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Young, that the element of cancer is present in a proportion of cases hitherto quite unsuspected. It may begin as a small indurated nodule, in one or both lobes, and while developing remains confined for a relatively long period by the strong prostatic capsule. When it extends, its line of invasion is upward toward the vesicles rather than into the bladder. When the latter has become involved, if a radical operation is to be practised, extirpation must include not only the entire prostate, with its capsule, the urethra, the vesicles, but the adjacent portion of the base of the bladder. Early diagnosis in these cases is difficult, since it may occur at any age after fifty years, and, being connected with hypertrophy, produces symptoms masked by it, only the element of pain being more prominent. As the condition develops pain becomes rather disproportionate, spreads to the suprapubic region, and is intensified as the bladder fills. When pain is referred also to the rectum and lower extremities it is a suspicious symptom. The condition does not necessarily, at least at first, cause enormous enlargement. Therefore the obstructive features vary. If the portions involved can be left they will be found more dense and hard than the surrounding tissue. One peculiarity of prostatic cancer is that metastases occur more often in the bones than in the lymphatics. Consequently the pelvic nodes are not so often affected. Ulceration and intravesical tumor are rare.
Diagnosis.
—Early diagnosis is based on rapidity of growth, disproportionate pain, indurated contraction of the prostatic urethra near its apex, and absence of intravesical enlargement, as shown by the cystoscope. When there is much residual urine, without enlargement of intravesical lobes, suspicion is strengthened. If after removal of such prostate it should be shown to be more or loss dotted with “seed calculi,” as is possible, instead of with cancer, the benefit and relief to the patient would be none the less marked, while the prognosis would be all the better.
Prostatic hypertrophy leads to a collection of phenomena spoken of as prostatism These include mechanical impediment to urination, with consequent obstruction, sometimes with complete retention, and to the consequences of the same in the direction of infection and cystitis, with added features of pain, tenesmus, and pyuria. Prostatism is a matter of gradual development. Its earliest symptoms
are frequent urination with occasionally some difficulty or slowness in the act. From this as a beginning cases become gradually aggravated, until death finally ensues from retention, rupture of the bladder, pyelonephritis, or exhaustion in consequence of the pain and suffering entailed.
Prostatism may be imitated in persons whose prostates are not perceptibly enlarged, in whom the difficulty and obstruction are due to sclerosis and contracture of the vesical neck. This condition is especially common in elderly men, subjects of arterial sclerosis. This will account for instances of prostates which, on removal, are found hard and sclerosed, and yet not enlarged enough to be obstructive. If such a prostate could be divided by the cautery, benefit, even permanent relief, might ensue. Therefore, such a condition might be well attacked when diagnosticated (either by suprapubic operation or by perineal section), with the use of the Bottini galvanocaustic instrument, especially through a perineal opening.
Prostatic enlargement produces distortion of the prostatic urethra, which becomes longer, smaller, and sometimes deviated, with elevation of the level of the vesico-urethral orifice, and causes, by pressure on veins, more or less disturbance of the return circulation. Enlargement with impediment produces dilatation of the bladder, with possible involvement of the ureters or the kidneys, and thickening of the vesical walls, often with sacculation of its mucosa between its disturbed muscle fibers.
Finally come the consequences of septic infection with ammoniacal putrefaction of urine, pyuria, and perhaps pyelonephritis with uremia, which will be terminal. While the condition is generally regarded as belonging to the late years of life it may begin by natural processes at the forty-fifth year, although uncommon before the fiftyfifth.
660
Enormous prostatic hypertrophy, necessitating suprapubic cystotomy because of impossibility of catheterization from below (Socin and Burckhardt )
Symptoms.
—When a man past the middle years of life, previously free from urinary difficulties, is aroused to urinate more frequently than usual, especially at night, while the desire to urinate and the natural feeling of relief at the conclusion of the act are more or less perverted, the beginning of prostatism may be suspected. If in addition to these features the urine shows fermentative changes, or the presence of mucus or pus, the more or less disastrous consequences of obstruction have begun. Symptoms similar to these may be caused by the presence of calculus. It is therefore necessary to differentiate between this and prostatic enlargement. This is first done by a careful digital examination of the empty rectum, the index finger being gently introduced and made to so completely palpate the prostate, through the anterior wall of the rectum, that an accurate estimate of its relative size, as well as of any marked irregularity, may be made. If the prostate be enlarged the explanation is at once afforded. If there be but little apparent change noted by this method the surgeon should introduce a stone searcher. Manipulation with this, in a bladder distended with fluid, should reveal the presence of a calculus, or should indicate a lengthening of the prostatic urethra, with such distortion, as might make the introduction of the instrument difficult, while by further manipulation, its beak being gently revolved, he learns whether behind the prostate there is a pocket in which residual urine may be retained. The question of calculus being settled the patient should now empty the bladder naturally and as usual, after which a catheter should be introduced, in order to withdraw such residual urine as may be retained, whose amount should then be noted. This is a measure of the size of the postprostatic pocket which the patient fails to empty, and in which decomposition and pathological changes are especially likely to occur. Should such a pocket be found in a case without noticeable other enlargement (as detected through the rectum) it will indicate intravesical growth and the formation of the so-called “third lobe” or “median bar,” as it was formerly called (i. e., an outgrowth at the posterior end of the prostatic urethra, projecting upward into the bladder, impeding alike the exit of urine and the introduction of an ordinary instrument). Those expert with its use may gain still further information of value by use of the cystoscope.
Treatment.—The diagnosis thus established, the question of treatment is raised. Views concerning what is best have been largely modified by the operative methods recently introduced, and the advice given a few years ago is now frequently modified. So long as surgical treatment was unsatisfactory and incomplete it was to be postponed as long as possible. Under those circumstances patients were taught to use the catheter and established the “catheter habit.” Almost invariably they became careless, and the catheter habit led invariably to cystitis. Nevertheless circumstances may arise which make this good advice even today, as in the presence of other and serious disease, or of anything which makes radical operation inexpedient. Under such circumstances the patient must be impressed as profoundly as possible with the necessity for care and caution. If such a case has progressed to the stage of almost complete retention then the catheter should be used at regular intervals. If it be simply necessary to draw off residual urine once a day, then it may be used at night, at which time it would be well also to gently and carefully wash the bladder. It is possible in this way to temporize for a variable length of time, and until more serious conditions supervene. When, however, the prostate has enlarged so conspicuously as to be not only a constant impediment but a constant menace to the comfort and even life of the patient, one is brought to seriously consider which of the various mechanical methods for relief should be instituted. The choice must now be governed by the physical condition and the surroundings of the patient, as age, degree and character of the obstruction, and the extent of septic infection. One has again to choose between the most radical and usually the most satisfactory method of extirpation (prostatectomy), or one of the less radical and palliative operations, such as the Bottini operation with the galvanocautery.
A few years ago White and others laid great stress on the fact that after removal of the testicles there was notable atrophy of the prostate, and suggested the expedient of double castration or orchidectomy for this purpose. The method proved disappointing, although doubtless more or less effective in some cases, and so objectionable to many patients, for obvious reasons, that it has been
practically abandoned. The less mutilating substitute of division and exsection of a portion of each vas deferens (vasectomy) has for the same reason been discarded.
When radical measures become necessary the choice should be made between the galvanocautery (i. e., canalization of the base of the prostate and its median bar by means of the instrument devised by Bottini) and the bolder and more radical method of extirpation (prostatectomy). This prostatectomy is done by either the suprapubic or the perineal route. As between them there is often room for choice, for reasons mentioned below Each method has its advocates and its opponents.[71]
[71] The question of credit and priority for these operations has been of late much discussed. To McGill, of Leeds, and Goodfellow, of San Francisco, should be given most of the credit for the earliest perineal operations, while Fuller, of New York, who first performed the suprapubic operation in 1894, should probably be given credit for the latter, although it has been evidently unjustly claimed for Freyer, of London Belfield, of Chicago, was also one of the earliest advocates of extirpation of the enlarged prostate
Suprapubic Prostatectomy.
—It is of assistance in this method to have the empty rectum somewhat distended, and held up by the introduction of a rubber bag, which may be later distended with water or with air. By this means the prostate and floor of the bladder are pushed upward toward the operator’s finger. This is, however, by no means necessary, but simply advantageous. The first part of the operation is essentially that described as suprapubic cystotomy. The bladder being thus opened and the prostate carried upward by a sound, which should have been inserted in the urethra, the finger first accurately notes its dimensions and the direction of its enlargement. Blunt scissors are now used, or the sharp finger-nail, for making an opening through the mucosa and prostatic covering, through the capsule of the latter, down upon that body. This opening is preferably made near the urethral entrance. The balance of the operation consists in blunt dissection by the end of the finger, i. e., enucleation of the prostate from within its enclosing capsule and surrounding tissues (Fig. 661). More or less disturbance of the basal structures is necessitated, but as the surgeon becomes expert the
amount of this disturbance becomes relatively surprisingly small. In most instances it is possible also to practically strip off the prostatic tissue from the urethra, so that it is rarely necessary to tear or to cut across it in order to lift the prostate out of its bed. In the average case it is possible in this way to enucleate the prostate in a single piece, and to remove it as an entire organ. If, however, it should prove too large for the bladder opening which has permitted the procedure it would be better to morcellate it, or so far divide it with scissors as to permit its extraction piecemeal. Its removal leaves a bleeding cavity at the base of the bladder, with torn and separated tissues, and a pocket where the prostate used to lie, into which urine will be poured from above, while it cannot ordinarily be at first easily emptied from the more or less injured urethra connected with it. From this surface there will be at first considerable oozing, mostly venous. Should this be serious and prolonged a quantity of gauze may be packed into it through the opening, and pressure thus made. Such packing should only be retained for a few hours. Ordinarily it is sufficient to provide at once for drainage. My own preference is to make double provision for this by the passage of a catheter through the urethra, and by the insertion of a drainage tube from above, whose lower end rests within the pocket. It is a great desideratum to drain the urine as fast as it accumulates, and, at the same time, to keep the patient dry. This is best effected by a method described later, of complete bladder siphonage, which can be resorted to in either form of operation. It is again advisable to get the patient into the sitting posture, which should be done within a day or two, or as soon as his strength will permit, in order that gravity may assist in drainage. (See p. 1003.)
Suprapubic prostatectomy Process of enucleation by finger-tip of one hand in the bladder, the other hand making pressure in the perineum (Hartmann )
When difficulty is met in enucleation assistance is derived by the introduction of one or two fingers of the disengaged hand into the rectum, by which certain manipulation can be effected from below that will be of material help. Pressure in the perineum or manipulation of a sound may also be of assistance. So soon as satisfactory drainage through the urethra can be effected the suprapubic tube should be removed, and the wound thus encouraged to close.
Perineal Prostatectomy.
—Perineal prostatectomy constitutes a similar attempt at enucleation, effected from a different direction. The patient now being in the lithotomy position, with the rectum not only emptied but sterilized, the perineum is widely opened. While the
removal may be accomplished through a median incision it is better to have ample room, therefore by a semilunar flap a sort of trap-door should be raised, its apex downward, through which easy access to the deep perineum is afforded. It is only necessary to divide the central tendon of the recto-urethral muscles before the operator arrives at the apex of the prostate and the membranous urethra. The latter, being exposed at this point, is usually divided upon a grooved staff. Here, at its junction, the capsule is usually divided by a free opening, through which the finger-tip is insinuated and made to strip the capsule from the prostate itself. By different operators instruments have been devised which facilitate much of the subsequent work. Perhaps the best of these is the double-blade retractor of Young, which, shaped like a sound, can be opened after introduction, and made to serve excellent purpose by traction upon its handles. If, now, the perineal route have been large enough, and retracted sufficiently, the prostate can be so pulled down into the wound as to be exposed to sight as well as to touch. The effort is sometimes made to enucleate the prostate entire and withdraw it whole, but usually to separate each lateral mass by itself. It is advisable to seize with strong tenaculum forceps and pull down the loosened portions of the organ, in order that it may be more easily separated at its upper part; but it has now been found unnecessary to either open the bladder above the pubis, or even to expose it by an opening through the skin so that it may be pressed down, traction from below taking the place of suprapubic pressure, whatever is needed in the latter direction being effected through the uninjured abdominal wall (Figs. 662, 663 and 664).
First exposure of prostate after introduction of sound through opening just in front of it (Proust )
F . 663
Enucleation of a portion or all of the prostate by use of the index finger (Proust )
F . 664
Hemisection of prostate, each half being secured within the bite of vulsellum forceps (Proust )
The balance of the procedure must depend on the size and character of the growth. To strip off a naturally adherent capsule is quite easy, but to detach one which has become firmly adherent through old inflammation or cancerous infiltration is sometimes extremely difficult. Thus enucleation may sometimes be effected in two or three minutes. The stripping and enucleating process should be carried around the prostatic enlargement and into the bladder, and the effort should be to make the smallest possible rent in the vesical mucosa, as well as to separate prostatic tissue from around the urethra rather than to tear or mutilate the latter. Experience and patience will permit the accomplishment of this to a surprising degree. Morcellation may be an aid in removing large masses, and no hesitation should be felt in dividing a mass of tissue which does not come out easily through the wound (Fig. 665).
Prostate removed by the perineal route: A, lateral lobes; B, intravesical growth particularly obstructing urethral entrance (Proust )
The organ once enucleated, there results a bleeding cavity, at the base of the bladder, which, however, is now opened below and should drain itself easily. If the surgeon’s finger and his instruments have been kept, as they should have been constantly, within the prostatic capsule there is no possibility of harm to the rectum, which, however, may be utilized for assistance in the manipulation should it be required. There remain, therefore, after enucleation the checking of hemorrhage, provision for drainage, and suitable narrowing of the wound. The first and second of these are usually combined by the insertion of a tube, of sufficient rigidity to permit a gauze packing to be placed around it. This should be connected exteriorly with a suitable drainage tube, and bladder siphonage be provided. The wound around the tube is closed by two or three deep sutures, usually of silkworm-gut, since it tends naturally to close by pressure and requires but little further attention.
The greatest harm likely to be done in this operation is injury to the seminal vesicles, above the prostate, between which and the prostate itself the surgeon may not distinguish, with unnecessary mutilation of the posterior urethra. Occasionally, in spite of great care, the rectum will be slightly lacerated. Injury or destruction of the vesicles might lead to impotence, while mutilation of the urethra would be followed by delay in repair, with uncertainty of subsequent bladder action and control.
Subsequent treatment consists in removing both gauze and tube at the earliest possible date, which should not be later than the fourth day; after this irrigation may be given once or twice a day, with the least possible use of instruments.
In either of these methods of prostatectomy the greatest reliance is to be placed upon natural processes of repair. In some way, which seems almost inscrutable, torn bladder and more or less mutilated urethra come naturally together and connection is reëstablished.
After this brief description of operative methods there remains only to contrast them. The especial advantages of the suprapubic method are the total avoidance of perineal fistula, of disturbance of the deep urethra, of the perineal structures, of the seminal vesicles, and a minimum of disturbance of the entire basal portion of the bladder, with a greater theoretical possibility of speedy restoration of its
function. It is the method of choice with certain operators of large experience. It seems especially indicated in cases of pronounced intravesical enlargement, but may be made difficult in obese individuals.
In behalf of the perineal route must be alleged the advantage of seeing much of what one is doing, of being really nearer to the field of activity, and of more perfect control of the mass which is to be removed, as well as the fact that the prostate is not an intravesical organ.
Whichever method be adopted the patient should be encouraged to be up and about as soon as possible. Subsequent bladder control comes with varying rapidity to different patients. Urinary fistulas are not likely to persist in patients who have not worn drainage tubes too long. After two or three weeks it is advisable to pass a sound occasionally, in order to maintain proper direction of the urethral canal and prevent formation of stricture. Bladders in which there has been a serious complication of cystitis should be irrigated through the openings so long as they are maintained.
The operation of itself is not a very serious nor difficult measure. It is too often performed on feeble or septic patients, as a last resort, when it is too late.
The galvanocaustic operation is done with an instrument devised by Bottini, shaped like a lithotrite, with a movable platinum blade, which can be heated to the desired degree by the electric current. This instrument is introduced into the deep urethra until its beak enters the bladder, after which the latter is turned half around; then the electric current is turned on, the movable caustic blade gradually withdrawn by a screw mechanism in the handle, and made to traverse a distance of one inch to one inch and a half, previously measured, and in such a way as to burn a channel through the floor of the prostatic urethra, and through any median bar or obstruction which may exist. This is the principle of its use. At one time it was popular, although of late prostatectomy seems to have supplanted nearly every other method. Nevertheless in certain cases it will be found of advantage. I have preferred to combine it, in most cases, with a small perineal opening, introducing the instrument after opening the membranous urethra, and having it in this way much
more completely under control. Through the opening thus made subsequent bladder drainage can be effected if desired. It permits also of more perfect exploration of the bladder with the finger.
CANCER OF THE PROSTATE.
Extensive cancerous involvement of the prostate puts a case beyond the pale of operative surgery, except for palliative purposes, though either perineal or suprapubic drainage may be made for final and temporary relief, the case admitting of nothing else. As mentioned above many apparently ordinarily enlarged prostates prove to contain cancerous elements. It has been found that, when not too extensively involved, prostatectomy in these cases gives as good results as in the absolutely non-malignant.
Siphon drainage of bladder, with Cathcart’s S-tube (its essential feature). May be applied equally well to perineal or urethral tubes, or to drainage of other cavities.
BLADDER SIPHONAGE.
A matter of great importance and comfort for the patient is an effective siphonage of the bladder after it has been opened. This has usually been accomplished by the use of a Y-shaped tube, one of the branches connecting with a suitable reservoir for water, hung above the level of the body, the other with a tube connecting with the bladder, while from the lower end another tube connects with a suitable reservoir on the floor. This is rarely effective, and can only be made so by inserting the S-shaped tube devised by Cathcart in the lower drainage tube. With this, and a suitable regulation of the flow, the water can be made to escape, drop by drop, and make an effective suction that completely fails without the use of Cathcart’s tube. The device is illustrated in Fig. 666.
C H A P T E R LV I .
THE MALE GENITAL ORGANS.
THE PENIS AND URETHRA.
The most common congenital defects of the penis are connected with elongation of the prepuce or with abnormality in the construction of the urethra. Aside from these, however, rare congenital abnormalities have been met with, as, for instance, a double or bifid penis, or its almost complete absence. The former is perhaps to be regarded as an atavistic condition, having its prototype in the kangaroo. Misplacement of the organ is usually apparent rather than real.
PHIMOSIS.
Except as produced in consequence of disease, i. e., by edema or inflammation with swelling, phimosis indicates a congenital condition, either of elongation or constriction of the prepuce, usually with adhesions to the glans. A considerable proportion of male children are born with more or less complete conditions of this kind. These are not so abnormal anatomically, but they lead to serious complications later in life. An extremely tight prepuce is often complicated with stenosis of the meatus, the combined result being a practical stricture at the end of the urethra, through which the infant has to strain with each act of urination. This is a common predisposing cause of hernia. Whether the prepuce be adherent, or so constricted as to make it a retentive sac, there will accumulate between it and the sensitive mucous surface of the glans more or less smegma which, as it decomposes in the course of time, becomes excessively irritating, and a fertile source of reflex disorders, involving even distant parts of the body. Thus in young boys especially, convulsions, chorea, epilepsy, and various other
neuroses are produced, while, in addition, its perpetuation produces a condition of unnatural excitability which leads again to habits of masturbation or to sexual irritability and unnatural excitability.
Every newborn male infant should be carefully examined in order that the above condition, if present, may be remedied. This remedy will consist, in mild cases, of forcible retraction of the elongated prepuce, with separation of any adhesions uniting it to the glans. Preputial stenosis may be overcome in some cases by simply slitting up the dorsum, which, if not too long, may be thus released and not require circumcision. On the other hand a much elongated and contracted prepuce should be sufficient justification for prompt circumcision. At the same time any unnatural contraction of the meatus may be overcome by trifling incision. If every boy baby were thus carefully inspected and relieved, if necessary, there would be fewer reflex disorders in young children.
Incidentally it may be said that, in lesser degree, the same thing may apply to girl infants, in whom the clitoris, although small, should nevertheless be freely uncovered by retraction of its miniature hood or prepuce. When this is not easily possible it should be made so. Disorders of the same general character as easily arise in girls, from this same general cause, as in boys, nocturnal incontinence being a frequent expression thereof. In my opinion the teaching of obstetrics should not be considered complete without unmistakable reference to these matters.
Phimosis in the adult may be brought about by disease, especially in connection with a prepuce already retentive, or elongated and difficult of retraction. Retained secretion beneath such a prepuce is a fertile source of danger of all kinds, as well of venereal infection as of cancerous growth. Surgeons in the Orient have described calculi, even of considerable size, found in this location as the result of retention of matter which should not have been at all retained, this condition being noted most often among the Chinese.
Infection, usually gonorrheal, of the concealed surface of the prepuce, which has a distinctly mucous character, is known as posthitis; that of the covering of the glans as balanitis; while, in effect, whatever appears in this location will essentially be a balanoposthitis. If such a condition do not easily subside by
irrigation, with a small nozzle introduced beneath the margin of the prepuce, it will then be necessary to slit up the dorsum, or make a complete circumcision, in order that the affected surfaces may be made accessible. The same is true in cases of chancroid and even in cases of chancre; incision or circumcision being justifiable whenever indicated.
PARAPHIMOSIS.
Paraphimosis implies an opposite condition, where the prepuce, having been retracted, is caught behind the margin of the glans and cannot be released nor brought forward. This may be the result of undue effort to retract a very tight but otherwise normal prepuce, or is frequently the result of an acute inflammation, where edema and solid exudate so solidify the tissues as to make them inflexible and almost immovable. In mild cases of paraphimosis cold applications, or pressure with patient manipulation, may be sufficient to restore the proper condition. An extreme degree of such constriction would threaten the nutrition of the glans, to the extent even of possible gangrene, and sloughing of some portion of the end of the penis is not an infrequent result of a neglected condition of this kind. Under these circumstances constriction must be released, it being usually sufficient to apply or inject cocaine, and then with scissors or blunt bistoury nick or incise the constricting ring, to a degree sufficient to release it and permit the desired result; in one way or another this must be attained, else more or less sloughing is sure to follow.
Other rare malformations of the urethra include its more or less complete obliteration, in some portion at least, or, more often, its sacculation or dilatation in certain areas, the result being the formation of pockets or pouches. Such abnormality may persist to adult life, and finally contain a considerable amount of retained urine.
EPISPADIAS AND HYPOSPADIAS.
Epispadias and hypospadias constitute defects in the urethral construction, so that urine escapes at some point much nearer the body than normally intended. A complete degree of epispadias
