An Address on Some Problems of Prostatectomy: Delivered before the Harveian Society, November 16th, 1922
Authors: J. Thomson-Walker
Journal: BMJ (1923)

MANY patients are strangely uinwilling to undergo any treat- ment as a preliminary to operation, partly owinig to the desi-e to get the operation over quickly, and partly to lack of under- standing of tlle gravity of thie post-operation comtplications.The more one sees of prostatic surgery tile mere onie is convinced that many of the colnpiicatious wlicil follow prostatectmy, some of wlich may be fatal, are avoidable by treatment before the operation.I will discuss two of thlese complications.1. BOWEL 'COMPLICATIONS.Post-operative distension of tlhe bowel may occur in all dearees of severity, foin-a slighlt flatulent distension with1 difficulty in gettina thie bowels opened after the operation, to a prolonged-diStens;ion -f the' bowel ending fatally from pressure on the diaphragm and interference withi the hleart's action.It occurs also iin all degrees of acuteness or chironicity.The most strikinig examPle of' an acute caSe that I h1ave scen was a mnan of 60 withi a full abdomen anid flabby muscles, from whom I remiioved an enlarged prostate and a bladder growthi.Thr1ae o-peration wVas simple, and there was little bleeding.ProgrCess aS 'Orni UItil the fourtlh day, whien there was a sud!den pain iif the epigastrium in the ear1ly morning.This disappeared, but reappe-,p-ed later, and th1e abdomen commenced to swell up.Thw distension becaine thi't thle skin Was tense and, 'laZed.After tWO hours' acute distension t1e 'heart beCamne embarrassed and the patient died.A doctor related a case to me of a woman, aged 50, who suffered from distension of tl]e abdomen un- controlled by treatment for seventeen years, withI about six periods, lasting two or thlree days, of intermissioL], duringwhich tl]e abdomen became flaccid.The urine contained pus and blood., Po8t mortem both kidneys,were septic and con- tained stones.This is an ekample of 'thecondition in its most chronic state.Between' these two extremcs are tlle common types, lasting for a few days to, ten'days.The post-operative cases, are usually controlled by treatment, but may cause much anxiety and are occasion'ally fatal..This post-operative distension in urinary surgery is not confined to prostatic aud bladder cases, for it 'is not uncommon during the first few days after kidney operations, and may occur in septic kidney conditions without-operation..In looking for a catuwe for the condition-we must remember that in kidney opera'ticns 'tlhe colon is stripped from its attaclh ment to the kidney and below thlis, and there is sometimes a good deal of 'trouble in separating 'adlesions at the extra- peritoneal aspect of tli'e colon.WVhen we remember also that in septic kidney conditions perinephiitis is constantly present, a3d tllat this m'ust involve 'tlhe contiguous wall of tlle colon, there is no difficulty in recognbizing that a local paralysis of the colon is likely to occur leading to distension with flatus, which spreads to'other parts of tile colon.In prostatic cases so simple an explanation is not possible.In most of those 'I liave'"seen the colon was distended, and constipation,and-hiccup Nwre, frequent, but in some cases tile stomach was the organ affected, ana the distension affected the upper part of the abodoen.;.in, these, vomiting of coffee- ground material is usually 'a' sympto'.Most of tilese are cases of enlarged pros'tatebwith 'back pr'cssure on the kidneys, and in soine of them, suchl,as.that-wli.chI have described, uraemic symptoms actuatly 'appear.'It is likely, therefore, that uraemia may lhave sometiliitg to do with causing tile condition.But there are cases that occur in younger men without sepsis or uraemia.Two 'elements, I believe, enter into the c*usation: one is flatulent distension of lhe bowel from intestinal fermentation, and the other is exhaustion of the sympathetic nervous system resulting' from uraemia, intestinal toxaemia, or shock.Recently it lias been suggested tllat post-operative dilatation of the stomach is due to dragging on the mesentery by the