Vol. 60, 1909 - University of North Carolina at Chapel Hill

10 THE CHATLGTTE MEDICAL JGURXAL
slryclniiiie, enforced rest for several days moval en masse, is not touched; a large
before operation, persuasively prepare the drainage tube is inserted and the usual
organs, heart, kidneys and bladder for the after-treatment is carried out.
coming insult of the operaiion. By Bry son's subprapubic method, the
Since about 1887, when it was first ap- wound is packed with vaseline and iodopreciated
and anatomically understood that form gauze. His results have been most
the prostate could be removed, there have encouraging, he claiming that impotence,
been many suggestions, innovations and urinary fistulse and incontinence are not so
modifications about the course of and the frequent as by the perineal route. This
best method to do away with this overgrow- operation, however, is primarily contraining
pathological hypertrophy. dicated in very fat persons and in con-
It is with no fear that most surgeons will tracted bladders.
boldly enter the peritoneal cavity, and un- The writer has had no absolutely satissex
a woman by removing her uterus and factory syphon age of the bladder after the
appendages, or uterus alone, for a poor, suprapu1)ic removal, the constant leaking
little unoffending, subperitoneal oi mural and excoriation of the skin being sources of
fibroid, and yet, when it comes to their own considerable discomfort to the patient,
sex with the operation outside the peritoneal By the perineal route, the mortality at
cavity, the urinary channels olDStinately the hands of the various operators is 5}4
blocked to the passage of urine, the patient percent., or one-half that of the suprapubic,
house-ridden and a source of ammoniacal The operation is extra-peritoneal, and in a
annoyance to himself and friends, the sur- field where nature has been peculiarly gengeon
hesitates, since the operation, though erous in her blood supply. This means an
not attended with any unusual risk, "emas- early union and a quicker repair. It does
culates, " does away with procreative pow- not seem to be thoroughly understood how
ers and, consec|uently, should be most cau- the prostate can be removed from around
tiously considered. Surgical measures de- the urethra without injuring the tube. The
vised for the relief of this condition have writer would liken it to a tunnel, with its
been many: Prostatic dilatation; Ilawley's appropriate masonrj', going through a
suggestion of doing away with the pelvic mountain; the mountain might be removed
floor; Bier's iliac ligation; Ilelferich's re- and still leave the tunnel with its masonry,
section of the vas; White's castration; The trouble is, however, that the line of
Ridygier's resection; Delageniere's luxa- cleavage is not accurately determined, and
tion of the prostate; Dittel's coccygectomy in the haste of the operation the mountain,
followed by prostatectomy; Ismardi's ex- tunnel and all are taken away. The hull
cision of the vas, leaving testicles; Bottini's is left— it is extraperitoneal, it is outside
urethral cauterization; Chetwood's canter- the bladder—the floor of the bladder has
ization; transvesical prostatotomy; subpra- not been injured or torn, union is happy
pubic prostatectomy and parineal prosta- and results are good. By the suprapubic
tectomy are some of the most important. It route, the hole left behind must permit of
is Mr. b'reyer, of London, who, having for leakage and extravasation with consequent
many years operated at St. Peter's Hospital chances of infection.
for stone, now leads the subprapubic school The writer believes that the inverted Y,
for the radical attack on the prostate. The starting well anteriorly with the divergent
mortality gathered from the many opera- branches on either side of the anus posteritors
who remove the prostate by this route orly, is the incision of choice. It is carried
is about II percent. down upon the bulb which is now better
Having had the opportunity to observe dissected and turned to one side than inthe
operation of Mr. Iacro-sciatic ligament. It now breaks
method of choice, in the last 17 cases the into several divisions," and running centralwriter
has performed this operation alone, ly, spreads out upon the perineum. This
.\s IS tlie danger to the peritoneal cavity in artery being cut, has retracted deeply and
the subprapubic method, so is the danger more than once caused serious and fatal
to the rectum in the perineal method. By hemorrhage. The writer would call atlen-
!• reyer's method, the resultirg blood-clot in tion to its anatomical location. Pressure
he sheath caused by the subprapubic re- firmly applied to the inner surface of the