Repri?ited from The Boston Medical and Surgical Journal 
of March 7, iBBg. 
SUPRA-PUBIC PROSTATECTOMY 
IX A PATIENT AGED SIXTY-NINE YEARS, THE SUB- 
JECT OF PROFUSE HiEMATURIA FROM AX 
UNUSUAL SOURCE : RECOVERY.1 
F. S. WATSON, M.D. 
L. G-. M., set. sixty-nine years, in vigorous health 
until ten years ago, when symptoms of urinary ob- 
struction from an hypertrophied prostate began. 
Not long after this he had an attack of retention 
of urine, which was relieved by a metal catheter, 
and the instrument was used to draw the water for 
a few days (he then had a prostatic abscess?, 
which evacuated, apparently spontaneously, into the 
urethra). 
Five years ago occurred a second attack of reten- 
tion, followed by inability to pass the urine natur- 
ally, and the necessary regular use of the catheter, 
which condition has persisted ever since. Three 
years ago first noticed blood in the urine: the haem- 
orrhage was profuse, filling the bladder with clots 
which could not be evacuated through the catheter, 
and causing great distention of the bladder. This 
first attack of the bleeding apparently had no con- 
nection with the use of the catheter. 
The bleeding was repeated only two or- three 
times in each of the first two years following its 
first appearance. 
1 Read before the Society for Medical Improvement, Feb. 11,1889. But during the last year it has become more fre- 
quent, latterly once in about two months. The 
quantity of blood is-generally great at the onset 
of the attack,.then gradually diminishes during the 
succeeding days, leaving the urine quite clear at the 
end of about a week. The haemorrhages are inde- 
pendent of exertion, and there is no pain except 
from the retention due to the over-distention from 
clots. During the past year the patient thinks he 
has noticed fleshy bits in the urine. There has 
been no pain. The history is, as you see, absolutely 
typical of bladder tumor, lacking only the positive 
confirmation of seeing the growth with the cysto- 
scope, or finding the characteristic fragments micro- 
scopically in the urine. Such confirmation the 
patient stated he had received in New York, from 
a physician of high authority, who, the patient says, 
told him. that a villous growth was plainly visible 
through the cystoscope, and that the microscopic 
examination also furnished further proof of its 
presence. 
This I have noted, in order to make prominent 
the fact that an exceptional condition may (if the 
patient-correctly quoted the doctor’s opinion) lead, 
as in this instance it proved to be, to a faulty diag- 
nosis, even in the presence of snch positive proof 
as was furnished. 
When the patient came to me early in December 
he was very ansemic and still weak from his last 
haemorrhage, about a month previous. During 
three days I examined the urine, failing, however, to 
find any positive evidence of a bladder tumor. Two 
things, however, were evident, namely, the haem- 
orrhages were of undoubted bladder origin, and 
they undoubtedly meant the patient’s death at no 
remote period. Upon these grounds I advised 
operation. The choice of routes into the bladder was through 
the perinseum or from above the pubes. As he had 
a greatly lengthened posterior urethra due to the 
prostatic hypertrophy, and also a large and disten- 
sible bladder easily raised above the symphysis 
pubis, the latter way was selected. The cysto- 
tomy was done in the usual manner, with Petersen’s 
technique. The inner surface of a thin-walled 
bladder was found to be entirely smooth, and no 
villous or other growth was present, except the 
projecting lateral portions of a greatly enlarged 
prostate. These jutted boldly backward into the 
cavity of the bladder, each lateral portion being 
about the size of a very large Spanish chestnut. 
They were connected by a less prominent median 
ridge, which had been perforated about half-way 
from its base, at some time previous,by an instrument. 
Surrounding this hole was a surface of the size of the 
end of one’s thumb, covered with dabby and exuber- 
ant granulations, and this area was the only intra- 
vesical source of the haemorrhages to be found. 
The lateral portions of the prostatic hypertrophy 
were then divided into halves by a blunt pointed 
bistoury, and each portion removed by a wire 
ecraseur to its base; the median portion, together 
with its granulating surface, was taken away with 
scissors and curette. 
The bladder and outer wounds were both left 
open, and a large double rubber drain, reaching to 
the bottom of the bladder, was placed in them. 
Hemorrhage during and after the operation was 
but slight, and ceased on the fourth day, recurring 
for one day moderately, when the sloughs separated 
from the wounds at the end of two weeks. There 
has been none since (three months). A single drain- 
age-tube was substituted at the end of a week, and all drainage was removed on the twelfth day. The 
wounds united on the sixteenth day, and the patient 
was up and about on the eighteenth day. A week 
later, having been very restless, and sleepless for 
four nights preceding, heart failure occurred, the 
first sound becoming scarcely audible; the pulse 
rose to 100-110. The urine rapidly diminished 
in quantity, and was deficient in its solid con- 
stituents. The patient was pallid, and greatly 
prostrated. Dr. Whittier saw him at this time 
in consultation. Digitalis, stimulants, and ap- 
propriate feeding restored the patient. On sub- 
stituting tinct. strophanthus for the digitalis 
forty-eight hours later, he relapsed into his for- 
mer dangerous condition, which was again over- 
come by digitalis, etc. From this time he steadily 
gained, and went home at the end of six weeks 
from the date of operation, and has continued to 
do well since then; voluntary power of urination 
was not, however, restored. He reports, a day or 
so since, rapid gain in strength, and in all respects. 
This case presents, I think, points of unusual 
interest, the chief of which is that already noticed, 
namely, that in rare instances prostatic hypertro- 
phies may so simulate symptomatically in every 
respect other bladder growths (papilloma, etc.) as 
to entirely mislead, and furnish much apparently 
positive evidence of their existence. 
Another matter of importance in connection with 
such a case is the advice as to operation. If the 
diagnosis is of bladder tumor, operation looking to 
its removal should always be advised, provided it is 
believed to be benign, and unless the patient is too 
far exhausted to undergo the operation. This in 
view of the successful results attained in many in- 
stances, and the necessarily fatal termination of the 
disease, if left to take its course. ■ If the growth is, on the other hand, believed to be 
cancerous, then the decision as to surgical interfer- 
ence turns on the question of pain; if this be severe 
a palliative operation by drainage should be advised; 
if painless, the disease had better be left to itself, 
in view of the inevitable result in any case. 
Advice as to operative interference in cases of 
prostatic hypertrophy should, I think, be based 
upon the indications that I have recently pointed 
out in a Avork upon this subject (“ On the Opera- 
tive Treatment of the Hypertrophied Prostate ”), 
viz., “ Necessary, frequent (once an hour), painful 
catheterization, or urination without the catheter, 
especially when accompanied by a foul or haemor- 
rhagic cystitis. Attacks of retention; and failure 
to relieve such condition by palliative treatment.” 
When such symptoms are present in any patient, and 
due to obstructive enlargement of the prostate,opera- 
tion should, I think, almost always be advised, and 
undertaken before the patient is so reduced by the 
effects of the malady as to make the operation 
almost necessarily fatal, and consequently imprac- 
ticable. 1 need not delay here to discuss operative 
methods. It is unquestioned, of course, that under 
the best’ of circumstances extensive surgical pro- 
cedures, in these cases, will always be dangerous, 
and that fact must of course always be included in 
advising them. But such risks are, I think, to be 
preferred, in \dew of the highly probable benefit 
attending a successful issue, to the inevitable and 
near end of the patient’s life, and the constant 
torture he must experience in whatever inter- 
val may precede that termination, if the case 
be left to palliative measures that have already 
proved ineffectual. 1 know of no picture more 
pitiable than that of an old man, a slave to the constant and painful use of the catheter and a 
tormenting desire to urinate. In the case I have 
reported the operation was not undertaken prima- 
rily for relief of the obstruction to urination (for 
the patient’s bladder was quiet), but to avert if pos- 
sible death from hemorrhages. This object is in 
all probability accomplished. 
COPPIgS * ny??D, THE AW9R9VIN press, eOSTQN,