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J. A. (Joel Asaph) Allen.

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or I should have made some inquiries with regard to the effect
that was found upon eunuchs, but I have already written to Dr.
Keating, vice-president of the medical college there, and asked him
if he would gather some statistics on that subject, which I hope
in due time to receive. Hunter observed this fact long ago with
regard to the shrinkage of the prostate gland in animals, and the
enlargement of it during the rutting season, so that there seems to
be good ground for Dr. White's view in regard to that. Now, as
to the advisability of doing this. When one considers the suffering,
if it is once demonstrated that that will produce the effect, there
oan be no question of the advisability of doing it, because there is
scarcely any man that would not be perfectly willing to part with
the testicles to get relief from the intense suffering these cases
involve. There might be a great deal said on the subject of palli-
ative treatment, a good deal of caution given with regard to the
use of the catheter, and the dangers of cystitis as the result of it ;
but, as the hour is already late and I have taken up a good deal of
your time, I will make way for others.

Dr. William H. Heath : With respect to Dr. Hartwig's
paper, like Dr. Tremaine, I did not know what was to be talked
about. Dr. Hartwig has covered the whole ground of prostatic
diseases. Some statements are not in accord with my experience.
In the first place, as to prostatic abscesses. I have seen quite a
large number; I have never seen one open through the perineum.
I have seen them open internally and into the rectum, and have
opened them into the rectum myself, but I have never known them
to open elsewhere. The removal of the prostatic gland is ana-
tomically possible ; surgically, it is unjustifiable. Referring to
the most important and the common affection of the prostatic
gland, hypertrophy, there is one part of the treatment that has not
been considered — namely, the preventive and early treatment of
prostatic obstruction in cases of enlargement of the gland. Har-
rison, of London, who has just been quoted, has made prominent
the preventive treatment of obstruction by mechanical dilatation.
It consists in the " maintenance of the waterway," as he calls it, by
the systematic passage of soft bougies, ironing out, or molding
away, as it were, the encroaching mass. The time to institute
this is in earliest stage, when frequency of micturition, and par-
ticularly at night, indicates that the tumor is beginning to inter-



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410 PROSTATIC DI8BA8B.

fere with arination. Its object is to lessen venous congestion, and,
therefore, irritation, and keep the urinary level, thus averting the
serious chain of consequences so likely to ensue. A slight obstruc-
tion does not preclude its employment. The value of this pro-
cedure has !demonstrated itself to me many times, and should be
tried in every suitable case.

Castration, as a remedy for enlargement of the prostate, is, as
yet, an unknown factor. It would seem, however, that when the
conditions were such that a man would be willing to part with
these organs, it would be too late to be of benefit, while, on the
other hand, few would be willing to make the sacrifice for dangers
yet remote and amenable to other methods. It would be valuable
to know how soon and to what extent atrophy follows. Subcu-
taneous division of the vas deferens has been tried.

The question of operation for prostatic obstruction arises in
numerous cases where catheterization is no longer possible. By
what route and what should be done are each in themselves enough
for discussions. The suprapubic, with perineal drainage, is the
accepted one. In general, too much should not be attempted in the
old and feeble, as many of these cases are. Drainage alone often
gives satisfactory relief. The medical treatment of these cases
should not be overlooked by any means. By regulating the diet
habits, and keeping the urine mild and aeeptic by internal admin-
istration of salol, boracic acid, etc., cleanliness, gentleness in use
of catheter, comfort may be had and the dreaded days postponed.
Among the better class, many become more expert than any sur-
geon in manipulating their own cases.

While the importance of gentleness and patience in instrumen-
tation in prostatic as well as stricture cases is generally understood,
cases yet frequently come into the hospital lamentably punished.
It seems almost impossible to some to resist the inclination to use
force.

Dr. W. C. Phelps : I have very little to say on this subject ;
Dr. H^rtwig has so thoroughly covered the ground. I have about
come to the conclusion that Dr. Tremaine has spoken to you about.
I have had occasion, several times, to make suprapubic cystotomy
in cases that have come into the hospital, or that I have taken
there, and up to this time I am sure that I have not tised any other
method, and have not really known any other method to offer any
sort of chance of relief. That it is a very great relief, I am abso-
lutely certain. I have had patients that were utterly miserable in



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PBOSTATIC DISEASE. 411

every sort of way, where they had reached a point where catheter!-
sation was a very painful procedure, where pas was constantly
flowing along the catheter, sometimes where it would flow out from
an over-distention of the bladder, with septic conditions, etc.
Take a case like that and make suprapubic cystotomy. The patient
lies quietly in bed, and, once in a while, is able to get up and go-
around with an apparatus similar to that which Dr. Tremaine has
shown. I have had patients live some time, but I have never yet
run across a case where my patient was able to walk around and
draw off his urine, as Dr. Tremaine mentions in that old Irish-
man. I saw him, and it was certainly a very great relief to him,
and a very remarkable and successful case. Those I have had
have not been so mild as that ; all of them have had pus. I hardly
think that there was any pus in that patient of Dr. Tremaine's ; I am
not quite certain ; but where pus has formed in the bladder I most
always fubeerve more or lass kidney trouble, or something of that
sort, and the patient is pretty apt to pretty soon die.

I had a case, last Summer, of an abscess of the prostate, which
came out in a curious way. It was a case of appendicitis, that came
into the hospital, on which I operated for a very immense abscess,
reaching down into the pelvis. The patient got along very well
at first, and then the temperature commenced to run up again,
with a difficulty of passing the bowels. I put my finger into the
rectum, to see if there was anything .there, and I found an immense
swelling of the prostate. That was excised, and I drew, probably,
a pint of pus.

Then, there is one case, I remember, which was a very remark-
able case of enlarged prostate. I never saw one so marked or so-
large. There was a rim all the way around the internal opening
of the urethra, that is, the neck of the bladder. I think it stood
up, at least, an inch from the wall of the bladder, entirely around.
It was not an enlargement of the middle lobe. It seemed to be an
enlargement of the whole gland, and the only way any operation
could have relieved that man would have been by tunneling down
through the lower part of it. It would have been absolutely
impossible for the urine to have got over that rim ; it seemed to-
project at least an inch into the bladder.

Dr. Mtntbr : In regard to the treatment of those cases of old
gentlemen with the difficulty in passing urine, its getting offen-
sive in smell, and, at last, these other complications — the question
is what to do under those circumstances. Last Summer I got a



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412 PBOSTATIC DI8BASB.

most serioas hemorrhage in an old gentleman, seventy-six years of
age, with an enlarged prostate, and who had catheterized himself
for years. The bleeding occurred and recarred, and was almost
<^lear blood. I syringed it out, and used iodine and gave ergot,
and injected alum and acetate of lead. Then, I got the idea one
day — why couldn't we use antipyrin, as, perhaps, the hemorrhage
was temporary in character and capillary ; and I applied a twenty
per cent, solution of antipyrin, and it checked the hemorrhage
then and there. I used that in three other cases, and in each case
the hemorrhage was stopped short by the use of antipyrin in a
twenty per cent, solution. If this is useful in capillary bleeding,
and stops, for instance, bleeding of the nose and bleeding from the
brain in operations on the brain, I see no reason why it should not
be applicable in such cases as this.

In regard to the operation itself, there is none easier in the
whole range of surgery than suprapubic cystotomy ; that is, on con-
dition that the bladder will contain six or eight ounces of water,
and that you have access through the rectum. First, I generally
dilate the bladder ; it makes it a great deal easier. And I want
to call your attention to the fact, that it is still easier if you inject
air into the bladder instead of water. That is a question that has
been brought up lately, I have forgotten by whom, in cases of
suprapubic cystotomy — simply fill the bladder with air. The air
is more elastic, and does not produce rupture so easily. As far as
the extirpation of the prostate itself is concerned, I have never
-done that operation. I have made dozens of cystotomies probably,
but they -were for other reasons — cancer of the bladder, for
instance, stone, and so on, and in one for a peculiar case of stric-
ture.

Dr. Rochester : There are one or two points I would like a
little information on. Dr. Tremaine, in his remarks, said that
where there was frequent urination in a man over forty years of
age, it was a very probable indication of enlarged prostate. It
seems to me that the first thing I would think of under such con-
ditions would be an investigation of the reaction of the urine, as
to whether that frequent urination might not be due to acid.

I have in mind three cases of men between forty and fifty who
presented this symptom of frequent urination, particularly at
night, which has been corrected by simply correcting the acidity
of the urine.

The next point that came to my mind was this matter of the



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PROSTATIC DISEASE. 419

operation of castration for the cure of enlarged prostate, and the
fact that dogs had been operated apon and it had been shown
that the prostate had markedly decreased in size. I want to ask
whether it is known whether the dogs that were operated on were
old dogs or yoang dogs, and whether that woald not have some
bearing upon the matter of the prostate. In men in whom the
prostate is enlarged to a great extent the function of the testicle
is largely gone, and the question arises whether in those circum-
stances the removal of the testicle would have any effect whatever
in reducing the enlargement of the prostate. Of course, I can>
understand that if the prostate be enlarged in younger men, where
the function of the testicles is markedly present, that it might
have some effect upon the reduction of that swelling ; but in
old men, in whom the function of the testicles is largely gone,,
would it have any effect in reducing the size of the prostate?

Dr. Thornbuey : Along the line of Dr. Rochester's remarks ^
I desire to accentuate the factor of sexual excess as a causative
factor in enlargement of the prostate ; and, in doing that, I simply
expound the views of an eminent Southern surgeon, who has had
opportunities for a very extended observation among colored men,
in whom we all know sexual excess is very frequent ; and he claims
that sexMil excess > is, par excellence, the cause of enlargement of
the prostate, and that the enlargement takes place before the func-
tion of the testicle is materially impaired, and is the direct cause
of the trouble ; and Dr. White's experiments go to fully substan-
tiate this fact, of which he gave a very elaborate account here last
summer, at the meeting of the American Surgical Association.

Dr. Heath : Dr. Tremaine said that enlarged prostate was
not quite so common with young men as with old men, and that is
very true. That is quoted by a good many authorities. There is
no question about it, that every man that has ever lived has com-
mitted sexual excesses. There is no question about the relation
between sexual excesses and enlarged prostate. There is no rela-
tion. That is an exploded idea. In fact, the prostate gland is
not a gland at all, but a muscle, and the hypertrophy might just
as well come from emissions and from sexual excesses. The fact
of sexual excesses I do not think has anything to do with it. I
do not think we know why it occurs any more than we know why
tumors occur in colored women in the uterus ; not a bit. We do
not know the action at all.



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414 PROSTATIC DISEASE.

Dr. Habtwig : Of coarse I have to refute Dr. Tremaine's
statement that I did not mention White's experiiAents on dogs.
That was the very last thing I said. I am sorry that I cannot
answer Dr. Rochester, because I did not see the otiginal account
by White, as to whether those dogs were tested with regard to their
age. Indeed, this is a question of pertinence, I think, as regards
our conclusion concerning men, because it is just as doubtful to
my mind as it is whether castration in old age will have the same
•effects as castration at an earlier age.

The effects of antipyrin, as alluded to by Dr. Mynter, are
•certainly very gratifying in all cases of bleeding, and I should
suppose that it would have a satisfactory effect in the bladder too.
It is certainly in keeping with what I know of the effects of the
antipyrin.

But the essence of what I should have liked to hear from the
gentlemen, I did not hear, and that is what the opinion is in regard
to operating on cases which show only the premonitory symptoms
— the summons to urinate too often at night — simple indications
which cause us to examine for enlargement of the prostate, and
where we do find enlargement, while cystitis does not as yet exist,
and while we know that this very man will, within five, or six, or
eight years, have serious trouble. There it is really difficult to
give advice ; there it is a little difficult to form an opinion ; and
there it is where I could not form an opinion, in spite of studying
the whole literature of the subject. This is a thing which I think
the future must elaborate. The statistics are at present, of course,
too meager to admit of forming an opinion. So I can but say that
I come to the conclusion, after hearing what all the gentlemen
have said, that the conclusions of my paper, the original conclu-
sions, are correct.

Dr. Tbemainb : I would like to have an opportunity. I think
it is very important to answer Dr. Hartwig upon one question,
df the Academy will permit. I do not wish to take up the time, but
I think the matter is too serious to be passed over.

Dr. Hartwig has asked a question which I thought I answered.
I thought I said that when catheterization could be done, and
there was no impairment of the general health, and the patient
•could go right along, and once or twice, or three or four times a
day, remove the residual urine, when there was still no cystitis,
when the health was unimpaired, and practical comfort could
result from that, that was no time for operative interference ; but



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CLINICAL REPORTS. 415

there came a time when that relief did not oome, and when there
was difficulty in getting relief in that way, and that before cystitis
oame on in a marked degree, or sabsequent renal changes or general
impairment of health, then was the time for operation ; and there
€an be no question, I think, about that. So that if Dr. Hart wig is
in doubt, I think that clearly answers the point, and I think that this
is the general consensus of the best surgeons who have studied this
class of cases. I am called almost every day of my life to see such
•oases ; and I advise that operation. The difficulty is to get patients
to consent to it. Only within the last week or two I urged upon
an old gentleman that he have this operation done. He put it off,
and put it off, under the advice of his attending physician, the
general practitioner — who will go along and temporize, and
temporize, and temporize, until the golden opportunity is gone,
and then send their patients in awful suffering into their graves,
when a little operation, timely done, would give them years of
•comfort and life, as I have proved and demonstrated again and
again.

Now, I think the question can be answered, and it is answered ;
and if anybody is in doubt about it, let them call me in in their
practice.



(sfJnicaf J^eporfA,



CLINICAL MEMORANDA FROM THE SURGICAL CLINIC
AT THE SISTERS' OF CHARITY HOSPITAL.

By HERMAN MYNTER, M. D.

Professor of Surgery Niagara University and Surgeon to the Sisters' Hospital.

SYNOPSIS OF ONE YBAR's WORK IN THE HOSPITAL.

During the year 1893, 300 surgical patients, exclusive of gyneco-
logical and ophthalmological cases, were admitted to the Sisters'
of Charity Hospital. Of these, 265 cases were treated in my
service, the rest in the services of Drs. Mickle and Heath. While
this number is somewhat less than in former years, particularly on
account of the largely increased number of injured persons from
the manufacturing districts who seek admittance to the down-
town emergency hospitals, the work has in reality very much in-
•creased, and a much better class of patients, both from the town
and surrounding country, have availed themselves of the, at least



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416 CLINICAL REPORTS.

in Western New York, nnsarpassed facilities of the Sisters' Hospi-
tal. The old repagnance of former years against hospitals begins
to die out, and the community has learned at last that nowhere
can a serious operation be performed with such ease to the
surgeon and safety and comfort to the patients as in a well-con-
ducted hospital. That such is the case is best seen by the large
number of private patients constantly found in the hospital, or wait-
ing for vacant rooms. The hospital has been crowded during the
whole year, 1,755 patients having been treated, vs. 1,678 in 1802, and
in the coming year we hope the other half of the hospital will be
built. It is the intention of the Sisters to finish this largely for pri-
vate patients alone, confining the wards, medical and surgical, to the
old building. During the year, the new aseptic clinic and oper-
ating room, built in marble and cement, has been finished at large
expense. It is unsurpassed in the State of New York, outside
New York City ; thoroughly aseptic, and supplied with every
surgical convenience and appliance. Every wound treated there
has healed by first intention.

By looking over the list of operations performed, 183 in num-
ber, it will be seen how many have been of the cla^s called major
operations, and how small the mortality has been, particularly of
those on whom large operations have been performed.

Two cases died of appendicitis, with general peritonitis, having
been sick, respectively, eight and six days before being sent to the
hospital. In both cases, perforation of the appendix, from gan-
grene, with septic peritonitis, was found. Two similar cases, oper-
ated on second and third day, recovered promptly by laparatomy.

Two cases died after laparatomy, sent to the hospital for
obstruction of the bowels. In one case, the lesion was found to
be peritonitis from ulcerative gangrene of the cecum ; in the other,
extrauterine pregnancy, with rupture of the sac, and enormona
intra-abdominal hematocele.

Three cases died of fracture of thebaseof skull, with contusion
and laceration of brain. One case of double amputation of the legs
died shortly after admission. He had laid during the whole night,
with his legs crushed by a railroad, in a ditch near Tonawanda.

One case died of pyemia, from a deep-seated abscess on the neck;
another from similar cause, from acute infectious osteomyetitis.

One old man, with an enormous inguinal hernia, reaching
almost to the knee, died on the third day after Bassini's operation^
from fatty heart. There was no symptom of peritonitis present.



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CLINICAL REPORTS.



417



A particularly deplorable case was that of a young man, who
entered the hospital on account of acute hydrpnephrosis. A sim-
ple exploratory incision was made in the lumbar region, and a
floating kidney found, which, by twisting, had closed the ureter.
The kidney was fastened by the usual method and the wound
plugged with iodoform-gauze. Much to our surprise and regret,
he died of shock on the second day. l^o postmortem was allowed.
This is the second case only in which death has occurred as the
direct result of an operation during my connection with the Sis-
ters' Hospital.



DISEASES OF BONES AND JOINTS



Abscess of bone

Tuberculous arthritis

Caries

Crushes

Coxitis

Fractures, simple

Fractures, compound

Fractures, comminuted

Fractures, of pelvis

Fractures, of patella

Fractures, of skull

Fractures, of base of skull

Necrosis

Sprains

Synovitis, chronic

Synovitis, tuberculous

Anchylosis

Pes valgus dolorosus

Dislocation, shoulder

Dislocation, thumb

Dislocation, elbow

Periostitis, simple ;

Epiphysitis, tuberculous

Osteomyelitis, acute infectious

Osteomyelitis, chronic

Bowlegs

Vicious union of fracture of femur and tibia

AFFECTIONS OF SOFT PARTS.

Abscesses, acute

Psoas abscesses

DiCfuse cellulitis *

Burns and scalds

Syphilis, primary

Syphilis, secondary

Syphilis, tertiary

Ulcers, varicose

Wounds, lacerated

Wounds, incised

Hernia, Inguinal



I
6
6

7
8

34
3
3

I

2

3
4
5
3

2

3
4

I

2

I
1

7
5
3
5

I

2
lO

4
5
4
3
4
4
M
5

2

8


I
5

2

7

I

27

2
2

I
2

3
I

4
3

I

4

I

2

I

I

6
5

2

5
I

2

9
4
5

2

13

5

2

4


2

4

2

I
2

I

2

4
3

I


I





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418



CLINICAL REPORTS.



DISEASES OF BONES AND JOINTS.



Hernia, femoral

Urinary calculus

Foreign body (catheter) in bladder . .

Acute myositis

Gonorrhea

Hydrocele

Hematocele

Varicocele

Epididymitis, gonorrhoica

Epididymitis, tuberculosa

Strictura, urethra

Strictura, recti

Pyonephrosis, from tuberculous kidney

Hydronephrosis

Urinary fistula

Floating kidney

Obstruction, bowels

Appendicitis

Gastritis

Cleft palate

Contusions

Congelation

Mastitis

Epilepsy

Ulcerating amputation stump

Senile gangr^e

Aneurism, ext. carotid



TUMORS.

Scirrhus

Sarcoma

Epithelioma

Neuroma

Lipoma

Villous cancer of the bladder . .

Fibroma

Hematoma

Lymphadenoma

Ganglion bursa semimembranosa

Hygroma of neck

Atheroma

Gunshot wound of chest ....

Lymphangitis

Clavus .

Abscess of brain

Extrauterine pregnancy ....

Carbunculus dorsi

Subdural hemorrhage

Pleurisy

Empyema

Harelip

Ectropion

Tuberculous glands

Hemorrhoids

Fistula in ano



Total 300



35



«2



u



20 19



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CLINICAL REPORT.



419



OPERATIONS PERFORMED.



i: o

a a



Dbformitibs —

t'lastic operations

Tenotomy

Osteotomy, linear

Osteoclasis

Brissement forcA for anchylosis ....

Harelip operation

8taphyloraphy

AMPUTATIONS.

Arm

Knee

Leg (Sedillot)

Leg (Symes)

RESECTIONS.

Knee

Elbow

Hip

Shoulder

Maxilla sup

Of rib, for empyema

Arthrotomy of elbow, for anchylosis . .

TREPHINING.

For fracture skull • • • . .

For epilepsy

For intradural hemorrhage

Fpr abscess of brain

For acute infectious osteomyelitis . . .

For chronic osteomyelitis

Sequestrotomy

Scraping carious bone

Removad tuberculous osteitic focus . .

TUMORS REMOVED.

Scirrhus of breast

Sarcoma of breast

Sarcoma of neck

Fibroma

Neuroma

Lipoma

Vaginal hysterectomy, for cancer uteri .

Iniiamed lymphatic glands

Hygroma of neck

Ganglion bursa semimembranosa . . .
I Tuberculous epididymitis

OTHER OPERATIONS.

Appendicitis, laparatomy

Appendicitis, extraperitoneal operation .

Laparatomy. for obstruction

Laparatomy, extrauterine pregnancy . .

Herniotomy, for strangulation

Herniotomy, radical cure (Bassini) . . .

Cystotomy, suprapubic

Cystotomy, perineal

Litholapaxy

Urethrotomy, internal



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420



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 42 of 78)