Clothing may make the man, but at the end of the 19th century, accessories were what counted most for men with benign prostatic hyperplasia (BPH). No finery did more for men suffering from enlarged prostates than bowler hats, walking sticks or umbrellas. For stashed discreetly in the hat bands or hollow cane-shafts were one of the few means of relief for a man suffering from BPH-related restricted urine flow: a catheter.
BPH, an enlargement of the prostate, is a common condition in men more than 50 years old. The growing organ compresses the urethra and causes an obstruction of urine, making it difficult to empty the bladder completely, and 100 years ago, reasonable treatments such as transurethral resections of the prostate weren't always readily available.
But that didn't stop physicians from attempting to treat this ailment. Centuries passed as doctors tried a number of different treatments, such as the notion advanced by Pennsylvania's William J. White in 1893 that the removal of testicles in normal men would shrink their prostates.
Other approaches proved more promising. In September 1891, Southern Pacific Railroad physician George Goodfellow, of Tucson, Ariz., removed prostate tissue through an incision made in the perineum (the area between the scrotum and rectum). While this procedure isn't documented, Goodfellow has been credited with the first perineal prostatectomy.
New York City's Eugene Fuller originated the suprapubic procedure where the prostate is removed through an incision made through the lower abdomen and bladder. Nearly a century after reporting six successful cases, he was memorialized with the AUA's Eugene Fuller Award in 1985.
Johns Hopkins's Hugh Hampton Young accumulated even better results. He used the same incision as Fuller to remove the prostatic mass, but he also pushed the gland upward from the rectum to ease and complete the excision, thus distinguishing his approach and making the removal more complete.
This innovative maneuver was one of many by Young, who came to be known as the "Father of American Urology." On October 8, 1902, he developed his perineal approach using a specially crafted "tractor" to draw out the prostate of Samuel Alexander and remove the enlargement. Alexander, a patient from Hawaii who insisted that Young perfect his technique before his operation, was an inspiration to Young. "My indebtedness to him," he later wrote, "is great."
Others, such as Britain's Terence Millin, added their own techniques. Millin perfected and popularized today's retropubic operation in 1945, pursuing an abdominal cut directly into the prostate.
But not all prostatectomies involved incisions. In introducing his "punch" procedure, April 1, 1909, Young produced an endoscopic alternative to "big" operations for small tissue. Using his own remodeled urethroscope, Young made an incision into the urethra, caught the obstruction and sheared off the enlargement with a snug cutting tube. Once the enlargement had been removed, his patient urinated freely.
Producing less pain and fewer complications than open surgeries, Young's punch procedure gained many fans, though none as celebrated as James Buchanan "Diamond Jim" Brady.
Brady found in Young an intrepid surgeon who would take on his chronically inflamed prostate in an April 12, 1912 procedure. Even a stormy post-operative course wouldn't mar Brady's generosity; he made a donation that founded the James Buchanan Brady Urological Institute at Johns Hopkins. Young was its first director.
Others added their own twists to the transurethral procedure. New York City's Maximilian Stern launched the present-day "resectoscope" in 1926, using a moveable tungsten wire to whittle the obstruction, thus creating the basis for today's transurethral resection of the prostate.
In South Carolina, Greenville physician Theodore M. Davis used his engineering background to control bleeding by perfecting the electric current supply and adding today's double foot switch to create seamless cutting-to-coagulating surgery.
New York City's Joseph F. McCarthy fashioned a lens system that widened the vision field considerably and changed the sheath of the instrument, resulting in modern Stern-McCarthy resectoscopes.
But such innovations weren't the only advances in BPH treatment. By the 1990s doctors had added drugs to their arsenal. "Alpha-adrenergic blockers," such as tamsulosin, impede prostate and bladder muscle tension to promote better urination. Androgen suppressors, such as finasteride, shrink the prostate by blocking the conversion of testosterone into dihydrotestosterone, a player in BPH.
But these drugs have drawbacks. They aren't cure-alls. Yet, until scientists can prevent BPH by finding its cause, doctors are left to attack its symptoms. Fortunately, with increasingly elegant treatments, today's sufferers can hang up their bowler hats and save their walking sticks and umbrellas for strolling in the rain.
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