Conservative, Yet Effectual Treatment 
of Hypertrophied Prostate by Electro= 
Incision, Done Through the Urethra; 
Presentation of Specimens of Hyper= 
trophied Prostate; Demonstration of 
Bottini = Freudenberg Electro=lncisor. 
BRANSFORD LEWIS, M.D., 
St. Louis, Mo., 
Genito-Urinary Surgeon to the Baptist Hospital—Consultant in 
Gcnito-Urinary Surgery to St. Mary's Infirmary, to Missouri 
Pacific Hospital, City Hospital, Female Hospital, Etc. 
sr. ;louis, mo.: 
Reprinted Pirvirmy 
February n, 1899. Conservative, Yet Effectual Treatment of 
Hypertrophied Prostate by Electro-In- 
cision, Done Through the Urethra; 
Presentation of Specimens of 
Hypertrophied Prostate; Dem- 
onstration of the Bottini- 
Freudenberg Electro- 
Incisor.1 
BRANSPORD LEWIS, M. D., ST. LOUIS, 
Genito-Urinary Surgeon to Baptist Hospital; Consultant in Genito- 
urinary Surgery to St. Mary’s Infirmary, to Missouri 
Pacific Hospital, City Hospital, Female 
Hospital, Etc. 
The treatment of hypertrophied prostate with ob- 
struction has been divided into the palliative and the 
radical or operative plans. The former, during the 
many years that the profession has been working on the 
subject, has embraced pretty nearly everything under 
the sun that could be applied to the patient or his pros 
tate, either externally or internally, that gave any prom- 
ise whatever of exercising an alterative or reducing ef- 
fect on the enlarged gland; while the operative plan, 
after having been sifted through numberless illusory, 
though often alluring procedures, of late years has been 
practically reduced to three modes that have been widely 
recognized by the profession; they are prostatectomy, 
castration, and vasectomy. These methods have now 
lßead by invitation at the twenty-fourth semi-annual meeting of 
the Southern Illinois Medical Association, held in Cairo, Illinois, 
November 17 and 18, 1898. 4 
been on trial for a sufficient length of time to Justify 
some definite conclusions as to their merits. 
Prostatectomy, consisting in the removal of the pros- 
tatic tissue to re establish the urinary channel, whether 
it be done through the perineum or by suprapubic in- 
cision, or both combined, must be done with the patient 
under general anesthesia—chloroform or ether; and 
everyone who has had such cases under observation 
knows the marked danger of giving them either chlo- 
roform or ether. He knows, in the first place, that such 
patients are the subject of backward urine-pressure on 
account of the obstruction; which backward pressure 
has been in effect for months or years before medical 
assistance is sought; and which has, in the meantime, 
in a very large proportion of cases, already involved 
the -kidney.pelves in chronic suppuration. So that, 
aside from any danger coming from prostatectomy it- 
self, a serious danger threatens from the anesthesia 
which makes the operation possible. 
But when we remember that to this danger, in an 
aged individual, usually already debilitated from the 
various effects of the disease, in doing prostatectomy 
we open up the bladder, make entrances for infections, 
cause hemorrhage sometimes very severe, institute 
drainage that is never free from objectionable features, 
often accompanied by leakage, wetting of clothes, etc , 
even if it is fortunate enough to drain the bladder ef 
fectually. Considering these various conditions that 
are inseparable from this operation, it is no wonder 
that it has a mortality of from 15 to 20 per cent; and 
no wonder, also, that the medical world hailed with de- 
light the proposal of another operation, a few years 
ago, that, it was at first thought, would answer the pur- 
pose of prostatectomy without entailing its dangers. 
Castration was that operation; and from the strong 
theoretical considerations backing it, as well as the nu- 
merous cases of apparent relief or cure reported, it gave 
promise of being a great acquisition in the surgery of 
the prostate. Later, when the simple operation of vasectomy was proposed as a sub- 
stitute for even the mild operation 
of castration, it was considered that 
almost the acme of surgical simplic- 
ity had been reached in this connec- 
tion. 
But a few years’ collective inves 
ligation has taught the profession 
that very little can be expected from 
these two procedures; that though 
their mortality is only 7 or 8 per 
cent, their promise of cure is so 
small as to furnish very little temp- 
tation to the man to sacrifice his 
testicles or his sexual ability. 
So that, until the advantages of 
the electro-incision operation were 
made known to the profession, the 
choice in the radical treatment of 
prostatic hypertrophy has lain be 
tween prostatectomy with its dan- 
gers, and castration or vasectomy 
(ligation of vasa deferentia, with 
removal of a portion of the tubes), 
with their small hope of relief and 
their attendant sexual mutilation. 
However small this last consideration 
may be theoretically or from the 
medical standpoint, it is of large 
import from the patient’s standpoint. 
So the choice has not been an in- 
viting one. The operation I wish 
to speak of is not a new one; it 
has twenty-three years of success 
behind it. In 1875, Bottini, of Italy, 
first made use of what he called an 
electro-cauterizer. Introduced down 
the urethra and the current of elec- 
tricity turned on, it burned the whole 
prostatic urethra. Later, this instru- 
ment was modified so that it burned 
just at one point—that part with 
which the platinum blade came in 
contact; and a cooling channel, 
through which ice-water ran, pre- 
vented the heating of the remainder 
of the instrument. 
A. Irido-blatinmu blatl ■ 
B. Staff. 
C. Handle. 
i). •Water-cooling tabes. 
E. Wheel. 
E. For batterj-attneliin'l.J 
G. Electric cord. 6 
Later still, Freudenberg, of Berlin, simplified tbe 
mechanism of the instrument and made it sterilizable 
by boiling. It is this latter instrument that I present 
to you now. 
Notwithstanding the fact that Bottini did his best 
to keep the profession informed of the progress of his 
work by regular and numerous reports in the medical 
press,2 it is only in the last few years that the profession 
has given the subject the attention it deserves. 
Bottini has operated upon 80 cases, with only two 
deaths; and in those that obtained relief, there has 
been no recurrence. That is, to put it statistically, a 
mortality of per cent. 
As you see, the Freudenberg Bottini incisor is shaped 
somewhat like a lithotrite, having a handle, staff and 
base for electrical attachment, with a wheel to control 
the play back and forth of the irido-platinum cautery- 
blade that slides in the groove of the staff. The latter 
is tunneled for the passage of ice water up and back 
through it, for cooling purposes. The effect desired 
is that of a cauterizing incision, not electrolysis; 
consequently the blade must be red hot to produce 
that effect. An ordinary battery will not suffice. I 
have been using the ordinary alternating street current 
of electricity, modified by an Aloe’s converter; or, if 
operating at the office, where the direct current is 
made, the only converter that has proved equal to the 
demands was that furnished by the Wilbrandt Surgical 
Instrument Company. The technique of the operation 
is, briefly, as follows: 
After a cystoscopic examination to determine the lo- 
cation of the obstructing prostatic overgrowth, the 
bladder is emptied as completely as possible. A half- 
dram or more of four per cent cocaine solution is intro- 
duced by means of a deep urethral syringe into the 
2“Galvani,” 1874, tome x; La galvano-caustica nella piactica chir- 
urgica, Milan, 1876; Arch. f. klin. Chirurgie, Vol. xxi, 1877, and Vol 
liv, 1897, Heft 1; and La Clinica Chirurgica, July 31, 1896. 7 
prostatic urethra and vesical neck. While awaiting the 
five minutes allowed for cocainization, a final test of the 
electro-incisor is made The blade is brought to a 
cherry red glow and the current is shut off by opening 
the switch of the converter. The connecting screw on 
the incisor should not be used for this purpose as it 
works too slowly for such a strong current as is neces- 
sary. 
The water-cooling stream working perfectly under an 
assistant’s charge, the incisor is introduced into the 
bladder. As it enters the bladder its beak is naturally 
turned upward. The obstruction is, in the great ma- 
jority of such cases, Jocated at the floor of the vesical 
neck—the so-called third lobe. This, then, is the prin- 
cipal point of attack. The instrument is turned within 
the bladder so that the blade points downward; the 
beak is thereby hooked over the prostatic bar or third 
lobe and is drawn forward, so as to tightly hug that 
part of the organ. While it is being held in this posi- 
tion with the right hand, the left forefinger is intro 
duced into the rectum and feels for the point of the in- 
cisor through the posterior wall of the bladder. This 
maneuver tells much with regard to the thickness of 
the obstructing part and the extent of incision needed, 
as well as of the proper adjustment of the incisor. The 
finger is then withdrawn, to prevent any disarrangement 
of that adjustment. The assistant turns on the current 
and the cautery-incision is slowly carried forward 
through the obstructing bar or nodule. Time given 
for the advance of the blade insures the thorough searing 
of the wound surfaces and wards against hemorrhage. 
Bleeding is practically nil—the most that I have seen 
being merely a slight tinging of the first fluid coming 
from the bladder after operation. 
Since it often occurs that the obstructing outgrowth 
assumes the shape of a collar around the urethro-vesical 
opening, it is advised to make more than one incision; 
and the custom has been to make one incision poste- 
riorly, one anteriorly, and one into the lateral lobe that 8 
is most enlarged. I prefer to make them posteriorly 
and on both sides, omitting the anterior one, as I be- 
lieve obstruction seldom arises from that direction. 
Having completed the three incisions, the blade is 
returned into its niche and the current is turned off. 
This latter was overlooked by one operator, who began 
to take out the instrument with the blade red hot; the 
result was embarrassing, to say the least. 
Now comes one of the most gratifying features of 
this operation: The patient gets up and walks to his 
bed, complaining but little, if any, of pain. No chill, 
no fever, no hemorrhage! No drainage tubes to clog, to 
be washed or readjusted. No prolonged confinement to 
bed and no sogging with dripping or seeping urine. He 
simply rests for twenty-four hours and then gets out 
as he likes. After one operation, done at my office, on a 
patient 75 years of age, he went home on a street car, and 
was up the whole of the following day; and all he com- 
plained of was a little soreness at the vesical neck and 
an unwonted urgency to urinate when the desire came 
on. 
While there is no especial after-treatment required, I 
think it best to encourage internal antisepsis by giving 
urotropin or the salicylates. 
Often, for the first few days or a week, the effects of 
the operation are the opposite of favorable: The swell- 
ing of the tissues following the cauterization decreases 
the size of the outlet, apparently, and the irritation in- 
creases the frequency of urination. Sometimes, even, 
catheterization must be resorted to for withdrawal of 
the urine. But following that period, just when patient 
and doctor are beginning to have misgivings about the 
success of the operation, the good effects begin to make 
themselves manifest. The stream begins to flow more 
easily, more freely, and is projected more ably. There 
is liable to be some burning during the passage of the 
stream—but the old fellow barely notices this in the 
reviving memories of bounding boyhood when a tall 
imagination likened his stream to that of a fire engine 9 
After a few days a test shows a distinct decrease in 
the amount of residual urine. Two to four ounces are 
already knocked off of this barometric signal of back- 
ward pressure. And later, corresponding to the increas- 
ing completeness of emptying the bladder, there is 
marked lessening in the frequency of urinations. One 
of my patients was thus reduced from 15 or 20 urina- 
tions in 24 hours, to Bor 9. And another, whose resi- 
dual urine had been a bladderful; i. e., all of his urine 
was passed by catheter, now shows only from one to 
three drams after voluntary urination. 
Of course, even with effectual opening up of the urin- 
ary outlet, it is not justifiable to expect immediate re- 
storation of bladder expulsive-power; that organ has 
been too long subjected to the injurious influences of 
backward pressure to admit of that. So that it is on 
this account, I believe, that there is a considerable vari- 
ation, from time to time, in the ease and completeness 
with which urination is carried out. The patient last 
mentioned, who ordinarily now shows only two or three 
drams of residual urine, occasionally “stammers” in his 
urination and there will be several ounces left over, as 
a result. But even this hesitancy is rapidly being over- 
come during the present week. 
In certain oases it is necessary to repeat the opera- 
tion because of incompleteness of result after its first 
application. Freudenberg has performed it twice on 
two patients, and three times on one, before getting the 
desired result. But it was obtained, finally, in each 
case. From an observance of the reports of these re- 
peated operations, as well as from my own experience, 
I suspect that the repetitions are superinduced by lack, 
on the part of the beginner, of skill and experience 
with the technique. My first two cases had to be “done 
over” a second time. But, as before mentioned, since 
the operation itself causes so little disturbance and the 
reaction following it is practically nil, this is not a very 
serious objection. It can be performed two or three 
times, if necessary, with impunity. 10 
My faith in the efficacy and preponderating advan- 
tages of this operation does not, of course, rest solely 
on my own experience with it. My cases have been 
too few, and the time since operating too short to make 
any final deductions from them. But when, in addition 
to the marked evidences of benefit already achieved in 
them, I get together and study the statistics of others 
who have done a considerable number of the opera- 
tions, I must grant the force of the figures. 
In the first place, the father of the method, Bottini, 
has operated, according to the latest reports accessible 
to me,8 upon 80 cases, with 2 deaths. Of these 80 cases, 
57 were operated upon with his older instrument (cau- 
terizer), while in 23 the newer one (incisor) was used. 
Of the first group of 57 cases, 43 were successful (32 
cured, 11 improved); and of the second group, 23 cases, 
all were successful. Percentage of mortality 25; of 
cures 82.5. 
Freudenberg has operated 34 times upon 29 patients 4 
I have not been able to obtain full reports on all of 
these, but on the first 13 of the series full reports5 have 
been given, af follows: Two of them died; one, from 
embolic pneumonia, as a result of the operation; the 
other, twenty-four days after the operation, from an 
exacerbation of already-present pyelitis, etc. Of the 
II cases remaining, 7 had had complete retention; 4 
incomplete. All were markedly benefited by the oper- 
ation, only 3 having still some residual urine that re- 
quired occasional catheterization. In one case there 
bad been such a degree of irritation that the patient 
had been urinating from sixty to seventy times in twen- 
ty four hours; which was reduced to eight or ten times 
by the electro incision. 
Simon6 reports eight cases operated on in Czerny’s 
3 Berliner klinische Wochenschrift, April 12, 1897. 
4New Yorker medicinsche Monatsschrift, July, 1898 
sNe>jr York Medical Journal, February 11, 1898. 
6Centralblatt fuer die Krankheiten der Harn- und Sex.-Organe, Bd. 
ix, Heft 8, 1898. 11 
clinic at Heidelberg, in 1897. Of these eight cases, two 
died; one as a result of complicating affections of the 
heart, lungs and kidneys (nephritis), and the other in 
connection with co existing arterio sclerosis, severe 
urethral strictures, and pyelo nephritis. Of the remain 
ing six cases, four were cured, one was benefited and 
one proved a failure. This last was the first case oper- 
ated upon in this series. In these oases the instrument 
as improved by Bottini (not Freudenberg) was used. 
Willy Meyer,7 of New York, was the first to adopt 
the method in this country. He reported three eases, 
with one death. Of the two that lived, one was mark- 
edly benefited, and one proved a failure (but one oper- 
ation being done in this case). 
Henry H. Morton8 reports five cases with no death. 
The results are stated to be as follows: “Reduced fre- 
quency of urination in every case, and removal of the 
obstruction offered by the prostate, so that the patients 
could entirely and completely evacuate their bladders. 
In each case the patients were able to dispense with the 
catheter, which they had formerly depended upon to 
empty their bladders ” 
My own cases, in brief, are as follows: 
Cask I,—Mr. B , referred by Dr. Brokaw, aged 74 
years; well preserved and in good general health when 
he came to me, January 13, 1898. From the history 
then given, the obstruction to the urinary outflow bad 
evidently been gradually increasing for ten or twelve 
years. For that length of time he had been required to 
get up and urinate at least once nightly; for about six 
years, twice nightly; and for the most of 1897, from 
three to five times nightly; for the twenty-four hours 
there were from from fifteen to twenty, sometimes 
twenty-five urinations. Residual urine 1022, slightly 
acid, very cloudy, containing much pus; no albumen, 
no sugar. For eight months he received from me pal 
7Medical Record, March c, 1898. 
BMedical Record, September 17, 1898. 12 
liative treatment consisting of periodical irrigations of 
the bladder, nightly catheterization, internal antisepsis, 
etc. This at first caused some improvement, but later 
did nothing more than retard the progress of the nat- 
ural course of the disease and its complications. 
At the time of operating, September 14, 1898, the pa 
tient was, symptomatically, in about the condition de- 
scribed; and there were from four to six ounces of 
residual urine. I operated at my office. There was 
but little pain; no hemorrhage, no fever nor general 
reaction 
Three weeks afterward he was urinating from eight 
to ten times in twenty-four hours; residual urine from 
two to three ounces. The patient was taking much 
pride in the increased size and freedom of the stream. 
There was less irritation than formerly; but the urine 
remained cloudy. The improvement was definite and, 
to the patient, satisfactory; but in view of the fact that 
I had been ultra conservative in the extent of my in- 
cisions, it being my first trial of the method, I consid- 
ered it probable that a second and more extensive in- 
cising would secure even better results. This was done 
on October 25. At this time I made use of a maneuver 
that I have not seen mentioned by any writer on the 
method. In a recent discussion of the technique of the 
operation,® Dr. Freudenberg mentioned that in one of 
his cases a fold of bladder mucous membrane had be- 
come caught and burned by the blade of the incisor; 
and to prevent such an accident, he advised that the 
operation be done with the bladder full of boracic acid 
solution; that the close contact of the instrument with 
the prostate would express any fluid that might tend to 
come between them, admitting of uninterrupted activity 
on the part of the blade. Experience with this sugges- 
tion in a late operation as well as an experiment in a 
cup of water, make me doubt its utility. The blade 
will not get red hot if in contact with any quantity of 
9 New Yorker medicinische Monatsschrift, July I, iggS. 13 
water; and if there is only a small amount present, as 
pre-supposed by Dr. Freudenberg, this would be liable 
to become superheated and scald the adjacent parts. 
Therefore, in order to smooth out the bladder folds and 
at the same time to avoid interference with the action 
of the blade, I injected air into the bladder from a 
bulb-syringe. It was satisfatory in every way. 
This 'operation was done too recently (three days ago) 
to report its results. 
Cask ll.—Mr. J., referred by Dr. H. M. Pierce; aged 
47 years; married. Although this patient was of so 
youthful an age for “senile” hypertrophid prostate, the 
effects of obstruction had been progressively increasing 
for a considerable length of time. Nine years ago 
(that is, at the age of 38 years) he suddenly became un 
able to pass any urine. This complete retention lasted 
for the greater part of a day. After it passed off, he 
noticed a gradually increasing frequency of urination, 
both by day and night. For ten years, his wife states, 
he has been getting up once or twice nightly to urinate. 
In 1897 actual difficulty of expelling the urine was first 
realized by him, and it became so severe and painful 
that he called on Dr. Pierce. Boric acid washings and 
catheterizations gave temporary relief. There was no 
stricture present, the catheter meeting with obstruction 
only after reaching the prostatic urethra; and enlarge- 
ment of the prostate was felt per rectum. 
Later, the patient was lost sight of for a time and in 
mean time consulted other surgeons, receiving vesical 
irrigations by some, and having one testicle ablated by 
another—with no relief. On his returning to Dr, 
Pierce this fall, I was consulted and we found the fol- 
lowing; Marked anemia with a cachectic appearance 
that reminded one strongly of cancer. A large bubo, 
tender and adherent, in the right groin; right testicle 
absent; almost entire inability to urinate voluntarily— 
reliance being placed altogether on the catheter in lieu 
of that function. Urine 1018, acid, intensely cloudy 
from pus; non albuminous. Prostate, felt through the 14 
rectum, was the size of an apple. Soft rubber catheter 
could be introduced only with great difficulty, and 
sometimes not at all, whereupon a metal one would be 
necessary. 
The statement of the patient that bladder washings 
had usually only aggravated the irritation, was borne 
out by our trial of them. No treatment outside of an 
operative one appeared to be feasible. I will say that 
at first I was strongly impressed with the close sem- 
blance to malignancy presented by the case; the youth- 
ful age (for “senile” hypertrophy), the inguinal adenitis, 
the cachectic appearance, etc.; but a closer study led 
me to a confirmation of Dr. Pierce’s diagnosis of ob- 
structive prostatic hypertrophy. 
Operation October 3; retention practically complete. 
No reaction; no improvement in the stream until seven 
days afterward, when he passed a good stream of urine; 
two days later did this two or three times in one day— 
and then there was a halt in his progress, the inter- 
ruption seeming to be connected with an intestinal irri- 
tation which caused diarrheic movements, abdominal 
pain and griping. After awaiting another week or so 
for more improvement in bladder expulsion, we re- 
peated the operation on October 20. Since then be has 
become able to empty his bladder at each act, leaving 
only two or three drams of urine residual. I have 
often found this much urine remaining in healthy blad- 
ders after voluntary urination; so I do not believe so 
small an amount should be dignified with the term 
“residual.” 
Cask 111 was operated on this afternoon, so no report 
will be made of it at present. 
The quettion might be very pertinently raised as to 
whether, granting the tangible advantages claimed for 
the Bottini method, it will prove applicable to all cases 
of prostatic obstruction? 
The pathological specimens which I present should 
throw some light on that question. No 1, you notice, 
presents the obstruction in the form of a prostatic bar 15 
stretching across the posterior aspect of the urethro- 
vesical opening. Behind the bar is the bas fond, a deep 
receptacle in which residual urine evidently collected 
in the person’s life-time; and in front of it is an almost 
equally deep depression formed by the long and deep 
curve of the prostatic urethra. It seems practically as- 
sured that if this bar had been burned through with 
the incisor, without re uniting afterward, the obstruc- 
tion would have been done away with. In this second 
specimen the obstruction is in the form of a jutting 
nodule that evidently acted in the manner of a ball and- 
socket valve. If the blade of the cautery should miss 
the nodule in such a case a good chance of failure 
would, no doubt, be run. For that reason, as well as 
others (for the purpose of excluding stone, for in- 
stance), it is decidedly of advantage to examine the 
bladder and prostate as thoroughly as possible with the 
cystoscope before operating. The same cocainization 
will serve for both procedures. 
It seems reasonable to expect, though, that if such a 
nodule receive a good searing, either directly through 
it or on its surface, it will undergo atrophy similar to 
that noticed in the tonsil after removal of only a por- 
tion of it by cauterization. 
[627 Century Building]