REPRINTED RROM 
ANNALS 
SURGERY 
L.S PILCHER A M. M D. 
FREDERICK fREVES. F.RCS, 
EDITED BY 
). WILLIAM WHITE. M.D 
WILLIAM MACE WEN. M.D, 
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UNIVERSITY OF PENNSYLVANIA PRESS. 
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JUNK, 1890 
FURTHER EXPERIENCE IN THE EFFECT OF THE 
SIMULTANEOUS LIGATION OF BOTH INTERNAL 
ILIAC ARTERIES FOR HYPERTROPHY 
OE THE PROSTATE GLAND. 
By WILLY MEYER, M.D., 
OF NEW YORK, 
Professor of Surgery at the New York Post-Graduate Medical School and Hospital; Attending Surgeon to 
the German and New York Skin and Cancer Hospitals; Consulting Surgeon to the New York Infirmary. FURTHER EXPERIENCE IN THE EFFECT OF THE 
SIMULTANEOUS LIGATION OF BOTH INTERNAL 
ILIAC ARTERIES FOR HYPERTROPHY OF 
THE PROSTATE GLAND.1 
By WILLY MEYER, M.D., 
OF NEW YORK, 
PROFESSOR OF SURGERY AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL 
AND HOSPITAL; ATTENDING SURGEON TO THE GERMAN AND NEW YORK 
SKIN AND CANCER HOSPITALS; CONSULTING SURGEON TO THE 
NEW YORK INFIRMARY. 
FOR many years the subject of the radical cure of hypertrophy 
of the prostate has been under discussion, and that with 
good reason. The troublesome retention of urine, resulting 
in almost every instance, sooner or later requires relief. When 
the patient has become tired of using the catheter or unable to 
enter the bladder with the same the surgeon will be called upon 
to bring help. He now can try to treat the trouble symptomati- 
cally or he can strive for a radical cure. In other words, he 
either will establish permanent drainage, in order to eliminate the 
worst symptom, “ retention,” and thus improve or even cure other 
dependent symptoms, or he will perform an operation with the 
outspoken purpose to reduce the size of the prostate gland, and 
thus remove the obstacle to the outflow of urine at the neck 
of the bladder. Suprapubic drainage has been wonderfully im- 
proved lately. The method of Witzel, who establishes an 
oblique canal through the wall of the bladder by burying the 
1 Read before the Section on Genito-Urinary Surgery of the New York Academy 
of Medicine, December II, 1894. The publication of this article has been purposely 
delayed. The author wanted to gather, if possible, some more personal experience 
with reference to the value of the operation in question. As no suitable cases, how- 
ever, were encountered, in which this mode of procedure was applicable, the article 
is now published as read fifteen months ago. WILL Y ME YER. 
tube in the latter by an ingenious mode of stitching, makes a 
water-tight fistula from the beginning.1 Prolonged suprapubic 
drainage will, however, only very exceptionally influence the size 
of the hypertrophied prostate gland. In almost every instance 
the patient has to wear the permanent catheter for the remaining 
part of his life. If he fails to be clean, when changing the tube, 
he will infect or reinfect his bladder and often also the generally 
dilated ureters also the pelvis of the kidneys, etc. 
Therefore, if there be a way of reducing the size of the 
hypertrophied prostate and therewith re-establishing the normal 
outflow from the bladder, this way should be proposed after care- 
ful consideration of the given case. 
That this is feasible by surgical interference only is self 
understood.2 
Multiple are the operations proposed for attacking the 
swollen prostate. 
Omitting consideration of prolonged drainage of the blad- 
der with a very large tube through the median incision, with or 
without prostatotomy and overstretching of the prostatic urethra, 
a treatment which, in my estimation, can produce a passing 
favorable effect only, we can divide the operations devised for the 
purpose into two classes. 
(1) Those in which the operation attacks the gland directly. 
(,a) Through the urethra. 
A groove is burned into the gland with the help of a gal- 
vano-cautery porcelain burner (Bottini). 
(b) By the sacral route, so-called lateral prostatectomy 
(Von Dittel). 
1 The operation was originally devised and performed for making a gastric fistula, 
Centralblatt fur Chirurgie, 1891, p. 601. See also Willy Meyer, “ Recent Methods of 
Gastrostomy for Stricture of the CEsophagus,” American Journal of the Medical 
Sciences, October, 1894. 
1 Lately, English, of Vienna, studied the influence of the internal use of pros- 
tate-tablets (made from the gland of bullocks) on the hypertrophied prostate in nine 
patients (Wiener klinische Wochenschrift, 1896, No. 4,p. 66). The results have not 
yet been striking: treatment is continued. So far he saw less frequency of micturi- 
tion, especially during daytime; smaller amount of sediment and albumen in the 
urine; less trouble in emptying the bladder. English, therefore, proposes to try this 
palliative treatment in patients who have yet little trouble and no residual urine. ILIAC LIGATION FOR PROSTATIC HYPERTROPHY. 
3 
(t:) Through the suprapubic incision. 
The gland, especially its middle lobe, is nipped away piece- 
meal with the rongeur forceps, or a wedge is cut out with scis- 
sors, or it is destroyed with Paquelin’s cautery or the galvano- 
cautery. 
I omit perineal prostatectomy after the median incision, no 
doubt a most uncertain operation. 
(2) Those operations in which we try to reduce the blood- 
supply of the swollen organ, and by that means cause atrophy. 
This can be done— 
(a) Indirectly, by removing the testicles (Lannois, Ramm, 
Haynes, White).1 This explanation of the curative influence of 
castration upon the swollen prostate gland—namely, the perma- 
nent removal of “ the frequent, intermittent, active hyperaemia of 
the genital system, which is produced by the presence and secre- 
tion of the testicles by nervous reflex”—seems to me the most 
plausible one. I have mentioned it before.2 
(b) Directly, by ligating the arteries which feed the prostate, 
—that is to say, simultaneous ligation of both internal iliac arteries 
(Bier’s operation).3 
It is this latter procedure which I am going briefly to con- 
sider in this communication from personal experience. 
I take it for granted that the members of the section are 
acquainted with Bier’s original article on this procedure, also, 
probably, with a brief article of mine which deals with the same 
subject, and appeared in the July issue of the Annals of Sur- 
gery, 1894. 
On April 8, this year, I presented to the New York Surgical 
Society my first patient on whom I had performed the operation 
under discussion. 
1 Since December, 1894, the following substitutes have been proposed for this 
operation: unilateral orchidectomy; double ligature, and division, evulsion, subcu- 
taneous incision of the vas deferens. 
2 Annals of Surgery, 1894, Vol. xx, p. 50. 
3 I was astonished, when reading Dr. White’s thorough and most valuable arti- 
cle, “ The Results of Double Castration in Hypertrophy of the Prostate,” Annals OF 
Surgery, July, 1895, to find, in his compilation of the various procedures of surgical 
treatment of the hypertrophied prostate up to 1895 (pp. 33-35), Bier’s operation noj 
even mentioned. 4 
WILL Y ME YER. 
Case I.—Man, aged fifty-five years, very fat, syphilitic, re- 
peated gonorrhceic infections; absolute retention for six months; 
severe purulent catarrh and atony of the bladder ; bilateral pyelitis. 
Operation October 5, 1893. 
Left side; patient on his back. Incision five to six inches long, 
slightly convex outwardly from a point about two fingers below the 
tip of the eleventh rib to a point corresponding to the junction of 
the middle and outer third of Poupart’s ligament. Internal iliac 
artery easily reached. 
It was difficult, however, to expose it conveniently for splitting 
its sheath. The latter was done with a curved scalpel, which had 
been handed and used by mistake. Haemorrhage, when surrounding 
the vessel with the aneurism needle. Division of the artery. Repeated 
trials securely to ligate the proximal cut end of the artery, and thus 
check a stubborn haemorrhage coming from the same, failed. Clamp 
put on and left in place for safety’s sake on proximal and distal end 
of the artery. Partial closure of wound at both ends by buried cat- 
gut sutures, layer by layer. Loose tamponade around forceps. 
For the operation on the right side, patient was transferred upon 
a table permitting of Trendelenburg’s posture, Incision down to 
the peritoneum, the patient being in horizontal position. When 
dividing the transversalis fascia the tightly-adherent, very thin peri- 
toneum is injured in two spots. The very small wounds are sewed 
up at once. The wound having been sufficiently deepened to the 
parietal peritoneum in its entire length, the pelvis of the patient was 
raised to an angle of about seventy degrees. Access to the vessels 
thereby greatly facilitated. Yet, on account of the direct descent of 
the internal iliac into the true pelvis, after its branching off from the 
common in this case, the two ligatures could not be placed in proper 
distance in order to divide the artery between them. Two stout cat- 
gut threads were therefore tied around the internal iliac artery about 
one inch apart, trusting to the occlusion of the vessel by thrombus. 
No division of the artery. Wound closed entirely without drainage, 
stitching layer by layer. Primary union of wound on right side. 
Clamps removed on left side on the fifth day. On the twelfth day 
after the operation secondary arterial haemorrhage. This came, as it 
was found at the subsequent operation, from a necrosed spot in the 
anterior wall of the external iliac artery caused by pressure of the 
forceps, which, as stated, had to be left in place. Ligating of the 
common iliac artery with silk close to the aorta, catgut having cut ILIAC LIGATION FOR PROSTATIC HYPERTROPHY. 
5 
the arterial wall repeatedly, and of the distal end of the external 
iliac artery with catgut. Loose tamponnade of the large wound. 
The ligature of the common iliac caused gangrene of the toes and 
a part of the metatarsus, which latter necessitated partial amputa- 
tion of the forefoot. The large wound in the groin healed slowly 
by granulation. 
(а) “ Result of the operation,” as far as the size of the prostate 
is concerned. 
Six months after the operation the prostate on rectal palpa- 
tion is almost normal in size. The length of the urethra, which 
was twenty-three and a half centimetres before the operation, has 
been reduced to twenty-one and a half centimetres. 
(б) Functional result of the operation with reference to mictu- 
rition. 
Twelve hours after the operation the patient began to pass urine, 
two ounces, in a very fine stream, voluntarily, for the first time within 
six months. During the following fifteen days he frequently voided 
small quantities through the urethra, but also had to be catheterized. 
Eighteen days after the operation he commenced to pass larger amounts 
at a time with a satisfactory stream ; largest quantities on October 25, 
—550 cubic centimetres. He urinated every one to two hours. On 
October 26, three and a half weeks after the operation, 130 cubic 
centimetres having just been voided, the catheter withdrew 730 cubic 
centimetres of residual urine. Two days later 225 cubic centimetres 
were voluntarily passed at 1 a.m., iio at 3 a.m., and at 5 a.m. the 
catheter withdrew a full quart of water. The muscular power of the 
bladder evidently was greatly reduced (atony). Yet continuous re- 
tention did never set in again, after the operation had been per- 
formed. As soon as the foot had healed, and the patient began to 
walk about, he regained better power over the bladder. On April 
28, when leaving the hospital, patient was able to hold his urine two 
to four hours, and then pass ten to twelve ounces in a forcible stream. 
Still the bladder, when tested, always showed a residual urine of 300 
to 750 cubic centimetres. I am convinced that atony was the only 
cause of the patient’s inability to completely empty the viscus. 
Three months ago the patient, who resides in the South, returned 
to New York and to the German Hospital. A wound on the outer 
side of his foot, firmly healed after he had left the city five months 
ago, had reopened. He had not used the catheter so far. He voided 
the urine about every two hours during the day and three to four 6 
WILL Y ME YER. 
times during the night. The rest at the hospital acted unfavorably. 
The frequency of micturition increased, the quantity passed each 
time correspondingly decreased; retention again set in, when with 
slowly rising temperature an abscess formed in the left hypogastric 
region, caused by the silk ligature around the common iliac. The 
ligature was discharged with a large amount of pus. The wound is 
now, December 6, almost healed : prostate only very slightly en- 
larged. There is no doubt in my mind that the complications in 
this case have materially marred the result of the operation. Espe- 
cially detrimental to a proper contraction of the atonic bladder 
wall must have been the suppuration in the retroperitoneal space ; 
the abscess at its lower end presented a regular purulent pericystitis. 
Case II.—Man, aged sixty-three years; uneducated, deaf, very 
anaemic ; hypertrophied prostate ; absolute retention for three months 
as far as it could be ascertained. At time of admission bladder 
reaches the umbilicus. Mercier’s elastic catheter refuses to enter the 
bladder. I succeeded with Trendelenburg’s prostatic catheter sound, 
modified by myself. A slight haemorrhage and some rise of tempera- 
ture followed. 
In view of the difficult catheterization and the social condition 
of the patient—he lived alone with his aged wife—I deemed it best 
not to establish a suprapubic fistula. Could I have had the chance to 
properly explain the pros and cons of the contemplated operation to 
the patient and his wife, I believe castration would have been my 
choice in this case. But under the circumstances the medico-legal 
aspect of this interference prevented me from doing so. 
I therefore resorted to Bier’s operation. On May 21, 1894, 
patient being in a slight Trendelenburg’s posture of about 30 degrees, 
I cut down to the parietal peritoneum under aseptic precautions. It 
was apparent to everybody present how easily the peritoneum could be 
stripped from the transversalis fascia in this posture as soon as the 
latter had been incised by a small cut. Air was at once aspirated 
into the properitoneal space. Although there was not a particle of pro- 
peritoneal fat, the finger of the left hand could be gently pushed for- 
ward under the fascia and the latter then divided on the same. I think 
this point of putting the patient into Trendelenburg’s posture of about 
30 degrees, when dividing the abdominal layers, is of importance. 
It certainly saves time and guards against injuring the peritoneum. 
If properly adhered to and carried out, it will prove of benefit in all 
operations where we have to enter the retroperitoneal space. As soon ILIAC LIGATION FOR PROSTATIC HYPERTROPHY. 
7 
as the peritoneum was exposed the pelvis was raised to an angle of 
about 75 degrees. Now all the retroperitoneal tissues, even those of 
the true pelvis, were easily accessible to my hands and eyes. The large 
vessels were not atheromatous as far as could be felt, but soft and 
elastic. As proposed in my former article,1 I did not open the sheath 
for a greater distance in order to divide the artery between two catgut 
ligatures. I used silk and tied the artery only once after having 
opened its sheath. Not a drop of blood was lost during these 
manipulations. Sponging was not needed. The pelvis then was again 
lowered to the original angle (30 degrees), and the peritoneum allowed 
to drop back in its place. The wound was closed with catgut (con- 
tinuous suture) layer by layer. Dressing with iodoform gauze and 
collodium. The same operation was at once done on the other side 
with equal satisfaction. There was not the slightest shock afterwards. 
Time of operation just one hour. Healing of the wounds ideal. No 
rise of temperature. On account of patient’s deafness all inquiries 
must be made in writing. This made the after-treatment very annoy- 
ing. On the third day after the operation the patient began to develop 
subnormal temperature without any apparent cause. This phenomenon 
increased in spite of suitable treatment. Patient died in a comatose 
condition seven days after the operation. 
A very limited autopsy only was permitted. Primary union of 
the wounds ; the internal iliac arteries did not show arterial sclerosis. 
However, one common showed an atheromatous, macroscopical 
deposit. Silk ligatures aseptically healed in place. On the one side 
no thrombus whatever in the artery on either side of the ligature. 
In the other one a thrombus three-quarters of an inch to an inch in 
length had formed in the afferent and efferent part of the vessel. It 
was adherent to the wall; it did not reach up to the bifurcation of 
the common. 
Functional Result.—Patient voided his urine in a fine stream a 
number of times during the night following operation, also on the 
following days. Retention did not set in again. 
Case III.—Man, aged sixty-five years; syphilitic; prostate 
uniformly enlarged ; its upper edge can be reached by rectal palpa- 
tion ; length of urethra, twenty-two and a half centimetres; retention 
for two weeks. 
July 19, Bier’s operation in the posture as described above. 
1 Annals of Surgery, 1894, Vol xx, p. 49. 8 
WILL Y ME YER. 
Right Side.—The large vessels having been exposed, it was seen 
that the common and external iliac arteries were slightly atheromatous 
but pulsating. The internal iliac artery, of the size of an ordinary 
lead-pencil, appeared to be in a state of pronounced arterio-sclerosis. 
Its pulse could not be seen nor could it be felt. The silk ligature, 
after having been thrown around the vessel, did not break the cal- 
careous shell of the latter’s wall in spite of my steady, strong pull. 
Having my former experience, the haemorrhage, in mind, I now, I 
fully confess it, did not venture to force my way through. The 
vessel thus remained untied. The ligature was left in place and the 
wound hermetically sealed. 
Left Side.—Exactly the same condition ; common and external 
iliac artery pulsating; internal iliac presenting a cord, which did 
not change its calibre whatsoever. In order not to have done the 
work entirely in vain, I this time ventured to pull on the silk ligature 
with sudden short jerks. To my delight the hard adventitia gave 
way; the artery was successfully tied. Haemorrhage did not set in. 
Suture and dressing of the wound as usual. 
I regret to-day that after this experience I did not at once re- 
open the wound on the right side and perform the same manoeuvre 
in tying the vessel. The operation would then undoubtedly have 
been successful on both sides, and the patient most probably better 
off than he is to-day. As it were, only the left internal iliac was 
tied. 
I wish to emphasize here that the internal iliac arteries were 
by no means thrombosed. This was shown by the ligature on the 
left side, which deeply constricted the vessel. There merely was 
such an exceptionally marked arterio-sclerosis that the pulse as such 
had ceased. The calcareous shell in its tight grasp around the vessel 
was stronger than the heart’s action of the patient. Time of opera- 
tion fifty-five minutes. The wounds healed kindly without the 
slightest reaction. Patient was up and about on the fourteenth day 
after the operation. 
The functional result of the operation, however, was nil. Reg- 
ular catheterization was required. When after four weeks no improve- 
ment with reference to micturition had taken place, I gave in to the 
patient’s earnest demands, and established a suprapubic fistula ac- 
cording to Witzel’s method. It proved to be water-tight from the 
beginning, and functionates very satisfactorily up to date. Patient 
removes the stopper on catheter every three or four hours and empties ILIAC LIGATION FOR PROSTATIC HYPERTROPHY. 
9 
the viscus. Since the end of September a small quantity of urine can 
be voided through the urethra. On October 29 he passed in my pres- 
ence twenty-five cubic centimetres through the normal channel and 
per catheter 125 cubic centimetres. (Proportion = 1 : 5.)1 
But what appears to be, in spite of the functional failure of the 
operation, of the greatest interest and, I believe, of importance, is 
the fact that on rectal examination the left lobe of the prostate is 
almost one-third the size of the right one. On the left side the inter- 
nal iliac artery had been successfully ligated. This phenomenon— 
the decrease in size—was already well marked four weeks after the 
first operation ; it is still more pronounced to-day. It proves that 
the ligation of the internal iliac artery really caused atrophy of the 
respective side of the prostate gland. Under the 9th of December 
he writes me from a town in Pennsylvania, where he lives, that he 
now passes “ very much water through the penis.” 
In reviewing the many questions which present themselves 
as a matter of fact, on considering this new and fascinating oper- 
ation, I shall pick out a few only, trusting that the discussion 
may bring out yet others. 
(1) Does simultaneous ligation of both internal iliac arteries 
deserve a place among the operations for the radical cure of the 
hypertrophied prostate gland ? 
The result of my three cases, just related, with reference to 
the radical cure of the trouble, I fully admit, is far from being 
brilliant. One patient was only partially improved ; one died of 
unknown cause, just seven days after the operation; the third has 
not been improved at all. However, in order to be just, it should 
not be forgotten that the first case was a complicated one from 
the beginning, the secondary haemorrhage, the long confinement 
to bed on account of the nutritive changes in the foot following 
ligation of the common iliac, recurring within the last weeks, the 
formation of the retroperitoneal abscess due to the fact that the 
1 October 29 : the vesical fistula is absolutely water-tight. Now nine ounces can 
be filled into the bladder, the patient standing, and not a drop escapes along-side the 
catheter. The bladder when being stretched to this extent empties itself through the 
urethra at short intervals. Two ounces can be held in the bladder when the catheter 
is removed and there is no leakage from the fistula. If more water be poured in 
it runs out. 10 
WILL Y ME YER. 
silk ligature had to be left behind in the depth of a suppurating 
wound, all these annoying accidents naturally must interfere with 
the functional result. Yet I believe that after a while it will be 
found that the operation has not been done in vain. If in this 
case somebody wants to find fault, it should be with the oper- 
ator, but not with the method. Whether in my second patient 
the operation was the immediate cause of death I should not ven- 
ture to decide. I for my part believe it was not. Perhaps the 
narcosis or the catheterization before the operations had more to 
do with the fatal issue than the operation itself. 
In my third case the artery was successfully tied on one side 
only. However, the case is of the greatest importance for prop- 
erly estimating the value of the operation. There had been a 
uniform enlargement of the entire gland before the operation. 
Four weeks later a marked palpable atrophy of the left lateral 
lobe has taken place already, whereas the right of course still 
presented its original size. This phenomenon becomes gradually 
more pronounced. This fact gives, in my estimation, the ligation 
of the internal iliac artery its firm place among the radical 
operations for the relief of this trouble. It also proves that 
even in marked arterio-sclerosis of the respective vessels, liga- 
ture is feasible and effective. It will be of weight to add here 
that in two of Bier’s cases a very marked decrease in the size 
of the prostate could be demonstrated a couple of weeks after 
the operation. 
(2) Can we apprehend that the reduction in the size of the 
gland will be permanent ? 
I would answer, unhesitatingly, “ Yes.” The two internal 
iliac arteries alone feed the gland. There are, of course, capillary 
anastomoses with other arteries, so as to prevent gangrene of the 
respective parts. But this communication with other arteries 
through the capiliary system will never throw such an amount of 
blood into the gland as to cause again swelling of the meanwhile 
atrophied organ. To a doubtful mind further observation of cases 
thus operated upon has to prove this assumption. 
(3) Is the operation a difficult and serious one ? 
Answer.—The operation is not at all a difficult one if per- ILIAC LIGATION FOR PROSTATIC HYPERTROPHY. 
11 
formed in the various angles of Trendelenburg’s posture, as de- 
scribed above. It can be well performed on both sides inside of 
one hour. If we use silk instead of catgut, one ligature will 
suffice to a permanent occlusion of the vessel. The artery need 
not be cut between the two ligatures. Secondary haemorrhage is 
thus excluded. If left in an aseptic field, the silk ligature, being 
aseptic itself, will no doubt be encapsulated, without giving rise 
to an abscess in the future. The wound should never be drained 
but closed entirely by buried sutures (continuous), stitching layer 
by layer. In order to facilitate this part of the operation, I 
found it of advantage to make the wound slightly funnel-shaped, 
the two ends of the incisions in the different layers of the abdom- 
inal wall can then be well seen. By thus sealing the wound, a 
ventral hernia will be avoided. 
(4) Shall the operation be an extraperitoneal or a transperi- 
toneal one? 
I should decidedly answer, “ Extraperitoneal,” in spite of 
doubling the incision. It must be remembered that in almost all 
the cases which will, perhaps, be subjected to this kind of opera- 
tion, we have to deal with older, often very stout, subjects with 
fatty degeneration of the heart, etc., who bear intraperitoneal 
interference not as well as younger persons. 
(5) In which cases is the operation advisable? 
I believe the operation is indicated in all cases of hyper- 
trophy of the prostate where absolute retention is of recent date 
and marked dilatation with atony of the bladder has not yet set 
in, and where we seem to be justified to strive for a radical cure. 
In such cases the operation certainly stands the comparison with 
biting away or cutting out portions of the prostate after supra- 
pubic incision, for it leaves the parts in their normal anatomical 
relation and removes the obstruction at the neck of the bladder 
in the simplest way : by producing progressive atrophy of the 
organ which causes the obstruction. It also keeps the generally 
older patients in bed for only ten or fourteen days, the wounds 
healing by primary union under the first dressing. The wounds 
which open bladder or urethra for attempting a radical cure of 
the hypertrophied prostate do not heal per primam, and keep the 12 
WILL V ME YER. 
patients in bed for a number of weeks. Hypostatic pneumonia 
is the threatening foe. 
In view of the brilliant functional results after castration, 
also after resection or division of the vas deferens, I should say 
to-day (time of publication), “ Bier’s operation seems to be indi- 
cated only in patients below the fiftieth to sixtieth year with 
absolute retention of urine due to the hypertrophied prostate, 
who are tired of catheter-life, but who refuse to lose one or both 
testicles, and also are unwilling to become sterile, in spite of the 
probability of an otherwise undisturbed power of sexual inter- 
course.” The surgeon may well, at times, be confronted with 
such a case. 
If a patient with hypertrophy of the prostate is satisfied to 
have his testicles removed (or vasa deferentia resected), or, if 
not that, to wear the catheter in a suprapubic, though water- 
tight, fistula for the remainder of his life, I should, of course, not 
persuade him to have Bier’s operation done on him, so much the 
more not as there are, on account of the relative youth of the 
operation, no observations yet at our disposal which prove that 
the atrophy will be a permanent one. 
In conclusion, I should say that the operation seems to me 
to fully deserve a fair trial by surgeons in general.