stream and difficulty in starting it, about three or four years before the first consultation, March, 1904. At times he could not start the urine for many minutes. By rectal palpation the prostate did not seem enlarged at all, but by aid of the retrograde cystoscope, a large posterior median lobe was seen projecting into the bladder. Perineal prostatectomy was performed on May 18, 1904, through the inverted-Y incision. The patient was a very nervous subject and was unable to bear even slight pain. His recovery was complicated by right epididymitis and lobar pneumonia. He recovered completely, however, and was able to urinate in a full, strong stream, and has since been attending to his duties incident to merchandising. CASE 14.-Complete prostatic retention; marked general debility; perineal prostatectomy; re corery. Julius G., Missouri, aged sixty eight years; referred by his nephew, Dr. Wichmann, of St. Louis, April, 1904. The patient had then had prostatic obstructive symptoms for five years, and had been using a catheter for half that time. For the previous year he had seldom been able to pass any urine voluntarily, relying on the catheter altogether. The patient was very tall, meager, feeble and cadaverous-looking, with snow-white hair and beard. There were eight ounces of residual urine. Rectal palpation showed no enlargment of the prostate, but the retrograde cystoscope showed marked intra-vesical enlargement posteriorly, laterally and anteriorly, excepting a narrow groove where the lateral lobes met anteriorly. Perineal prostatectomy was performed, followed by return flow doubletube drainage. While the patient had serious misgivings as to the outcome, he made an uninterrupted recovery, and has since been able to hold his urine three or four hours at a time, and to empty his bladder completely. ments. CASE 15.-Prostatic obstruction; extreme emaciation; perineal prostatectomy; rectal fistula; partiel relief; death after one and a half years. Adam N., Missouri, aged sixty-three years. First consultation, May, 1904. The patient had had urinary trouble for ten years-serious for three years. He was very debilitated and emaciated on his arrival; this fact is noted as having an important bearing on subsequent develop. He complained of a sluggish and interrupted stream, and had four ounces of residual urine. The retrograde cystoscope showed marked intra vesical enlargement of the lateral lobes. Perineal prostatectomy, with continuous stream drainage afterwards. He stood the operation well and suffered no shock. The usual examination of the rectum at the end of the operation showed it to be intact at that time. Two days later part of the gauze packing of the wound was removed, and on the third day the balance, at which time it was noticed that there was a small opening in the anterior rectal wall connecting with the wound. This perforation must have resulted from the breaking down of the tissues as a result of their lack of vitality-in sympathy with his general debility. It had taken three days to develop after the operation. It is possible that the gauze packing had some influence, but it was not thought to have been unusually tight. The patient was relieved of his urinary obstruction, but the fistula gave him much trouble, some urine leaking into the rectum when he passed it, for most of the time, and rectal gases appearing in the wound. Several efforts were made to repair the leak by direct closure of the fistula, but they only succeeded in narrowing its calibre. The patient declined to have a more radical operation (that of Ziembiecki) done. His general ill-health, from digestive disturbances, influenced his decision in this respect, and also impelled him to go home before he should have done so. At any rate, his was an unsatisfactory outcome, influenced mainly by accompanying unfortunate but unavoidable conditions. He lived for a year and a half afterwards, not suffering from urinary obstruction, but failing to regain strength and a martyr to digestive competency. The urethro-rectal fistula, while persistent, was not the greatest of his complaints, and might, indeed, have been removed had he had the strength and vitality and courage to undergo the ordeal of further operating. CASE 16.-Prostatic obstruction and multiple vesical calculi in a hump-backed individual; removal by perineal incision; recovery. W. S. B. McC., Illinois, aged fifty-five years; first consultation, July, 1904. This was a remarkable case in many respects. The patient was a subject of marked kyphosis since childhood, being hump-backed to a degree that usually causes death before the time of life attained by this patient. His urinary symptoms dated from a year and a half back. At the time of his arrival he was urinating with excessive frequency, with in tense pain at each act. He was so exceedingly tender that no vesical examination could be made with satisfaction until he had lain in the hospital and received soothing treatment for ten days. Rectal palpation disclosed a large and tender prostate. The retrograde cystoscope showed a beautiful picture of many stones low in the bas fond. August 5, 1904. perineal lithotomy was done, a tight vesical neck thoroughly dilated with the uterine dilator, and twenty three stones removed, most of them larger than a pigeon's egg (Fig. 1). August 20, another cystoscopy revealed five more stones behind an overhanging posterior lobe of the prostate (Fig. 2). August 23. by enlarging the perineal wound, the posterior lobe was removed (Fig. 3), together with the remainder of the stones which had been seen with the cystoscope. The patient's heart was in serious embarrassment for several hours, after which he revived promptly and made a fine recovery, being able to hold his urine the usual length of time and to empty the bladder at will. It is sad to note that after complete recovery from all urinary disturbances and pursuing his occupation of traveling salesman for severa months, he contracted pneumonia and died at his home in Illinois. He was able to undergo the prostatectomy and removal, in stages. of twentyeight stones from the bladder, but succumbed to Fneumonia. CASE 17.-Severe obstruction; perineal prostatectomy; death, after two months, from uremia. Col. R. D. L., St. Louis, aged sixty eight years; referred by Dr. Walter Yost, September, 1904. Prostatic symptoms of ten years' standing. Severe attack six months before first con sultation, of complete, unrelieved retention, for a number of hours. There were six ounces of residual urine, of light specific gravity. Both lateral lobes of the prostate apparently equally enlarged. October 4, 1904, perineal prostatectomy was done through an inverted-V incision. The patient was very corpulent and there was considerable bleeding; some difficulty in enucleating the firmly imbedded prostate. Double tubes for continuous irrigation-drainage were left in the bladder, but gave trouble from time to time. About three weeks later there was some interference from re-contraction of the vesical neck, some urine being retained after voluntary evacuation. The neck was dilated with the deep urethral dilator, and the patient was sitting up in a few days, then able to empty the bladder. A few weeks later, without apparent cause, he suddenly had a chill, followed by temperature of 105°. He rallied for a few days, when suppression of urine ensued, only four ounces of urine being secreted in the forty-eight hours before his death. corpulence and renal implication contributed to the lethal end in this case, though they did not explain the sudden setting up of suppression and uremia that occurred two months after the operation and after his return home from the hospital. CASE 18.-Obstructive retention in an alcoholic; perineal prostatectomy; death from delirium tremens. Bladder Both Jacob S., St. Louis, aged sixty-eight years; referred by Dr. Jacob Friedman, October, 1904. Patient had been troubled with nightly urination for ten years, and a slow stream and difficult urination for three years. At the first consultation he had complete retention, the catheter withdrawing fifteen ounces of urine. It had to be passed three or four times in twenty-four hour', as he could not bear the retained catheter. The patient was a chronic alcoholic, but on account of the complete retention, the exhausting pain in connection with the passage of the catheter and other disturbing factors on conference it was thought necessary 10 operate; that was taken as a choice nest of stones between two evils, the other being impossible of continuation. Perineal prostatectomy was done Noven ber 8, 1904, through the inverted-V incision; drainage by double tube and continuous irrigation. The patient began to get nervous and to refuse food on the second day, and although the bladder and wound remained in good condition, he soon developed delirium tremens and died eighteen days afterwards. CASE 19.-Prolonged obstruction; general depletion and exhaustion; perineal prostatectomy under spinal anesthesia; complete recovery. Peter V., Illinois, aged sixty eight years. He had urinated once at night for fifteen years; troublesome symptoms since 1898, when he had complete retention and was relieved by a soft rubber catheter, feeling quite well again in a few days. He continued thus until 1900, when he was severely bruised while riding horseback, in Chicago, where Dr. Lydston used the catheter and gave him treatment. In June, 1904, he got worse and again consulted Dr. Lydston, who advised some operation, which was declined. From that time he lost weight rapidly, being reduced from 185 pounds to 110 pounds. He conferred with me in March, 1905. He was then urinating every hour, day and night; had moderate bleeding at the end of the act. A soft rubber catheter met Four an obstruction in the prostatic region. ounces of purulent residual urine; bladder highly inflamed. Patient had been bed-ridden for several weeks and was much emaciated and depressed. Cystoscopy revealed a large globular posterior lobe jutting into the bladder. It very much resembled a stone, being white, smooth and rounded, but no contact click could be felt with the cystoscope, such as may be elicited in the presence of a calculus. March 18, 1905, under cocaine spinal anesthesia, perineal prostatectomy was done, removing the globular lobe the size of a walnut, accompanied by forcible dilatation of the vesical neck that was contracted. The patient conversed during the operation, in which absolutely no pain was felt; no shock or nausea after Perineal incision. FIG. 2.- ive calculi in a nest under the project ing Jobe of the prostate, shielded from the sound but visible with Dr. Lewis's retrograde cystoscope. Case No. 16. wards. He made a splendid and complete recovery, being able to retain his urine for several hours, to empty his bladder, and has since expressed himself as delighted with the result. CASE 20.-Complete prostatic retention; perineal prostatectomy; recovery. W.S.W., Missouri, aged sixty-four; referred by Dr. Miller. First conference in March, 1906. Had urinary obstructive symptoms for the past eight years; for the past four or five years had had great difficulty in urinating; acute and com |