Original Articles

REPORT OF TWO CASES OF PROSTATECTOMY FOLLOWING ELECTRICAL INCISION OF THE VESICAL OUTLET AFTER THE BOTTINIFREUDENBERG METHOD, WITH REMARKS.*

J. P. BRYSON, M.D., St. Louis.

Professor of Genito-Urinary Diseases in the Medical Department of Washington University.

HINKING it might be interesting to have a demonstration of the condition of the vesical outlet and the prostatic urethra after electrical incision of these parts by the Freudenberg modification of Bottini's instrument, I report two cases wherein I have opened the bladder, after having first attempted to deal with the obstructing overgrowths by this procedure.

Case I. Timothy F., æt. 70, entered St. Louis Mullanphy Hospital September 30, 1898, giving history of disturbance in urination for the past seventeen years. Beginning with slightly increased frequency, both day and night, dysuria, pyuria, occasional hematuria, gradually progressed until the climax was reached in an attack of retention about twelve days before admission. Treatment soon cleared up the urine, permitted a cystoscopy which, with other physical examination, enabled me to arrive at a diagnosis of hypertrophic enlargement of the prostate, with intravesical projection, en collarette. The case appearing to be one suitable for electrical incision, this was done on November 3d. With the Freudenberg modification of the Bottini incisor one incision was made on the floor of the vesical outlet, beginning just within the bladder, the beak of the instrument having been hooked well down against the posterior surface of the projecting collar before heating the knife. The bladder was empty, and with the knife at a high heat, the screw was turned until the register showed a projection of 23 centimeters. The patient complained of no pain, arose from the operating table and went to his room without assistance. There was very little reaction for three days. On the fourth day there was *Read before the Medical Society of City Hospital

Alumni, February 2, 1899.

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sharp bleeding, fever, greatly increased frequency, and pain with sudden increase in pyuria; this, despite the free use of urotropin and the strictest asepsis. No catheter had been passed. By the 8th day symptoms of a prostatic abscess opening into the bladder had developed. This required the use of the catheter and vesico-urethral irrigation. An attempt to perform continuous drainage, with a soft catheter tied in, failed. The condition steadily became more serious, until on the 19th of November prostatectomy became necessary. This was done by the combined supra-pubic and perineal routes. In fact, a suprapubic cystostomy formed the first step in the operation, and this was followed by a median perineotomy, the splitting of the capsules of the prostatic overgrowths from their urethral sides and their removal by excochleation. The prostatic capsule was almost emptied, the large masses being easily removed, without incising the bladder neck.

I first searched for the incision made by the cautery, and found it, somewhat to my surprise, to be in the form of a curved instead of a straight line, through the posterior part of the projecting collar. The incision was largely of the bladder wall, as it rose from a deep pouch to bend over the prostatic projection. Thus the anterior part of the trigone was divided by the cautery, and the first joint of the index finger could be pushed into a cavity, apparently between the bladder and the prostatic mass. This I took to be an abscess cavity which had dissected off the bladder from the base of the prostate. Disturbing that part of the incision which involved the trigonal angle caused free hemorrhage, and it was probably the source of the bleeding in the first instance. I have for a long time avoided incising the bladder wall in doing a prostatectomy, believing this to be the most prolific source of bleeding, and I believe the majority of operators hold to the same view. I would say, in this connection, that I have ceased for the past seven years to cut away these projecting growths with knife or scissors, and avoid twisting them off, as much as possible. By the former method one cannot avoid cutting the bladder wall in its most vascular part, and by the latter, considerable portions of the mucous membrane may be stripped up. In each case both hemorrhage and infection are invited. Wherever it is possible I incise

the projection at a point well down the urethra, and I push a finger through the incision and pull the growth out by stripping off the capsule. When excochleation cannot thus be done, it is better to use the rongeur forceps, catching portions of the growth firmly in their jaws, and pushing away the free parts with a finger of the left hand, thus avoiding tearing up the mucous membrane, which is usually the most resistant part. I have thus removed some large prostatic masses by morcellation.

It remains only to add that this patient made a satisfactory and uneventful recovery. His urine was now almost clear, there was no residual urine, and he rose once at night to micturate.

Not

Case II. Wm. D., aet. 74; suprapubic prostatectomy had been performed by me June 30, 1898; satisfactory recovery had followed with the exception of a persistent suprapubic fistula, which, in my opinion, was due to the presence of a transverse bar stretching across the vesical outlet, and which had not been incised for the reason just stated, viz.: the dangers incident to dividing the trigone. The prostate had been a large one, but its removal was not difficult. Unsuccessful attempts to close the fistula by freshening its edges and suturing were made on September 10th and 21st. The patient's health was poor, he having suffered several attacks of entero-colitis. desiring to anesthetize so weak and depleted a person, I determined to attempt to divide the obstructing bar with the electrical cautery incisor of Freudenberg, on November 6, 1898. Despite the use of cocaine and the cooling of the instrument with ice water, the operation was attended with great pain. On the seventh day there was sharp hemorrhage followed by fever, pyuria and diarrhea. He thus continued to suffer until December 13th when he requested an operation, and the perineum was opened, a finger was passed into the bladder, the bar incised and a large hard-rubber drainage tube put in. This lowering This "lowering of the floor of the bladder" resulted in closure of the fistula; but it also enabled me to ascertain the condition of the prostatic urethra after prostatectomy as well as the results of the electrical incision. The prostatic urethra was found to be wide, smooth and covered by mucous membrane. One rather small ridge was felt to left posterior side, but since it ran longitudinally and seemed to offer no obstruction, nothing was done with it. The transverse band appeared to stretch across the middle of the trigone, and the incision by the electro-cautery was felt as an irregular groove, probably crescentic in shape, as a flap could be made out, the convex edge of which was directed to the left. Manipulation of this groove, which was probably onefourth inch in depth, caused rather free bleeding, which was arrested by pressure of the Watson's drainage tube.

Referring to the operation of electro-cautery incisions for prostatic overgrowths, I consider that we are not yet in position to estimate its value as a lifesaving procedure, nor even to say in what cases it should be performed. Of the etiology and early stages of prostatic hypertrophy, we know practically nothing. In well advanced cases, when the patients are willing to entertain serious measures for relief, we find not one, but several conditions requiring correction, and this, too, in persons well past middle life, and often presenting the degenerations of senility. The enlargement is obstructive in a double sense; it obstructs the urinary flow, but probably even more important, as a pathologic condition, it obstructs the the venous drainage of the bladder by pressure upon the periprostatic vein and the plexus of Santorini, this causing not only stagnation of urine, but interference with the nutrition of the bladder wall-a lowering of its vitality. Then comes cystitis, decomposition of the urine, backward urinary pressure, renal inadequacy and pyelonephritis. All of this bears directly upon the choice of operation, since it renders free drainage almost always necessary. Moreover, in the larger prostates there is a degree of intra-capsular tension, which has a direct bearing upon the question of incision without enucleation and drainage, with free, aseptic washing. The same condition is found in uterine myomata. In incising these larger prostatic growths, I have often observed that the incision gaped widely, separating the capsule immediately adjacent, and opening the way for infil. tration of (most frequently septic) urine. In this way the prostatic abscess was probably caused in the first case reported. On the other hand, in two or three cases I have removed such small projections of overgrowth, and with such marked relief of all symtoms as to be truly astonishing. In the earlier stages of prostatic hypertrophy the growths must be small, and are often localized. It seems to me that such cases offer the best opportunity of being benefited by the electrical incisions, provided they could be accurately diagnosticated. I should hesitate long before incising, either with knife or cautery, a considerably enlarged prostatic lobe, in high tension and soon to be brought in contact with septic urine, without free drainage and opportunity for free washing.

It is of the highest importance that cases operated on be reported with a view to criticism, for only in this way may we be able to ascertain what we may expect and what we may promise from the operation. The literature of this sort within my reach is limited. In the New York Record, Willy Myer reports in detail twelve cases with four deaths (33 per cent mortality); 50 per cent were reported cured, 66 per cent improved. Of those reported cured, one was 50 and another 52, making it doubtful if there was a considerable degree of hypertrophy. In the Weiner

cent improved.

Klinische Wochenschrift, December 1, 1898, A. Von Fritch reports ten cases with one death (10 per cent); 10 per cent permanently improved. The death was due to prostatic abscess. In an attempt to reach the larger statistics of Freudenberg and Bottini, one encounters insuperable obstacles. Von Fritsch combines the tables of three operators, making 127 operations, with 7 mortality and 50 per cent cures. He says that these tables probably do not represent the true state of the case-a statement with which

most operating surgeons will agree. Contrary to Bottini's assurances, there are pronounced dangers in the operation. Deaths have been reported as due to phlebitis, thrombosis affecting the vesico-prostatic plexus, pyelitis, embolic pneumonia, sepsis and abscess. Some of these causes of death appear in prostatectomy, it should be remarked. I have had two deaths from septic thrombosis occurring, apparently, in the plexus of Santorini. It still remains to be seen whether electrical incision as at present practiced accomplishes the desired object, and even whether it has a lower mortality than prostatectomy at the hands of experienced operators. This can only be determined by the reporting of all cases operated on and observed for a sufficient length of time.

THE TREATMENTT OF INOPERABLE SARCOMA
WITH COLEY'S MIXED TOXINS.
REPORT OF CASES.*

BY PAUL Y. TUPPER, M.D., St. Louis, Professor of Applied Anatomy and Operative Surgery, Medical Department of Washington University.

HE purport of this paper is primarily to emphasize the earnest work done recently in the care of that class of malignant growths known as sarcomata, and incidentally to note a limited experience of my own in the same direction.

Years ago it was repeatedly observed that certain cases of sarcomata were inhibited in their growth, and at times apparently destroyed, by an attack of erysipelas. This at first was simply a striking phenomenon. Later, when it became known that erysipelas itself was due to a definite organism which could be cultivated, its virulence modified, and its products elaborated outside the human body, the thought naturally suggested itself that a practical means of antagonizing and probably destroying sarcomata was at hand. The virulent streptococcus itself was first used as a means of infecting the sarcomatous growths, but this proved dangerous. In 1891 Lassar substituted the toxin for the living cultures, and a year later Spronck treated a series of cases with a preparation of the toxins of erysipelas prepared in the same *Read before Missouri State Medical Association at Sedalia, May, 1899.

way as Koch's tuberculin, but with no encouraging results. No cases having been successfully treated with the erysipelas toxin alone, it remained for Coley then to combine with the toxin of erysipelas the bacillus prodigiosus, and with this combination, or "the mixed toxins," as he is pleased to call it, carry out the series of carefully executed observations presented last year to the American Medical Association. In this report of 140 cases-the character of the respective growths treated having been determined by skilled pathologists-we find that all the cases were more or less benefited by the treatment, and that quite a number of them were apparently completely cured and have outlived the three-year limit agreed upon in operative cases. Although be

fore this time the mixed toxins had never been used in the human body, Roger of Paris had found in his experiments on rabbits that the addition of the bacillus prodigiosus to the streptococcus of erysipelas increased materially the virulence of the latter; and to this increased virulence Coley attributes largely the success of the toxins. He thinks, moreover, that the curative action of the mixed toxins can be explained only on the ground that sarcoma is of micro-parasitic or infectious origin, drawing attention to the fact that the streptococcus of erysipelas exerts a marked influence upon syphilitic and tubercular tissues, both due to a specific micro-organism, and is apparently negative in its influence upon growths not infectious in origin.

In the report referred to, a varying degree of success is shown in the treatment of the several types of sarcoma with the mixed toxins. Unquestionably the spindle-celled variety responds most promptly and satisfactorily to their influence-more than one-half of this class of sarcomatous growths having disappeared entirely, and every case showing decided improvement. Of the cases of the round-celled variety about one-half show more or less improvement, some disappearing entirely; the remaining half failing to show any effect from the treatment. The melanotic type is least influenced of all. In the ten cases treated by Dr. Coley there was no case in which there was more than a slight temporary improvement, notwithstanding the fact that there is on record a case of advanced melanotic sarcoma which disappeared entirely after an accidental erysipelas. Bearing practically on the subject matter of this paper are the investigations along lines which tend to establish the belief that certain of these growths heretofore broadly classed as sarcomata are, in reality, infectious granulomata. If such is admitted we can the more readily explain the rationale of the action of the mixed toxins in the presence of these growths. There is no absolute uniformity in the mode of disappearance of the tumor after the use of the toxins. This may be by absorption, or by a so-called coagulation necrosis

with fatty degeneration of the tissue cells. While the toxins are most effective when injected into the tumor itself, this is by no means necessary. Parts removed from the growth may be selected for the site of the injection. When this is the case, however, the toxins should be used in larger doses than when liberated in the tumor substance.

As yet the use of the mixed toxins has not become popular. Many have never given the subject any consideration whatever, and but few have honored it with serious thought. Of the number of these who have given it a clinical trial many have unjustly tested its efficacy in malignant tumors indiscriminately, losing sight of the fact that nothing is as yet claimed for its use in growths other than sarcomatous and that only in certain of this type has its effectiveness been proven. Again, indifferently prepared and consequently inefficient toxins have been used, and probably, too, the application of the toxins in many cases has been carelessly made. All of this tends to depreciate the value of this agent in the mind of the profession at large. Is it not manifestly fairer to draw our conclusions from the operations and experiences of Dr. Coley, who as a scientific investigator is well-known, and whose statistics are based upon careful, painstaking research extending over six or eight years? My own experience is very limited and extends over only two years, and comprises only two cases whose course could be continuously observed. However, it has been such as to encourage me to persist in the use of the mixed toxins in selected cases of sarcoma.

Case I. Mr. F. J. C., aged 47 years, business man; consulted me on November 29, 1896, for an enlargement about the size of a pecan immediately over the styloid process of the ulna, left forearm. This increased rapidly in size and began to suppurate. In consultation with Dr. E. H. Gregory it was decided to remove the growth-its appearance and deportment suggesting malignancy. This was thoroughly removed by dissection, December 22, 1896, and the site cauterized with the actual cautery. The specimen was examined by Dr. Kodis, Pathologist of Washington University, and it proved to be a sarcoma of the small round-celled variety. The wound healed by granulation, and no further trouble was noticed at the site of the operation until February 11, 1898. At that time I found, immediately to the proximal side of the scar, a swelling about half the size of a hen's egg. This, he stated, had existed for several weeks, and was increasing rapidly in size. Dr. Gregory again saw the case with me, and we promptly concluded that this was a return of the original disease. Not wishing to sacrifice the member without some conservative effort, I immediately commenced the injection of Coley's mixed toxins directly into the growth. These were made daily, commencing with a

half minim and gradually increasing the dosage until fifteen minims were reached. The injections were continued for almost twelve months, lengthening out the interval between the injections as the disappearance of the growth became apparent. At the end of seven months the growth had entirely disappeared, partly by sloughing and partly by absorption, although the injections were kept up, as stated, to prevent, if possible, its reappearance. At present the man is in perfect health, and presents no evidence of the sarcomatous growth, other than a soft, pliable scar, with no surrounding induration whatever.

Case II. Mrs. Robt. B., widow, aged 58 years, was sent to me March 15, 1897, by Dr. Joseph Grindon, for a fixed growth in the neck, which had been noticed for several weeks, and was increasing rapidly. It was apparently malignant, but an exploratory incision was made under an anesthetic, with a view of determining the possibility of removing it in its entirety. This was evidently impracticable, and a section of the growth was removed for microscopical examination. This was made by Dr. Kodis, Pathologist of Washington University, who pronounced it a spindle-celled sarcoma. The injections of Coley's mixed toxins were immediately begun and persisted in, as in the former case. The amount was never increased to more than 10 minims. At first the injections were made directly into the tumor, but owing to an occasional excessive reaction, resulting probably from the injection entering a vein, they were afterward continued at a distant site. In 4 months all evidences of the growth had entirely disappeared. In January, 1899, I was called to see the patient and found that she had two growths in the upper portion of the neck, one in the breast and one in the axilla. The masses in the neck contained pus, which was liberated. The injections of the toxins were resumed, with the result that suppuration occurred in all of these masses, and they entirely sloughed away. day she is apparently in as good health as she was before the first appearance of the growth, with the exception of a discharging sinus running underneath the upper portion of the sterno-mastoid muscle. This, however, presents no evidences of suspicious induration. The breast and axilla have entirely healed and the integument is drawn into the axilla, as if the contents had been removed by dissection.

EYE COMPLICATIONS OF CEREBRO-SPINAL MENINGITIS.*

BY J. ELLIS JENNINGS, M.D., St. Louis.

To

N most cases of cerebro-spinal meningitis the inflammatory exudate sooner or later invades the cranial nerves, and may extend to the eyeball itself, causing great injury to its structures and in *Read before the St. Louis Medical Society, April 22, 1899.

some cases resulting in complete blindness. The nature of the disease, its quick onset, its severe constitutional symptoms, delirium, and often fatal termination, so absorb the attention of the physician that the changes going on in the eye may escape notice.

Early in the disease a more or less severe conjunctivitis may develop, associated with photophobia. In some cases, especially when the disease runs a prolonged course, the nutrition of the cornea becomes interfered with, it becomes hazy, an ulcer forms, leaving a more or less extensive opacity. The iris also may become inflamed, though not so frequently as the cornea.

All the symptoms just mentioned are of minor importance, and may occur during the course of many other systematic diseases. Much more to be dreaded, are dilatation and inequalities of the pupils, nystagmus, ptosis, squint, neuritis and atrophy of the optic nerve, and purulent choroiditis, all of which indicate that the inflammation has extended to the cranial nerves and eyeball.

Third Nerve Complications.-When the inflammation extends to the motor oculi center a characteristic group of symptoms appears. The pupils are at first somewhat contracted owing to irritation of the nerve fibers. This irritation, myosis, is not affected by light or shade. As the disease progresses the pupils become dilated, and either react sluggishly to light or remain fixed. This dilatation or mydriasis is a serious prognostic sign and indicates the stage of depression with paralysis of one of the branches of the third nerve. If there is complete paralysis of all the branches of the third nerve, a remarkable appearance is produced. The upper lid droops (ptosis), the pupil is semi-dilated and immovable, the power of accommodation is lost, and the eye rotates outward. In some cases the squint is transient, or it may be of slight degree and only become apparent when the patient is requested to turn the eye in various directions. These patients often complain of diplopia (double vision). Of three fatal cases of cerebro-spinal meningitis recently seen by my friend, Dr. Tuttle, external squint appeared in two cases, in one on the second day, in the other on the third day.

Optic Nerve Complications.-Inflammation of the optic nerve may occur in this disease, but is rare. Randolph, of Baltimore, saw it six times in forty cases, and Schirmer, according to Gower, in one only of twenty-seven cases examined. The neuritis is due to an extension of the inflammation from the meninges along the sheath of the optic nerve. If the optic neuritis is well-marked, the ophthalmoscope shows the optic disc or papilla of a deep reddish tinge approaching the color of the adjacent choroid. It appears cloudy, swollen, and the edge of the disc is obscured. The arteries are narrowed, and more or less concealed in the tissue of the nerve-head. The

Optic Atrophy.-After the neuritis has subsided, in the course of weeks or months, the nerve gradually loses its reddish tint, becomes pale, then white, as a result of atrophic changes. Both arteries and veins are narrowed and vision is lost.

Purulent Choroiditis is sometimes seen in the disease and is due to septic emboli which invade the choroid. The suppurative process rapidly extends to the vitreous and uveal tract, causing violent pain in the eye, swelling, and redness of the lids. The cornea becomes hazy, pus forms in the anterior chamber, the iris is discolored and adherent to the lens. The pupil appears yellow from pus in the vitreous, and the tension of the eyeball is raised. The choroiditis may subside at this point, leaving the eye sightless and atrophic, or the suppurative inflammation may extend to all the tissues of the eyeball, resulting in panophthalmitis, rupture of the cornea and a discharge of the pus. The pain then subsides, the globe shrinks, and sight is destroyed.

The Treatment of Syphilis.-L.. BOLTON BANGS* declares that it is not enough to say that a man has syphilis, and therefore he must take mercury; he must also be maintained at the highest possible level of health. Mercury is interdicted only on account of some idiosyncrasy of the patient, and its administration should be begun as soon as the diagnosis is established; there is nothing to be gained by delaying till the appearance of the eruption; the method of treatment must depend on the nature of the case; if mercury is well borne when taken by the mouth, this is the preferable mode; at times injections should be substituted; only in certain malignant forms should hypodermic injections of bichloride be given. The condition of the glands throughout the body is the most important guide to indicate the direction of treatment; in general, long continued and gentle treatment for three years affords protection from the effects of the disease later in life. The chancre should be excised whenever it is so situated as to make it feasible. Iodides should be used with mercury in the tertiary stage.

*Gaillard's Medical Journal, May, 1899.