The patients included in class "b" are naturally the legitimate successors of class "a." The same indications for operation prevail. Class "c" comprises the cases par excellence in which nothing but palliative measures should be considered. Fortunately they comprise quite a proportion of cases of enlarged prostate, and while in some of them operation might have beep justified at an early period, it cer thinly is not so at a more advanced period of life as long as measures of palliation keep the patient perfectly comfortable.
In class " ci" are embraced patients in whom the only hope of prolongation of life and relief of symptoms is in operative measures, the character of which is to be determined largely by the local condi tions found at the time of operation.
In class "e" there is to the mind of the author but one indication, viz., suprapubic section with or without operation upon the prostate proper, and invariably with prolonged subsequent drainage. The question of operation upon these patients is determined by the exis tence of the calculus, but modified by the same considerations re garding complications and the strength of the patient, as in cases in which calculus does not exist. It is true that brilliant results are re ported from the operation of litholapaxy in prostatiques. It neverthe less seems to the author less rational and more dangerous upon the average than suprapubic section and drainage, especially if the oper ation be clone in two stages.
The operative measures indicated in hypertrophy of the prostate range in severity from simple suprapubic section and drainage to removal of the hypertrophic tissue, the selection of operation being dependent upon the variety of hypertrophy present, the condition of the bladder and kidneys, and the degree to which the strength of the patient has been undermined by the disease. Simple suprapubic section and drainage is alone to be thought of in quite a proportion of advanced eases with serious complications. A permanent arti ficial suprapubic urethra is the only measure of relief for these cases. The anresthesia, is the feature of the operation most to be dreaded, and where practicable it is advisable to perform the operation in two stages, both being clone under cocaine. Should distinctly cir cumscribed posterior pros tatic tumors exist they should be removed. For this, general ancesthesia is required, and as a rule chloroform is the to be preferred. It is sometimes possible to remove a pedunculated growth with the finger alone. In these advanced cases, however, it is advisable not to perform cutting or tearing operations about the vesical neck. It should be remembered that in these cases a high degree of vesical sepsis exists, and the slightest abrasion of the interior of the bladder is quite a serious matter. In some in stances it is advisable to defer all operative measures at the vesical neck, either permanently or until such time as the bladder and gen eral condition of the patient have improved under the influence of vesical drainage and irrigation. Should prostatotomy or prostatect omy, however, be decided on, through-and-through drainage should be instituted. A perineal boutonniere does not greatly complicate the operation, and is quickly performed, the added security afforded the patient being a sufficient warrant for its performance. In younger subjects, linear prostatotomy, or prostatectomy with through-and through drainage may be undertaken with a much better prospect of cure than in the cases just described.
The most recent operation for the relief of enlarged prostate, cas tration, seems to be meeting with some success. The author has had no experience with it, but it is worth consideration providing the pa tient's virility has 'disappeared, otherwise it is better to construct an artificial suprapubic urethra, with or without operation on the pros tate proper. Castration is an operation not to be lightly undertaken,
as certain historical medico-legal cases have shown. Should future experience demonstrate that it is frequently successful, the surgeon should still exercise the greatest circumspection in the performance of this operation. A patient who appeals perfectly reconciled to the loss of his testes may subsequently look at the matter in a different light. There is a suggestion of grim humor in the new procedure ; the oophorectomy craze of the recent past is still a vivid recollection.
The indications for any particular operations upon the prostate proper are governed entirely by the variety and form of the pros tatic hypertrophy. It is obvious that in quite a proportion of cases of prostatic hypertrophy, the treatment must devolve upon the gen eral practitioner and consist of measures of palliation. The author desires to impress upon the practitioner, however, the fact that the cases in which palliative measures should be selected and relied upon throughout are to be determined only by careful study. Palliative treatment, as a matter of routine, should no longer be accepted as the inevitable in prostatic hypertrophy, excepting under circumstances in which it is impracticable to place the patient under suitable con ditions or in proper hands for operative measures. The palliative measures of treatment necessarily have a more important practical interest to the general practitioner than to the genito-urinary spe cialist. The function of the latter is often that of a consultant only,' the management of the case, if operative measures are not advocated, being subsequently relegated to the family practitioner. Compara tively few cases of such prolonged duration as are those of enlarged prostate remain throughout under the care of a surgical specialist. It is to be remembered that the primary source of discomfort in incipient cases, is irritation of the vesical neck incidental to the hyperaemia and resulting hyperplasia of the prostate and its environs. Hyperacidity of the urine and the gouty or rheumatic diathesis are also likely to exist. Proper measures of treatment to correct the diathetic condi tion and remedies calculated to correct the irritating properties of the urine are always of service. Anaphrodisiac remedies are also fre quently beneficial. The remedies which have proven most service able in allaying vesical irritability are, buchu, triticum repeus, san dalwood oil, copaiva, ustilago maidis, uva ursi, ulmus, and some others of a similar character. No one of these various remedies may be said to be equally satisfactory in all cases. It is very often neces sary to do some experimentation in order to determine which remedy is most efficacious in a particular case. Bromide of potassium and ergot in full doses combined with gelseinium has seemed to be of especial value in the experience of the author. This combination not only has a special effect upon the involuntary fibre and vascular supply of the prostate but also a special action upon hypersexual activity, which probably has much to do with the causation of many cases. The occasional passage of the sound and catheter, usually advised even in incipient cases for the purpose of withdrawing resi dual urine, is beneficial. In incipient cases, however, the benefit is derived, not from the withdrawal of residual urine, which, if it be not infected, has little or no influence upon the irritation present, but by allaying hyperFesthesia of the prostatic urethra.