With the Compliments of the Author. 
PAPERS UPON 
GEJMITO- URINARY SURGERY. 
By a. T. CABOT, A.M., M.D., 
Surgeon to the Mass. General Hospital. 
XIX. Observations upon Acquired Hydronephrosis. 
XX. Observations upon Stone in the Bladder; Recurrence 
of Stone : Choice of Operation. 
XXI. Another Successful Case of Uretero-Lithotomy. 
XXTI. Personal Experience in Modern Operations for the 
Relief of Prostatic Obstruction. 
BOSTON: 
DAVID CLAPP & SON. 
1 89 9. PAPERS UPON 
GERITO-URINARY SURGERY. 
By A. T. CABOT, A.M., M.D., 
Surgeon to the Mass. General Hospital. 
XIX. Observations upon Acquired Hydronephrosis. 
XX. Observations upon Stone in the Bladder; Recurrence 
of Stone : Choice of Operation. 
XXI. Another Successful Case of Uretero-Lithotomy. 
XXII. Personal Experience in Modern Operations for the 
Relief of Prostatic Obstruction. 
BOSTON: 
DAVID CLAPP & SONl 
1899. OBSERVATIONS UPON ACQUIRED HYDRONEPHROSIS.1 
Any obstruction in the urinary passages between the kidney and the 
outer air may cause an accumulation of urine in the renal pelvis and 
lead to a hydronephrosis. It is with the obstructions in the upper part 
of the ureter due to some acquired mechanical disarrangement of that 
tube that this paper has to do. 
Whether these acquired, uon-congenital cases of hydronephrosis are 
due in any part to congenital malformation or malposition of the ureter 
is a matter which in most cases must remain in doubt. For when 
these cases come to autopsy the acquired changes due to the pressure 
and displacement of parts by the great accumulation of fluid, mask 
and make doubtful the original condition. 
Two forms of obstruction are found in these cases. These are val- 
vular folds at the entrance of the ureter; and contortions of this tube 
in the first part of its course which favor the kinking and closure of it 
when the heavy kidney presses down upon it. 
Taking first the valvular folds at the ureteral orifice: their etiology 
is somewhat doubtful. Yirchow regarded the condition to be conse- 
quent upon a congenital oblique insertion of the ureter in the pelvis, 
while Simon thought that this slanting insertion was an acquired con- 
dition due to the stretching of the pelvis and the pressure of it down 
towards the ureter. Kiister believed that an inflammatory swelling of 
the pelvic mucosa was necessary to assist Simon’s displacement in form- 
ing a valve. He thought that the swollen mucous membrane was 
shifted somewhat on the submucosa and so partly pushed over the 
ureteral orifice. 
Hansemann explains the valve formation by the pull of the kidney 
upon the comparatively immovable upper part of the ureter. It is 
1 Read before the Surgical Section of the Suffolk District Medical Society 
January 8, 1896. 4 
plain that if this part of the ureter is fixed, as Englisch asserts, and 
the kidney then sags downward it carries the ureteral opening with it 
and produces a valvular condition such as is seen diagrammatically in 
the cut, at b. 
This explanation seems applicable and satisfactory in many of the 
cases, and accounts for the not infrequent association of hydronephrosis 
with mobility of the kidney. 
It also helps us to understand those instances in which by change of 
position an escape of the retained fluid is brought about. As the valve 
is usually formed by the falling of the kidney downward, Hansemann 
recommends raising of the hips of the patient in order to correct 
the condition. It is, however, to be remembered that the displacement 
of the ureteral orifice may be upwards or to either side if the pelvis 
dilates unequally in different parts, and in this case some other than 
the inverted position may straighten the orifice. lie saw one case at 
autopsy in which a hydronephrotic kidney had the orifice so dis- 
placed upward that it was only made patent when the pelvis contained 
considerable fluid and so dragged the kidney down by its weight. This 
condition was tested by the injection of varying quantities of water 
and it was found that a certain amount of distention of the pelvis was 
necessary to alter the orifice so as to allow of the escape of fluid 
through it. 
The effect of position in relieving such mechanical obstructions may 
also be helped by kneading and moving the tumor about, and in these 
ways relief may sometimes be obtained in those cases of intermittent 
hydronephrosis where the valve is not a very perfect one. 
The hydronephrosis sometimes owes its origin to some temporary 
condition, as for instance, to the stopping of the ureter by a blood-clot, 
by an inflammatory swelling or by other pressure from without. If, 
now, this temporary cause is removed, the weight of the hydrone- 
phrotic sac may then be sufficient to keep up the obstruction by main- 
taining the valvular condition by the downward pull of the kidney. 
Under these circumstances a very thorough aspiration, by relieving the 
weight, may suffice to correct the condition, and, indeed, a certain 
number of cures are obtained in this way. 
Drainage of the sac through an incision in the loin is a more efficient 
means of treatment in such cases, for the constant escape of the fluid 5 
gives the sac an opportunity to shrink up and resume its more natural 
contour. Moreover, the nephrotomy gives the opportunity of drawing 
the kidney up to the loin and fixing it there, thus preventing any 
further sagging down. 
a. Diagram of normal condition. 
b. Diagram showing change produced when the kidney sags 
and carries the urethral orifice downward. 
In this way cures have been obtained and the following operators 
have been fortunate with this method, more or less perfectly carried 
out: Weir,1 Peters,2 Tuckwell,8 Cabot.4 
The disadvantage of this method of operating is, that, in case the 
obstruction for any reason remains, the patient is annoyed by a per- 
sistent urinary fistula. With the fear of this result in view and the 
valvular nature of the obstruction being recognized, it is natural that 
attempts should be made to obviate it by direct surgical correction of 
it. Unsuccessful attempts to relieve the valve at the entrance to the 
ureter were made by Simon6 prior to 1876, by Trendelenburg6 in 
1890 and by Kiister7 in 1891. In Simon’s and Trendelenburg’s 
operations the ureter was slit up for a considerable distance as it lay 
alongside the pelvic wall and then an attempt was made to unite the 
divided borders of the ureter to the lower part of the pelvis. Kus- 
ter began his operation on the same plan, but finding a stricture, 
ended by resecting the upper end of the ureter. All these cases 
resulted fatally. 
1 New York Medical Record 1880, xvii, 294, and 1882, xxi, 477. 
2 Loc cit., 1882, xxi, 477. 
3 London Lancet, 1882, ii, 141. 
4 Boston Medical and Surgical Journal, February 22, 1883, 
6 Chirurgie d. Nieren, vol. ii, Stuttgart, 1876, 
6 Volkmann’s Samml. klin. Yortrage, No. 355. 
7 Archiv. f. klin. Chirurgie, Bd. xlvi, Heft 4, p. 850. 6 
In May, 1892, Fenger1 did a successful operation for valve forma- 
tion by cutting through the fold that made the valve and so applying 
the sutures as to convert the longitudinal cut into a transverse wound. 
In this case he left a bougie in the ureter for two days and stitched up 
the kidney that was movable. Myuter2 has since done a similar 
operation, likewise with good result. 
These cases are too few to enable us to reach any decision as to 
whether this is the best way to correct this condition. We must 
remember the etiology of the valve formation, and must accept the 
fact that many cases have recovered after a simple nephrotomy with 
fixation of a movable kidney. We may feel, however, that if a dis- 
tinct valve formation is found, Fenger’s method of division may be 
practised without adding materially to the danger of the operation, for 
the chance of infiltration of urine must be slight when the tension is 
wholly removed by lumbar drainage. These operations are certainly 
attempts in the right direction, for they seek to re-establish the function 
of the kidney; while a nephrectomy, which is the last resort in these 
cases, is an unscientific proceeding when it removes an organ still doing 
good work. 
We come now to consider the other form of obstruction due to 
mobility of the kidney. A tortuous condition of the upper end of the 
ureter may be associated with a very movable kidney. This happens 
so often that it is probable that the twisted condition of the ureter is 
dependent on the mobility of the kidney. Sometimes, too, an obstruc- 
tion in the lower part of the ureter leads to a dilatation of the upper 
part of that canal, which in this case becomes tortuous and may lead 
to an actual torsion. If, now, at any time by twisting or kinking, a 
retention of urine is caused and leads to an accumulation in the pelvis, 
the heavy kidney pressing down towards the already twisted ureter 
aggravates the previously existing condition and produces a permanent 
stoppage. The point of obstruction in this case may be at some little 
distance from the pelvis. 
Under such circumstances a good result may perhaps be attained by 
frequent aspirations which, emptying the kidney, allow of a shrinkage 
of the pelvis and in this way pull up the ureter into place. A nephrot- 
1 Transactions American Surgical Association, vol. xii, page 142. 
* Annals of Surgery, December, 1893. 7 
omy, however, offers a much better chance of cure, for by drawing up 
and fixing the kidney in the loin it tends to straighten the ureter aud 
so to restore its calibre. 
If, however, the ureter is so slack and tortuous that its condition does 
not seem to be remedied in this way, it might even be worth while to 
resect the upper part of the ureter and, after straightening the tube, to 
insert its upper end into the pelvis in the manner practised by Kiister 
and recommended for correction of this condition by Tuffier.1 This is, 
however, an operation difficult of performance and not devoid of danger. 
As a less dangerous proceeding, the writer would suggest that this tor- 
tuous condition can be corrected by inserting a bougie and leaving it 
in situ for several days. In this way the various curves of the canal 
are effaced while the pelvis is contracting and pulling it into shape. 
Furthermore, a moderate amount of inflammation is set up in the walls 
of the ureter which stiffens them, attaches them to the parts about and 
thus tends to keep the form given to the tube. The writer has carried 
out in one case this plan of operating and with so much success that 
he reports it as a suggestion for future trial. The history of this ex- 
perience is as follows: 
Miss H. M. A., thirty-two years of age, was sent to the Massachu- 
setts General Hospital by Dr. Cooper of Northampton on March 25, 
1895, with a cystic tumor of the abdomen. Catamenia had been ir- 
regular and rather scanty. For four years, from the time she was 
twenty-two until she was twenty-six, she suffered a great deal of pain 
in the right side of the abdomen. Two years ago she first noticed an 
enlargement in the abdomen a little to the right of the median line, and 
the past year she has had an increase of the pain, which has been almost 
constant and is more noticed for a week following the catamenia. She 
has never noticed any symptoms in connection with urination. 
Examination showed that she was thin and pale, of a feeble muscular 
development. Nothing found in the chest. Examination of the ab- 
domen when lying on the back showed a large, fluctuating mass in the 
right side extending up uuder the liver and going well down to the 
brim of the pelvis. When she stood up, this mass rested across the 
lower part of the abdomen just above the pelvis, and the region about 
the neighborhood of the liver was then empty. 
1 Annales <Jes Mai. des Orgades Genito-Urinaries, January, 1894. 8 
The catamenial history had led to the diagnosis of an ovarian cyst, 
but the position of the tumor when she was on her back strongly sug- 
gested a hydronephrotic kidney. The examination of the urine was 
wholly negative. The great mobility of the tumor made it seem pro- 
bable that if it were the kidney it must have a long meso-nephron, and 
there was danger that a puncture in the loin might traverse the peri- 
toneal cavity. We thought it wise, therefore, to explore by an ab- 
dominal incision, which was done March 29th. 
The tumor was found to be a large hydronephrotic kidney, which 
was extremely movable as had appeared by previous examination. 
With the hand in the abdomen guiding the aspiration, a needle was in- 
troduced through the loin and the sac entirely emptied. The abdominal 
wound was then closed. This operation was followed by no reaction, 
and the patient made a good recovery. 
The examination of the fluid drawn gave the following result: It 
was of a pale, amber color, with a specific gravity of 1.007, and having 
a slight trace of albumin. The sediment consisted of brown, granular 
cells with occasional granular and fibrinous cylinders, like renal casts. 
The examination for urea showed that the fluid contaiued 1.01 per 
cent. 
For at least a fortnight there was no sign of any refilling of the cyst, 
but at the end of that time the tumor began again to be noticeable in 
the loin. Examination of the urine soon after the operation gave a 
specific gravity of 1.020, a slight trace of albumin. In the sediment 
hyaline and granular casts, with fat adherent. 
The patient was in a rather feeble condition during her convales- 
cence, with edema of the ankles, which postponed further operative 
treatment. On May 7th, her condition being then pretty good, the 
kidney was opened in the loin, and after it was emptied the ureter 
could be seen emerging from the cyst by a funnel-shaped opening and 
running in a tortuous course downward towards the pelvis. There 
was no valvular appearance to the opening of the ureter, nor any con- 
dition which could be corrected by incision or other alteration of that 
orifice. 
The mechanical condition which had led to the hydronephrosis ap- 
peared to be a twisting of the ureter at some point in its tortuous 
course, that point not being determinable after the sac was emptied 9 
and the parts were lax. It being desirable, therefore, to efface, as far 
as possible, all of these abnormal twists and turns in the ureter, a gum- 
elastic bougie, about No. 6, French, was introduced and carried with 
some difficulty down through the ureter until it reached the neigh- 
borhood of the bladder. The sac was sewed to the edges of the wound 
through the muscles with continuous catgut. A drainage-tube was 
then introduced into the pelvis of the kidney, and the bougie was left 
in situ. 
The recovery was rather slow, but, as far as the healing of the wound 
went, was uneventful. The bougie was removed at the end of three- 
aud-a-half days, and the drainage-tube was out in nineteen days. There 
was a considerable escape of blood-stained urine through the tube, 
which was caught in a bottle and examined. 
On May 8th the urine from the bladder had a specific gravity of 
1.025 and contained an occasional pus cell and hyaline cast of large 
diameter. Twelve ounces were passed from the bladder, that is, from 
the left kidney, in this twenty-four hours. 
May 11th (four days after operation). The urine draining from 
the loin had a specific gravity of 1.015, while that from the bladder 
had a specific gravity of 1.008. 
May 13th. The urine draining from the loin and collected in a 
bottle measured eight ounces, some considerable quantity being lost in 
the dressings. It was cloudy with pus and blood, while the urine from 
the bladder was clear. 
May 14th. The urine from the right kidney had a specific gravity 
of 1.010, while that from the left kidney through the bladder had a 
specific gravity of 1.008. 
May 18th. The specific gravity of the fluid from both kidneys was 
the same, 1.010. 
May 21st. The urine from the drain in the kidney contained 0.5 
per cent, of urea; that from the bladder contained 1.39 per cent, of 
urea. 
May 26th. The urine ceased to come through the wound, and the 
urine in the bladder began to contain a little blood and pus. 
June 1st. The wound in the side having been drawn together on 
the previous day, there began to be pain in the abdomen, and on June 
2d there was a chill and the temperature went to 105°. There was 10 
soon an escape of urine and pus from the wound, and after this all 
went well. The sinus finally closed on June 21st. 
The patient was seen and examined November 30, 1895. She had 
made a considerable gain in flesh and strength. She reported that in 
October she had an attack of dull pain in the right side, which lasted 
a week. The lumbar scar was solid. In tbe right renal region was 
an indefinite sense of resistance, but no defined tumor. The abdomen 
was so thin that any considerable enlargement could have been easily 
made out. 
The examination of the urine at that time showed it to be acid, with 
a specific gravity of 1.017, and to contain no albumin. The sediment 
was considerable, and consisted mainly of vaginal cells and mucus with 
an occasional small round cell. 
This case is interesting, first, because of the considerable degree of 
activity retained by a kidney so long affected by a very great dilata- 
tion. This is shown by the quantity and quality of the urine obtained 
through the loin, a quantity certainly underestimated owing to the 
necessary loss in the dressings. 
The function of this organ was well worth retaining even had the 
operation required been as severe as that of nephrectomy. When we 
take into account the far greater safety of a nephrotomy, the argument 
in favor of the more conservative method is greatly strengthened. If 
nephrotomy is done first in these cases, we have the opportunity to do 
a nephrectomy later if the occasion requires. 
The second point of interest is the success which attended the treat- 
ment of the ureter. The restoration of permeability of the canal 
which was accomplished by the bougie and assisted by the fixation of 
the sac in the loin, seems to have endured for a sufficient time since 
operation (seven months), to lead to the hope that it may prove per- 
manent. 
How far this method may be relied upon in these cases must be 
shown by the accumulation of experiences. Also, it will be interest- 
ing to see whether the valvular obstructions at the renal orifice of the 
ureter can likewise be corrected in this way. 
Dr. Christian Fenger1 in his published case mentioned above, left 
1 In a private letter Dr. Fenger writes me that he has left a bougie in place 
in three other cases of combined valve and stricture. In these cases the bougie 11 
a bougie in the upper part of the ureter for two days. This he did 
“ partly with the same object with which we pass a sound through a 
meatus which we have cut, to prevent healing with restoration of the 
part cut; partly to keep the narrowest portion (operation territory) 
dilated during the first twenty-four to forty-eight hours, during the 
time when hemorrhage might leave a clot around the ureter and com- 
press it.” 
The experience in my case suggests a question as to how important 
a role the bougie played in bringing about the success of this case of 
Dr. Fenger’s, and we are led to wonder whether, combined with fixa- 
tion, it would have been efficacious even without the division of the 
valvular fold. Tuffier reports that he has cured nine cases of inter- 
mittent hydronephrosis by fixation of the movable kidney approxi- 
mately in its normal position. Others have had similar favorable 
experiences showing that these valvular obstructions are not always 
difficult to correct. 
•was left in the upper four to six inches of the ureter for from two to four days. 
In none of the cases did it do any harm. Encouraged by this experience of Dr. 
Fenger’s, I shall try to keep the bougie in the ureter for more than three days in 
my next case, in order more certainly to get the desired effect in straightening 
and establishing the patency of the canal. OBSERVATIONS UPON STONE IN THE BLADDER; RE- 
CURRENCE OF STONE; CHOICE OF OPERATION. 
The cases which I have used in this study of the recurrence of stone 
in the bladder comprise all of those of which I have notes. I find in 
these notes that I have done one hundred and thirty-five operations 
upon one hundred and nineteen patients. These operations divide 
themselves into one hundred and fifteen litholapaxies with four deaths. 
Thirteen suprapubic lithotomies with four deaths* Three lateral 
lithotomies with no deaths. Two median lithotomies with one death. 
Two vaginal lithotomies with no death. 
This list only includes cases of formal operation under anesthesia 
and takes no note of the many instances in which a crushing and 
pumping operation has been done with or without cocaine for the re- 
moval of small recurrent stones or for retaiued fragments. 
Among these patients are two instances in which a uric-acid stone 
has re-formed in consequence of the persistence of the diathesis that 
led to its original formation. On one of these patients I operated 
twice and upon the other three times. 
There are nineteen instances in which a phosphatic stone has ap- 
peared some months or years after the removal of a primary stone. In 
two or three instances the primary stone was a uric-acid calculus, in 
all other cases it was phosphatic. 
In six of these cases the previous operation had been done by some 
other operator. 
This recurrence of a phosphatic stone may be due to the persistent- 
ly alkaline condition of the urine. Several instances of this sort have 
come to my notice, the most striking of which was a case of multiple 
calculi in which within a fortnight of a thorough washing out the blad- 
der would again contain from fifty to one hundred little, separate, well- 
formed stones. This tendency was finally overcome by frequent pump- 
ing out of the calculi combined with medical treatment directed to 
making the urine acid. While phosphatic stones may occasionally 13 
depend in this way simply on the condition of the urine, it is much 
more common to see them as the result of some local condition. 
In two or three cases the recurrence may perhaps be regarded as 
the result of an incomplete operation, leaving a fragment to serve as 
a nucleus for a new stone. This accident has usually been avoided 
by care in washing out the bladder with the evacuator, ten days or a 
fortnight after the litholapaxy. In some such cases several washings 
have been necessary before the bladder was found to be entirely free 
from calcareous matter. 
In one case, of a woman,' the projection into the bladder of two 
stitches put in by two other surgeons for the closure of the opening 
made in doing a vaginal lithotomy led to the repeated recurrence of 
calculi until the stitches were found and removed. 
In two cases sacculated stones which lay concealed in pockets in the 
vesical wall gave rise to repeated stone formation in the bladder cavity. 
The removal of the stones loose in the bladder was followed in each 
case by such a cessation of symptoms that the presence of the encap- 
sulated calculus was not suspected, but it was finally found by a cysto- 
tomy done for the purpose of discovering the condition to which the 
recurrence of the stone was due. 
Finally, certain local conditions of the bladder wall favor the for- 
mation of stone and lead to constant recurrences until they are re- 
moved. 
It is notorious that'tumors and granulating surfaces within the blad- 
der are prone to be encrusted with salts. The crystallography of stone 
formation is interesting in connection with these cases of calcareous 
deposit on granulating surfaces. 
The crystals that exist in the urine do not tend to cohere and form 
a stone except in the presence of albuminous material. Rainey showed 
many years ago that the presence of colloid or albuminoid sub- 
stances in a solution causes cystalline materials to become spheroidal 
in shape and to coalesce in rounded form. This is the law of mole- 
cular coalescence which has a very decided bearing upon stone forma- 
tion in the bladder. 
As long as the urine is non-albuminous, crystals of uric acid or ox- 
alate of lime may form in the urinary passages, be washed along and 
discharged with the urine without forming a stooe. But when albu- 14 
min is present, either in the pus thrown out in consequence of some 
irritation or in the serum exuding from a granulating surface, we have 
conditions favorable to “ Molecular Coalescence.” 
The following case is an interesting illustration of this method of 
stone recurrence: 
M. V. B. M., fifty years of age, came to see me in the autumn of 
1894, with considerable irritation of the bladder for which he was us- 
ing the catheter by a physician’s advice. At this time the symptoms 
did not strongly suggest a stone and the searcher could not be intro 
duced on account of the extreme sensitiveness of the neck of the blad- 
der. Palliatives were advised with resort to an ether examination if 
the symptoms persisted. He was seen again nine months later and 
the symptoms were then so suggestive of stone that he was etherized 
and a soft stone was crushed and pumped out. This calculus was so 
small that it seemed as if it must have been of recent origin. 
The operation was an easy one and during convalescence it was 
found that the bladder emptied itself almost completely at each urina- 
ation. Six weeks after this operation the bladder was pumped out 
thoroughly without ether and a small amount of calcareous matter re- 
moved. 
Five months later he again had symptoms of stone and another 
phosphatic stone was removed by litholapaxy. This operation was 
done at the Massachusetts General Hospital and he was kept in the 
hospital for more than three weeks, during which time his bladder was 
carefully pumped out several times and entirely cleared of calcareous 
matter. He went out with the urine clear and acid. Soon after, how- 
ever, it became evident that the stone was forming again. The con- 
stant reappearance of phosphatic stones in a bladder which completely 
emptied itself and in a urine which was never excessively alkaline 
seemed to indicate that there was some special cause for the deposit of 
calcareous matter. The patient now deoided to submit to a suprapubic 
cystotomy for the purpose of discovering and, if possible, relieving 
the condition that so favored the recurrence of stone formation. 
The bladder was accordingly opened. Its wall was found in a tolera- 
bly healthy condition and the prostate was not markedly enlarged 
and the post-prostatic pouch was not deep. Just posterior to the pros- 
tate and midway between the ureteric orifices was a little prominent 15 
tumor with a roughened surface somewhat encrusted with lime salts. 
This was seized with a pair of cutting forceps and easily removed* 
Examination of this tumor by Dr. W. F. Whitney showed it to be a 
little myoma with an ulcerated granulating surface. 
Since that operation, done two years ago, there has been no return of 
stone formation, and the patient has now gone to the Arctic regions 
in command of a whaling ship. 
The case was a striking one because the stone formed in an acid 
urine and in a bladder that emptied itself at each urination. These 
facts forced us quickly to the belief that some local condition was re- 
sponsible. 
In many cases of enlarged prostate we have a similar condition 
of ulceration on projecting outgrowths. I find among my cases five 
in which such a condition was demonstrated either by operation or au- 
topsy. Doubtless other cases of recurrence were due to a like cause 
but were finally overcome by keeping the urine acid and by irrigation 
with solutions of nitrate of silver and nitric acid to favor healing of 
the ulcerated patches. 
It has frequently been urged by advocates of cutting operations that 
recurrence of stone is especially prone to occur after litholapaxy ow- 
ing to incompleteness in the operation. My experience does not coin- 
cide with this view; for the cases of recurrence after litholapaxy have 
with one or two exceptions, been shown to be due to a general dia- 
thesis or to the local conditions described above. The suprapubic op- 
eration, too, is far from being exempt from the opprobrium of failure to 
prevent recurrence of calculous formation. I have seen three instanc- 
es of stone recurrence after suprapubic removal. One patient had an 
experience which was interesting in this connection. lie had a stone 
removed suprapubically in 1892. He had a second stone removed by 
suprapubic incision in 1895. In 1896 he had a stone removed by 
litholapaxy, and after that he had small stones removed by Chismore’s 
evacuating lithotrite without anesthesia about once in three months 
He finally consented to have the bladder opened a third time for the 
removal of the third lobe, which was believed to be ulcerated. The 
condition suspected was found and removed, with relief from stone 
formation and also with restoration of the function of urination. This 
case has been reported at length elsewhere and only so much of it is 
repeated as has a bearing upon the question of stone formation. 16 
The conclusion that I would draw from the study of these cases of 
recurrence is that the constant reappearance of a phosphatic stone in 
the bladder usually indicates the existence of some local cause which 
should be sought and removed. 
The suprapubic route affords the best opportunity for inspection and 
for the operative treatment of any condition found. When that con- 
dition is an ulcerated projection from the prostate it should be 
thoroughly removed and the lower edge of the urethral opening should 
be so cut down as to bring it well to the floor of the bladder. 
It is also of interest to study in these cases the rate of mortality and 
the conditions under which death occurred. Comparative rates of 
mortality, however, cannot be judged, as the number of cases in which 
a cutting operation was done is small and the cases selected for litho- 
tomy were, in several instances, in a serious condition, owing to pro- 
static obstruction and the advanced inflammatory conditions of the 
bladder and kidneys. The operation, too, was often not a simple cys- 
totomy but included the removal of a portion of the prostate or the 
difficult extraction of an encysted calculus from its pocket. 
Tne patients were as a rule old. The average age of those upon whom 
litholapaxy was done was sixty years and a month. This is calculated 
from ninety cases in which the age is recorded. My recollection of 
the cases in which the age was not recorded enables me to say with 
confidence that they would not have materially altered the average 
above obtained. 
The average age of those subjected to suprapubic cystotomy was a 
little over sixty-two years. 
Two of the four deaths after litholapaxy were due to pneumonia 
consequent upon a chronic bronchitis that existed at the time of the 
operation. These patients were feeble men, one sixty, the other sixty- 
nine years of age. The third patient was seventy-one years of age 
and had complete obstruction in the prostate, and the urine was sup- 
pressed, so that the contents of the bladder at the operation consisted 
almost wholly of stringy mucus, and he never secreted any urine after 
that time. 
The fourth case was that of a woman sixty-two years of age. A 
RATE AND CAUSES OF MORTALITY. CHOICE OF OPERATION. 17 
hard stone weighing a little over an ounce was removed by lithola- 
paxy and at the same time some glands in the neck, which were exten- 
sively tuberculous, were curetted. The patient did very well for a 
time. The temperature fell to normal and recovery seemed assured, 
when she gradually began to fail and died six weeks after the operation, 
death being due rather to the tuberculosis than to the operation. 
No one of these deaths can be directly ascribed to the operation. 
But even if they were all counted as deaths from litholapaxy the rate 
of mortality would be a little less than three and one-half per cent., 
which is very low considering the advanced age of the patients. 
Certainly this experience justifies the feeling that litholapaxy is the 
operation of choice which can be offered to these patients as com- 
paratively devoid of risk. 
The suprapubic operation would then be reserved for those patients 
in whose bladders other conditions (foreign body, sacculated stone, 
ulcerating projections) exist which require an opening into the bladder 
for their proper treatment. 
Of the four deaths after suprabubic cystotomy two occurred in old 
men of seventy-two and seventy-seven years, in whom a great dimi- 
nution of urine existed at the time of operation and a progressive ces- 
sation of this function steadily progressed till the time of death. 
One old man of seventy-two with an abundant urine of 1.005 spe- 
cific gravity was operated by suprapubic section on account of sudden 
profuse hematuria. A very small stone was found and the bleeding 
was wholly stopped, but although the wound did extremely well he 
presently became mildly delirious and died uremic. 
The last case was that of a man of sixty-one who had a sacculated 
bladder, two diverticula of which contained stones. These diverticula 
were on each side close to the ureteric orifices and so placed that 
the stones pressed upon the ureters and occluded them. One of these 
stones, which projected into the cavity of the bladder, was found and 
removed. The other one, which lay at the bottom of the deep, nar- 
row pocket with a very minute opening into the bladder, was not 
found. This patient lived about a mouth after the operation and slow- 
ly died of suppression of urine due to pyelo-nephritis. 
The death after median lithotomy was in the case of a very feeble man 
who had been leading a very exhausting life as a missionary in a hot 18 
climate and who, on his voyage home, had a small stone become wedged 
in his prostatic urethra leading to great and constant tenesmus and much 
inflammation at the neck of the bladder. The operation really con- 
sisted rather in a prostatomy than a cystotomy, and the patient slowly 
died of septic conditions in the wound, probably started by the inflam- 
matory conditions which existed before the operation. 
All these deaths after cystotomy were in bad subjects and might, in 
almost every case, be said to have occurred in spite of the operation 
rather than in consequence of it. Still it is my feeling that two or per- 
haps three of tkeoe patients might have survived a litholapaxy had the 
operation been possible. 
Some years ago I expressed the opinion that litholapaxy should be 
the operation of choice in the treatment of stone in the bladder and 
that a cutting operation should be resorted to only under special con- 
ditions, then enumerated, which made the crushing operation impos- 
sible or especially difficult and dangerous. My added experience of 
about one hundred cases confirms me in my feeling that litholapaxy 
is much the safest operation for the removal of stone and that it is 
usually competent to work a complete cure. 
In cases where it fails of a cure a further search for the cause of re* 
peated stone formation should be made—by suprapubic cystotomy 
when necessary. If before operation we have good evidence that a 
local condition exists which favors calcareous deposits this may be a 
sufficient reason for selecting a suprapubic operation at the outset. 
Certainly in a case of aggravated prostatic obstruction demanding re- 
lief from that condition a suprapubic operation is demanded, and the 
coincident presence of a stone, while aggravating the symptoms and 
increasing the need of relief, does not in any way affect our choice of 
operation, which is directed at the more important and fundamental con- 
dition. ANOTHER SUCCESSFUL CASE OF URETERO-LITIIO- 
TOMY.* 
In the Boston Medical and Surgical Journal for September 11, 1890, 
I reported a case of operation for the removal of a stone lodged in the 
middle portion of the ureter. 
At that time a brief reference was made to another case in which a 
stone was removed from the lower portion of the ureter in a woman. 
As this stone was reached and removed in a manner not hitherto em- 
ployed, so far as I can learn, I will give a more complete report of the 
case. 
Mrs. S., a rather stout woman of thirty-nine, was seen by me, May 
15, 1890, in consultation with Dr. J. L. Williams and Dr. W. A. 
Morris. She had for fifteen or sixteen years been subject to attacks of 
renal colic, always on the left side, and almost always followed by the 
passage of stones. 
The last severe attack was in December, 1888, but since that time 
she had had a number of slight attacks during which she had passed 
twenty or more small stones. The attack in which I saw her began 
five or six weeks before my visit, and had continued ever since, with 
pain of varying intensity. 
The urine was at times much diminished in quantity, and for several 
days before the consultation had been very scanty (from four to six 
ounces a day). It had, during this time, been loaded with urates. On 
that day it had become more abundant and less thick. 
The patient had a good appearance, with moist tongue, quiet and 
steady pulse and normal temperature. She was perspiring rather freely. 
The pain in the region of the left kidney, and running down towards 
the bladder, was intermittent and spasmodic in character. 
* Read before the Boston Society for Medical Improvement, October 27, 1890, 20 
In the left lumbar region was a distinct tumor about as large as tWo 
fists, which was sensitive to pressure. There was also a point of 
tenderness deep in the left side of the pelvis. By vaginal examination* 
a little hard mass was found in the left broad ligament close to the cer- 
vix uteri. This felt about as large as the last joint of the forefinger, 
and it was very sensitive to pressure. The palpation of it during the 
examination started a spasmodic pain in the left side, that had a bear- 
ing-down or expulsive character. 
A sound introduced into the bladder could be carried to within about 
three-quarters of an inch of this little hard mass, but could not be 
brought in contact with it by the most careful bimanual manipulation. 
Dr. Williams had examined Mrs. S. a few days before, and was sure 
that at that time this hard mass could not be felt. It therefore seemed 
that the calculus must have moved some distance down the ureter 
during the time that had elapsed since the examination. 
In view of this fact, and also encouraged by the increase in the 
amount of urine in the preceding twenty-four hours, we decided to wait 
and see if nature, aided perhaps by manipulation with the finger per 
vaginam, would not be sufficient to propel the calculus into the bladder, 
from which it could be easily removed. Soon after this the husband of 
the patient was taken suddenly sick and died, and owing to the disturb- 
ance on this account, nothing was done or thought of for some time. 
Finally, towards the end of June, the patient entered the Massachusetts 
General Hospital for operation, if such seemed desirable. 
On July 1st the calculus could be felt in exactly the same place 
where it had been detected by examination in May. 
On July 4th the patient was etherized for operation. An incision 
was made over the calculus through the vault of the vagina just to the 
left of the cervix uteri. The calculus was easily reached, the grating 
of the knife upon it being distinctly felt during the first incision. 
After the end which presented had been thoroughly uncovered, it was 
found that the rest of the calculus was so tightly grasped by the tissues 
about that it could not be easily extracted. In fact, the presenting 
end broke to pieces under the grasp of the forceps with which extrac. 
tion was being attempted. After trying many manipulations in vain, a 
blunt hook was passed up alongside of the calculus into the ureter 
behind, then turned aud hooked over the upper end, and traction with 21 
this, aided with the finger pressing the tissues aside, finally accomplished 
the removal of the stone. 
The moment it came there was a rush of pus from above. This pus 
was of ordinary thickness, apparently not much thinned by urine. 
Probably from ten to twelve ounces escaped. A T-shaped rubber tube 
was introduced into the ureter through the opening made. After the 
pus had fully escaped, the tumor in the abdomen was found to have 
disappeared. The patient made a good recovery, and the urine, which 
was very scanty just after the operation, gradually increased in quantity 
until it became sufficiently abundant. Drainage through the fistula was 
kept up for some time, and finally, when the drainage-tube was re- 
moved, there seemed to be no tendency for the opening to close, there 
being a constant, moderate discharge of pus through it. She recovered 
strength slowly, as is usual in those cases where the kidneys are 
seriously involved. She left the hospital on the 25th of July. She 
continued to gain strength after getting home, and finally was able to 
be about as usual, doing her ordinary work. 
She was last heard from in November, 1890, and at that time there 
was still a fistula in the vagina, discharging a small amount of pus. No 
urine ever came through the fistula, showing that the long distension of 
the kidney during the complete stoppage of the ureter had sufficiently 
destroyed the cortex, to stop excretion. If at any time the escape of 
pus into the vagina becomes a serious annoyance, it can be stopped by 
the removal of what remains of the kidney. 
The stone that was removed weighed one hundred and ninety grains. 
It was elongated, and evidently made up of two stones which had 
become attached together, as there were two nuclei, one at each end of 
it. This case shows that a calculus lodged in the lower part of the 
ureter in a woman can be safely reached through the vault of the 
vagina without injury to the peritoneal cavity. This is an important 
fact; for this lower end of the ureter, where it narrows just before 
entering the bladder, is a not uncommon point for the lodgment of a 
calculus. PERSONAL EXPERIENCES IN MODERN OPERATIONS 
FOR THE RELIEF OF PROSTATIC OBSTRUCTION. 
In a paper written in 1896, at the request of the Executive Com- 
mittee of the American Surgical Association, and read before their 
meeting at Detroit, I stated that I thought the time then too early for 
the formation of positive opinions as to the merits of the various opera- 
tions for the relief of obstruction in cases of hypertrophied prostate. 
At that time the recorded cases were few, and many of them had 
been under observation for but a short time since operation, and con- 
clusions as to the final result were often impossible. 
It is this question as to the permanence of results which, next to 
the question of immediate mortality, has the greatest interest for us. 
To hasten the final correct solution of this question it is very desirable 
that surgeons dealing with this class of cases should put on record all 
observations coming within their opportunity, both of patients operated 
upon by them, and of those seen by them after operation by others. 
In this way only can we speedily accumulate the data necessary for 
a correct judgment. 
This is my reason for presenting a short of my own exper- 
ience in this field of work. The present success that attends the use 
of our modern soft catheters in cases of prostatic obstruction has re- 
duced the number of cases in which I have had to resort to operation 
to the few which follow: 
Six Cases of Prostatectomy. 
Case 1. — W. D. was seen by the writer in September, 1892, at 
which time he was sixty-five years of age. He was first troubled with 
frequent urination thirteen years before. Three years later he was 
forced to begin the catheter life, which had thus lasted for ten years. 
Within the year before he was seen he had begun to have a good deal 
of pain in the rectum and glans penis. At the same time the fre- 23 
quency with which he had to use the catheter increased, so that for a 
short time before entrance he was drawing his water two or three 
times an hour. The urine was ammoniacal, and contained much ropy 
pus. 
September 17, 1892, he was operated by suprapubic incision. The 
third lobe projected backward into the bladder, forming a tumor the 
size of a hen’s egg, ulcerated on the surface. This was cut off level 
with the proper bladder face of the prostate. One month later the 
suprapubic opening was sufficiently closed to enable the patient to pass 
urine normally (the first time in ten years). 
-This patient has been seen at varying intervals since his recovery, 
the last time five years after operation. The urine has been passed 
completely by natural efforts, the frequency being from five to eight 
times in the twenty-four hours, and the urine has remained clear and 
acid. 
Case 2. — C. E. L. began to be troubled with pain in urination 
and with increased frequency in 1888 or 1889, at which time he was 
forty-six years of age. In 1891 he had retention after a long march 
with the Grand Army of the Republic. This was relieved by the 
catheter, but returned some days later and troubled him more and 
more until 1892, when he was obliged to establish the catheter life, 
after this time passing no water by the natural efforts. In 1895 he 
had symptoms of stone, and litholapaxy was done on May 23d of that 
year. 
At this time rectal examination showed a prostate of moderate size. 
The litholapaxy afforded him some relief, but on May 4, 1896, he re- 
entered the hospital with pronounced symptoms of He was 
advised now to have the stone removed by suprapubic incision in order 
that the prostate might be dealt with at the same time. Consenting 
to this, he was operated upon on May 6th. Four stones were removed, 
and it was found that the obstruction at the orifice of the urethra was 
due to large projections into the bladder from both lateral lobes. 
These were cut off with rongeur forceps, and were found to consist 
of prostatic tissue with dilated glands. Three weeks after operation 
the suprapubic wound was sufficiently closed to enable him to begin to 
pass water without the use of a catheter, and from that time on he 
passed the greater part of his urine in this way, using the catheter 24 
about once a day in order to secure one thorough emptying of the 
bladder. 
In January, 1897 (nine months after operation), he wrote that he 
was able to pass his water without the use of the catheter, but could 
not wholly empty the bladder. Some days he could very nearly do so; 
on other days he could not more than half empty the bladder naturally. 
He was then urinating about every two hours. 
In May, 1898, he was again much troubled by pain and frequent 
urination. He re-entered the hospital, and a small stone was crushed 
and pumped out. After this he was again comfortable and was able 
to pass water with ease. 
Case 3. — H. T., seventy years old, was seen by the writer in 
1896. He had been troubled with difficulty of passing water for the 
past ten years. Since 1887 he had depended wholly on the catheter. 
In 1886 he began to have pain and more frequent need for catheter- 
ization. At the time the prostate was large, hard, and irregular in 
shape. Examination under ether showed the presence of a stone, 
which was removed by litholapaxy. After several months, however, 
the pain began to return, and a suprapubic operation was done, five 
stones removed, and a ring of projections around the bladder end of 
the urethra was cut away. After this his pain was decidedly relieved, 
and he has had no recurrence of stone; but he still relies on the cath- 
eter to empty the bladder. 
In this case of an old and frail man it was not deemed advisable to 
do an extensive operation on the prostate, and only the portions that 
projected into the bladder and were ulcerated were cut away. It was 
not expected that the power of urination would be restored, but the 
case is reported here in order that mention should be made of every 
operation of the nature of a prostatectomy done by the writer. 
Case 4. — W. T. D., sixty years of age at time of operation. 
Obstruction to urination and frequency began at fifty-five. The trouble 
was gradually progressive until at fifty-nine the patient suffered much 
with pain in the back and testes. A catheter was passed and drew 
about a pint of urine. For a year now he depended almost wholly on 
the catheter, passing practically no water by the natural efforts. At 
the end of this time, July 6, 1897, he had a sudden hemorrhage into 
the bladder. The clots were removed, and under constant drainage 
the bleeding stopped and the urine became clear and acid. 25 
On July 13, 1897, a suprapubic cystotomy was done. The urethra 
was occluded by a third lobe, of considerable size, with projections 
also from both lateral lobes. All of these projecting masses were 
thoroughly removed with rongeur forceps. Hemorrhage was consider- 
able, but was controlled. The bladder was drained by two tubes 
through the suprapubic wound. Recovery was uninterrupted and 
satisfactory. 
As the suprapubic wound closed it was found that the patient had 
recovered the power of voluntary urination. Two months after opera- 
tion he was urinating naturally every two to three and a half hours in 
the day, and was not up in the night, and the amount of residual urine 
was two ounces. 
At the end of seven months he noticed that the urine came a little 
harder and the amount of residuum varied from three to six ounces. 
At this time a No. 30 French sound was passed. 
On April 20, 1898, the patient wrote that he was holding his water 
all night after passing the catheter in the evening. The residual urine 
varied from two to six ounces. During the day, after passing the 
catheter in the morning, he held his water until noon and then passed 
it every two or three hours until bedtime. 
Case 5. — T. McC., sixty-eight years of age, entered the Massa- 
chusetts General Hospital March 17, 1898, having had difficulty in 
micturition for eighteen months. For a year he had depended entirely 
on the catheter. At the time of entrance he had a profuse hematuria. 
Examination showed an enlarged prostate, hard and somewhat irregu- 
lar in shape. 
A suprapubic incision was made on March 22, 1898. Upon open- 
ing the bladder much blood and many large clots escaped, and an 
ulcerated and projecting third lobe of the prostate was found. The 
patient being in a poor condition the bladder was packed with gauze 
and two drainage tubes were inserted. This effectually checked the 
hemorrhage. 
On April 7, 1898, his condition being much improved, the wound 
was dilated and the enlarged third lobe of the prostate was cut away. 
Drainage was provided by two tubes. Convalescence was satisfactory. 
The suprapubic wound slowly contracted, and closed on May 16th* 
After this the patient passed urine freely by the natural efforts. 26 
This patient was seen in August, 1898, and although he had con- 
siderable cystitis, the bladder completely emptied itself by the natural 
efforts. 
Case 6. — E. D. B., age fifty-eight, entered the Massachusetts Gen- 
eral Hospital February 2, 1898. For nine years he had had frequent 
micturition and bladder tenesmus. On the advice of a physician he 
had used a catheter for over eight years, three or four times in the day 
and twice in the night, using a soft-rubber instrument. Several times 
within the past year he had found small stones in the eye of the cath- 
eter. He had also had hematuria several times. 
He was operated upon February 5, 1898, by suprabubic incision. 
No stones were found in the bladder. The enlarged middle lobe of 
the prostate was cut out. Pathological examination of the fragments 
removed showed them to consist of dense fibrous tissue, in which were 
imbedded many large dilated gland acini. On March 10th the patient 
passed about four ounces of urine naturally. By March 16th the 
patient passed nearly all of his urine by the urethra and catheterized 
himself twice a day. When discharged on the 22d he was passing 
increasing amounts of urine daily, although a small amount still es- 
caped by the suprapubic opening. Soon after getting home the supra- 
pubic opening closed, and he began to pass all of his urine per 
urethram. 
Mr. B. remained comfortable through the summer and autumn. As 
cold weather approached he began to suffer some discomfort in the 
bladder. Presently he began to pass a little gravel, and a small fistu- 
lous opening appeared in the suprapubic scar. 
On March 6, 1899, several small phosphatic stones were crushed 
and pumped out. Immediately after this operation Mr. B. again be- 
came entirely comfortable. 
Five Cases of Orchidectomy. 
Case 7. — J. W., age seventy-five, had been troubled with diffi- 
culty of urination for five years. When seen by the writer in Dec., 
1894, he was using the catheter regularly and was unable to pass 
water without it. At this time a stone was found in his bladder, 
which was removed by litholapaxy, and at the same time orchidectomy 
was done, with the hope of relieving the prostatic condition. This 27 
operation was followed by a maniacal condition, which persisted for 
two months. He first passed water voluntarily forty-three days after 
operation. He gradually got better and left the hospital, passing a 
small part of his water himself, but requiring the use of a silver 
catheter for the removal of the greater part of it. He continued well 
for some little time, but toward the end of May he took a long ride in 
a carriage, which again started acute bladder irritation, and he gradu- 
ally failed and died. 
At the autopsy the prostate was found to be about the size of a 
hen’s egg, and the third lobe about the size of a pullet’s egg, project- 
ing upward and backward into the bladder. On its apex was a calca- 
reous deposit firmly adherent. In the post-prostatic pouch there was 
considerable fine calcareous gravel. 
Case 8. — J. E. S. was seventy years of age in May, 1893, when 
he was seen by the writer, who removed, by litholapxy, a phosphatic 
stone as large as a pigeon’s egg. Previous to this operation the 
patient had used a catheter occasionally; after it he depended on the 
catheter for a time and then resumed urination by the ordinary efforts. 
In November, 1894, he was passing urine every hour in the day, then 
passing the catheter at bedtime and resting quietly all night. Residual 
urine at this time was about two ounces. During that winter, while 
in the South, his bladder was very troublesome, and he came north to 
seek relief from the cystitis. 
In January, 1895, orchidectomy was done by Dr. Fowler, of Brook- 
lyn. He made rather a tedious convalescence, but when seen by the 
writer again in July, 1896, he expressed himself as very comfortable. 
He was at this time passing water every one or two hours in the day. 
At night he slept until 4 a. m. The residual urine at this time was 
still two ounces, but the irritation was much less than formerly. 
Case 9. — T. O’B., sixty-seven years of age, first noticed difficulty 
of urination in the spring of 1895. Soon after this he began to have 
pain in connection with urination, and the urine six months later be- 
came muddy. The frequency of urination was constantly increasing, 
so that by May, 1896, he was passing water every twenty minutes, 
and was in a good deal of pain in the interval. 
Examination showed a prostate the size of a lemon, hard but 
smooth. The bladder was distended so as to be felt as a tumor 28 
reaching well up toward the umbilicus. The catheter drew fourteen 
ounces of residual and was then withdrawn, although the urine was 
still running steadily. Ilis mental condition was dull. 
On the sixth of May, under cocaine anesthesia, double orchidectomy 
was done. The cords were tied with animal tendon, but these liga- 
tures slipped later in the day, and the wounds had to be opened and 
the cords tied with silk. Before these were secured he had bled con- 
siderably, but not excessively. For two days he was in a delirious 
condition, but then began to improve, and on the fourteenth (eight 
days after operation), showed decided improvement in urination, hold- 
ing his water from three-quarters of an hour to an hour. Ten days 
after operation, examination of the prostate showed a very marked 
diminution in size, and the catheter drew but ten ounces of residual 
urine. A month later the residual urine had fallen to five ounces. 
He was then urinating ten or twelve times in the day and three times 
in the night. 
In July the residual urine was only three and one-half ounces. In 
the middle of September it was only two ounces, and a little later 
there was only nine drachms. He was at this time passing water every 
two hours in the day and only up twice in the night. The prostate 
was at this time about the size of a pullet’s egg, some portions of it 
being harder than others. It did not have, however, the nodularity of 
a malignant prostate. 
In November, 1897, he re-entered the hospital in the service of Dr. 
J. C. Warren. He had then for six months been having more trouble 
with frequency and pain in urination, and the residual urine at this 
time was found to be seventeen ounces. He was much improved by 
his stay in the hospital, but at the end of eight days left, in conse- 
quence of trouble in his family, and has not been seen since. 
Case 10. — S. H. W., seventy-five years of age, was seen in Octo- 
ber, 1894. At this time he had symptoms of stone, and by litholapaxy 
several uric-acid stones were removed. At this time urination was 
free, and there was little, if any, residual urine. The prostate was 
enlarged to the size of a pullet’s egg. It was not tender to the touch 
and its surface was smooth. 
Considerable discomfort in urination was felt through the years 1895 
and 1896, and in the autumn of the latter year there was so much pain 29 
that an ether examination was made to determine whether there was 
any recurrence of stone. Nothing was found, but following this ex- 
ploration there was a rise of temperature, with pain and tenderness 
about the right kidney. A week later there was a complete stoppage 
of urine, requiring the systematic use of the catheter. The quantity 
of urine fell from one hundred ounces in the twenty-four hours to fifty 
ounces, and the patient’s general condition being such as to excite ap- 
prehension, constant drainage through a catheter was established. 
There was now an immediate improvement, and the temperature soon 
fell to normal, the quantity of urine again rose to the neighborhood of 
one hundred ounces in the twenty-four hours, and the pus, which had 
been considerable in it, quickly disappeared. 
One testicle was now removed under cocaine anesthesia, and a week 
later the other was similarly removed. The wounds healed quickly by 
first intention. On the day following the second operation the per- 
manent catheter was removed and he passed a catheter about every 
two hours. At the end of five days he began to pass some urine by 
the natural efforts, and from this time he was able to partially relieve 
the bladder in this way. At the end of three weeks the amount of 
residuum was only half an ounce. He at this time urinated about 
once an hour. 
Urination continues to be frequent and associated with some pain, 
but he has been much stronger and more comfortable since adopting 
the habit of wearing a soft-rubber catheter for constant drainage at 
night, so that his sleep is not disturbed. 
Case 11. —J. G. H., sixty-nine years of age, was seen in consulta- 
tion with Dr. Lathrop, of Dover, N. H., May 28, 1898. For six 
months he had been troubled with frequency of urination — no pain. 
Latterly, the obstruction had become so great as to constitute serious 
difficulty in starting the stream, especially at night. On the morning 
of the day that I saw him Dr. Lathrop was obliged to draw the water 
for the first time, drawing one and one-half pints. 
Examination showed the prostate enormously enlarged, extending 
beyond the reach of the finger and filling the pelvis from side to side. 
Its surface was smooth and regular, suggesting a condition of extreme 
hypertrophy. A soft-rubber catheter and a silk coudd were both 
tried, but failed to pass. Orchidectomy was advised, on the ground 30 
that the obstruction seemed to be from the lateral pressure on the 
urethra. 
After the patient’s return home he resumed spontaneous urination, 
which was accomplished, however, with considerable straining. 
Two days later orchidectomy was done under cocaine anesthesia. 
Following this operation he had complete stoppage, and constant drain- 
age was established through a catheter. Frequent efforts were made 
to dispense with this, but it was not possible to do so for more than 
three weeks. The power of urination was very slowly re-established, 
and during convalescence the symptoms pointed strongly to the exist- 
ence of a subacute pyelitis. 
Mr. H. was seen in August. He had recovered strength very 
slowly and was still feeble. 
In October he was very weak and evidently failing. At this time 
Dr. Lathrop discovered a tumor pushing up out of the pelvis. The 
nature of this swelling was never positively settled, but Dr. Lathrop 
thought that it appeared like a new growth rather than a collection of 
pus or other fluid. The appearance of this tumor makes it probable 
that this was a case of malignant growth in or near the prostate, and 
this is good reason for the failure of the orchidectomy. 
Unilateral Orchidectomy. 
Case 12. — A. L. began in 1890 to be troubled with considerable 
difficulty in urination, he at this time being about sixty-one years of 
age. Examination showed that residual urine to the amount of four 
ounces existed. Resort to the catheter led to some little irritation of 
the urethra, and after some trouble with cystitis it became necessary 
to permanently establish the catheter life. Since that time he has de- 
pended upon the catheter for passing the water. 
In 1896, on returning from Europe, he took cold on board the 
steamer, and this was followed by inflammation and suppuration in 
both testes. The right testis quickly recovered on evacuatioR of the 
abscess. The left one became chronically inflamed and had to be re- 
moved. For a short time after this operation Mr. L. found himself 
able to pass an ounce or two of urine, but this power was soon again 
lost, and he returned to his catheter life as before. Since that time he 
has been in good health, having no inflammatory trouble with his 
bladder, and expressing himself as extremely well. 31 
Four Cases of Orchidectomy Followe<1 Later bv 
Prostatectomy. 
Case 13. — J. T. A., sixty-six years of age, in 1896 consulted me 
by the advice of Dr. J. M. T. Finney, of Baltimore. He first began 
to be troubled with difficulty of urination in 1890, and finally, in 
October, 1892, was obliged to adopt the permanent use of the catheter. 
In May, 1892, he was operated upon by Dr. W. S. Halsted, in Balti- 
more, for stone in the bladder, by suprapubic cystotomy. At this time 
Dr. Halsted found some outgrowth of the middle lobe of the prostate, 
the whole gland being considerably enlarged. In July, 1895, Mr. A., 
being again troubled with urinary irritation, applied to Dr. Gordon, of 
Portland, by whom he had an orchidectomy done. About a month 
later, a stone being discovered in his bladder, it was removed by supra- 
pubic cystotomy. At this time, on opening the bladder, Dr. Gordon 
found the prostate much shrunken. 
He was first seen by the writer June 19, 1896, at which time he 
was again suffering from symptoms of stone in the bladder. A 
searcher, being introduced, touched a stone. In using this instru- 
ment the prostatic urethra seemed long and rather rigid, so that it 
offered some resistance to its passage. At this time the prostate, with 
the finger in the rectum, seemed to be of moderate size, and had a 
firm resistance. The stone was removed by litholapaxy. For some 
months Mr. A. was comfortable, but then had a return of irritation, 
and again a small, soft calculus was crushed and pumped out. The 
next year this crushing and pumping out of calculous matter was re- 
peated two or three times, and when it was evident that a strong ten- 
dency to the reformation of stone existed, the opinion was given Mr. 
A. that he had an ulcerated third lobe of the prostate upon which this 
calcareous matter was forming. He, however, preferred not to under- 
go a third suprapubic operation for its removal, and persisted in the 
plan of palliation, by the occasional removal of soft stones, until the 
autumn of 1897. He then decided to follow the writer’s advice, and 
have a cutting operation done for the removal of the third lobe, and 
for this purpose consulted Dr. J. M. T. Finney, of the Johns Hopkins 
Hospital, as he preferred to have the operation done at home. 
Dr. Finney wrote me later that he operated on October 15, 1897. 32 
He found the middle lobe of the prostate about the size and shape of 
the last joint of his thumb. This covered the orifice of the urethra 
like a ball valve. It was ulcerated upon its upper or urethral surface, 
and had particles of calcareous material adherent. In the posterior 
cul-de-sac, which was rather deep, was perhaps a half ounce of sand 
and gravel. No stone of any size existed. The rest of the prostate 
had entirely atrophied, so that a finger in the rectum and a finger in 
the bladder appeared to have but the thickness of the bladder and 
rectal walls between them. Dr. Finney excised the middle lobe of the 
prostate flush with the bladder wall. The hemorrhage was slight and 
readily controlled by gauze packing. Recovery was uneventful, and 
since that operation Mr. A. has passed the greater part of his urine by 
the natural efforts. He says the expulsive action seems to be improv- 
ing, but is not yet strong enough to enable hiua to thoroughly empty 
the bladder. 
Case 14. — J. R., age sixty-seven, had had difficulty in micturition, 
and had used the catheter for three years. He then entered the Mas- 
sachusetts General Hospital in September, 1895, and was operated 
upon by Dr. F. B. Harrington, who did a litholapaxy and double orchi- 
dectomy. He was much "relieved by the operation, and partially re- 
gained the power of voluntary urination, still, however, requiring the 
catheter every four hours. 
The prostate was not notably changed to the rectal touch when he 
left the hospital, one week after operation. 
On May 11, 1896, he entered the hospital again, under the care of 
the writer, having had a gradual return of symptoms. He had then 
returned to the use of the catheter for three and a half months. For 
two months he had had considerable hematuria, and was then using the 
catheter every hour. The prostate was as large as a horse-chestnut. 
On May 13, 1896, a stone was found and crushed. After this opera- 
tion the power of voluntary micturition was again partially regained. 
He re-entered the hospital, for the third time, March 16, 1898, 
having been comfortable until five or six months previously, when he 
began to have pain, and again had to depend wholly on the catheter 
which he used every hour. At this time the bladder would hold only 
about two ounces. On March 19 the bladder was opened by suprapu- 
bic incision, but no stone was found. The prostate was not enlarged, 33 
but across the urethral orifice there was a band of tissue, forming a bar 
at the neck of the bladder, which was cut away. Recovery from this 
operation was uneventful. The suprapubic wound soon closed, and 
the power of voluntary urination was almost wholly regained, the 
catheter when used occasionally showing only half an ounce of resi- 
dual urine. 
Case 15. — J. B., seventy-seven years old. He had had difficulty 
of urination for six years, with burning and occasional passage of 
gravel. He had used a catheter for four years, and had been wholly 
dependent on its use for three years, passing it every two hours in the 
day and somewhat oftener at night. In October, 1898, double orchi- 
dectomy was done, and was followed by some relief of irritation, but 
without restoration of micturition. 
He entered the Massachusetts General Hospital in April, 1898. 
Physical examination showed a much enlarged prostate. The urine 
was very scanty, foul smelling, and loaded with muco-pus. Mr. B. 
was a very sick man, with dry tongue, utter inability to take food, and 
the mental hebetude of a patient already uremic. On April 9, 1898, 
he was operated by a suprapubic incision. There was much hemor- 
rhage from the bladder wall. Thirteen stones were removed, and a 
mass about the size of the last joint of the thumb, projecting from the 
prostate below the urethral opening, was cut away. Other smaller 
projections, encroaching on the prostatic urethra, were also removed. 
The patient bore the operation well, but the urine remained scanty, 
and the evidences of uremia became more marked. He gradually 
failed, and died on the fourth day after the operation. 
The masses removed from the prostate proved to be encapsulated 
firm tumors. On microscopical examination they showed a structure 
largely composed of muscular and fibrous tissue, in which were em- 
bedded irregularly-shaped spaces filled with epithelial cells of atypical 
forms. 
The growths nowhere showed any infiltrating tendency. They 
seemed to be adenomatous in character, but one pathologist thought 
them carcinomatous. 
Against this view was the fact that these little growths were scat- 
tered through the prostate, and in every instance were cleanly encap- 
sulated, as carcinomata are not. 34 
Case 16. — Mr. T., sixty-eight years of age, had been troubled 
with urinary symptoms for ten years. He began the constant use of 
the catheter in 1895. In 1897 the symptoms became so severe that 
an operation was advised, and on the seventh of August, 1897, orchi- 
dectomy was done by Dr. J. W. Elliot, at the Massachusetts General 
Hospital. He was somewhat relieved of pain and irritation after this, 
but depended wholly on the catheter until September 26, 1897, when, 
after eating onions, he began to pass urine naturally. He now 
adopted an onion diet, and began to pass water quite freely, using the 
catheter but once a day. 
In March, 1898, he again began to have pain and difficulty in urina- 
tion. This increased through the spring, until in May he was con- 
fined to the bed with much pain and tenesmus. At this time he was 
seen by the writer in consultation with Dr. Jones, of Southboro. An 
operation was advised, acceded to, and the bladder was opened above 
the pubes. Below the urethral orifice, and to the left of it, were con- 
siderable projections, which were ulcerated and encrusted with lime 
salts. These were freely cut away, and some bits of calcareous matter 
that lay free in the vesical cavity were removed. Drainage was es- 
tablished above the pubes. The patient made a good recovery, as re- 
ported by Dr. Jones. The suprapubic tube was kept in, however, for 
six weeks, thus establishing a fistula that was slow to heal. When 
this finally closed, the power of voluntary urination was restored. 
It is not my intention to offer any positive conclusions drawn from 
cases so few in number. It may be profitable, however, to make a 
brief resume of the results, and to point out certain ideas suggested by 
them. 
Of the cases of prostatectomy, eight (Nos. 1, 2, 4, 5, 6, 13, 14, 16) 
recovered the power of urination in a very satisfactory degree. 
One (Case 3), upon whom a confessedly imperfect operation was 
done, did not recover the power of voluntary micturition, and one 
(Case 15), an old uremic man of seventy-seven, did not live long 
enough to decide this point. 
Of the cases of orchidectomy, five (Nos. 8, 9, 10, 14 and 16) were 
more or less distinctly improved in the power of urination. Three of 
these (Nos. 9, 14 and 16) afterwards relapsed and showed as much ob- 
struction as before the operation. In one case (No. 10), while the 35 
power of expelling urine was restored, the intolerance of the bladder 
remained and the frequency of urination was excessive. 
Three cases (Nos. 7, 13 and 15) obtained no relief from the obstruc- 
tion after orchidectomy. 
In one case (No. 11) the subsequent course seemed to show that a 
malignant growth existed in the prostate and that the case was, there- 
fore, beyond the relief of any operation. 
Perhaps the most interesting observation of all is that among these 
patients there are five (Cases 7, 13, 14, 15 and 16) in which an orchi- 
dectomy failed to satisfactorily relieve obstruction and in which the me- 
chanical reason for this failure was afterwards investigated either by 
operation or autopsy. 
In four of these cases (7, 13, 14 and 16) the obstruction was found to 
be due to outgrowth into the bladder, or across the urethral orifice, of 
prostatic tissue that was not removed by the shrinkage following 
the orchidectomy. In my paper before the American Surgical Associa- 
tion I suggested that cases of this sort were suitable for prostatectomy 
rather than for orchidectomy, and the experience of these cases bears out 
this assumption. 
In Case 15 the obstruction was also found to be due to the encroach- 
ment on the urethra of little tumors in the prostate, which, not having 
shrunk after orchidectomy, were found and removed by the prostatec- 
tomy. While this case, then, is not properly to be included among 
those of hypertrophied prostate, in which orchidectomy failed of relief, 
it distinctly was a case which, having all the clinical aspects of hyper- 
trophy, was suitable for prostatectomy and not for orchidectomy. 
In three cases (13, 14 and 16) out of the four that had a prostatec- 
tomy after orchidectomy the restoration of function after the obstructing 
tissue was finally cut away was marked and satisfactory. The fourth 
patient (case 15), profoundly uremic before operation, died before the 
effect on urination was clear. 
In my former paper another conclusion, drawn from a study of the 
statistics then available, was, that “ the functional results of the two 
operations seem at present to be as nearly equal as possible, and the 
tendency to relapse shows itself in about the same proportion of cases 
after either operation.” 
This conclusion, which seemed true in the light of events up to 1896, 36 
is not borne out by my personal experience as embodied in the above 
report. 
My present feeling is, that prostatectomy offers a distinctly better 
prospect of relief than orchidectomy, and is especially applicable in the 
cases where the obstruction is due to the growth into the bladder of 
prostatic projections which encroach on the urethral orifice. 
In Cases 3 and 4 it is probable that the result would have been better 
had the lateral lobes of the prostate been thoroughly removed, either 
through the bladder or by the perineal route in the manner advocated 
by Alexander.