a small perineal incision gives us, judging from my experience with both methods of approach, the very best command with the least damage to the patient. I may state that I made suprapubic prostatectomy in 1886, perineal prostatectomy in 1893; and that my total operations exceed two hundred in number. But the thing I would try to emphasize is that we should not operate on all these patients that present symptoms of enlargement of the prostate; and I differ from Dr. Murphy in his recommendation that we operate early in all these cases. That may ultimately prove to be the wise thing; it seems to me, from my present observation, it is not the wise thing. A great many of these cases, even those in which there is actual adenofibroma, do not need operation; they never will need operation. I am disposed to be conservative, and to reserve operation for cases in which less radical means have failed to produce the desired result. General anesthesia, even without operation, is a serious matter for elderly men.

DR. F. KREISSL: The paper of Dr. Murphy has been discussed in all of its details in a very able and excellent manner by Dr. Belfield and Dr. Lydston, and I have nothing to add to what these gentlemen said. I wish, however, to make a few remarks concerning the technique.

Whenever I saw perineal prostatectomy performed, or did it myself, I appreciated the fact that it was a pretty bloody operation, notwithstanding the statements to the contrary. It is not so much the hemorrhage connected and following the enucleation, as the hemorrhage occurring before we reach the prostate. Communicating this idea to Dr. L. Barker and Dr. R. Turck, I tried to obtain proper subjects to study the anatomical conditions and distribution of the blood vessels in these tissues, but did not succeed on injected cadavers last year. Meanwhile Proust, working along the same line, found the bloodless route, describing it in the January number of the Centralblatt of Nitze. There is a distinct division between the vessels entering the bulbous and the ischiobulbar space, and those running to the rectum, produced by a space called "espace décollable rétrobulbaire." The key to this space is the musculus rectourethralis.

In dividing this muscle on a level with the median pelvic fascia, the rectum becomes mobilized and the space to the prostate is opened without a hemorrhage, provided the scissors are held parallel with the membranous urethra while cutting through the muscle.

The enucleation of the gland as described by Dr. Murphy is comparatively easy, and can be done rapidly, if there be no firm. adhesions between the gland and the capsule, but there are many cases in which the density of the adhesions is so extensive that the shelling out of the parenchyma cannot be accomplished without tearing away parts of the capsule. For these cases, morcellation, advocated by Ferguson, ought to be employed. I fully agree with Dr. Belfield that we ought to weigh carefully all the symptoms of prostatics before deciding on an operation. Especially should we inform

ourselves regarding the condition of the bladder, as I have repeatedly urged in my publications on this subject. We find frequently enlargement of the prostate associated with retention and tenesmus, but the latter symptoms are caused by the disease of and in the bladder wall, and not at all, or only to a small extent, by the hypertrophied gland. There the result of an operation on the prostatic will be disappointing, because the pathologic conditions in the bladder wall are so extensive and deep seated that they resist any treatment, be it medicinal or surgical.

DR. G. FRANK LYDSTON: I am especially gratified at the presentation of the subject of prostatectomy by Dr. Murphy, because he is a recent convert to an operation that he and I have had warm arguments upon in past years. I remember very well a case in which I did a prostatectomy, I think it was in 1890. The patient did not do very well. Dr. Murphy saw the case in consultation with me, and on the way home he expressed his feeling to me rather emphatically. I am glad to see that he has changed his mind.

Some remarks were made by Dr. Murphy and Dr. Belfield in reference to the relation of the prostate to the bladder. I have been puzzled, but none the less interested, by some of the statements that have been made with regard to the development of the prostate. The statement has been made by Mr. Harrison that children have no prostates, the prostate being developed at the age of puberty. If he had said that the glandulo-sexual elements of the prostate did not develop until puberty, I would not take any exception to that statement. But I was not satisfied until I had dissected a number of bladders and prostates of infants and found they had a pretty definite muscular structure which corresponds to the prostate body, and which apparently is a part or continuation of the muscularis of the bladder.

The operation described by Dr. Murphy was not quite clear to me. I would like to ask him a question. Did you remove the prostate, doctor, within the capsule, or did you remove the capsule and the prostate?

DR. MURPHY: I did not remove the capsule.

DR. LYDSTON: That is a point you did not make clear, especially in your remarks about the urethra being a part of the prostate. In leaving the urethra behind and having a pouch, I could not see how you could remove the prostate, and, at the same time, have a pouching of a canal, the lower wall of which has been removed. This brings up a point I wish to make, namely, that the term prostatectomy, after all, is a misnomer. Total removal of the prostate would not be a safe operation. It is not practicable if one is not absolutely regardless of the result, so far as life is concerned. I do not think Dr. Murphy made the point clear that in cases in which this operation is indicated and readily performed, it consists chiefly in shelling out adventitious tissue that is more or less circumscribed in character. The thing that has surprised me regarding perineal

prostatectomy is the manner in which it has been so enthusiastically advocated as a routine procedure. I was like Dr. Belfield, I had considerable affection for the combined operation, and I cannot say that I have gone back on the old love entirely. A thing that has puzzled me is that so many surgeons seem to attack all cases through the perineum. My cases may have been a little more peculiar than those of others, yet I do not think so. There are some cases in which I find it absolutely impossible to remove well defined tumors. through the perineum. I have a specimen here which I will pass around, that I do not believe any man living could have removed by the perineum. In this case the bladder was well filled with prostatic overgrowths, that had developed in the direction of the bladder, and it was just barely possible to reach their attachments through a perineal wound, and even through a suprapubic incision it was with difficulty that I could reach the fundi of these tumors. I believe that the tendency is to go to extremes in the surgery of the prostate. I have no doubt that the gentlemen who have reported such beautiful results following perineal prostatectomy have had a pleasant run of cases in which this operation was practicable. But I am free to say that I believe their experience will be no different than mine, and that they will sooner or later encounter cases in which perineal prostatectomy is not applicable. I reoperated a case two days ago, in which, as a consequence of the formation of cicatricial tissue and cicatricial bands at the vesical neck, perineal section became necessary, and in which I was compelled originally to do a suprapubic prostatectomy. In the secondary operation, with the prostate removed and nothing but cicatricial tissue behind, I could barely reach the vesical neck with my finger through the perineal wound, even when my assistant pushed the bladder down as firmly as he could. That there are certain cases to which neither suprapubic prostatectomy nor the perineal operation is adaptable is true. Dr. Belfield made that point. There are cases in which the Bottini operation is as good as anything else. I am free to confess, however, that I prefer a median division through a suprapubic incision by some other means than the cautery in most cases.

I have taken the liberty of bringing here four specimens which illustrate in a striking manner the varying facility of removal of the prostate by any method. I presume that the surgeon who happens to have a succession of cases in which he removes the prostatic tumors through the perineum may be led to believe that they are all simple operations, when performed in that manner. Here is a specimen in which there was a simple opening of the prostatic capsule through the perineum. The tumor was shelled out without difficulty-as easily as an onion can be peeled out from its covering. There are other cases in which that sort of thing does not occur so readily. I will pass around a specimen of a case in which the tumors had to be shelled out piece-meal. Here is another specimen in which the prostate was shelled out suprapubically. It shows the laminae, the fibrous

change in the prostate, and represents a difficult class of cases for prostatectomy, one in which the surgeon is very glad to do the combined operation in many instances. I will pass around another specimen showing circumscribed tumors that were removed by the perineal route without any particular difficulty.

With reference to incontinence of urine following these operations, like Dr. Belfield, I have serious doubts as to whether Dr. Murphy in all cases can remove the prostate and absolutely ignore the bladder or not invade it in any way. There are cases in which we are compelled to resort to dilation and to possibly more or less cutting for obstruction at the vesical neck, and in these we sometimes get incontinence of urine. In the ideal perineal operation, we are less likely to get incontinence of urine than in some of the suprapubic cases. I am satisfied, however, that by any method an occasional case of incontinence of urine will result.

In regard to the question of impotency following prostatectomy, I see no reason why the majority of patients, who have not reached an age to impair their virility, and in whom virility was marked before operation, should have impotency result. I performed vasectomy in one case, and did a prostatectomy on the same patient several years afterwards, and the patient has had no disturbance of virility. Some of my cases have proved to be more than usually virile after operation.

I was very glad to hear that Dr. Murphy's cases did not all go smoothly, as I had begun to believe that I was the only one who had such experiences. He stated that in one of his cases he put his finger through the rectum. I operated on a case some six weeks ago in which, a week following operation, rather extensive sloughing of the rectum occurred, and a fecal fistula resulted. That is an accident hardly to be expected, but the case illustrates that it may occasionally occur.

I have seen two cases of what I believe was septic embolism of the liver following perineal prostatectomy, which, however, did not result fatally, and I am inclined to believe that such cases may occur in the practice of other surgeons. I do not see how any method of operating can render the field thoroughly aseptic, especially in advanced cases. I do not know of any method of draining which will prevent the contact of septic material with the wound.

Dr. Murphy stated that in most of his cases early union occurred. That has been my experience; still in some instances accidents will happen.

Failure to afford relief by prostatectomy, even where the operation is thoroughly performed, has been the experience that many surgeons have met with, and the reason of that is that the operation, whether it is a suprapubic or perineal prostatectomy, has been considered adaptable to all cases, and contracture of the neck of the bladder has not been considered-in other words, the operation has not been completed. I presume that this is likely to occur in any case in

which we have the conditions described by Dr. Belfield, inasmuch as subsequent to prostatectomy division of the vesical neck was made. In conclusion I will state as my belief that no one operation is adaptable to all cases.

There were over 200 present.
Adjourned.

FRANK X. WALLS, Secretary.

Reviews.

PROCEEDINGS OF THE AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION AT THE FIFTY-EIGHTH ANNUAL MEETING HELD IN MONTREAL, QUE., JUNE 17-20, 1902. Published by the American Medico-Psychological Association, 1902.

The annual volume of this active society appears in its usual form. Most of the papers embraced have appeared in current periodicals but for those interested in the subject their joint appearance will be a source of satisfaction.

CLINICAL TREATISES ON THE PATHOLOGY AND THERAPY OF DISORDERS OF METABOLISM AND NUTRITION. By Dr. Carl von Noorden, Physician in Chief of the City Hospital, Frankfurt, Me. Authorized American edition translated under the direction of Boardman Reed, M. D. Part III. Membranous Catarrh of the Intestines (Colica Mucosa). By Prof. Dr. Carl von Noorden, with the collaboration of Dr. Carl Dapper. New York, E. B. Treat & Co., 1903. Price, 50 cents.

The two preceding parts of this series have been favorably reviewed in a previous number of THE RECORDER. To what was there said may be added that this very common and very intractable intestinal disorder calls for the most intelligent management and many points of great importance and interest will be found embraced in the present essay.

DISEASES OF THE STOMACH. A Text Book for Practitioners and Students, by Max Einhorn, M. D., Professor in Clinical Medicine at the New York Post Graduate Medical School and Hospital, etc. Third revised edition. New York, William Wood and Company, 1903.

We are pleased to see another edition, the third, of this eminently practical book. While it does not enter into all the details as some of