tuous, the valves give way, blood circulates through them but feebly, and phleboliths are very common; in fact, one would expect that their occlusion naturally, or by surgical means, would be a much simpler matter than would be the case with veins associated with unenlarged prostates.

Freyer, in his last recorded case in February of this year, still maintains that the whole prostate, including the capsule, is removed, and that the prostate is slipped off the urethra, "just as a bead is drawn off a string," leaving the urethra severed from its connection with the bladder, but otherwise lying loose and intact.

Cuthbert Wallace, in a recent very able review of this subject based on the examination mainly of post-mortem specimens, points out that so laminated is the peripheral part of the prostatic mass removed, and so definite are the lines of cleavage immediately within what ought to be the anatomical capsule, that it would be well-nigh impossible to say when operating whether the mass contained capsule plus prostate or not, and an inspection of the specimens before you will probably give you the same impression. On the other hand, it can hardly be said that only adenomatous masses are removed, for prostatic tissue is evident throughout the mass. My own impression in removing these prostates was that I had removed the whole prostate, which was practically riddled with adenomata.

One point which to my mind is somewhat in favour of the capsule itself being removed is the great resistance which is offered to the removal. The prostatic mass does not shell out, as we ordinarily understand the term, but a considerable amount of intelligently directed physical strength is necessary to tear away the prostate from its bed, so that the term "shelling out" would be a misnomer. Fenwick maintains that it would be impossible to remove many small prostates after this method.

I have, so far, completely removed the prostate in five cases. Their ages varied from 67 to 72 years. Four of them have completely recovered, and are able to void their urine as easily and completely as when they were young men. They are also able to retain their urine the whole night.

The fifth case was in too bad a condition for

radical operation. He had been very much troubled for about seven months, and finally suffered from complete retention. Some old inflammatory condition made all efforts to pass an instrument futile. He was opened suprapubically, and the prostate (the smallest of the lot) was removed with great difficulty. He lived for a week, and died of uræmia, with almost complete suppression of urine. These cases

where catheterism has been attempted, and even where the bladder has not been entered, very often die after a median cystotomy pure and simple from gradually increasing suppression of urine. There is no help for it, operative treatment is the only hope for some of these cases where catheterism is practically impossible or productive of intense pain. We all know that some men suffer from retention, are catheterised and completely recover; but, still, every now and again one dies, and radical treatment when acute symptoms are absent is certainly wisest.

I shall only mention one case in detail, as it presented features of interest. This patient, aged 70 years, came to me first some time ago with stone in the bladder and a very large prostate. He was in a bad way, and looked very ill. I attempted to crush the stone, which I knew was in a deep pocket, but I could do no more than clew off the projecting portion, so that I was compelled to open suprapubically. The bladder-wall was red and inflamed, and covered with phosphatic patches. The stone after which I had struggled was with difficulty broken up and scooped out of a bottle-shaped pocket. The old man recovered, and submitted to a vasectomy before he went home. months after, Dr. Walley, his medical attendant, sent him back to me very poorly with great frequency, deep-seated perineal pain, and passing a lot of pus at intervals. The seat of the pain in particular made me feel sure that stone was present, so I reopened suprapubically and removed 16 facetted stones and the whole of the prostate. When he left me he had clear acid urine, no pain, no residual urine, and he was able to hold his urine for 11 hours.

Four

I might add that the vasectomy did not appear to have had any appreciable influence on the prostate. This case reminds me of one in which I blundered some time ago, but I gladly tell the story with the hope that the lesson may be of service to others. About two years ago when I was trying the effect of vasectomy on enlarged prostates I had an old man in Prince Alfred Hospital with chronic cystitis and enlarged prostate. The cystoscope was useless, the prostate was so large. Sounds revealed nothing. He went away with instructions to return and report himself. He did return, and visited a surgical confrère. The surgeon in question could find no stone, but thinking that stone might be present operated suprapubically and removed several from a post-prostatic pouch. The old man went home with a sinus, and was in a very short time as bad as ever. I expect that he formed more stones. Removal of the prostate would have given him as good a result as these cases I have been speaking about.

I think few of us are aware of the rapidity with which stones form in the bladder, particularly phosphatic stones. I have known a stone as large as a pigeon's egg form within four months after suprapubic removal of stone. In such a case one could positively swear that no remnant had been left. I have known the same thing happen after litholapaxy, and cystoscopic examination had shown a clean bladder free from débris.

There are just a few points of interest about these cases. Operation has been refused some

I purposely passed my finger round to the triangular ligament and broke it off, and then worked the mass towards the bladder. At all events the result was all that could be desired. It is also evident that the so-called internal sphincter has nothing to do with micturition, nor does micturition depend for its initiatory stimulus upon the integrity of the prostatic urethra. Freyer, in his reported complete removals, has left the urethra, whether from design or not he does not say. My own impression was that a flaccid tag end of urethra

prostatic patients because they have had a fairly low specific gravity urine with albumen. Four of these patients had urine whose specific gravity was from 1010 to 1013 and a varying quantity of albumen, which was of less importance because pus was present also. After recovery the albumen disappeared and the specific gravity rose.

Some writers, in speaking of this operation, have been somewhat concerned lest the integrity of the prostatic urethra should be disturbed. Apart from the sexual aspect of the question, the prostatic urethra without the prostate seemed to me to be of little value, so

was far more likely to give rise to stricture than no urethra at all in a situation where the narrowing up after the removal of a large prostate could hardly be so complete as to block the passage altogether. Certainly the result in these cases has been admirable, and absolutely normal micturition has been established.

When one considers the condition of these poor unfortunates straining to pass urine every hour or half-hour, with painful urethritis and foul urine, worried with want of rest and bodily and mental pain (hardly the conditions one would choose for the performance of a

E

major operation), the results are very gratifying, and the risk would be much reduced if the prostates could be attacked before instrumentation and septic conditions have been established.

Men are apt to treat too lightly the introduction of their patient to a catheter life. For my own part I invariably point out to my patient the seriousness of the step, for not only has it happened in one or two cases of my own, where every conceivable precaution was taken, but also in the practice of extremely careful men, that catheterism in a perfectly clean bladder has been followed by death within two or three days or as many weeks; yet such clean cases do admirably after operative treatment and free drainage.

The operation known as Bottini's practically aims at cutting with a red-hot platinum blade a channel through the prostate so as to open up the urethra and allow urine to pass out by the low level gutter thus formed. A battery of 45 to 50 ampéres is required to heat this blade in the damp tissues. The shaft of the instrument is kept cool by means of a waterjacket. The bladder should contain about five or six ounces of water at the time of operation.

Bottini and his disciples claim that this operation has a lower mortality and a greater percentage of recoveries than any other operation for the relief of prostatic hypertrophy.

Some operators met with poor success, but this can hardly be altogether attributed to the operation. My own impression is that the indiscriminate operating on every case has done more to damage the operation than anything else. The great amount of cutting and the large sloughs which must invariably follow such incisions in a very large prostate are likely to be a source of danger, partly from the difficulty in getting rid of so much necrotic material and partly on account of the hæmorrhage likely to take place on their separation.

The larger the prostatic mass the greater would be the difficulty in obtaining a good result by this method, though, at the same time, the amount of obstruction to micturition must by no means be measured by the amount of residual urine. An examination should be conducted with the cystoscope, and if it is impossible to mount over the prostate so as to see the bladder wall, it may, as a rule, be taken for granted that the prostate is a large

will indicate whether there is a uniform upheaval, a central median nodule, or a lateral excess in growth. Without this evidence the prostatic incisor would, indeed, work in the dark. It is certainly a poor condemnation of the instrument to say that it must be used in the dark. A man who has not eyes at his finger tips would find surgery a very small field indeed. A lithotrite is a dreadfullooking tool which is used very well in the dark. The obstacle may be first seen, its size estimated, the length of the urethra measured, and the length of the cut measured; in fact, when conducted thoughtfully and intelligently there are few operations which are safer and which are attended by more pleasing results; the results, in fact, give the best reply to the carping critic.

Willy Meyer, in 1900, reported on a series of unselected cases which were taken as they came; this number has been considerably amplified since then. His cures amounted to about half, the relieved about 30 per cent., and the deaths to 10 per cent. These results are remarkably good when one considers that two at least of those who recovered suffered from pyelitis.

I have so far operated on nine cases, and they were to a certain extent selected cases.

1. A man of 50, with frequency three times in the night, 2 oz. of residual urine and more or less constant pain at the neck of the bladder and across the loins. Eight hours after operation he felt a little stinging pain. He was operated on nine months ago. Since then he has had no residual urine, and is in good urinary health.

2. A man, 70 years old, with absolute retention and a rather large prostate cystitis and pyelitis. He improved, was able to pass urine, with still 2 oz. of residual urine. Six weeks after operation he died of pneumonia following influenza.

3. A man of 62 years of age, with 4 oz. of residual urine, and passing urine every two hours at night. He now has about 2 drachms of residual urine and feels quite well, having no nocturnal frequency.

4. This patient was 83 years old, with foul urine and 13 oz. residual, with all the attendant misery which usually accompanies such a case. He was getting about the ward at the end of three weeks after operation, with clear urine and 14 oz. residual urine, when he fell and bruised himself so extensively that he died in a few days. His urinary health remained good until his death.

5. This patient had submitted to a partial prostatectomy when suffering from complete

prostatic retention.

He recovered to the extent of having 4 oz. of residual urine, which did not improve. Within two weeks of the operation by the Bottini method he had perfect urinary health, and was able to completely empty his bladder.

6. This man had three ounces of residual urine. I failed on the first occasion to make a sufficiently thorough cutting away of the prostate, so that he still had an ounce and a half of residual urine, though he felt extremely free from the pain and very great frequency which had worried him so much of late. In fact, he stated that he used to pass his urine from ten to 20 times every night. While in hospital it varied from ten to 12 times between nine o'clock and daylight. After the second operation the residual urine was reduced to one and a half drachms. I think it very probable that this will still further diminish.

The 7th, 8th and 9th were cases of complete and partial retention; the cure was absolute in two, and almost absolute in the other.

It certainly does appear that some degree of finality is being arrived at with regard to the operative treatment of prostatic hypertrophy. The operations of vasectomy and orchectomy will bring about the reduction of the normal prostate, and are of service in reducing the size of congested and irritable prostates; but I know from my own observation that they have but little effect on the prostate whose increase depends on adenomata, and some other well-established pathological changes.

Bottini's operation seems to be particularly adapted to early cases. The risk is slight, the recovery rapid, and the pain which follows is wonderfully little. If recurrence should take place the operation may be repeated. The measure of success which attends the operation must depend to a great extent upon the operator's knowledge of the precise character of the obstruction to be attacked, and if the gland be so large that cystoscopic examination is impossible, it would certainly be wiser to adopt a suprapubic or perineal operation, partly because a removal of a portion, or preferably the whole of the gland, would bring about a more certain cure, and partly because it would be impossible to negative the presence of a post-prostatic stone.

Those large adenomatous prostates which are so satisfactorily removed by the suprapubic method in one mass are just the cases which are attacked with the least satisfaction by the Bottini method. No doubt the great difficulty to be contended with is the reluctance of patients and medical men to submit cases of early prostatic trouble to operative treatment, though undoubtedly this is the time when operative treatment may be carried out with the smallest

amount of inconvenience and danger to the patient, and the greatest amount of satisfaction to the operator.

Whether the prostate is completely removed or not, matters little. I think it is plain to anyone who examines these specimens that all the prostate that could be left might be represented by the thickness of a piece of brown paper; at all events, it would not be likely to interfere with the restoration of normal micturition. The truth may be arrived at some day when some patient dies and his pelvis is examined.

I hardly like to complete this record without referring to our indebtedness to Freyer for having brought so prominently before the profession the complete removal of the prostate. He may not have been the first to remove the prostate completely, but he was certainly the first to recognise what such a complete removal meant to recognise the fact that he could in selected cases set out to effect a complete removal, and with an excellent prospect of

success.

To the advocates of catheterism let me say one last word: I simply speak from my own experience. The bladder of prostatic patients will always be found to be aseptic unless stone is present or an instrument has been passed. There is every probability that prostatic patients suffering from vesical stone owe its presence to the fact of a stone having arrived from the kidney or to cystitis having been induced in a healthy bladder by the introduction of a foreign body. There is every reason to believe that stones do not originate in the bladder unless sepsis or a foreign body is present.

(Read before the New South Wales Branch British
Medical Association.)

A CASE OF PLACENTA PRÆVIA WITH CONTRACTED OS AND RIGID CERVIX.

By C. E. Todd, M.D., and H. A. Sweetapple, M.D., Adelaide.

case

MIDWIFERY cases in which placenta prævia occurs always cause considerable anxiety, and when to this condition a rigid cervix and tightly contracted os are added, the becomes at once not alone extremely difficult to the accoucheur but dangerous in no slight degree to the patient. If one may judge by the number of examples of this condition published in the medical journals, one would come to the conclusion that such cases were not very rare. Up to the time that this case occurred in my own practice I had come to the conclusion, on thinking over papers on the subject, that if an anesthetic had been pushed to the full extreme, the os and cervix would have

dilated or at least be easily dilatable, and that delivery could be accomplished with comparative ease. This I have always found to be the case, and I think with very few exceptions it is the rule. However, this is not always so.

Mrs. C. I., at. 24, was eight months pregnant with her first child. After some unusual exertion she felt an abdominal pain, and had a slight blood-stained vaginal discharge. When I saw her a few hours after the commencement of her symptoms she was in bed, and the pain and bleeding were very much diminished. Per vaginam the os was tightly contracted, and the presentation could not be accurately made out. She was ordered to keep her bed, and when I visited her in two days' time I found that all pain and bleeding had ceased.

As a precaution another two days' rest was enjoined. The next afternoon she got out of bed to pass urine, and while doing so felt a sharp abdominal pain, with faintness. She was lifted back into bed, and a considerable amount of blood came from her vagina. On my visit, two hours afterwards, I found the patient blanched and faint. Hæmorrhage was still going on, and the os was about the size of a florin. The cervix was not at this time rigid; it appeared to be dilating, and on introducing two fingers I could feel the placenta presenting. This I was able to separate some two inches up from the os, and on the left side I came upon the free placental margin. The bleeding was at once diminished, and henceforth was not a cause of urgent anxiety.

As labour pains were increasing in severity and frequency and the head was presenting, I waited an hour in the hope that labour would terminate naturally. At this time the os and cervix felt moderately soft, and as bleeding still persisted, I decided to give ether and deliver. I anticipated no difficulty, but after getting the patient completely under an anæsthetic I found, on vaginal examination, that the cervix had elongated and that the os was now hard and almost closed. I directed the experienced nurse, who was continuing the ether, to push it still further, but even then only with the greatest difficulty could I insinuate my two fingers into the cervix. All attempts to introduce a blade of the forceps were fruitless. Still thinking that if the ether had been pushed to the full extent dilatation would be possible, I sent round for Dr. Sweetapple, who gave the anesthetic fully, but the cervix and os remained as rigid as before. Neither Dr. Sweetapple nor I could dilate sufficiently to get more than two fingers into the uterus. We decided, therefore, to desist and to give 20 grains of chloral every hour for three hours. On our return the

patient had taken 60 grains. Dr. Sweetapple decided to give chloroform, and on examination I found the cervix and os somewhat softer, but still I could not dilate sufficiently to introduce the forceps. As my hands were rather cramped I took over the administration of the chloroform, and Dr. Sweetapple, after many efforts, at last succeeded in getting the instruments on, and I delivered without any great difficulty. The placenta followed immediately on the birth of the child, which was dead. The patient made an excellent recovery, and I got a teno-synovitis of my right wrist, which kept it stiff for at least three weeks. This was a case unique in my rather long experience of midwifery. As I have stated, I have hitherto always thought that all that was necessary to enable the os uteri to be dilated fairly easily was that an anæsthetic, ether or chloroform, should be pushed to the extent of producing complete muscular relaxation. I would like to hear the experience of those present on this point, but I have always found it so in practice.

The question arises as to what would have been the right course of treatment if we could not have dilated sufficiently to apply forceps. Dr. Sweetapple, to whom I feel much indebted for advice and assistance in this case, and I came to the conclusion that there were two courses open to us. One was to leave the case for some time in the hope that the os and cervix would finally soften and dilate, and that then we could apply instruments or let delivery take place in the natural way. Against this, of course, was the fact that the woman was exhausted, and that bleeding was still going on a little. We could, of course, check the hæmorrhage by gauze plugging, but this is not a very efficient means of controlling bleeding in a case of this sort. The other course of treatment, which I think was the one we had decided upon, would have been to put the patient up in the lithotomy position in a good light, make a final effort at dilatation, and if this was impossible, to make what incisions were necessary into the os to enable the forceps to be applied. We should then have stitched up the cervix and os as in an ordinary Emmet operation.

No doubt some of the members here to-night will have had similar cases, and we shall be glad to hear how they conducted them.

(Read before the South Australian Branch of the
British Medical Association.)

In the New South Wales prisons steps are being taken to establish a new system of criminal identification on the lines of the combined Bertillon and Galton methods. A comprehensive criminal register is in course of compilation, and already the anthropometrical lines of a large number of prisoners have been taken.