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J. A. (Joel Asaph) Allen.

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spermatozoic activity and lengthens the life of the sperma. This
was proven by Fuerbringer, but I find that already long before
it was proven, only I forgot where I saw it.

V. Tuberculosis is always a part of the general tuberculosis
of the genital tract, and astonishes sometimes through the insig-
nificant effects on the part of the prostate. Treatment, according
to general rules.

VI. Atrophy requires no treatment, and is much more fre-
quent in old age than used to be supposed.

VII. Tumors are, except the fibromyomatous, almost always
cancerous. Treatment will probably always remain inefficient,
althoagh palliation, especially of the hemorrhages, is possible,
unless a new efficient cancer remedy should be discovered. Yet,
attempts at radical cure have been made. Euester and Barden-
heuer have extirpated sub-peritoneally the prostate and bladder,
and implanted the ureters into the rectum, but both patients died
after 5 resp. 14 days.



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400 HABTWIG : P&OSTATIC DISEASE.

VIII. Stones in the prostate are sometimes formed and felt
per reotam, or by the bougie, and have been removed from the
perineum or from above, even through the urethra, in a few
suitable oases.

IX. Neurosis of the prostate was construed as a separate
affection by Home, 1818, and credited to fissures in analogy to
fissures of the rectum. I cannot obtain the original work, and so
I am left in doubt as to the causation. If such could be ascer-
tained, analogous treatment, as elsewhere in fissures, should obtain,
but it seems to me that Home may have seen a neuralgia of the
nervous pudendus, as I did, where the flabby penis used to jerk
regularly, and where electricity seemed to do some, but little,
good.

X. Hypertrophy and fibromyomata. The hypertrophy of the
prostate, which generally appears above fifty, but has been seen in
babies already, is either due to an increase of the connective
tissue, or particularly to the formation of fibromyomata micro-
scopically in perfect keeping with fibromyoma of the uterus, when
extreme sizes are met with. The enlargement is in the first case
more even, in the latter more lobular ; an enlarged lateral or
central lobe, or even three enlargements. Such fibromyomata can
be shelled, respectively, twisted out of their seat after incision of
the mucous membrane. The prostate weighs, normally, ten to
fifteen grammes, is about thirty-two mm. long and broad, eighteen
ram. thick, and develops suddenly during puberty, but reaches
its full size only at twenty-five. It contains about forty glands
and ducts. In regard to the value of operative partial removal,
the opinions are divided up till today. Already Civiale and
Mercier have removed pieces, but as late as 1885 Erichsen writes
still that operations were both dangerous and inefficient, and have
been almost unanimously condemned. In fact, the sole treatment
of enlarged prostate consists in the regular use of the catheter.
When prostatic enlargement does not admit catheterization, punc-
ture above the pubes should be made and the canula left in situ.
Canalization of the prostate is barbarous and correctly abandoned »
Brandes (and I may add Leasure, 1855,) punctured through the
symphysis pubis, but there is not sufficient evidence of the merits
of this procedure. So far I have cited Erichsen.

On the other hand, already in 1852, Demarquay recommended
for prostatoliths to incise across the perineum, separate the rectum
from the urethra and prostate, incise the latter, and remove the



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HABTWIO : PROSTATIC DISEASE. 40 1

Stones, and considers the danger small. I do not speak of the use
of medicines as they all proved inefficient. Only Heine claimed
results from injections of iodine with Pravaz's needle into the pros-
tate, in 1875, hut he found no followers. I tried his plan once
without success ; the patient died. There Brandt maintains to
have seen improvement from massage of the prostate. Thompson
and Guyon, two weighty men in geni to-urinary diseases, oppose
operative measures. The first cites a man who used the catheter
for twenty-two years, till he died at ninety, and another who used
the catheter on himself 35,000 times. Guyon opposes on the
ground that the prostatic enlargement is only a part of a general
genito-urinary sclerosis, forming a superabundance of connective
tissue in the bladder, and preventing the latter, through loss of
muscle, from emptying itself completely, even when the mechani-
cal obstacle is removed, and cites, as sample cases, where the same
trouble existed with atrophy of the gland. I am inclined to
believe, though, that he dealt with cases of paresis of the bladder
from nervous causes. Long rows of other men believe in the
efficiency of operative proceedings. Newman, in New York, in
momentary cauterizations ; Bottini, in burning away the obstruct-
ing part. Bruce Clark used Bottini's method, and dropped it again
for the suprapubic operation, on account of better seeing. Bottini's
results are remarkable. At the Tenth International Medical
Congress, August 7, 1890, he reported fifty-seven cases, with two
deaths. In thirty-two cases a perfect cure was effected ; in eleven,
improvement; in twelve, the result was nil.

In 1882, Biedert reported five cases of galvanopuncture per rec-
tum, with decided reductions. He used the cathode. Leopold
Casper, paper before the Berlin Medical Society, April 18, 1888,
used fifteen to twenty-five milliamp^res for ten to fifteen minutep,
and obtained in four cases considerable shrinking of the prostate,
with quite an amelioration ; thinks, though, that if the hypertro-
phy is particularly in the middle lobe, that he would not
expect much. Of course, he disinfects the rectum before intro-
ducing the needle, and the latter is isolated up to the tip. For a
test, he made a dog's testicle shrink from walnut down to almond
size.

McGill, in Leeds, had from thirty-three suprapubic operations
sixteen per cent, deaths.

Mansell Moullin had twenty per cent, from suprapubic ; only
eight per cent, from perineal operations.



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402 habtwig: prostatic disbasb.

Norton reports foar complete successes from the nse of his
prostatome, introduced by perineal incision.

Tobin used the ecrasenr per urethram, guiding the wire with
two fingers through suprapubic incision.

B. Schmidt and Moullin saw one recurrence of an operated
hypertrophy after nine months. Eiister saw, after a partial supra-
pubic excision, an aggravation of the ability to void the urine
spontaneously. On the other hand, he had three decided improve-
ments by operating between rectum and prostate, and excising
portions of the lateral lobes. Lately, Dittel reports by this pro-
ceeding a fine success. Helf erich had no improvement by supra-
pubic excision in one case. Israel and Bergmann had no lasting
improvements suprapubically ; Landerer, a splendid one. Esmarcb
had two excellent successes by chipping out from the perineum,
but great losses by pneumonia. The latest sanguine statements
for combined suprapubic and perineal operations introduced by
M. Schmidt, come from Belfield, who maintains, for about four
weeks, a stretched condition of the prostatic urethra, after the
combined incision, in the manner of Harrison, by a catheter
inserted through the perineal wound. He collected four cases
(American Journal of the Medical Sciences^ November, 1890, page
439,) of combined perineal and suprapubic operations, with one
death. Twenty-five per cent, of other forty-one cases of radical
operation for which he gathered statistics, voluntary micturition
was reestablished thirty-two times, but only in a few, and he says,
it is expressly stated, that the evacuation of the bladder was comr
plete as well as voluntary. This is the main hitch. Thompson
states that after two years of catheterizing, the bladder will never
empty itself completely. This is not absolutely true, but very
often. The statistics are sadly lacking on this point, as well as
many original reports, as not sufficient stress has been heretofore
laid upon it, while it is an all-absorbing question, indeed. The
question of residual urine is the question of cystitis — remaining
permanently or not. No bladder which is not emptied perfectly
can be kept free from cystitis, and, if such persists, difficulties of
micturition remain, and the cure is imperfect, though voluntary
urination is reestablished. I have seen several prostatics who had
to use the catheter, though they were able to urinate, just because
of the irritation from residual urine, and the treatment of the
cystitis remained without avail, which was promptly successful
where residual urine was absent. Even Keyes, who pays atten-



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hartwig: prostatic disease. 403

tion to this point, neglects to consider it in a number of his pub-
lished suprapubic and perineal operations. In three cases he
obtained perfect emptying of the bladder after suprapubic opera-
tions.

If I draw the facit of my reading, I can but join with Eeyefii's
opinions {Medical Record, October 31, 1891), the best mortality
statistics, showing at least 13 6-10 per cent. (Keyes), it is trying
to kill a mosquito on a man's nose with a club when you advise
early operation, as Belfield does, although I admit that early
operations should furnish better statistics. If early, we should
operate so early as not to deal with any cystitis or other
secondary changes, in order to obtain the advantages of asepsis,
which is wellnigh impossible later on. On the other hand, we
should not refuse operating in the seemingly most hopeless cases,
as some astonishingly good results in such cases are recorded. To
gain time, in some cases, we may satisfy ourselves for a while with
suprapubic puncture, substituting the trocar for a well-fitting
catheter, over which we withdraw the canula. The perineal drain-
age is more inconvenient. At all events, at the present state of
statistics, we are in duty bound to lay the truth, and nothing but
the plain truth, before a prostatic we meet, and let him choose for
himself. Our patients live only once, and we have no right to
take their lives in our hands by their blind permit. They should
be enabled to choose intelligently whether to prefer their discom-
fitures and their final outlook, or the risks of operations with their,
after all, so frequently deficient results. The choice of the way to
operate will be ofttimes quite bafiling. Statistics of suprapubic
operations are worse as to the number of deaths, but better in
regard to results, if death did not follow. Combined suprapubic
and perineal operations admit of the most perfect handling, but
the danger to life is, of course, greatest. Want of personal expe-
rience makes me shy of expressing an opinion, but I should judge,
a priori, that DittePs operation, of separating the rectum and
slicing out the requisite amount of prostatic tissue, if it were pos-
sible to avoid wounding the urethra, ought to be the ideal, because
the most snrgic&l proceeding. Were it not for the profuse bleed-
ing and poor seeing, I would feel certain of my opinion.

The latest for enlargement of the prostate is castration, in
analogy of oophorectomy, for uterine fibroid. Two results are
cited by Rocum (CentrcMlatt fur Chirurgie, No. 35, 1893). The
paper being inaccessible to me at present, I cannot judge the real



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404 PBOSTATIC DIREASE.

value from details. White had already shown, in dogs, the shrink-
age of the prostate after castration. Civiale saw it accidentally in
a lithotomy ; Bilharz and Pelican in eunuchs.

DISCUSSION.

Dr. Tkemaine : I labor under some disadvantages in discus-
sing this subject, because I was not aware what points Dr. Hart-
wig was going to take up. I had no synopsis of his paper ; and
to go over the whole ground of diseases of the prostate would take
up too much time and weary you. I supposed, however, that the
subject he was going to discuss was that which must interest all
of us, viz., senile hypertrophy of the prostate. When we come to
consider that about one man in fifteen, past middle life, has some
enlargement of the prostate, and one man out of perhaps eight or
ten, if not a still larger proportion, after fifty-five, has hypertrophy
of the prostate in some form, and his life then begins to be some-
what of a burden to him, it is a matter which interests us all most
seriously. I fancy that every gentleman in this room has, at some
period of his life, and perhaps almost every day of his life, come
in contact with just such cases, and has been worried very much
to know what to do ' with them. I confess I share that difficulty
with all of you. There is no subject in the whole realm of
surgery that is more difficult, and, perhaps, none which now
engages the attention of surgeons more generally. Dr. Hartwig
has gone over the ground very extensively upon the literature of
the subject, and he has collected the views of some gentlemen.

Now, these are confiicting. Guyon, for instance, assumes that
this is a part of the degenerative changes that take place in old
age, accompanying atheroma, and so on. I do not think that
view is tenable, and I will not weary you with going into the
reasons why. And I do not agree with Harrison, who is also a
distinguished author on this subject, that enlargement of the pros-
tate comes as a result of the pouching of the bladder, and is a sort
of hypertrophy of muscle, as it were, from the efforts of the
bladder to expel, and goes on increasing in this way, with the
residual urine pouching down the bladder behind the prostate, I
think a more correct view ; and I speak of this matter of the
histology of the subject because a rational understanding of that
may lead us into the correct ideas with regard to treatment. I
believe the better opinion nowadays, with regard to this, is the



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PROSTATIC DISEASE. 405

opinion which is entertained by many, that enlargement of the
prostate gland is analogous with the fibroid of the uterus.

For a long time the prostate gland has been spoken of and
thought of as a urinary organ. ' I am quite satisfied in my own
mind that it is not ; that it is a genital organ ; and, as stated,
excessive venery, perhaps, conduces to enlargement of the prostate,
although there is one thing that might perhaps militate against that
view : that enlargement of the prostate i^ generally found, or more
frequently, in old bachelors than in married men. You can draw
your own conclusions.

However, the most important matter for us to consider is,
what is to be done. First, the symptofns. We will talk of them
a moment. The symptoms may be divided into subjective and
objective. One point that I want to make just here is that enlarge-
ment of the prostate occurs much earlier than usually taught by
the text-books. I have seen it in men between forty and fifty
years of age. As a rule, it is said in the books, and by various
writers, to occur generally after fifty-five, but I do think that the
enlargement commences much earlier than is generally believed.
Now, with regard to symptoms. If a patient says he has to get
up to urinate frequently during the night, and has no stricture,
the presumption is at once in favor of enlarged prostate. If, in
addition to that, the urine at times smells badly, I should
suggest an examination, and that by the rectum, and the
probabilities are that enlarged prostate will be found. But this is
somewhat deceptive sometimes, because the enlargement takes
place inwards, as it were, against the bladder, and very little
enlargement is found in the rectum. I have seen just such a
case as that. Now, we go on with our examination, and use an
instrument, and that instrument enables us to determine somewhat
the nature of the enlargement. If an ordinary catheter passes in
without difficulty, and yet there is* a difficulty in the outflow of
the urine, the chances are that that enlargement is of the valvular
character, and I wish I had been able to bring a specimen which
once was in my possession, now is no longer, to show this evening,
in which there was, at the middle lobe of the prostate, a regular tit-
like valve. If that case had been recognized during life and operated
on, it would, doubtless, have resulted successfully, because that little
valve could have been removed readily by the forceps or by the
ecrasenr, and the patient relieved. That is one way in which we
can determine the nature of the enlargement. If, on the other



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406 PROSTATIC DISEASS.

hand, there is no obstruction to the flow of urine, and yon pass an
elbow catheter, and that goes in after a time, stops at about seven
inches, and then goes in with a jump, the presumption is in favor
of enlargement of the middle lobe. If, on the other hand, but a
narrow-tail — rat-tail — catheter can be passed in with difficulty, and
deflects to one side or the other, the presumption is in favor of
enlargement of the lateral lobes. Now, the first two forms of
enlargement are those most amenable to treatment, in my judg-
ment. It has been my lot to see a great many of these cases, and
I am seeing them almost every day.

With regard to treatment, when there is difficulty in urinating
and frequency of urinating during the night, and some amount of res-
idual urine in a man otherwise healthy, I think careful catheteriza-
tion, to remove the residual urine, is the best mode of treatment ;
but that involves the most scrupulous care with regard to cleanli-
ness of the catheter, and is almost impossible of attainment. It is
almost impossible to impre'ss upon the patient himself that scrupu-
lous cleanliness which is so necessary to prevent cystitis. Now, so
long as you can keep clear of cystitis, and so long as you can
remove this residual urine by catheterization, I should certainly
advise against an operation ; but there will almost certainly come
a time when catheterization becomes difficult, when its results are
not so good as they were previously ; in other words, when the
relief afforded is not so great, and then the question of operation
must come up, because that is the golden moment. If you allow
that to pass, you will soon have cystitis, septicemia, pyemia, ure-
mia, if you choose, and death. I can cite you many instances that
have occurred in this city, under my observation, where I have
urged operation. One, the case of a medical man that was well
known to us all here, and who resisted the operation, allowed the
opportunity to pass, and the results followed which always do in
such cases — uremia and death.

Now, with regard to the choice of operation — the kind of opera-
tion. Some ten years ago, I had the honor to invite the attention
of the medical profession in America to suprapubic cystotomy. At
that time, the operation was barely alluded to in our various text-
books. It had not then been done even by some of the great genito-
urinary surgeons of the world, notably such as Sir Henry Thomp-
son, and by none of any eminence or distinction in America. It was
reserved for cases of very large stone, as a last resort. At that
time, in the American Surgical Association, great objection was-



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PROSTATIC DISEASE. 407

urged against it. One gentleman, Dr. Roberts, of Philadelphia,
made the prediction, and stated that he desired to place himself
on record — that before ten years that, viz., suprapubic cystotomy,
would be the received operation. His prediction has been more
than verified. The suprapubic operation is now being done whole-
sale by almost all surgeons of this country, and done very success-
fully by Dr. Hunter McGuire, of Richmond, in just such cases as
this, enlarged prostate ; and he reports the most remarkable suc-
cesses. Dr. Belfield, of Chicago, whose work I am familiar with
and have observed a good deal of it, has been remarkably success-
ful too. The suprapubic route, I think, will readily commend
itself to you all, because you have the advantage of inspection,
and you can reach any portion of the bladder, or any portion of
the prostate, with your finger. The perineal route has some
advantages, but a surgeon must have a much longer forefinger than
I have if he can reach the prostate ; and I do not think one man
in a thousand has a forefinger with which he can reach an enlarged
prostate by the perineal route and be able to make that dilatation
which is necessary. By the perineal route, of course, catheteriza-
tion has to be kept up for some length of time, and the dread of
hemorrhage is not so very great, because a tube can be intro-
duced and surrounded by what the French call the chemise a
cantUey which is made of iodoform gauze, and hemorrhage arrested
in that way without difficulty. But the suprapubic operation
enables you to inspect every portion of the bladder, to reach every
portion of the bladder, and, if prostatectomy is necessary, to per-
form it with very little risk. Suppose, for instance, the enlargement
be of the middle lobe, the enlarged part of the prostate projecting
can be readily pinched off with the forceps, the vesical orifice
dilated with the forefinger, and the patient can, in all probability,
get immediate 'relief. But suppose that the lateral lobes are
enlarged, and lapped over in this way, just as my thumbs here,
lapping over that way (indicating), why, of course, there it
becomes a more difficult operation, and to excise a portion of the
prostate there, is a somewhat serious undertaking, on account of
the hemorrhage. That objection has been met, though, very
beautifully by Dr. Eeyes, of New York, by packing with iodoform
gauze the bladder and carrying a catheter through the urethra,
attaching a thread, and drawing that thread out through the
urethra, so that the bladder can be packed twenty-four hours, and
hemorrhage arrested that way by antiseptic gauze, or iodoform



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408 PROSTATIC DISEASE.

gauze preferably. So that objection is removed. Now, this has
been saccessfuUy done.

Dr. Hartwig referred to Moallin's tables. I think his later
tables give a percentage of 14.3, about the same as by the perineal
route. That shows that increased skill is brought about by
increased experience, as in many other forms of surgical opera-
tion. I will not weary you with reciting cases, but there was one
very notable case that I operated on some four or five years ago,
where the patient suffered intensely from enlarged prostate — a
man eighty-two years of age. I did the suprapubic section, and
established an opening there, and had made at that time a little
apparatus, which I will show you, which has since been improved
on by an Eastern surgeon. Dr. Gerish, I think, of Portland, Me.
This is a little hard rubber drainage-tube, with a flange and cap,
— which was made for me by an electrician in this city — held in
place by an elastic band, and was worn successfully by the old
gentleman for several years afterward. He was a patient of Dr.
Callahan's. I am not sure whether he is alive now, but he was,
three or four years after, in comparative comfort. I think Dr.
Phelps assisted me in the operation. You remember the case,
Doctor ?

Dr. Phelps : Yes.

Dr. Tbemaine : Now, I have had five other cases — none of
that advanced age. A remarkable point of that case is the
advanced age, and the complete comfort that was given the old
gentleman. Dr. Hunter McGuire establishes a fistulous opening
there, and does away with the necessity of the tube ; but I think
this is an advantage, using an instrument of this kind. I think I
may claim to be the originator of this instrument, although it has
since been modified and improved by Dr. Gerish, of Portland. I
wish Dr. Hartwig had quoted, if it is familiar to him, a paper
written recently by Dr. White, of Philadelphia, who has traversed
this whole subject thoroughly, and has elaborated one view, that
which was based on the analogy of these tumors of the prostate,
or enlarged prostate, with hypertrophy of the uterus, and sug-
gested by reduction of hypertrophy of the uterus after removal of
the ovaries.

White made a series of very elaborate experiments on
dogs, and demonstrated beyond question that in dogs the
prostate shrunk after castration ; and it has been suggested
since that castration was not necessary, but that ligature



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PROSTATIC DISEASK. 409

of the spermatic vessels would accomplish the same purpose.
I regret that I did not know this when I was in Egypt last Winter,



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 41 of 78)