he capsule, I decided to open the bladder by the uprapubic route. I did so for the purpose of (1) epressing the prostate within reach, and (2) re1oving the stone.

On introducing the finger into the bladder, a very rge stone was felt, also the left lobe of prostate, hich had been enucleated through perineum, was so found lying loose in bladder, where it had been ished by previous manipulation, after having been rn loose from its attachments. Some difficulty was perienced in removing the stone through the suapubic incision, as it was a large one. The abdoml wound was partially closed by suture and Guy's double tubes were introduced and the bladder s drained through the perineum by a large ca

:ter.

Ten days after the operation, the patient was doing Il and sitting up; the suprapubic fistula was 1 open; but the perineal fistula was about closed. On March 24 the abdominal and perineal wounds e healed; urine was passed about every three rs, the capacity of the bladder being 4 oz., the dual urine amounting to one ounce; there was pain on urination. No. 24 F. sound passed ly; the meatus was small and the patient refused submit to meatotomy. The general condition good.

omments.-I. This case shows the importance lways remembering the possibility of the presof a vesical calculus, and searching the bladder re the operation with a stone searcher, or, when ible, by a cystoscopic examination.

In the unmixed adenomatous type of prostatic rgement the tumors can be shelled out easily ugh a perineal incision alone, but fibrous tumors erstitial fibrous hyperplasia) are so adherent it may be necessary to make an incision into the ler, or at least into the space of Retzius, in : to get the prostate within reach and hold it y enough to enucleate. The various forms of atic retractors may often here be used to adge.

have difficulty in passing water, which grew steadily worse. Two days ago he had complete retention of urine, which was unrelieved until a catheter was passed and 64 oz. of urine withdrawn, some being left in the bladder. left in the bladder. Examination through the rectum showed a large soft prostate as big as a lemon.

Perineal prostatectomy (Bryson's operation) was performed on October 20, 1902. The man was delirious for three or four days after the operation, but little fever and the pulse was good. The bladder was drained with a tube for a week; the urine contained a good deal of blood.

On November 5 the patient was up and on November 10 he could hold his water for three hours at a time. The perineal wound was still open. On November 25, the skin of the scrotum covering the hernia became gangrenous spontaneously and sloughed, but the patient was doing well and perineal wound was nearly closed.

On January 5, 1903, the perineal wound was nearly closed, and the man passed water with perfect ease

three or four times a day and once or twice at night.

CASE IV. Enlarged Prostate and Stricture, Prostatectomy.-B. W., retired sea captain, aged 72 years. He had several attacks of gonorrhoea in youth, but had no trouble in passing water before the present attack, which came on suddenly and without apparent cause on February 27, 1903. The bladder was distended. A guide was passed, but the tunnel catheter would not pass the stricture; a quart of bloody urine flowed away, however, alongside guide, emptying bladder. On February 28, external urethrotomy was performed and a very tight stricture in the membranous urethra divided. A tumor was enucleated from the left lobe of the prostate, but slipped up into the bladder and was extracted with stone forceps. The right lobe of the prostate was not enlarged and the bladder was drained with a catheter (34 F).

After enucleation tumors often escape into the bladder and are difficult to grasp with stone forceps.

2

bladder, even when the gland is enormously enlarged and extends up very high.

2. Forceps is of great use in delivering the pieces after they have been loosened from attachments by the finger.

3. The fact that the lacerated surfaces of the posterior urethra became united during the process of healing shows the necessity of keeping the canal open by the passage of large sounds.

CASE VI. Senile Hypertrophy of Prostate, Bottini Operation, with Prostatectomy Subsequently.J. D., æt 67, laborer. Seven years ago trouble began with diminution of strength of the stream and tenesmus in passing water, with several attacks of retention, the last occurring in May, 1899, for which he entered the hospital. There was marked enlargement of both lobes of the prostate, and the cystoscope showed an enlarged middle lobe projecting upwards like a nipple. On May 15 a Bottini operation was performed, three cuts being made posteriorly, interiorly and to the left side. Complete retention was not relieved, and great aggravation of cystitis followed, making necessary an external urethrotomy in order to drain the bladder. Examination with the inger through the perineal incision showed the cuts nade by the Bottini knife distinctly. The posterior ut had divided the obstructing posterior lobe of the rostate. Palpitation with the finger in the rectum howed the thickness of the tissues between the recum and the incision to be about half an inch. The osterior cut gaped open widely enough to admit the nger. The anterior cut was half an inch deep, and Iso gaped to some extent. The internal vesical orice was well opened up by the cuts, and the obstrucon of the posterior lobe was entirely severed. The adder was completely destitute of contractile power ad could not force out water injected into it with syringe. The loss of contractile power of bladder peared to explain the apparent failure of Bottini's eration to relieve the retention, since the operation ened up a free channel for the urine. The bladr was drained for about one month.

On leaving hospital, the patient could pass most of water through the penis, but retention soon rened, and for the last four years he has had to pend entirely on the catheter to empty the bladder, ng it about four times a day. He has been comtable and able to work, but the Bottini operation ed signally in this case to relieve retention. In ie, 1903, he came again into the hospital, saythat since the operation he had worked every but had to depend on the catheter. About one th ago the urine became very bloody; the bladwas irritable and the patient had to pass the eter every two hours; the catheter was introed easily.

'n July 2 perineal prostatectomy was performed. prostate was very difficult to enucleate, being ely adherent to the capsule, and during enucleaa tear into the rectum occurred. The tear was ed up immediately. The convalescence was un-. tful but the opening in the rectum did not heal the patient left the hospital with a urethrorectal la. He went to New York later and the fistula operated on and closed by Dr. J. P. Tuttle. mment.-This case shows the difficulty in enuing a prostate when Bottini's operation has been previously.

CASE VII. Prostatectomy.-A. M., aged 65, farmer, has suffered more or less from retention of urine for the past ten years. Lately he has had a great deal of irritation and almost constant desire to urinate with complete retention. He was treated for three months at the Poughkeepsie Hospital for severe cystitis, and was failing in strength when he entered Long Island College Hospital. His general condition was very poor; atheroma was very marked, the radial artery being like a pipe-stem. There was a beginning bed-sore on the back. The prostate was large and the cystitis was severe.

Perineal prostatectomy was performed by Dr. H. E. Fraser. The wound healed entirely and the pa

tient could take a 32 sound; he passed water a couple of times at night, but had about 8 oz. residual urine for which the regular use of the catheter was advised.

Comment. The patient's condition was very unfavorable for any operation, as he had a high grade atheroma, beginning bed-sores, and severe cystitis. Nevertheless he stood the operation well and made a satisfactory recovery.

CASE VIII.-Prostatectomy and Division of Stricture.-E. R., aged 65 years, ship builder, had gonor

Two years ago external urethrotomy was done in St. Peter's Hospital, the tube being left in for five weeks. A fistula in the perineum remained open until six weeks before his admission to the Long Island College Hospital, on August 8, 1903. He then had a tight stricture not admitting a catheter. The urine was voided with great difficulty every hour, about half an ounce at a time, with pain and tenesmus. On August 12 external urethrotomy was performed. The deep and anterior strictures. were divided and prostate was shelled out through the perineal wound. The bladder was drained. The patient made an uneventful recovery. The temperature never exceeded 99.5° after the operation; the maximum pulse was 80. He was discharged from the hospital one month after the operation.

CASE IX. Enlarged Prostate, Prostatectomy.G. B., aged 64, dock superintendent, had always had good health. He had gonorrhoea twice, but no trouble resulted until three years ago, when he began to have a constant desire to urinate with straining. He was catheterized and over one quart of water drawn off. In June, 1902, he consulted me. Examination showed a prostate, 11⁄2 inches in diameter, and a stricture of large calibre. There was complete retention of urine. The patient went on comfortably, using catheter three times a day until November 10, when, retention occurring, a physician was called, who made a false passage and did not get into bladder. I relieved the patient with a guide and tunnelled catheter.

On November 12, 1903, prostatectomy with division of stricture was performed. The entire prostate containing the prostatic urethra was removed en masse. Recovery was uneventful. Two months after operation the perineal fistula had healed, a No. 30 F. sound being passed with ease; the residual urine measured one ounce. The man passed water once at night and three time during the day.

Comment. In this case, although the entire prostate and prostatic urethra were removed, the ejaculatory ducts were evidently uninjured and coitus was satisfactorily performed.

CASE X. Senile Hypertrophy of Prostate, Prostatectomy.-J. R., æt. 63, a sea captain, was always well and strong. He had had gonorroha two or three times. Began to have trouble with his water in October, 1903, passing only a small quantity frequently. His condition improved later, and for the last five weeks he had used a catheter three times a day and passed a cupful of water himself at each act of urination.

The prostate was enlarged and soft, 21⁄2 inches in diameter. A No. 24 F sound entered easily; the residual urine was 7 or 8 oz.; the urinary amber, acid, slightly turbid, containing slight trace of alubumin; Urea gr. vi to the ounce, no casts, pus, or blood. On December 19, perineal prostatectomy (Bryson's operation) was performed. A stricture of large calibre was divided in the deep urethra; the lateral lobes of the prostate were removed and the middle lobe was found to be enlarged and prominent, projecting into the bladder like a ball valve; this was also removed and a drainage tube was introduced. Very little hemorrhage occurred and shock was inconsiderable. The patient did well for one week after operation, the bladder being drained well, and blood

soon disappeared from the urine. The temperature ranged from 95° to 100°. The secretion of urine was free, about 30 oz. a day.

On December 26 the perineal tube was removed and a sound passed easily into the bladder.

On December 27 the patient had a chill, and the temperature rose to 106°. He had persistent vomiting, feeble pulse, and almost complete suppression of urine. The temperature ranged from 100° to 105° until his death on December 29.

At the autopsy by Dr. Van Cott, a large quantity of orange-gold fat was seen in the abdominal pa rietes and mesentery. The right heart was dilated and filled with ante-mortem clots, which had beer some time in forming. The myocardium containe considerable fat; the valves were all normal. The arteries were generally very atheromatous. The spleen was large and studded with infarcts. The lungs were emphysematous, otherwise normal. Both kidneys were small, with adherent capsule and surface uneven from old cicatrices; the cortex was thin irregular in thickness, dull, with markings fairl distinct. The liver was quite large and showed signs of marked hypertrophic cirrhosis and fatty degereration. The prostate gland, previously removed operation, showed the capsule and operation wound healthy with no evidence of infection. The caus of death was uncertain, probably acute nephritis.

The results in the cases just reported in detail be summarized as follows: Ten patients operated x most of them desperate cases and all old men. I deaths-one from infection of the suprapus wound, one from acute nephritis ten days after operation. Two patients obliged to use the cathe subsequently, on account of the residual urine. S both had complete retention before the operab and now can pass water, are not troubled with in quent urination and are perfectly comfortable. C formerly operated by Bottini's method, had a into the rectum which was subsequently closed, had complete restitution of bladder function. Tremaining five were entirely relieved and did not fe quire further use of the catheter.

We all know how utterly unreliable statistics a and we have been misled many times by placing trust in lying figures. Personally the writer is clined to accept the honest opinions of men who had enough experience, so that their views ca crystallized into a definite statement of facts. At through these facts, which, gathered slowly and painstaking care, at the cost often of human s ing, and sometimes of life itself, that the art medicine and surgery move along in a steady

of advance.

If the writer may then be allowed to ex his opinion on the operation of perineal prosta tomy as done by Bryson, he would summaris advantages as follows:

1. The comparatively low death rate. 2. The rapidity, ease and facility with whi prostate can be enucleated.

3. The trifling amount of hemorrhage and s 4. The excellent bladder drainage and abil keep the patient's bed and dressings dry.

5. The rapid convalescence, the patient g out of bed within ten days.

6. The complete restitution of the bladder functions in most cases.

REFERENCES.

1. Mitteil a. d. Grenzgebieten der Medizin und Chirurgie, VII Bd. Jahr., 1900. English translation by Dr. Robert Holmes Greene, published by E. R. Pelton, 1903.

2. Nature of Prostatic Hypertrophy. Journal Am. Med. Assn., April 22, 1902.

3. For the description of the pathological changes in Prostatic Hypertrophy, the author is indebted to a personal communication courteously made to him by his friend Dr. Harlow Brooks.

4. Annals of Surgery, November, 1902; St. Louis Medical Review, February 22, 1902.

32 SCHERMERHORN STREET.

HOSPITAL NOTES ON EPIDEMIC CEREBROSPINAL MENINGITIS.

BY JOSÉ M. FERRER, M. D.,

NEW YORK.

VISITING PHYSICIAN TO ST. VINCENT'S HOSPITAL AND THE
FRENCH HOSPITAL.

THE following notes are offered as a contribution to the history of the epidemic of 1904:

During the Spring and Summer there were adnitted to St. Vincent's Hospital twenty cases of pidemic cerebrospinal meningitis. Two entered in March, five in April, nine in May, two in June, and wo in August.

The cases appeared after an exceptionally severe inter, marked by the great prevalence and mortality f pneumonia.

The patients all came from the tenements. Eight ere Italians, ten from the United States, one from ngland and one from Ireland. Twelve were males nd eight females. Three were married and sevenEen single. Nineteen were whites; one was a gro. There were more adults than children. The es ranged from 3 to 39 years, as follows: 3, 5, 7, 10, 11, 14, 16 17, 18, 20, 21, 23, 24, 24, 25, 28, 29, and 39.

Of the twenty patients, ten died (50 per cent.) : e on the day of admission, one on the day after, o in 2 days, two in 3 days, one in 5 days, one in days, one in 34 days and one in 105 days. Of the eight Italians, six died (five males and one nale). Of the ten from the United States, three d (females). The English woman also died. In five males and five females succumbed. The cases did not materially vary from the classicourse so often described. Eleven were long es; nine were short. The duration of the long es that died were, as nearly as could be ascerEed, as follows: One (K. F.) 14 weeks, one P.) 12 weeks, and one (T. D.) over 4 weeks. long cases that recovered lasted as follows: e (M. McC.) 13 weeks, one (W. B.) 7 weeks, (A. L.) 6 weeks, one (F. J.) 5 weeks, two (G. nd D. Q.) 4 weeks, one (J. C.) 3 weeks and one P.) about 3 weeks.

f the short cases that ended in recovery one H.) lasted 3 days and one (A. McK.) about 2 <S. Of the short cases that died, one (E. H.) Id d 2 days, two (L. C. and J. F.) were ill 3 days, (F. C. and F. P.) 4 days, one (M. McC.) 6 and one (S. B.) 7 days.

here was some variation in the types of the disNo fulminant cases were met with. Sixteen e cases, though of varying duration, might be ified as of the ordinary type. One was of the ntic type, one of the intermittent type, one e abortive type, and one of the chronic type.

The symptoms noted might be analyzed as follows: All the patients had pain in the head-severe as a rule. All had more or less fever. All had some degree of retraction of the head and rigidity of the neck. All had delirium of varying intensity at some time. All had more or less leucocytosis. Constipation was the rule, except in two patients, who had early diarrhoea. Seventeen had vomiting at some time-most of them at the beginning. Fifteen had general hyperæsthesia. In fifteen Kernig's sign was elicited. Twelve had initial chills. Three had chills late in the disease. Fourteen had stupor, off and on. Eleven developed coma. In one instance the coma lasted ten days before death. Twelve had general rigidity of the body. One had

clonic spasms of the face. Ten had opisthotonos. Seven had the typical eruption. Nine had herpes labialis. Two had rose spots. Five had convulsions. Five had strabismus. Six had earache, deafness and slight discharge.

Complications: In two cases broncho pneumonia was noted. In two congestion of the kidneys. In one double parotitis. In one vascular keratitis. In four there was marked pain in the joints and limbs, though no true arthritis was noted.

The following sequela were noted: In one paralysis of limbs. In one atrophy and partial blindness of one eye. In one deaf-mutism and idiocy. In six deafness.

Lumbar puncture was done in eleven cases. In four of these the culture was positive; in seven negative.

In the treatment, the following were employed: Ice bags, sponging, laxatives, enemata, morphine, potassium bromide, potassium iodide, ergot, quinine, Warburg's tincture, sodium salicylate, strychnine sulphate, digitalis, whiskey, fluid diet followed as quickly as possible by light diet.

Appended are short reports of six of the cases: Ordinary type; fatal case; complicating parotitis; autopsy.-S. B., an Italian flower maker, 18 years old, single. In the United States six months. Admitted to my wards May 26, brought thither by ambulance.

It was difficult to obtain a history of his family, previous health and habits, as neither he nor his friends spoke English. He was said to have had malaria in Italy recently. He had had no severe previous illness.

His present attack began suddenly two days ago with intense pain in the head which later extended to the nape of the neck. On the day of invasion he had two severe chills which were attributed by him to his malaria. He had marked nausea and frequent vomiting, which continued most of the second day. There was much thirst and the fever seemed high. The pain in the head and neck increased and he became delirious at times. No eye or ear symptoms were noted. The bowels had moved.

The second day of the disease his neck became very stiff, the head was retracted and drawn to the left side. His headache, and tever continued and he grew worse.

disease, his temperature was 104 1-5°, pulse 90 and On admission to the hospital, the third day of the respirations 44. He looked very ill. The head was retracted and drawn to the left. The entire body would become rigid on attempts to move him, and he would complain of pain. There was general hyperæsthesia. Kernig's sign was elicited.

On rounds he seemed mentally clear for the time being and told me of his two chills, of his vomiting, of his malaria and wanted to know if he was dan