THE CINCINNATI SANITARIUM. A Private Hospital for mental and nervous Disorders, Opium Habit, Tnebriety, Etc. Twenty-five years successful operation. Thoroughly rebuilt, remodeled, enlarged and refurnished. Proprietary interests strictly non-professional. One hundred and fifty patients admitted annually. Detached apartments for nervous invalids, opium habit, inebriety, etc. Location retired and salubrious. Grounds extensive. Surroundings delightful. Appliances complete. Charges reasonable. Six trains daily. Thirty minutes from C. H. & D. Depot, Cincinnati, to Sanitarium Station. Electric cars from Fountain Square, Cincinnati, to Sanitarium entrance. For particulars, address ORPHEUS EVERTS, M.D., Superintendent, College Hill, Station K, Cincinnati, Ohio. DENVER MEDICAL TIMES VOLUME XIX. OCTOBER, 1899. NUMBER 4. ORIGINAL COMMUNICATIONS. EXPERIENCE WITH THE BOTTINI OPERATION IN HYPERTROPHY OF THE PROSTATE.* By LEONARD FREEMAN, B.S., M.D., Professor of Surgery, Gross Medical College; Surgeon to Arapahoe County Denver, Colorado. Hypertrophy of the prostate is one of the most annoying and fatal complications of advancing years. It fixes its relentless grasp upon the bladders of all sorts and conditions of men at an age when they are entitled to rest and comfort. Until recently we have been comparatively helpless in the presence of t is affliction, although life could some times be made tolerable by irrigation of the bladder and the constant use of a cat ter. Within the last few years numerous methods of treatment have been suggested, among which are castration, resection of the vasa deferentia, ligation of the internal iliacs, prostatectomy, establishment of a suprapubic fistula, cauterization through the rectum, the administration of animal extracts, etc., None of these expedients is reliable, while some are mutilating and dangerous. When the question is fairly presented, there are few men who will submit cheerfully to castration, or even to vasectomy; and although there have been improvements in prostatectomy, the operation is still difficult and attended with considerable danger in the debilitated. Enrico Bottini, of Pavia, has come nearer to solving the problem than any one else. For twenty-two years he has been operating successfully with an ingenious instrument of his own. invention. For various reasons his work attracted but little at tention until within the last two years, although it is now beginning to receive the recognition to which it is entitled. The symptoms accompanying hypertrophy of the prostate arise from difficulty in emptying the bladder, due to pouching * Read before the Rocky Mountain In'er-State Medical Association, at Salt Lake City. behind the gland and to direct obstruction of the urinary passage. In order to effect a cure, the level of the urethra must be lowered and a free outlet for the urine provided. These requirements can be fulfilled in most cases with Bottini's galvanoprostatic incisor. It contains a concealed platinum blade, heated by electricity, with which grooves are burned through the glandular substance. The procedure has a number of advantages: (1) There is no mutilation and no external wound, the manipulations being carried out through the urethra. (2) A general anaesthetic, so dangerous in the old and debilitated, is not often necessary, local anaesthesia being usually sufficient (Guitéras employs nitrous oxid gas). (3) There is very little. hemorrhage, the vessels being sealed by cauterization. (4) There is comparatively small danger of serious infection, and usually but moderate rise in temperature, the wounds being necessarily aseptic. The charred surfaces tend to prevent absorption until granulations appear. (5) In most instances patients may sit up. and even walk about in two or three days, which is of advantage in those who are old and feeble. (6) The effects may be almost immediate, more or less urine being voided within a few hours where it was previously impossible to pass a drop. (7) but few relapses have been observed; in fact improvement has a tendency to be progressive. (8) The operation may be repeated, if for any reason the first attempt has been unsatisfactory. (9) The mortality is lower than with other effective measures. (10) Patients will avail themselves of this method of treatment when they will refuse to submit to castration, prostatectomy, etc. It is not claimed that Bottini's method is free from danger or inconvenience. Old and feeble men, with inflamed bladders and diseased kidneys, are poor subjects for any operative procedure, and a death will sometimes occur no matter how trivial the nature of the intervention. Even the mere passage of a sound will at times result fatally. The assertion is not toc strong, however, that up to the present time the use of the gal vano-prostatic incisor offers a better chance of relief with less danger than any other surgical measure. Bottini's apparatus resembles a lithotrite, the male blade of which is replaced by a platinum knife which can be heated by a current of electricity passing through the handle. Running through the entire length of the instrument, to the end of the female blade and back, is a channel for the passage of ice water, which prevents unnecessary burning of the tissues. The electricity may be obtained from a suitable battery or from the city current, the strength being regulated by a rheostat. Leaving out many necesasry details, the operation is performed essentially as follows: The instrument is first tested, in order to determine the strength of current necessary to bring the blade to a good red heat, and the cooling apparatus is adjusted so as to insure a continuous flow of ice water from a fountain syringe. The patient's bladder is washed out and emptied by most operators, although Freudenberg prefers to have the viscus well filled, for which purpose either air (Lewis) or water may be employed. Cocain or eucain is then injected into the posterior urethra, when, after an interval of about five minutes, the operation may be begun. The instrument is inserted into the bladder and its beak hooked over the inferior rim of the prostate, where it is firmly held, and, as soon as the ice water flows freely, the previously determined amount of electricity is turned on. To make sure that the platinum knife is sufliciently heated, one should wait ten or fifteen seconds; then the screw at the end of the handle is slowly turned, dragging the heated blade through the floor of the prostate. The length of the incision, previously determined by rectal and urethral examination, is regulated by a scale inscribed upon the shaft of the screw. A cystoscopic examination is at times of advantage. It is surprising how easily the procedure may be accomplished. Too little resistance would mean too great heat, while too great resistance would suggest either an increase of the current or a pause until the knife became reheated. Pain is often slight. It is generally advisable to make at one sitting two or three incisions, one through the floor of the prostate (the most important), and one through each lateral lobe. There is usually but moderate after pain, although burning is experienced in voiding urine. Bleeding, if it occur at all, is nearly always trivial. The bladder may be irrigated daily to assist in the removal of bits of sloughing tissue, although this is not always necessary or even desirable. Many cases recover rapidly and can be discharged within three weeks, but my own experience has been that a considerably longer period may be required for complete recovery. I have eight operations to report and my success has been such that I shall employ the method further, as suitable cases present themselves. Seven of the cases were operated upon by myself, and one by Dr. H. E. Warren of Denver, who employed iny instrument. There were no deaths. The work was done at St. Anthony's Hospital, Denver. Case I-Age 69. General condition good. Frequent nocturnal urination and gradually decreasing stream for many years. Had used catheter for a long time, although could pass a little urine spontaneously. Moderate cystitis. Lateral lobes of prostate much enlarged and firm. Operated May 18, 1898. General anaesthesia. Two incisions-middle lobe 3 cm., left lobe 2 cm. Passed urine spontaneously within a few hours; at first strongly tinged with blood, which soon disappeared. Out of bed on second day. Temperature went scarcely above 100°. Irrigation of bladder for several weeks. Before operation, a No. 7 soft catheter could be passed with difficulty; when discharged, a No. 15 entered the bladder easily, and the stream was correspondingly large. Residnal urine much decreased, although it had not disappeared when the patient left the hospital. Urinated at night once or twice only. A moderately severe unilateral epididymitis developed several weeks after the operation, following the instillation of nitrate of silver. At the end of a year the condition of the patient was still good. Case II.-Age 73. General condition fair. Frequent nocturnal urination and decreasing stream for several years. During last six weeks could pass no urine without the aid of a metal catheter-a rubber instrument would not enter the bladder. Considerable cystitis. Lateral lobes of prostate much enlarged and firm. Operated August 20, 1898. Cocain anaesthesia. But little pain. Two incisions-median lobe 3 cm., left lobe 2 cm. No hemorrhage. Out of bed on second day. Catheterization was necessary for three weeks, the bladder being frequently irrigated. On tenth day the temperature went to 104°, without other alarming symptoms (abscess of prostate?). First spontaneous urination (2 ounces) on nineteenth day, which rapidly increased to a full and forcible stream. Residual urine disappeared. No. 15 soft catheter easily passed. At end of about nine months was still in good condition. Case III.-Age 67. General condition poor-emaciated and feeble. Frequent nocturnal and diurnal urination for four years. Stream very small for a long time. Much straining.. Considerable cystitis. Lateral lobes much enlarged and firm. Operation January 9, 1899. Two incisions-middle lobe 3 cm., right lobe 3 cm. Cocain anaesthesia-little pain. Hemorr hage trifling. Passed urine spontaneously until second day, when had to employ catheter. Urine contained a slight amount of blood at first. Out of bed on second day. No fever, except with an attack of double epididymitis, which came on after the first week and ended in suppuration within the tunica vaginalis. The result was at first excellent and in every way satis factory to the patient. Gradually, however, the frequent desire |