TREATMENT OF THE HYPERTROPHIED PROSTATE.
Until within recent years the treatment of hypertrophy of the prostate embraced only measures of palliation. Internal medication and treatment by pressure in the hope of absorbing the adventitious tissue composing the overgrowth had alike proven ineffectual. Rad ical methods of surgical relief were considered inapplicable. In the minds of a large percentage of the profession this same view holds at the present day. In the light of the developments of modern aseptic surgery, however, particularly in the direction of operations upon the genito-urinary tract, this old-time view should be abandoned. The author has no desire to foster a spirit of surgical hyperactivity, but he is firmly convinced that there is a wide field for judicious operative measures in the treatment of hypertrophy of the prostate. It is of course admitted that radical measures are not applicable to all cases, but it is also claimed that the results of operations by surgical routinists should by no means be taken into consideration. In cer tain quarters it is held that surgical intervention is not to be thought of until the patient is in such a desperately bad condition that oper ative measures afford very little prospect of success. The surgery of the prostate has never been given a fair opportunity for development. The cases which are submitted for operation are usually those in which all other measures of treatment have not only failed but com plicating conditions have arisen which seriously enhance the dangers of operation. Operative statistics based upon the results obtained in the class of patients upon whom we at present have the most frequent opportunities of operating are practically worthless excepting in so far as they bear upon the radical cure or recovery from the operation in a particular class of desperate cases. With a proper understand ing of the limitations and indications of the operation and a judicious selection of cases there is no reason why early operations upon the prostate should not yield excellent results. In the opinion of the author, radical operations upon the prostate would be comparatively safe if performed prior to the development of septic complications or renal disease—i.e., if performed at a comparatively early period after the development of the urinary obstruction. A fairly good prospect
of success, sufficiently good to warrant operative interference, exists even after vesical complications have arisen, providing the kid neys have retained their structural and functional integrity. Inas much as mechanical obstruction and sepsis sooner or later cause serious vesical and renal conditions in by far the majority of prosta lives, it is evident that operation should be done much earlier than is usual. In a work designed for medical men rather than surgeons elaborate descriptions of operations would be out of place. Some general considerations, however, may be of value.
From an operative standpoint cases may be divided for consid eration into : (a) Incipient cases in men of moderately advanced age with com paratively healthy bladder and kidneys.
(b) Advanced cases in patients of otherwise rugged health in whom the renal function appears to be properly performed, the blad der not being seriously involved, but in whom there is a progressive increase of urinary obstruction.
(c) Marked cases in subjects of advanced age in whom serious renal and bladder complications exist, but in whom palliative meas ures are successful.
(d) Advanced cases irrespective of the age of the patient in whom serious complications exist, but palliative measures are of no avail.
(e) Cases complicated by vesical calculus.
In class "a" we have to deal with men of middle age or beyond it in whom symptoms of urinary irritation and obstruction have just begun. Measures of palliation, with strict attention to the rules of genito-urinary hygiene and the occasional passage of the steel sound, may allay the irritability of the vesical neck and either greatly retard the advance of the hypertrophic process or practically prevent it. In some instances these measures of palliation are so signally success ful that operation is not to be thought of. Where this is not the case, however, or where after moderately successful palliation for a period of months or years the urinary obstruction and irritation in crease or attacks of retention come on, surgical interference is justi fiable and should be performed before serious vesical and renal com plications have time to develop, and while the constitution of the patient remains practically unimpaired by vesical irritation, chronic urinary fever, loss of sleep, etc.