MEDICAL APPOINTMENTS. NEW SOUTH WALES. Cummings, Harold Lytton, L.R.C.P., M.R.C.S. Eng., to be Government Medical Officer and Vaccinator at Braidwood, vice Dr. R. Llewellyn, deceased. Ellis, Laurence Edward, M.B., M.Ch. Univ. Syd., to be Government Medical Officer and Vaccinator at Manilla, vice Dr. W. F. C. Lowson, resigned. Graham, Mabel Jessie, M.B. Syd., to be Government Vaccinator at Petersham. Moffit, Charles Gordon, M.R.C.S., L.R.C.P., D.P.H. Lond., to be VICTORIA. Chapman, John Taylor, L.R.C.P., to be Officer of Health for Kennedy, Thomas John Moore, M.B., to be Health Officer for the WESTERN AUSTRALIA. Elphick, Edward, to be District Medical Officer at Newcastle, and TASMANIA. Morris, Dr. Andrew B., to be Officer of Health for the District of St. Helens. QUEENSLAND. Dixon, Graham Patrick, M.B., M.Ch., to be Official Visitor to the Reception House at Maryborough, vice Henry Croker Garde, F.R.C.S. Edin., etc., resigned. Roe, James Morris, M.B. Syd., to be Medical Officer at Tenningering (Mount Perry). NEW ZEALAND. Allen, Sydney Chalmers, M.B., B.Sc., to be Assistant Medical Officer of the Lunatic Asylum at Seacliff. Bond, Joseph Henry, L.R.C.S., etc., to be Public Vaccinator for the District of Thames. Fleming, William Alexander, M.B., to be Public Vaccinator for the District of Balclutha. Frengley, Joseph Patrick, M.D., D.Ph., etc., Wellington, to be a District Health Officer. Horne, George, M.D., D.Ph., etc., to be Public Vaccinator for the District of New Plymouth. McCleland, Hugh Augustus, M.R.C.S., etc., to be Public Vaccinator for the District of New Plymouth. McKelvey, Alexander Neil, L.R.C.P.I., L.R.C.S.I., etc., to be Assistant Medical Officer of the Lunatic Asylum at Auckland. Watson, Frederick James, M.R.C.S., etc., to be Public Vaccinator for the Districts of Bulls, Rougotea, and Sanson. To be Pubic Vaccinators under "The Public Health Act 1900"-- Bluett, Peter Frederick William, L.R.C.P. Edin., L.F.P.S. Fitzgerald, William, M.B., etc., 1895, Granity Perceval, Montagu William Cairns, Lic. and Lic. Midwif., PROCEEDINGS OF AUSTRALASIAN MEDICAL BOARDS. NEW SOUTH WALES. Campbell, Archibald Way, M.B., Ch.B., Univ. Adelaide 1896. WESTERN AUSTRALIA. Finlay, Hunter, L.F.P.S. G. 1860, M.D. Glas, 1860. Moore, William Edward, L. & L.M.R.C.P.I. 1891, L. & L.M.R. C.S.I. 1891. BIRTHS, MARRIAGES AND DEATHS. BIRTHS. BICKLE.-On 8th July, at Warra Warra, North-terrace, Adelaide, the wife of L. W. Bickle, F.R.C.S., Ed., of a daughter. JENNER.-On July 9th, at "Evama," Norton-street, Leichhardt, N.S. W., the wife of Dr. W. Jenner, a daughter. MACCORMICK.-July 8th, at 125 Macquarie-street, Sydney, the wife of Alexander MacCormick, of a son. MARSHALL.-July 16th, at 30 College-street, Hyde Park, Sydney, the wife of George A. Marshall, M.B., of a daughter. M'DONAGH.-July 22nd, at 173 Macquarie-street, Sydney, the wife of Dr. J. M. M'Donagh, a son. WILSON.-July 25th, at "Apheta," Nelson-street, Woollahra, Sydney, the wife of Professor James T. Wilson, M.B., C.M., Edin., of a daughter. MARRIAGES. KNIGHT-GULLAN.-On June 26th, at Presbyterian Church, Winchelsea, by Rev. J. C. Baird, of St. Andrew's, Geelong, Vic., Glen A. Knight, M.B., B.S., only son of Mr. Glen A. Knight, Bay-street, Fort Melbourne, to Maggie Violet, third daughter of Mr. M. K. Gullan, Carringle, Winchelsea. DEATHS. GIBSON-SMITH.-On June 23rd, at Balclutha, New Zealand, John Gibson-Smith, L.R.C.S., Edin.; aged 65 years. WESTBROOK.-July 26th, at his residence, 29 Bligh-Street, Sydney, Dr. Talbot Westbrook, aged 43. WOOLDRIDGE.-On July 11th, at Glenelg, S.A., Henry Wooldridge, F.R.C.S.E., late of South Yarra, Vic., in his 1st year. Dr. H. Skipton Stacy, 28 College-street, Sydney (late Resident Pathologist Sydney Hospital), examines pathological specimens, including Blood (Widal's reaction, corpuscular count, bacteriological examination of, etc.), Sputum, Urine, Tissues, and Throat Swabbings. MALE ATTENDANT for mental, inebriate, or general cases, seeks engagement. References and testimonials show 13 years' experience, including five years as attendant at Callan Park Hospital for Insane, three years as wardsman in charge of Singleton Hospital. Address J. HILES, 161 Cecily Street, Leichhardt. HUDSON'S "EUMENTHOL" JUJUBES (Registered) are a Gum Jujube containing the active constituents of wellknown Antiseptics, Eucalyptol, Thymus Vulg., Pinus Sylvestris, Mentha Arv., with Benzo-Borate of Sodium, etc., and exhibit the antiseptic properties in a fragrant and efficient form. Sold by all chemists; tins, Is 6d. Are Antiseptic, Prophylactic, reduce Sensibility of Mucous Membrane. Mr. W. A. Dixon, F.I.C., F.C.S., Public Analyst of Sydney, after making exhaustive tests, says :-" .. There is no doubt but that Eumenthol' Jujubes have a wonderful effect in the destruction of bacteria and preventing their growth. I have made a comparative test of Eumenthol' Jujubes and Creosote, and find that there is little difference in their bactericidal action. AUSTRALASIAN MEDICAL GAZETTE. COMPLETE PROSTATECTOMY AND THE By H. V. Critchley Hinder, M.B., Ch.M., Sydney, I HAVE appeared before you on previous occasions as an advocate of operative treatment for prostatic hypertrophy. I do so again to-night with the firm conviction that early operative treatment, before the kidneys have become disorganised, is the treatment which will most surely prolong the lives of our old and elderly men. However, I would rather not invite criticism to-night on the question of operative treatment versus catheter life, nor do I wish to review the operative treatment of prostatic hypertrophy, but simply to direct your attention to the results of these few cases which are illustrative of two methods of treatment which apparently have come to stay. I am well aware that I have before advocated the operation of Belfield, who aims at cutting away a low level channel through the prostate, in order to allow the bladder to be completely emptied, the sure test of the functionally normal bladder, the sure guarantee that backward pressure will not exert its baneful influence on the excretory ability of the renal organs. Belfield's operation has still a wide sphere of usefulness, particularly if associated with perineal drainage in those cases where the prostate is not very large, though the obstruction to urination be very complete. It is certainly not nearly so safe, not nearly so likely to be followed by good results in large adenomatous prostates which may be removed very satisfactorily in one mass. It must not for one moment be imagined that complete removal of the prostate is the operation of the future applicable for all cases. Recently, as you are all well aware, a very wordy warfare was conducted, in which the whole matter of precedence, the whole matter of complete or incomplete removal, depended on the answer to the question-What is the capsule? Mansell Moullin, in his very neat description of the anatomy of the prostate, speaks of the capsule and the sheath, a division which greatly helps us to a better understanding of this much debated question. The capsule of the normal prostate is the fibrous tissue layer which intimately surrounds the prostate, sending in fibrous septa, which support the muscular and glandular elements. This capsule has a more or less intimate connection with the sheath, which is altogether formed by the pelvic fascia passing on to the posterior layer of the triangular ligament below. This description, however, by no means settles the difficulty, for it is maintained that the adenomatous overgrowth in large prostates flattens out the normal prostatic tissue, giving rise to a distinct lamination at the outskirts, containing islets of normal gland here and there. The question at issue is this: Have we here, in the mass removed, prostate plus capsule, or have we split off and left behind a thin layer of the prostate which is firmly welded to or interwoven with the adjacent capsule? Fenwick, again, in the "Journal of Anatomy and Physiology," in 1886, gave a very clear account of the veins about the prostate, and he maintains that, inasmuch as the veins in old men are valveless and lying between what we understand to be the capsule and the sheath, they are yet so closely applied to the capsule that it would be impossible to tear away this capsule without tearing these veins, and that these veins being valveless, of great size, and but a very short distance from the iliac trunks, would bleed furiously, and speedily be followed by disastrous consequences. This is precisely what may happen in some cases. The smallest prostate I show you to-night has a small bunch of adenomata springing out just at the internal orifice of the urethra sufficient to give rise to а few months misery, repeated tenesmus, very difficult catherisation, and finally absolute retention. The rest of the gland was practically normal. The complete removal was begun and completed with the greatest difficulty, as the prostate had to be stripped and partly cut and torn from its bed. The venous oozing was marked at the time, and the reactionary bleeding was alarming, but was ultimately stopped by_gauze packing and manual pressure. I think the reason why we get hæmorrhage in small prostates, and why there is less fear in the large adenomatous variety is this: Fenwick, in 1885, pointed out that the veins forming a communication between the prostatic and hæmorrhoidal veins were in young people well supplied with valves, and I venture to presume that the same condition held good to a very great extent in older folk with normal urinary, or, at any rate, normal prostatic conditions. In old men suffering from prostatic trouble, the prostatic veins become tor 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 one. Rectal examination will probably confirm this. A very fair conclusion may be arrived at by simple examination with a short-beaked sound combined with the evidence obtained by passing the finger into the rectum. If the hypertrophy be not great, the cystoscope is extremely valuable, inasmuch as it 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 |