students have felt the need of a handy volume to which they can readily refer, and which is concise in its statements. This book before us, which we have carefully reviewed, seems to supply this want, and we congratulate the author in his successful arrangement of the text and his judicious selection of illustrations. It is a book which physicians, too, can use with profit, when in this day of rapid progress in the development of the anatomy of the brain, they wish to brush up on things new in this line. Students will, however, find it a desirable working text-book, and it should meet with favor from both medical students and students in psychology in the universities. F. P. N. THE July Scribner's Magazine is more than usually replete with articles of merit and profit, the following are only a few of the many interesting articles: The Slave Trade in America, by John R. Spear; The College Club Theatricals, by Charles Warren; Trees, by Frank French and beautifully illustrated; The Relief of Ladysmith, by Richard Harding Davis; Harvard College Fifty-eight Years Ago, by George F. Hoar; The Vain Shadow, by Duncan Campbell Scott; The River People, by Dexter Marshall. THE July Cosmopolitan is as usual a library in itself, containing articles of interest for every class of readers. First View of the Exposition of 1900, by F. A. Kidder; Henley Week, by Mrs. Burton Harrison; The Mystery (poem), by Charles Edward Thomas; Is Russia to Control All of Asia? by Alexander Hume Ford; Modern College Education, by David Starr Jordan; The Story of Annabel Lee, by Frances Willing Wharton; Women in Turkey, Their Rights and Wrongs, by Lucy M. J. Garnett; A Clerical Comedy, by W. A. Gill, and many others of equal merit compose this midsummer number. THE CENTURY CO. announces the discovery of a new romantic novelist in a New Yorker, Miss Bertha Runkle, whose maiden effort is to be The Century's leading piece of fiction for the next eight months, beginning in August number. It is described as a dramatic romance of love and adventure, and is entitled "The Helmet of Navarre." The scene is Paris during the siege by Henry of Navarre, and the action occupies but four days of the week preceding the Sunday when Henry entered the city to give his adhesion to the Catholic Church and accept its ecclesiastical rites-the occasion of his saying that Paris was worth a mass. The story is full of vigorous action, and the plot is said to be one of fascinating interest. Among the characters of the story are the king himself, the Duke of May. enne, who commanded the city during the investment, and a hero and heroine of much attractiveness. This story is, perhaps, another outcropping of the current tendency to romantic fiction, but it is said that it has not been influenced by any of the recent American successes in this field. PAPERS for the Original department should be in hand one month in advance, and contributed to THE MEDICAL FORTNIGHTLY exclusively. A liberal number of extra copies will be furnished authors, and reprints may be obained at reasonable rates, if request accompanies the manuscript. Engravings from photographs furnished free. Contributions, and books for review, should be sent to the Editors, 312 Century Building, St. Louis. Signature of contributor, for reproduction, should be sent with every article, on a separate slip; use heavy Ink, and allow autograph to dry without applying blotter. COLLABORATORS. LEWIS H. ADLER, Jr., M. D., Philadelphia. CHARLES W. BURR, M. D., Philadel- DILLON BROWN, M. D., New York. HOBART A. HARE, M. D., Philadelphia. F. J. LUTZ, M. D., St. Louis. FRANKLIN H. MARTIN, M. D., Chicago. J. M. MATHEWS, M. D., Louisville. E. E. MONTGOMERY, M. D., Philadel- ERNEST SANGREE, M. D., Nashville. EDWIN WALKER, M. D., Evansville. W. E. WIRT, M. D., Cleveland. H. M. WHELPLEY, M. D., St. Louis. Illustrations of Vasectomy, or Obliteration of the Seminal Ducts Relative to Hypertrophy of the Prostate and Bladder Atony. BY REGINALD HARRISON, F. R. C. S., LONDON, ENG., Surgeon to St. Peter's Hospital. THEN sufficient grounds were furnished for asserting that the nutrition W and growth of the prostate, whether normal or hypertrophied, might be importantly influenced by obliteration of the seminal ducts, or by removal of the testes,* the first stage may be said to have been reached in a series of observations which will probably prove of increasing value in practical surgery. Though experience is not yet sufficiently ripe upon this point there are good reasons for believing that a vasectomised or castrated male is not liable to undergo hypertrophy of the prostrate in the ordinary acceptation of the term. As this point, as now seems probable, becomes more fully determined, not only will a fact of great pathological importance be established, but it will be possible to indicate how by means of a simple and safe operation one of the most serious troubles of advanced life may be averted or controlled. I have reserved for this paper some illustrations of vasectomy, or more strictly speaking, obliteration of the seminal ducts by torsion, as described in my last article, in its application to the treatment of prostatic hypertrophy. Statistical information gathered from the mere collection of a number of cases having but little in common, is not of much assistance in a matter of this kind, where the conditions and circumstances are so varied. In *Surgery of the Hypertrophied Prostrate. Dr. J. W. White. Trans-American Surg. Ass'n. 1893. taking my results of vasectomy as practised to the extent, and during the period mentioned previously, I find they permit of being grouped as follows: First, where the effects are known to have been good, sufficient and enduring. Second, where they have been good, but restricted to certain conditions. Third, where they are alleged to have been inadequate or negative. The question of mortality arising from the operation is not one requiring consideration, as in the series of over 100 cases referred to previously, I stated I have never seen harm follow. The first group may be said to include cases of prostatic obstruction pure and simple without any other structural complication. Here the bladder is in no sense secondarily implicated structurally, and is capable on the removal of the obstacle in front of it, of both holding and expelling its contents. It is in this class of cases that shrinkage of the enlarged prostate, however induced, speedily leads to the restoration of the function of micturition in the fullest sense of the term. This group is best illustrated by cases where for some special or pressing reason the obliteration of the vasa was brought about at an earlier period in the history of prostatic obstruction than is usual. Hence this group is less numerous than the succeeding one where catheter life or the systematic use of this instrument had been resorted to previously. The following cases are selected: A man, aged 68, seen in 1896, with the ordinary symptoms of enlarged prostate, namely, frequent micturition, more especially at night, some degree of residual urine, and occasionally incontinence, the diagnosis being confirmed by rectal examination. He had been advised to use a catheter, but could not do so conveniently, as he had lost an arm. Double vasectomy with an interval of ten days between each section. I saw him nearly three years afterwards the prostate was reduced in size. He was quite well and had no occasion for the catheter. About the same time I divided the vasa of a man aged 65, whose work as a journeyman builder was greatly interfered with by frequency of micturition due to enlarged prostate. He also had been advised to use a catheter. He was treated in the same way as the preceding with a similar result, and was examined eighteen months afterwards. As this In 1897 I saw a man, aged 65, who in the course of his occupation travelled much by railway and otherwise. He had an enlarged prostate and much frequency, for which he was advised to use a catheter. meant giving up his livelihood vasectomy was practised with good results, and eighteen months afterwards he reported himself as quite well without requiring the catheter. Early in 1898 I saw a patient in consultation, where it had been necessary to tie in a catheter for retention of urine caused by a large prostate. This was so intolerable to him that I suggested vasectomy, which was done. I have heard on several occasions that he still remains in good health and able to urinate normally. Six months after the operation I found the prostate much reduced in size. A man, aged 67, upon whom I operated for stone by litholapaxy in 1893. There was also some enlargement of the prostate. He remained well till 1897, when symptoms of considerable enlargement developed, and though he had no recurrence of stone, he gradually became entirely dependent upon the catheter, and was liable, on slight provocation, to attacks of cys. titis and epididymitis. The frequent use of the catheter greatly interfered with his capacity and desire for an active outdoor life, and he was compelled to give up hunting and other exercises. In 1898 I divided both his vasa in the usual way, with the result that his prostate symptoms gradually disappeared, and he resumed his hunting during the whole of last winter, as he had previously done. He was able to give up his catheter, using it once in the twenty-four hours for washing out. He had accustomed himself to the latter as a precautionary method against stone, and though the process, he admitted, was hardly necessary he did not like to give it up. This appears to be the first published series of cases of prostatic hypertrophy treated by operation where the object of preserving the normal function of micturition as opposed to an artificial one as illustrated by what is known as catheter life, has been successfully demonstrated. * Before leaving this group I would observe that in every case it was explained that the section or division of the vasa might interfere with sexual possibilities. It may, I think, be claimed that in all these instances, and in others that might be mentioned, whatever influence, if any, was exercised on the sexual act the natural function of micturition was preserved to the person operated on, and the necessity for the permanent use of a catheter averted. When any question has arisen under these circumstances, so far as my experience goes relative to whether the urinary or sexual function should receive first and parmount consideration, it has invariably been decided by the patient in favor of the former. Passing to the second group of cases, where I have described the effects following as being good, but restricted to certains conditions. These include instances where structural changes in the bladder have supervened upon prostatic obstruction, and where catheter life, or the necessity for it, has been more or less developed. This group provides by far the greater proportion of cases to which this class of operations has been recently applied. In a previous paper I showed that there were certain structural effects which followed in the wake of prostatic and other forms of obstruction to the escape of urine by the natural passage, which were irrecoverable from. These have reference to the bladder as a reservoir capable of selfexpulsion. Hence in the consideration of the class of operations of which vasectomy is a type, cause and effect must not be confused. The prostate may be rendered in these ways incapable of obstruction any longer, but this by no means implies that the bladder can be made to expel. And yet the realization of the former by these means has in this way proved in many instances, which I will proceed to illustrate, an inestimable boon. In November, 1895, I operated on a man aged 70, with a very large prostate and increasing difficulty in catheterism which sometimes required hot baths and opiates before it could be effected. He had shaky hands which increased the difficulty. I advised a double vasectomy. Twelve months after this he wrote me: "I certainly am very much better than I was before the operation, and so long as I am quiet and able to carry out my regular treatment I get on very comfortably." A man, aged 75, very large prostate and increasing difficulty in passing his instrument. Double vasectomy in 1898. He soon found that he could pass his catheter quite easily, and again wintered abroad last year, with much comfort. He had been previously obliged to forego this change by reason of catheter difficulties. A member of our own profession, over 60, whom I saw in consultation, and advised vasectomy for enlarged prostate with frequent attacks of epididymitis, which confined him to bed, has entirely got rid of the latter painful complication by the obliteration of his ducts, and is now again in the active practice of his profession. The next case I shall refer to is the application of vasectomy as an adjunct to other surgical purposes. It was that of a man, aged 70, whom I operated upon for stone in the bladder in 1893. The prostate was so large that I had unusual difficulty in performing the ordinary operation of litholapaxy, and after removing a considerable portion of the stone in this way I had to abandon it without effecting a complete removal of the calculus. The patient, however, did well and was much relieved. In the meantime I divided both vasa, and after six weeks interval repeated the crushing operation. The considerable shrinkage that was thus effected in the size of the prostate rendered this proceeding easy and complete, For the relief of hemorrhage arising out of difficult catheterism in connection with prostatic obstruction vasectomy has been adopted with good effect in rendering the process easy and avoiding bleeding. This is only to be expected as the result of a process which is generally admitted as reducing the blood supply to the parts involved. Painful catheterism arising from spasm and tension as the instrument enters the prostatic urethra may be usually relieved in this way by the general shrinkage and relaxation of the gland that follows section of the vasa-I have had several illustrations of this. For reasons such as are here illustrated, and for others that might be added to the group, the obliteration of the vasa has proved of much service, though the voluntary and natural powers of the bladder, may either have not been, or but partially restored. Easy and safe catheterism has in this way been substituted for that which previously was painful, if not also dangerous. I will conclude with a notice of the third group of results of vasectomy, which seem to me to include the most interesting and suggestive of the series that I have here brought under notice. I refer to those instances where they are alleged, or seem to have been inadequate or negative. For the purposes of this paper I have made numerous inquiries by letter in addition to other sources of information, from patients who have undergone vasectomy since 1893, when I commenced to practise it with some frequency. Amongst these is a man now aged 81, upon whom I performed double vasectomy for prostatic enlargement of some years standing early in 1897. On writing to me he informed me that he did not think he had derived much benefit from this operation. The history of this case, however, will hardly bear out this statement. The patient has been |