PROSTATECTOMY must always be re garded as a formidable operation. There are rare cases in which a pedunculated ,growth of the middle lobe or a more or less circumscribed enlargement of one portion of the prostate may be easily and safely removed through a suprapubic opening. The removal of the entire gland either suprapubically or by the combined suprapubic and perineal meth ods is often a slow and tedious procedure -and one which is usually attended with severe haemorrhage. The class of cases in which this operation may be recom i mended includes those who are still com I paratively young and active, whose pros •tates are of the harder variety, and in whom castration is not to be mended for sentimental reasons, or be cause of the age of the patient.
In operating for the radical treatment of prostatic hypertrophy the patient is placed flat on his back; the bladder is carefully washed out, and then left mod erately distended, to the extent of from eight to twelve ounces. Then the blad der is opened suprapubically. The fore finger of the left hand is now introduced into the bladder, the location and extent of the prostatic obstruction are deter mined, and the vesical opening of the ure thra is located. In the right hand is grasped a pair of serrated-edged scissors with a long handle. These scissors are slipped along the left forefinger to the urethral opening, and are made to cut through the bladder-wall in that region. The cut extends from the lower margin of the internal vesical opening of the ure thra backward for an inch to an inch and one-half.
Then one of the forefingers is slipped through the vesical hole made by the serrated scissors, while at the same time the fist of the other hand makes firm counter-pressure against the perineum. By means of this counter-pressure the prostatic growth iS brought well into the reach of the forefinger, which is employed all this time in enucleating the prostatic obstruction, en snasse or piece piece. Enucleation should not be desisted from until all the lateral and median hyper trophies, as well as all hypertrophies along the line of the prostatic urethra, have been removed.
A perineal section is then made, and a large-sized (No. 26 American) soft-rubber tube is passed through the perinea] cut, and the cut through which the prostate was enucleated, into the bladder. After
this, hot-water irrigation is employed for some minutes, to wash out blood-clots and to stop oozing. Then the suprapubic wound is closed by a deep layer of catgut sutures, which include the bladder-wall, and by a more superficial layer of silk worm-gut (Florentine) sutures. About in the middle of the cut the catgut stitch is omitted and a deep Florentine-gut su ture is taken, which includes the vesieal wall and the whole extent of the lateral abdominal wall. This suture is not tied at the time of operation, thus allowing a rubber suprapubic drainage-tube to re main temporarily in position. At the end of four or five days this suprapubic drain may in most instances be removed: then this ligature can be tied. It is best not to remove these Florentine sutures till after the patient is up and about. One should avoid operating on individ uals in whom the large surface arteries are felt to be atheromatous except for the relief of suffering, since the chance is against their recovery. Fuller (Med. Record, Nov. 19, '9S).
In obstructive prostatic enlargement, perineal prostatectomy, combined with suprapubic cystotomy with perinea] drainage, as devised by Alexander, is the best method so far practiced. The peri nea] wound is dressed, as is usual, after perinea] section. The after-treatment consists in daily washing the bladder, the fluid being injected into the suprapubic tube. The suprapubic tube is removed on the fourth day and the lower tube three days later, after which the bladder is washed by a catheter passed through the perineum. A full-sized sound is passed at the end of the second week, and every five days until the perineal opening closes. Both wounds have usually healed in the course of five weeks. lf prostatectomy he resorted to earlier in the disease, while the patient's general condition is still good and while the bladder is not yet in fected, and the ureters and the kidneys are still in a healthy condition, the mor tality from the operation will be very considerably diminished; and a prostate thus successfully operated upon may be practically relieved or entirely cured of this most baneful disease. Parker Synis (Annals of Surg., Mar., '99).