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

ORIGINAL COMMUNICATIONS. 11
tuber ischii must control this hemorrhage, water, following the operation slaitngs nicrc
as it crushes the artery against its bony will be temporary, for they will take up
background. their duties as soon as the^^ can. if left alone
The incision in the membranous urethra and are not goaded to desperation by the
allows Young's retractor to be slipped into unnecessary use of stimulants,
the bladder and the prostate pulled down The writer has had in this series, three
toward the operator but still covered by the cases of cancer of the prostate which have
muscles and fascia. It is the posterior layer been denied operation. Starting centrally,
of the levator ani, which converging around concer manifests itself only when it has
the anterior margin of the rectum, splits gained sufficient size to obstruct the normal
again and encircles the prostate. These outflow of urine. It is then that it can be
fibres are the rectro-urethralis muscle and felt, per rectum, to be hard, that the gland
must be severed at right angles between the is slightly, if at all, movable, at syrametrirectum
behind and the i)rostate in front to cally enlarged and the finger swept up about
allow the gland to be pulled into view. A the internal ring and the concavity of the
large, flat retractor is put into the wound sacrum, may already notice metastatic enand
shoves back against the sacrum the largement there. As in the operation of pananterior
wall of the rectum. This is the hysterectomy, where the lumbar, retroperikeynote
to the operation. The levator ani toneal and iliac glands must be thoroughly
is now stripped from the median line to removed from beneath the peritoneum which
either side, the retractor pulled down upon, is stripped up, so in its anologue. cancer of
not using it as a lever against the under the prostate, the operation without removal
surface of the pubes to force the prostate of the enlarged glands is palliative only and
into view, but by firm, gentle traction down- cannot prolong life for any great length of
wards. With gauze, the surrounding ves- time. Again, when springing ])erii)herally,
sels and small structures are stripped back it soon manifests itself by the ulcerations in
and tiie sheath formed by tlie recto-vesical the rectum and bladder. The escape of
fascia is incised in the middle line, the fin- blood is large and uncontrollable. The
ger inserted between it and the capsule, and measures now adopted are for the relief of
the gland is ready for partial or total enu- the hemorrhage and pain, and not for the
cleation. relief of the condition.
We have already mentioned that the peri- The writer has sent letters to each patient
prostatic plexus of veins runs in tlie sheath of the series, and about .SO jiercent. have so
laterally andmesially. l"ew veins are found far replied. One says that he still has some
inferiorly, The sheath, then, may be in- leakage through the perineum. This parcised
in the middle line, strii)ped from the ticular operation was performed 17 months
capsule and, carrying with it the veins, ago. Two say they have to get up at night
there is no trouble about any great hemor- to urinate. In no instance was there an
rhage for they are still left behind intact, injury to the rectum. One states that he
\ large perineal tube, 2S I"., is inserted in has not lost his courage; one that he drips
the membranous urethra, the bladder irri- some after he passes his water. The latter
gated with a clierry-red iodine solution, the was a suprapublic evacuation en masse, a
wound sewed in layers, a small strip of one- thorough control of the sphincter never havfourth
inch gauze brought up on either side ing been established,
for the escaping serum and drainage, the In conclusion, the writer would call atskin
sewed together tightly and the patient tention to a complete prostatectomy as a
returned to bed. radical cure for chronic, relapsing, gonor-
In criticizing the operation as now per- rheal prostatitis. In this instance, the
formed in most of the hospitals, the writer young man contracted gonorrhea 10 years
would call attention to the fact of insuffi- ago. Since then, he has had innumerably
cient preparation of the operation. When outbursts characterized by severe diswe
recall that the back pressure which has charge, frecjuent and painful urination and
been maintained for so many years, is sud- relapsing epididymitis or epididymo-ordenly
removed, the necessary hypersemia cliitis. The prostate was moderately enand
congestion wliich follow the relief of larged, boggy and painful. Massage exthi
smechanical obstruction does not allow pressed on each occasion, pus cells, gonoof
the functional capacity of the organs in- cocci and broken-down products. Sitz-tubs
volved. l"or this reason, drugs are used to and rectal irrigations were religiously carstimulate
these congested organs. The ried out at each erujjtion, until wearied with
writer does not believe that this is based the fre(|uency of the attacks and underupon
the liest therapeutic principles. If standing that the source of infection was
before the operation the alimentary canal is the prostate, through realizing the severity
emptied f)f its contents, the kidneys helped of the operation, he willingly subject
to activity by drinking large