The Diseases of The Prostate

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SIR HENRY THOMPSON
THE PROSTATE
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1883
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THE
DISEASES OF THE PROSTATE

THEIR
PATHOLOGY AND TREATMENT

COMPRISING THE
Jacksonian Prize Essay for the Year 1860
BY
SIR HENRY THOMPSON

SURGEON EXTRAORDINARY TO HIS MAJLSTY THE KING OF THE BELGIANS
CONSULTING SURGEON AND EMERITUS PROFESSOR OF CLINICAL SURGERY TO UNIVERSITY COLLEGE HOSPITAL
FELLOW OF UNIVERSITY COLLEGE : HONORARY CORRESPONDING MEMBER OF
THE SOCIÉTÉ DE CHIRURGIE OF PARIS : ETC.
FIFTH EDITION
NE LUT
ICI ERI
MED S
200
LONDON
J. & A. CHURCHILL
11 NEW BURLINGTON STREET
1883
BY THE SAME AUTHOR .
Clinical Lectures on Diseases of the Urinary Organs :

Sixth ( Students') Edition, 8vo . 2s.6d.
Practical Lithotomy and Lithotrity ;

Or, an Inquiry into the best Modes of Removing Stone from the Bladder. Third
Edition, 8vo. 108.
The Preventive Treatment of Calculous Disease , and the Use of

Solvent Remedies .
Second Edition, fcp. 8vo. 2s. 6d.
The Pathology and Treatment of Stricture of the Urethra and

Urinary Fistulæ .
The Jacksonian Prize Essay for 1852 . Third Edition, 8vo. 10s.
N 69
T46
1823
PREFACE
TO
THE FIFTH EDITION
The preceding edition having been recently exhausted, I have

endeavoured to prepare a new one containing a résumé of all that is
known of the Prostate and of its diseases at the present date .
Numerous modifications and additions have been necessary , aris
ing in part from enlarged personal experience, and in part from the
increased extent of our knowledge generally in relation to this and
to kindred subjects.
A new chapter (Chap. XIII.) is added on operations designed to
relieve the sufferings of patients with advanced Prostatic Disease .
The new method of treatment now for the first time advised with respect
to some of these cases, will, I firmly believe, afford great relief to
some of them .
Finally, I am glad to be able to follow the course I originated in

6
issuing the last edition of my Clinical Lectures ; ' viz . to produce it in
a form adapted to students at one fourth of the former price. It is
pleasant to add that the result of that experiment has amply warranted
this new departure in medical literature.
35 WIMPOLE STREET, CAVENDISH SQUARE

December 1882 .
54078
PREFACE
TO
THE
Τ FIRST EDITION .
Having during the last few years enjoyed considerable opportunities for
the study of Prostatic disease, I have aimed at embodying, in the follow
ing pages, the observations which a careful and laborious prosecution of
it has led me to make. I should not have ventured to do so, had the
results altogether coincided with those obtained by previous inquirers.
The views here maintained of the Anatomy of the Healthy Prostate,
but particularly of the organ in its most common deviation from the
normal state, viz. when the subject of senile enlargement, differ
materially from those which have been commonly held . The conclu
sions I have arrived at are based on extended anatomical researches,
embracing an examination of not less than seventy original dissections,
forming preparations now in my own possession, in addition to such
observation of the contents of our metropolitan museums as I have
been able to make. The data from which such conclusions were
drawn have been appended, so far as it was possible to do so, that the
scientific inquirer may form his own opinions respecting them. The
points to which I desire especially to request his attention may be
briefly stated as follows
6
The assignment of the third ' or middle lobe,' as a separate
anatomical portion of the Prostate, to the abnormal history of the
organ ;-discussed in the first chapter.
The analogy between the enlargements and tumours of the Prostate
and those of the Uterus ;-discussed in the second chapter.
An examination of the alleged causes of enlargement of the
Prostate, resulting in new views of this subject ;-in the third chapter,
vi PREFACE TO THE FIRST EDITION.
The effects of enlarged Prostate in relation to the function of

micturition ;;-considered
; in the fifth chapter.
The researches in relation to Malignant and Tubercular disease of
the Prostate ; - in the ninth and tenth chapters.
6
The consideration of the bar at the neck of the bladder ; ' - in
chapter the twelfth .
Besides these, I have treated at length the subject of Diagnosis and
treatment of enlargement, and of the various complications which arise
in connection with it, perhaps, I may venture to say, more fully than
any preceding author .
And lastly, I have devoted a chapter to a consideration of that
important, but not uncommon complication of enlarged Prostate, stone
in the bladder ; and especially of the best modes of successfully apply
ing Lithotrity as a means for its removal. I venture to hope that in
discussing thus fully the question of Treatment, whether in relation to
the simple or the complicated forms of this common complaint, some
hints will be found which may prove useful in the various emergencies
of practice. I shall feel abundantly rewarded should some of my
professional brethren discover any such fruit as the result of my
labours .
WIMPOLE STREET, CAVENDISH SQUARE :

November 1857 .
CONTENTS .
PART 1 . THE ANATOMY OF THE PROSTATE.

PAGE
I. THE TOPOGRAPHICAL AND STRUCTURAL ANATOMY OF THE PROSTATE 1
II. FACTS RELATIVE TO WEIGHT, SIZE , AND MORBID CONDITION OBTAINED BY DIS
SECTING THE PROSTATE 19
PART II. THE DISEASES OF THE PROSTATE .
III, INFLAMMATION OF THE PROSTATE, ACUTE AND CHRONIC 24
IV. SUPPURATION OF THE PROSTATE ; ABSCESS, ACUTE AND CHRONIC 31
V. HYPERTROPHY OF THE PROSTATE ; ITS ANATOMICAL CHARACTERS 37

VI. TUMOURS AND OUTGROWTHS OF THE PROSTATE 47
VII. THE CAUSES OF HYPERTROPHY OF THE PROSTATE 57
VIII. THE SYMPTOMS OF HYPERTROPHIED PROSTATE . 64
IX. THE EFFECTS OF ENLARGED PROSTATE IN RELATION TO THE FUNCTION OF MIC
TURITION : RETENTION, INCONTINENCE, ENGORGEMENT, AND OVERFLOW . 69
X. TAE DIAGNOSIS OF PROSTATIC AND OTHER OBSTRUCTIONS AT THE NECK OF THE
73
BLADDER
XI. THE TREATMENT OF PROSTATIC ENLARGEMENT, FROM HYPERTROPHY AND SIMPLE

TUMOUR . .
79
XII. THE TREATMENT OF RETENTION OF URINE FROM ENLARGED PROSTATE • 100
XIII. ON THE PERFORMANCE OF OPERATIONS FOR THE RELIEF OF VERY SEVERE
SYMPTOMS RESULTING FROM ADVANCED PROSTATIC DISEASE 111
XIV. ATROPHY OF THE PROSTATE 117
XV . CANCER OF THE PROSTATE 119

XVI . TUBERCULAR DISEASE OF THE PROSTATE 128
XVII. CYSTS OR CAVITIES IN THE PROSTATE 130
XVIII. THE BAR AT THE NECK OF THE BLADDER 132
XIX , PROSTATIC CONCRETIONS AND CALCULI 141

XX. ON THE RELATION BETWEEN HYPERTROPHIED PROSTATE AND STONE IN THE
BLADDER 149
LIST OF ILLUSTRATIONS.
YIG. PAGE
1. A healthy prostate 4
2. Diagram of prostate 5
3. Ditto 5
4. Section of healthy prostate 15
5. Abscess of prostate 35
6. Section of prostate; commencing enlargement 39
7. Prostate ; great hypertrophy 40
8. Diagram of typical form of enlargement 41

9. Ditto .
41
10. Urethra rendered devious by enlargement 42
11. Ditto 42
12. Di 42
13. Bladder and prostate ; general hypertrophy 43
14. Small tumour causing total obstruction 43
15. Tumour of verumontanuin .

55
16. Tumours of prostate, largely developed 56

17. The same dissected 56
18. Prostatic tumour ; sacculated bladder .

73
19. Short -beaked sounds for exploring 76
20. Interior of the bladder with sound 76
21. Beaked sound hollow 77
22. Coudée catheter . 81
23. English gum catheter mounted on over-curved stilet 81

24. Prostatic catheters . 101
25. Olivary catheter 103
26. Neck of the bladder elevated by great hypertrophy of the prostate 105
27. Mercier's instrument for avoiding false passages . 107
28. Instruments for opening bladder above the pubes 113
29. Mercier's instrument for incising bar at neck of the bladder 139
30. Ditto for excision . 140
31. Prostatic concretions 143
32. Ditto . 143
33. Ditto 144

34. Ditto . 114
35. The author's aspirator for removing small calculi and fragments 152
THE
DISEASES OF THE PROSTATE .
PART 1. — THE ANATOMY OF THE PROSTATE .
CHAPTER I.
THE TOPOGRAPHICAL AND STRUCTURAL ANATOMY OF THE PROSTATE.
The Prostate as an Independent Organ-Mode of Dissecting - Limits of- Form - Size - Measure
ments - Weight - External Relations— Vessels and Nerves - Anatomical Conformation ; Lobes- .
History of the Third Lobe '-Prostatic Urethra, its Course and Character — The Utricle- Ejacula
tory Ducts — MINUTE ANATOMY – Its Fibrous Elements – Its Glandular Elements - Relative
-
Proportions of - Prostate Gland in Young Subjects — Its Weight, Size, and Relations.
In order to study the Pathology of the ' prostate gland ' is commonly applied, to
Prostate, it is necessary to observe accu- indicate with exact precision its anatomical
rately its normal structure, conformation , boundaries in every direction, or even to
and anatomical relations. The most com- substantiate an undisputed title to its
mon, aswell as important, morbid states recognition as an independent organ , in
to which this organ is subject, either that sense in which the word organ is
consist in, or are associated with, devia- very commonly understood . Forming a
tions from the natural size and form , as small portion of a large and important
well as from the natural disposition of the apparatus, which is continuous in structure
structures entering into its composition. throughout, it nevertheless exhibits pecu
It is apparent that its topographical rela- liar characters in the arrangement and
tions must be also deranged when devia- combination of its component tissues; a
tion from size in the direction of enlarge- special appellation may be therefore re
ment becomes considerable, as it not garded as appropriate and necessary for
unfrequently does. On the other hand, anatomical purposes. In like manner a
it is certain that the normal dimensions large and continuous division of the in
of the prostate have not been accurately testinal tube is recognised by anatomists
determined, inasmuch as very different as two separate portions, under the names
weights and measurements are named in of jejunum and ileum , although no
describing it by various authors. And, physical boundary line indicates the
lastly, our knowledge of its structure, to limits of their proximal extremities ;
>
say nothing of its physiological uses, is, specialities of structure and function
perhaps, less exact and defined, or, at all characterise each of these two portions,
events, has been so until late years, than but those of the one glide insensibly into
other topics in its history which are even the other.
less important to the student of disease. Another important circumstance sup
I propose, therefore, first to consider its ports the custom of regarding the prostate
normal anatomy in detail. as a separate organ , viz., the existence of
In entering on this subject it may be such a structure, or of some analogous
admitted that clearly defined marks are one, as an accessory to other sexual
wanting in the structure of that part of organs throughout a very large portion of
the human organism to which the term the animal series, not only in the verte
B
2 THE ANATOMY OF THE PROSTATE .
brata, but in the invertebrata also. And, which it is understood that the rectum
lastly, there is the consideration , of no itself has been carefully removed, without
little weight, which is supplied by the removing more of the fascia than is
fact that the prostate is subject to morbid necessary in the operation.
changes which, as will be seen hereafter, First will be seen the vesiculæ seminales
are peculiar to it, and which do not occur and vasa deferentia bound closely by a
in any adjacent or related structure. dense fascia to the posterior border of the
These remarks appear to be necessary prostate and base of the bladder adjacent,
at the outset to explain that,although the and requiring some careful dissection to
organ which is the subject of examination isolate them fairly. Each vas deferens
here does not possess characters so inde- has a vesicula seminalis on its outer side,
pendent as those which belong to such and approaches obliquely the median line
glands as the liver, the kidney, or the as it courses forward to the base of the
pancreas, it nevertheless exhibits charac- prostate, and just before entering it joins
ters of a nature so peculiar and distin- the vesicular duct to form the common or
guishing that we feel compelled to assign ejaculatory duct. These two vessels
to it the possession of an individuality should be carefully cleaned and traced,
and integrity which may perhaps be when they will be seen to perforate
somewhat overlooked if we study it the mass in a deep central interlobu
mainly or solely from that point of view lar depression or notch, and to enter
which regards it only as a fractional it in the middle line side by side. A
portion of some greater whole. layer of fascia, a portion of the recto
The name of prostate,' as applied to vesical fascia, may be now dissected from
the part under consideration, is supposed the inferior surface and sides of the gland, 1
to have been originated by anatomists, for which it forms an enveloping sheath,

from the fact of its standing before, or and several venous sinuses will be en
anterior to, the bladder or vesiculæ semi- countered lying between it and the proper
nales, in the supine position of the subject; capsule of the prostate, especially along
its name of ' gland ’ from the glandular its lateral borders, where those vessels are
structures which form a considerable part found large and generally filled with
of its component tissues. coagula, particularly in elderly subjects ;
The prostate gland of the adult is and sometimes in the latter containing
commonly described as resembling a also large phlebolithes. The proper cap
full-grown chestnut in size and form ; sule, which cannot be regarded as a mere
sometimes it is compared in the last- offshoot from any adjacent fascia, but is a
named character to the ace of hearts, the special envelope belonging to the prostate
small extremity being directed downwards itself, although thin, is firm in texture,
and forwards, and the base upwards and and defines clearly the form and limits of
backwards, in the erect positionofthe body.. the prostate here. Proceeding with the
When the bladder , prostate, and vesi- dissection by turning upwards a little the
culæ seminales, as well as the urethra for peritoneum covering the bladder, if we
two or three inches of its course anterior next clean the external layer or longi
to the prostate, are removed from the tudinal muscles of that viscus and trace
body and are fairly isolated from the them with care, some bands of the paler
neighbouring parts by dissection, the and less superficial fibres will be found
prostate appears as a mass having the inserted into the base of the prostate
form of a short truncated cone flattened above the point where the ejaculatory
between its pubic and rectal aspects, the ducts enter. These should next be
base of which surrounds the neck of the divided, and the longitudinal layer be
bladder and projects somewhat below it, turned aside from the base of the bladder
while its blunted apex ends at the fascial to the right and left of the middle line as
partition which stretches across the angu- well as the mutual interlacements of the
Iar interval between the pubic bones, and different vesical coats permit, and the
is known as the posterior layer of the inner or circular layer comes into view.
deep perineal fascia. The bladder should These, which are very pale in colour,
be slightly distended with tow, and the should be defined at the base and neck of
parts above named should be properly the bladder, where they are chiefly ag
secured to facilitate the dissection , with gregated, being very thin and scattered
the posterior or rectal aspect upward, from above, since by tracing them forwards
TOPOGRAPHICAL AND STRUCTURAL ANATOMY. 3
they will be found to be continuous with cular fibres mingled with a good deal of
muscular fibres similarly arranged , and connective tissue and some elastic fibres,
forming a considerable portion of the this layer forming part of a system of
prostate itself; and in order to observe longitudinal fibres underlying and sur
this continuity, the proper capsule must rounding in greater or less quantity the
be partially removed , with the superficial whole urethral canal.
and lateral portions of the prostate, which Thirdly, & circularly disposed layer of
contain a large proportion of glandular pale or unstriped muscular fibres of con
structure intermingled with interlacing siderable thickness posteriorly, where they
muscular and fibrous tissues, and which become continuous with the circular fibres
will be described when we consider the of the bladder, and becoming thinner as
minute anatomy of the organ . Into this they approach the membranous portion,
outer portion some fibrous prolongations over which they proceed and then termi
of the capsule proceed, and minute vessels nate. This layer contains also connective
enter the prostatic substance with them . and elastic fibres like the preceding.
But in order to trace the circular fibres Fourthly, beyond thislies the greater
of the bladder through the prostate, a part of the glandular structure properly so
prolonged and delicate dissection is neces- called, which intermingles with , and is
sary. By this means it is easy to demon- supported by, a considerable proportion of
strate that complete continuity of structure tissue, composed in part of pale muscular
exists to a considerable extent between fibre, and in part of connective and fibrous
the circular fibres of the bladder and the tissues, which, interlacing together, con
constituent fibres of the prostate, and that stitute the rest of the organ . It is this
they are arranged around the tube of the composite structure which, disposed in
urethra in the manner described . By masses chiefly in the lateral direction on
carefully continuing the dissection this either side, gives form and character to
annular series of fibres may be traced the organ .
along that canal, diminishing in volume Fifthly, the enveloping fibrous capsule.
as we proceed in the anteriordirection, as To what precise portion of the mass
far as to the bulb of the urethra, where lying anterior to the bladder and sur
they stop, having extended over the whole rounding the urethra, shall we assign the
of the membranous portion . In this latter limits of the prostate ? In front the pos
situation they have dwindled down to a terior ordeep layer of the perineal fascia
layer from one-half to one-third of a line may well be regarded as the boundary
in thickness, although quite distinct. If line. Behind we have no such limiting
next we make a longitudinal incision in distinction ,but we may proceed as follows.
the axis of the prostatic urethra through Taking a fresh specimen, in which the
these fibres with great care, we may turn bladder and prostate have been carefully
them aside and lay bare a longitudinal separated from the adjacent veins and
layer of delicate pale muscular fibres which fascia, and in which the vesiculæ seminales
lie immediately outside the mucous
brane which forms that canal.
mem- and ejaculatory ducts have been separated
These are and traced into the interlobular notch ,the
the muscular fibres which surround the basic extremities of the lateral lobes being
urethrathroughout great part of its course, defined, and division having been also
and which have been described in some- made in front at the perineal fascia, we
what different terms by Hancock, Hogg, should lay open the bladder, and, with a
and Kölliker. pair of scissors, cut away the walls of the
In order to present a clear and succinct bladder closely round the neck or vesical
view of the order in which the structures orifice of the urethra. In doing so we
constituting the prostate are arranged, and shall divide the circular fibres freely, and
particularly with regard to the urethra, some of the external longitudinal fibres,
which passes through it, we shall simply as well as the mucous membrane and
name them in the reverse order to that submucous tissues around the internal
already pursued , viz., from within out- meatus, particularly those forming the
wards. uvula or luette vésicale : the remaining
Firstly, the mucous membrane of the portion may then be accepted as a fair
urethra . specimen of the prostate gland in an iso
Secondly, a delicate layer of longi- lated condition.
tudinally disposed pale or unstriped mus- It is this mass with which we have to
B2
4 TIIE ANATOMY OF THE PROSTATE .
deal in respect of external physical cha- | forates it at a point a little in advance of

racters. the base itself, approaching, in fact, to the
First, as to form . A slightly trun- upper surface, so that the portion of pro
cated cone, flattened antero -posteriorly, state below the urethra exceeds by about
short, so that the diameter of the base one-third or one -fourth the length of the
exceeds by a fourth or fifth the measure- portion which lies above. On each side
ment of the longitudinal axis, the base of the base, the rounded posterior limit of
notched or indented for the entry of ducts, a lateral lobe projects, a little backwards
gives as fair a representation as a few and outwards, leaving a notch between .
words can supply . The projection of a 'median portion ,' or
A drawing faithfully representing such third lobe,' if present, is seen between
a specimen in thesupine position, and dis- the urethral opening and that for the two
sected in the manner described, not an ejaculatory ducts beneath .
ideal figure, will furnish a better concep- MEASUREMENTS.—The transverse dia
tion . ( See fig. 1.) meter is almost always the greatest, ex.
ceeding the antero -posterior by a fifth or
a sixth . These relations vary very much.
Sometimes the organ has an appearance
as if it had been compressed from before
backwards . It is much less common to find
the transverse measurement decreased.
In a series of fifty adult prostates which
I made the subject of a laborious investi
gation , and presented to the Medical and
Chirurgical Society, 1 thirty -three were
healthy. Their measurements and weights
are furnished in the following table :
THIRTY - THREE NORMAL PROSTATES.
seiguigiés osa
f'ig . 1.-A healthy prostate, from a man aged
thirty -five years. It was dissected, as described ,
page3, and was accurately drawn while in the Thick
magánézés
amigosoggi
No. Age Weight Length Breadth ness
fresh state. The organ lies with its posterior
or rectal surface downwards. The portion con
tiguous to the bladder is that which is nearest drs . grs . inches inches inches
to the eye ; the internal meatus being seen 1 79 4 48 1.4 1.45 .85
above, and the ejaculatory ducts in their de 2 42 3 37 1.3 1.4 .6
pression below . 3 47 4 57 1.8 1.7
4 85 4 44 1.25 1.55
5 47 5 33 14 1.7
Observing it more closely, the anterior 6 63 4 35 1.35 1.7
surface appears generally convex. I have 7
8
50
54
4 34
8
1.5
1.25
1.7
1.8
scarcely everfound any trace of a depres 90 4 58 1.25 1.85
sion in the line of the long axis, said, in 10
11
52
54
4
4
13
37
1.5
1.5
1.76
1.75
anatomical works, to exist and to corre 12 66 4 27 1.4 1.5
13 63 4 3 1.35
spond with the track of the urethra ; this 14 79 2 1.4
1.5
1.6
has been carefully, but unsuccessfully, 15
16
54
70
4 50 1.5 1.7
sought in numerous dissections. The 17 66
4
4
65
56
1.4
1.4
1.8
1.7
posterior or rectal surface is smooth and 18
19
74 4 4 1.3 1.6
61 4 16 1.3 1.6
also rather convex, but here the course of 20 56 3 56 1.25 1.75
21 21 1.3
the urethra is denoted by a shallow median 22 40
3
4
34
30 1:55
14
1.6
depression ,while the unyielding masses of 23
24
64
50
5
5 20
2 1.4
1.55
1.75
1.75
the lateral lobes are seen, one on each side, 25 73 4 48 1.6 1.8
and are still more readily recognised by 26
27
50
46
4
5
46
4
1.4
1.5
1.9
2-0
pressure with the finger ; two slight lines 28 66 4 35 1.5 1.75
of depreesion are also seen converging at 29
30
66
65
4
4
6
24
1.5
1.4
1.65
2.0
the basic part of this surface, which indi 31 55 5 30 1.3 1.8
32 54 14
cate the tracks of the ejaculatory ducts. 33 61
4
4
48
54 1.3
1.75
1.75
At the base are seen the internal meatus
of the urethra, and below it the inter
lobular notch and the funnel-shaped open- 1 In relation to this investigation , and the
ing by which the ejaculatory ducts enter. method in which it was pursued,it may be as well
explain , forsubject,
Itshould be observed that the urethra per- toallusion to the the purpose
thatthe of saving
various further
statements
TOPOGRAPHICAL AND STRUCTURAL ANATOMY . 5
An analysis of the measurements pro - tomy, the prostate as measuring twenty to

duces the following results : twenty- four lines transversely, and ten to
Inch .
twelve in thickness ; and on these esti
From base to apex the measure mates his calculations for that operation
ments ranged between 1 :3 and 1.8
But the measurement most com were based . They correspond, however,
monly met with was 1.4 very nearly with those by Deschamps,2 5
The greatest transverse, near Senn , Dr. Gross, and Dr. Hodgson , all
+
base, ranged between .
1: 4 and 2 0 of whom have made practical researches
But the measurement most com relative to the size of the organ .
monly met with was 1.75
The point of extreme thickness The important result of measurements,
when measured ranged between •55 and 96 as regardsLateralLithotomy, is the length
But the measurement most com of a line directed downwards and outwards
monly met with was about •7 | from the centre of the urethru ( which may
The measurements of twenty healthy be regarded as corresponding in the opera
tion with the bottom of the groove in the
specimens
and which which I have since
were sentto examined
the Royal Col-, staff) to the outer border of the prostate
lege of Surgeons, correspond very nearly beat its vesical extremity.
considered This line may
as falling midway between
to the above.
The measurement in inches may ihen the horizontal and vertical planes, form
beexpre ssed in average terms) asfol- ing with each, therefore, an angleof45 °,
lows : when the patient lies in the position for
Inch . lithotomy . It may be accurately deduced
From base to apex 11 to 11 from the form and measurements given
Greatest transverse diameter, about 1 above,and has been verified by numerous
Greatest thickness, about ſ to actual sections of the organ .
(See fig. 2. )
Average measurements of healthy
prostate in direction described
(see fig. 3 ) Ź of an inch
Ditto of small prostate , weighing
under 4 drachms of an inch
FIG. 2.
Fig . 3.
These are smaller than those given by
Dupuytren , who represented, in connec
tion with the subject of Bilateral Litho This, it will be understood , represents
the distance to the extreme border ; the
made , in this and other chapters, are founded extent, therefore, to which an incision
upon a dissection of upwards of sixty specimens
of the prostate, removed by myself from the dead should be carried in this situation may be
body, of which fifty, preserved in spirit, were ex- approximately determined therefrom .
hibited at the Medical and Chirurgical Society, WEIGHT. Various weights are as
Feb. 10, 1857, in illustration of a paper entitled
Some Observations onthe Anatomy and Patho signed by the principal writers on this
logy of the Adult Prostate,' and published in the subject; their estimates ranging between
The method
fortieth
of examination the Transactions.
of each
volume in case was as follows: The 4 and 8 drachms. No exact limit in this
8
organ was cleanly dissected out from the adjaceut matter can be affirmed ; probably from
parts, andthecarefully
bladder and other At
muscularremoved.
the neck
fibrous structures of the 4 to 6 drachms may be considered as a
which surround the vesical orifice of the urethra
were pared away pretty closely, but some very Mémoire sur l'Opération de la Pierre. Paris,
small portions of these were necessarily left, which 1836. p. 21.
could not be regarded as, strictly speaking, pro- 2 Traité Historique et Dogmatique de l'Opération
static tissue. Absolute definition is almost, if not de la Taille. Paris, 1796. Vol . i. pp. 39, 40.
quite, impossible. I was careful, however, to be 3 Traité d'Anatomie Chirurgicale. Paris, 1838.
80 exact, that any portions of adventitious tissue Vol. ij. pp. 327–330. Par. J. F. Malgaigne.
remaining wouldbe so small as not to invalidate 4 Diseases of the Bladder, g-c. Phil ., 1855, 2nd
69. Prostate Gland, and its Enlargement in
the conclusions drawn. Theanterior limit of the ed po The
organ , although not completely defined, is yet very
Dearly so ; no difficulty ,therefore, arises here. Old Age. London , 1856. p . 34.
range within which most normal prostates occupied by fascial, cellular, and muscular
will be found. The table just given shows tissues. Its base, which, as already ex
3 drachms 34 grains as the lightest, and plained , surrounds the neck of the bladder,
5 drachms 33 grains as the heaviest speci- is the uppermost portion : the entire organ
men in the healthy series. The average is directed somewhat obliquely down
is 4 drachms 38 grains : the prevailing wards, and a little forwards, so that the
weight also corresponds very closely with apex is the lowest portion, the median
the average, so that the usual weight of a axis corresponding with the median line
healthy adult prostate may be estimated of the body, on each side of which is
at about 41 to 48 drachms. Dr. Messer, placed a lateral lobe, the anterior face
of the Royal Naval Hospital, Greenwich, directed towards the pubes, the posterior
to whose labours I shall have again to towards the rectum.
refer, subsequently dissected 100 prostates, The prostate is maintained in this
all taken from subjects at and over the situation by various structures, yet not
age of sixty years. His observations led in a condition altogether fixed : since a
him to divide the preparations into three slight degree of mobility enables it to
classes, according to their weight, as fol- give way before the pressure, either of a
lows : distended bladder, or of aa loaded rectum ;
The first class, containing all those or, itmay be, from that of a finger intro
weighing less than 4 drachms, which he duced within the intestine. This condi
considered abnormally small. tion is provided for by several attach
The second class, of those weighing 4 ments.
and under 6 drachms, which he considered Firstly, its connection above with the
normal. This contained 45 preparations, neck of the bladder, which has already
weighing from 4 to 6 drachms. ` Average been described.
weight, 4 drachms 57 grains : ages from Secondly , it is attached below at its
sixty to ninety -four years. apex to the posterior layer of the deep
The third class, of those weighing 6 perineal fascia in the following manner :
drachms and upwards,which he considered This fascia, which is equally to be re
abnormally large. garded as the pelvic fascia, of which it is
His result, viz., an average of 4 really a portion, descends from the back
drachms 57 grains to the healthy gland , of the pubic bones, to the lower border
from forty -five preparations, comes very of which and of the adjacent ischia it is
near my own. I think, however, that this attached, closes in the pubic arch, and
division, though approximately correct, is becomes applied to the inferior surfaces of
not absolutely so, and that several ex- the levatores ani. During its course, and
amples of the organ placed in the first at about an inch below the pubic sym
class were not necessarily atrophied be- physis, opposite the apex of the prostate,
cause they weighed less than 4 drachms; a sheath is prolonged from it which en
and their admission into the normal class velops closely the organ, supporting be
would have diminished the average weight. tween its meshes the veins which run on
This question will be consideredhereafter. either side and in front of the prostate,
EXTERNAL RELATIONS. — Having thus and sending numerous communicating
defined the limits of the prostate gland, bands to the proper capsule of thethe same
pro
we may next enter upon its external re state itself. A continuation of
lations, or topographical anatomy, before fascia is prolonged to cover the vesiculæ
dissecting the organ itself, and considering seminales and bind them firmly to the
its internal arrangement and structure. base, or upper and posterior part of the
In the erect position of the body, the prostate, as well as to the bladder.
adult prostate is placed just below and • Besides these, there are the ligamen
behind the lower border of the pubic tous and muscular attachments of the
symphysis, that is, the summit of the prostate, the latter of which contribute
pubic arch, a distance of about three perhaps in some measure to its mobility.
eighths to five- eighths of an inch inter- First, the anterior true ligaments of
vening between the main body of the the bladder. These are constituted by the
prostate and the symphysis : and this is recto -vesical portion of the pelvic fascia,
the anterior part of which passes from the
Report on the Condition of the Prostate in
Old1 Age. ' By J. C. Messer, M.D. Trans. Med . posterior aspect of each pubic bone at its
Chir . Soc. vol. xliii.
lower border, as a strong whitish band, to
the anterior surface of the prostate on its moses with othersfrom the corresponding
way to the bladder, where it becomescon- vessel of the opposite side. smaller A
tinuous with the fibrous structures which supply is derived also by small and un
surround the neck of that viscus, and named branches from the internal pudic
belong to its muscular apparatus. They artery, and from the middle hæmorrhoidal
have acquired also the name of pubo -pro- branch of the inferior vesical artery.
static ligaments. The ligament of each Such is the usual mode of vascular
side corresponds with its fellow, and there supply to the prostate ; but there is also
isa groove or depression between the two, an unusual arrangement of the vessels,
where the fascia sinks to the apex of the which, occasionally occurring, it is no less
prostate, and becomes continuous with its necessary to be acquainted with than with
sheath there. the usual mode of arterial distribution
The muscular attachments of the pro- supplied to, or otherwise affecting, the
state are the levatores prostatæ . Each prostate .
muscle of this pair arises from an oblique When the pudic artery is small or
line on the posterior surface of the pubic defective, and fails in one or two, or, it
bone , its most anterior fibres descending may be, even in three of its named
to meet those of its fellow just in front of branches, another vessel supplies its place ,
and below the apex of the prostate, its and usually derives its origin from the
middle and posterior fibres continuing to trunk of the pudic, just before it makes
be inserted along the lateral borders ; in its transit through the sacro -sciatic fora
this manner the organ is, in a measure , men . This vessel is called the ' accessory
suspended in its place. pudic,' having been thus named by Mr.
The posterior surface of the prostate Quain, who has described the deviation
is somewhat convex in its character, and referred to, and has given drawings of it
is closely attached to the anterior wall of in his work on the Arteries, pointing out,
the rectum ; only a small quantity of thin moreover, an important practical fact con
fascia, continuous with its sheath from the nected with the anatomy of the prostate
recto -vesical fascia, existing between the which is involved by this deviation .
two. It is applied to that portion of the Mr. Spence, of Edinburgh, describes
rectum which is known as its middle cases in which the artery ordinarily
third, lying in the anterior concavity of supplying the prostate has not divided
the bowel here, but as this turns down into branches in the usual way, but has
wards through its lower third to open at pursued its course to the apex of the pro
the anus, there is a slight interval between
the bowel and the apex ; the line of the 1 Mr. Quain describes this vessel as follows :
urethra and the line of the bowel diverg- The course (of theAccessory Pudic),within the
ing considerably as each pursues its course . pelvis towards the prostate gland differs in dif
ferent cases according to the place of origin. Most
The outline and position of the prostate frequently the artery proceeds forward near the
may be readily made out by the finger, lower part of the urinary bladder : it layon the
which, when carried through the sphincter side 5 in of that organ in the body from which figure
plate 63 has been drawn ;andwhen placed on
ani ( the hand being in the supine posi- the anterior part of the pelvis arising from the
tion ), feels first immediately above it, sup- obturator
behind theorbody of the pubes.
epigastric, it descends immediately
posing the subject examined to lie on its ' In passing by the prostate and urethra — and
back , the posterior extremity of the bulb itis here that the exact situation of this artery is
of serious concern to the practical surgeon - the
and the membranous urethra ; then, as accessory pudic lies on the upper part of the gland,
the finger proceeds, the apex of the pro- or, it maybe,for a short spacelikewise on the
state ; and lastly its body, composed of posterior margin; and theu proceedingforward
two lateral divisions, widening outwards above the membranous part ofthe urethra, it
to its ase, which
is also definable if the reaches theperineum anddivides into theterminal
branches.' . I have not seen the accessory
bladder is empty , but not so, or with less pudic artery approach the side of the prostate in
ease, when it is distended with fluid . any case but one, and of this a drawing is given
VESSELS AND NERVES SUPPLYING THE in plate 63, fig. 4.'
** BRANCHES.— The accessory pudic has in some
PROSTATE. The inferior vesical artery bodies the course of the vesico-prostatic, and being
-
furnishes abranch, vesico -prostatic, which substituted forthis artery,or more properly,per
passesto the side of the prostate, andis baps
, an extension of it,furnishes branches to the
same organs in the pelvis.'— The Anatomy of the
the chief source of supply ; this vessel Arteries of the Human Body. By Richard Quain ,
divides into smaller branches in front of F.R.S. Page 443. See in connection with this
subject plates 63, 64, and 65, and the explanatory
the gland which supplies it, and anasto- | letterpress.
state, and has thus become the source of | ANATOMICAL CONFORMATION OF TUE PRO
dangerous hæmorrhage in lateral litho STATE.LOBES .
tomy. It has been customary to regard the
Numerous veinspass in front and along
the lateral borders of the prostate, into prostate as presenting, on anatomical
which the smaller vessels of the prostate analysis, several divisions, naturally in
dicated by contornation,, but subordinate
itself enter;; the large veinsin question to
a general continuity of structure.
commence in the dorsal vein of the penis, throug
which is аa vein of considerable magnitude. hout.
These are as follows :-Two lateral
The dorsal vein penetrates the deep
perineal fascia about half an inch below lobes,' which are symmetrical ; and a
6 7 6
thearch ofthe pubes. On arriving atthe behindtheurethra. Besidesthese there
prostate it divid es into two bran
ches,
each of which passe s by one side of the are portions of prostatic substance , which
gland and the neck of the bladder, where unite the lateral lobes before and behind
it unites and anastomoses with thevesical the urethra, to which special names have
veins, which are numerousand aggregated been applied ; for example, the isthmus
about the neck and base of the bladder. (to the posterior uniting portion) ; or, the
The name of prostatic venous plexus has anterior and posterior isthmus (to the
in consequence been given to the veins anterior and posterior uniting portions);
associated this situation, and they are and to the same part, the anterior and
prone to beinlarge, and sometimes tortuous posterior commissure. These shall be con
sidered separately.
or varicose, especially in elderly subjects.
From these sources the blood is returned I. The Lateral Lobes. —Not only does
towards the heart through the internal the conformation of the prostate at every
iliac veins.2 age, from childhood to adult life, indicate
Some minute vessels, chiefly venous, that it is mainly divisible into two lateral
may be traced beneath the mucous mem- portions, but the history of its early
brane of the prostatic urethra, for the development corroborates the same view .
most part taking parallel lines, on either Up to about the fourth month of fætał
side of the verumontanum ; these, how- life, the organ exists as two independent
ever, are much more obvious in the mem- lobes, which become united first posteriorly
branous and bulbous portions of the and then anteriorly during the filth month,
urethra than in the prostatic. so as to present the complete form soon
The lymphatics of the prostate enter after the middle of intra-uterine ex
lymphatic ducts, accompanying the veins istence ; the size, however, is extremely
under the fascial sheath. They are dis- small, and the general contour is less
tributed on the surface of the proper angular than that which it subsequently
capsule, and their efferent ducts carry assumes.
their contents to the lymphatics associated .The propriety of accepting these two
with the iliac vessels. A few lymphatics divisions may be held as undoubted.
also are found under the urethral mucous Each lobe may be regarded as nearly
membrane. ovoid in form . The two may be described
The nerves supplying the prostate and as lying side by side, as applied or very
adjacent parts are of considerable size, and closely approximating at their apices, as
constitute the prostatic plexus of the sym- diverging a little at their bases and
pathetic , which is a prolongation down-
wards from the inferior hypogastric
posterior
by aspect,
the canal and as slightly separated
of the urethra, which covers
plexus. As the nerves pass forward to with mucous membrane and delicate sub
the penis, they may be traced between mucous tissues their convex surfaces,
the levator anion each side and the gland, which are contiguous to each other in the
to which they supply filaments in their median line. The anterior borders of the
course . lateral lobes may be regarded either as
coalescing perhaps more correctly as
1 Edin. Med . Journal, vol. i. p. 157, 1841. united by or
a thin intervening portion of
2 This condition is well depicted in the work
onthe arteries just named. See plate 65,figs.2 muscular and connective tissue (see page
and 3, the
tortuous latter alluded
condition representing
to .
the varicose and 17) , but in any case it may be deno
minated the anterior commissure or isth
mus.
The posterior borders have a larger
interval between them , occupied con- years subsequently, viz., in 1811. Re

sequently by a larger interposing mass of specting the five dissections spoken of, the
substance, which has next to be con- author says, ' the appearance was not ex
6
sidered . These two lobes have rounded actly the samein any two of them.' The
posterior extremities, which, projecting first preparation appears to have been
somewhat, present an angular interval or from the person of an elderly patient,
notch between them , and this it is which who had died in consequence of this part
gives the conventional heart- shape to the being diseased ; thenipple-like process was
entire organ . very prominent.' In the next ,there was
4
II. The Third' or ' Middle' Lobe.— no apparent glandular substance' at all in
Lying between the posterior borders of the spot indicated. All that is said of the
the lateral lobes is a stratum of tissue third is, that there was a lobe blended
uniting them throughout their length. laterally with the sides of the prostate
As it approaches the base, this stratum gland ; ' but that there was really no dis
becomes thicker and sometimes has a tinct portion marked off as a lobe is clear,
rounded form, as if were a distinct from the importance attached to such a
isolated and independent formation, per- formation being detected in the two sub
forated about themiddle by the ejacula- sequent cases. The most distinct appear
tory ducts. It is that moiety of the ance was found in two su cts of twenty
stratum which lies nearer the apex to four and twenty -five years of age respec
which has been applied the term isthmus,' tively ; and upon the condition of the
or ' posterior commissure, while the organs in these (and not in five) his
thicker part, situated at the base, has re- account seems to have been based, and
ceived the appellation of “ third or middle from these two cases the existence ofan in
lobe,' and its existence as an independent dependent‘lobe ' wasdeduced . Whatever
lobe is regarded by most authorities in may have been their condition (and of
this country as a fact in normal anatomy. course senile enlargement was not present
This, however, I am compelled to call in in either ), the existence of a distinctly
question, and shall give the reasons for marked lobe between the ejaculatory ducts
doing so in detail. The idea appears to and the verumontanum , at the inner
have originated with Sir Everard Home, meatus of the urethra, is a rare and not a
who accorded to the part in question the usual condition. Had Home's researches
title of third ' or 'middle lobe,' after five included a large number of bodies, these
examinations of the organ by dissection, cases must have provedexceptional. Any
performed by Sir Benjamin -- then Mr.- appearance of a lobe in this situation must
a
Brodie, and he announced the result as the be regarded as belonging, not to normal ,
discovery of a middle lobe ' to the Royal but to morbid anatomy, a slight develop
Society , Feb. 20 , 1806 ; the inquiry ment being usually attended with some
having been first instituted, to use the signs of obstruction to the function of
words of his paper, only two months be- micturition. And thus it has been re
fore . ' Previous 10 this investigation ,' garded by some of the earliest labourers
>
says Sir E. Home, ' it was not known to in Pathological Anatomy, who have left
me that any distinct portion of the prostate to us the records of their observations. 6
gland was situated between the vasa Morgagni, for example, in his work “ De
deferentia and the bladder. These ducts Sedibus et Causis Morborum,' refers to it.
were considered to pass in the sulcus in several places as to a morbid growth
between the two posterior portions, in causing retention of urine ; in one of
close contact with the body of thegland."? | which he describes it, from his own dis
Notwithstanding this remark, the vasa section, in the following remarkably pre
6
deferentia had been described as perfora- cise terms: A roundish protuberance, of
ting the posterior portion of the prostate the bigness of a small grape, covered over
by several of the anatomical authorities of with the internal coat of the bladder.
the time, as E. Home afterwards learned, What this protuberance was I readily
a fact admitted in his first volume on supposed , and by forcing the knife into
• Diseases of the Prostate,' published five it, I cut through this and the contiguous
prostate gland at the same time, length
1 Philosophical Transactions, 1806, Paper viii. ways, and showed that was the same
" An Account of a Small Lobeof the Human Pro- nature with the gland;it that of
it was very
state Gland, which has not before been taken notice
of by Anatomists. By Everard Home, F.R.S. evidently continuous from it, and that.
10 THE ANATOMY OF THE PROSTATE.
there was no doubt but, if it had grown Morgagni therefore devotes great part of
out to a greater degree, it must have been the sixty -sixth and the whole of the
a very considerable impediment to the seventieth letters to the refutation of this
discharge of urine.' 1 In another case view. In the former, stating that, during
he describes the same appearance, pro- forty-four years as anatomical professor,
6
nouncing it beyond a doubt ‫ ܙ‬2
an excres- he had most carefully dissected at Padua
cence of the prostate gland.'? He quotes sixty or seventy bodies, and found it only
several similar cases from Valsalva, in four ; that he had made vivisection of
Thomas Bartholin, of Padua, and a dog for the express purpose of seeking
Valisneri, who indeed speaks of an en- it there, but in vain, and that he had
6
largement, as it were, a kind of lobe, decided that it could be nothing but ' a
from the glandular substance ' (of the morbid excrescence of the prostate gland
prostate ) which rose up within the appearing in old men, not rare, but
.
bladder, of the shape and size of a walnut, not so frequent.' That Valsalva, Pohlius,
and not on the anterior part, but on that and his friend Santorini, regarded it in
which lies adjacent to the intestinum the same light, the latter presenting it
rectum .' He enumerates other cases, in a drawing as a body prominent in 6
6
mostly from the Sepulchretum ' of Bone- diseased bladders,' besides referring to it
tus,3 besides alluding prospectively to as ' a circumstance which is diseased and
one which subsequently appeared in the unfrequent, and does not deserve to be
succeeding letter of his own work ; 4 and exhibited as perpetual and constant, to the
then makes the following generalisations great detriment and misleading of young
from the whole :
6
practitioners.'1 The seventieth letter
* If you attentively examine those ex- Morgagni devotes to the purpose of giving
amples which I have pointed out, the result of his forty - fifth year of teach
you will observe that they were all from ing anatomy , in relation to this very
old men ; and in like manner, if you subject, stating that he had dissected in
examine all my observations in which public five subjects, and in none of them,
there was the beginning of an excres- although he had sought most carefully,
cence , you will find that this was found was there any trace of this roundish
to grow out in the very middle of the protuberance,' or ' uvula .'
internal and upper circumference of the John Hunter similarly regarded it,
gland , posteriorly ; but whether all these after independent examinations of the
things happened by chance , or otherwise, organ , stating that ' a small portion of it
future observations will show . 5 (the prostate) which lies behind the very
Some considerable time after this that beginning of the urethra, swells forward
future was realised ; Morgagni returned like a point, as it were, into the bladder,
to the investigation of this subject, and acting like a valve, to the mouth of the
the cause of his doing so is of great in- urethra .'?
terest in relation to the present inquiry. It seems remarkable, considering the
It appears that a ' celebrated anatomist very slight grounds upon which the exist
of the time (Morgagni refers, without ence of a distinct third lobe as a normal
doubt, to Lieutaud, although he omits all and ordinary constituent of the prostate
mention of his name, as he states to be was affirmed by Sir Everard Home, that
his invariable custom when he proves a it should havebeen so generally received
contemporary to be in error) declared that without question by English anatomists
an eminence at the neck of the bladder to the present day. Its existence is
was not a morbid growth, but a small denied by most French observers. Cru.
part quite natural, and common to all veilhier expresses the general opinion
bodies, calling it the " uvula vesicæ .' when he says that, the ejaculatory ducts
i De Sedibus et Causis Morborum per Anatomen being substance into
in the received of the prostate,orachannel
a groove portion
indagatis. By J. B.Morgagni. 2 vols. folio. Venice, of variable size is indicated by them, but
1761. Letter xli , article 18 .
2 Idem . Letter xxxvii. article 31 . that it has no title to be called a lobe.
3 The Sepulchretum , sive Anatomia Practica. By
Theophilus Bonetus, M.D. Lyons, 1700 . Book i Observationes Anatomicæ. By Jo. Dom . San
iii . sects. 24, 25. torini. Venice, 1724. Chapter X., ' De Virorum
4 De Sedibus, fc. Letter xlii. article 11. Naturalibus, in explanation of tabula 2, fig . 2,
5 Idem . Letter xli. article 19. See the Eng- sects 20 and 22, pp. 201-205.
lish translation by Dr. B. Alexander. London, ? A Treatise on the Venereal Disease. By John
1769.
Hunter. 2nd edit. London , 1788. p. 170.
It is not, he says, an isolated piece, and

1
name of third lobe, and which appears to
should be called the median portion .'' entitle it to some distinguishing appella
The following is the result I have tion . Moreover, this character seems to
obtained after carefully prosecuting nume- be connected with that tendency to en
rous dissections of this part : large, which this part of the organ un
First.— I cannot find in healthy bodies, doubtedly possesses, and which will be
below fifty years of age, any formation in fully discussed hereafter. It is this, that
the situation described, capable of being the portion in question certainly contains
recognised as a distinct third ' or ' middle ' a larger proportion of glandular structure
lobe , and am compelled to conclude that than most parts of the entire organ . Thin
any marked prominence there, which slices from this portion placed under the
appears to possess independent characters microscope and compared with slices
(as regards size or form ), must be con- from other parts demonstrate this very
sidered abnormal or morbid. clearly.
Secondly . - There is unquestionably a Considering, then, all the terms which
thick uniting stratum of tissue between have been proposed to designate the
the lateral lobes, which is sometimes part in question, there does not appear
slightly thicker in the middle line, at the to be sufficient ground for continuing the
6
vesical or basic end, than at its borders, term lobe. On the contrary , it appears
where it becomes blended with those lobes. desirable to adopt that which the French
6
It is at this thickest part, three or four anatomists have employed, viz., the
lines below its urethral aspect, that there median portion, since it is sufficiently
exists a perforation for the entry of the accurate, and it is perhaps not wise, with
ejaculatory ducts. But in many cases out ample justification , to alter a term
this thickening in the median line does already used in that modern language,
not exist ; and it is to be remembered that which in scientific literature is perhaps, at
the part in question immediately under the present day, the most widely under 6
lies the uvula, which is not a portion of stood . If, retaining the terms lateral
the prostate,, but a prominence caused by lobes ' as universally accepted, we apply
crossing interlacement of muscular fibres to the part anterior to the urethra (stand
from the inner coat of the bladder, and ing position of the body ) the term an
>
sometimes prone to be unduly developed . terior commissure,' -a part which is about
If this fact is not borne in mind, a con- one inch in length — and the term ' pos
founding of the two structures may arise, terior commissure' to that which corre
and the error of regarding them as one sponds to it for the same length behind
will lead the observer to attribute inac- the urethra, it leaves that thicker portion
curately a middle lobe to the prostate ; of the organ which lies behind the veru .
and I think it has not unfrequently hap- montanum, which is penetrated by the
pened that the, existence of a distinct ejaculatory ducts,which is largely occupied
middle lobe has been affirmed after simple by glandular structures, and which is prone
inspection of the interior of the bladder, to great increase of size in age, to be
without further examination, which alone designated by the term 'median portion,'
can determine,, in all cases, whether a conformably to the practice already
small projection at the neck is due to pointed out.
hypertrophy of the tissues of the uvula, COURSE OF THE URETHRA THROUGH
or of the prostate, or to a small tumour THE PROSTATE. — Commencing at the neck

embedded in the organ at this point. of the bladder, the urethra continues
But, thirdly . — The posterior commis- through the prostate, in the erect position,
sural part in question does possess a downwards and slightly forwards. The
specific character, which distinguishes it great masses of the organ lie on either
7
from other parts — a character which ap- side of the canal ; a stratum of prostatic
pears to have been less prominently re- tissue lies in front, and another behind
garded , perhaps, than it has deserved to it. It has been a disputed question
be in the discussion of its title to the whether the anterior or posterior stratum
1 Anat. Path . du Corps Humain, livr, xvii. p. be the larger. Most observers state that,
condition, the larger por
3 , Paris, 1835-42. Par J. Cruveilhier. See also in the normalbehind
Traité d'Anat. Path. Générale. Tome 3me, p. 46, tion is found the urethra. Thus,
Paris, 1856. By the same. Langenbeck also takes Mr. Adams states that 6' two -thirds of the
the same view. Neue Bibl., b. i.p . 360. Hanover,
1818. gland are below this canal ' (the ure
12 THE ANATOMY OF TIIE PROSTATE .
thra ). On the other hand, Mercier long table with the pubic aspect uppermost,
ago asserted that the anterior stratum is the urethra is to be exposed by dividing
larger and thicker than the posterior, and all the tissue lying, in that position , above
he states that, after renewed examination, it, and by opening out the sides of the
he is assured of the accuracy of his incision. The following parts are then to
view.2 Dr. Hodgson, who has carefully be observed in that part of the urethra
studied the anatomy of the prostate, which lies under consideration.
writes as follows: - It is generally stated The vesical boundary of the prostatic
a
that the urethra lies at a distance of two urethra is the uvula vesicæ, seen as
lines from the upper and four lines from slightly rounded prominence of the floor
the lower surface of the gland. These of the neck of the bladder. From this
measurements are by no means constant; point forward the canal gradually expands
according to my observation, they are a little and presents a general indication
pretty regular in the prostates of young of hollowing or depression of the floor,
persons of eighteen to twenty -two years broken by a central longitudinal elevation,
eminence com
of age, while in older individuals the the verumontanum . This
amount of glandular tissue above the mences almost imperceptibly in a faint
urethra equals, and occasionally rather whitish line directly in front of the uvula,
>
exceeds, that below the canal.' 3 and gradually rising for six or eight lines
In order to examine more completely reaches then its highest point (about the
this question , I removed ten healthy adult of an inch ), having formed a longitu
prostates, and have made a very careful tudinal ridge in the central line of the
section from the anterior or pubic aspect urethra. It widens and becomes rounded
to the posterior or rectal one. From at the highest point, and then , somewhat
these preparations, now in the College of suddenly diminishing in size as it advances
Surgeons, the accuracy of the following forward, exhibits on the anterior slope an
report can be tested . opening which will be presently examined
The ages of the ten subjects ranged in detail; the ridge, gradually lessening,
between thirty -five and fifty -seven years; leaves the prostatic and enters the mem
all may be regarded as non-hypertrophied, branous urethra. The depression of the
by the weight test ; the lowest being 4 prostatic urethra, sinus prostaticus, is
drachms 10 grains, and the highest 5 thus divided into two lateral furrows, one
drachms 36 grains. on each side of the verumontanum ; in
In seven , the area of cut surface dis
these may be observed numerous little
played by a median section from pubic orifices, mouths of the prostatic ducts,
to rectal aspect, was about equal, above which, when examined with a common
and below the urethra (supposing the magnifying glass of low power, may be
organ removed and lying with its pubic counted without difficulty. Not less than
surface upwards) . In two, the area of twenty or twenty -four, sometimes thirty,
cut surface displayed was rather larger may in this manner be distinguished.
below than above; in one the converse They are ranged chiefly on each side of
condition was found. ( See fig. 4. ) the eminence of the verumontanum , but
But it appears to me, judging from a few may be seen both before and be
the conformation of the specimens, and hind it.
not from the cut surfaces merely, that The length of the prostatic urethra
there is a rather larger mass of prostatic varies from an inch and an eighth to an
substance below than above the urethra, inch and a quarter. Its diameter is usually
in all these specimens except two or represented by a fixed measurement; but
three. as the surfaces lie in apposition , except
The Prostatic Urethra.-- Supposing when distended by a functional act, it is
a specimen of the adult bladder and about difficult to represent accurately the calibre.
3 inches of the adjoining urethra, includ- The walls and surrounding structures are
ing the prostate gland and other under- extensible, and the calibre of the canal is
lying structures, to have been removed consequently variable, corresponding with
from the body, and to be placed on a in certain limits to the amount of pres
>
1 Cyclop. vol. ir. p. 146. Anatomy and Diseases sure exerted . Without unduly extending
of the Prostate Gland, 2nd ed., 1853, p. 1. them , the diameter, opposite the crest of
2 RecherchesAnatomiques . Paris 1841,p p.30. the verumontanum , may be regarded as
Subsequently, Gazette Hebdomadaire,, 1860, . 131.
3 The Prostate Gland. London, 1856, p . 22 . amounting to about to % of an inch ;
but at each extremity of the prostatic limit | a small sac already referred to as opening
the diameter, calculated in the same way, tanumon the. anterior aspect of the verumon
It is somewhat oval in form ,
is rather less.
The whole of the urethra thus exa- measuring ordinarily from two and a half
mined presents a surface of mucousmem- to four lines in length, and from two to
brane, which is covered with cylindrical three lines at itsgreatest breadth, although
epithelium , always arranged in two layers, occasionally found both largerand smaller.
a superficial and a deeper layer. The Its posterior extremity is the widest, and
membrane has, when fresh, a pale pinkish- the anterior is the narrowest portion. It
yellow tint, the structures which underlie is obliquely placed , the long diameter
it being pale, unstriped muscular, con- being directed towards, or a little below ,
nective, and elastic tissues, with fewer the median portion , and in the course of
minute blood -vessels than are found in the ejaculatory ducts which lie contained
the membranous and bulbous portions of in the substance of its lateral walls. The
the urethra, where a redder tinge conse- external orifice or mouth of the utricle is
quently exists. These submucous struc- sometimes extremely small, and it has
tures are composed chiefly of the pale, been occasionally seen altogether wanting ;
unstriped muscular fibres,intermixed with the orifices of the two ejaculatory ducts
a small proportion only of the white fibrous were then found opening on the anterior
and elastic tissues. The muscular fibres of the verumontanum .
are arranged in the longitudinal axis of The sac of the utricle is made up of
the urethra, and form aa thin but somewhat mucous membrane, covered with cylin
dense and strong layer immediately be- drical epithelium , and of a submucous
neath the mucous membrane throughout tissue attaching it to some bands of white
the prcstate ; they continue to have a fibrous tissue and pale muscular fibre, by
similar relation throughout the canal, al- which it insensibly unites with the mass
though in smaller quantity than in this of structures around. It contains mucous
situation. Posteriorly they are continu- follicles which appear sometimes to secrete
ous with the muscular layer immediately a dark reddish-brown and jelly-like ma
underlying the mucous membrane of the terial ; at least, such is found sometimes
bladder. It is by a development of these nearly filling the sac.
longitudinal muscular fibres of the urethra When in a quiescent state, the sides of
that the verumontanum is formed ; they the prostatic urethra are pretty closely
divide to define the mouth ofthe utricle and applied to each other, and the mucous
admit the orifices of the prostatic ducts. membrane then lies in very small delicate
These cavities are lined with a delicate longitudinal plaits, with a very shallow
membrane and epithelium (cylindrical) groove between each . A transverse section
shows the canal to have a form gererally
like that of the prostatic urethra itself.
The precise mode of arrangement of approximating to triangular, the apex
the minute blood - vessels beneath the pro- being upwards.
static mucous membrane is as follows. Course of the Common Ejaculatory
From the neck of the bladder to the most Ducts through the Prostate Gland .-- The
elevated portion of the verumontanum common duct, formed by the junction of
very few of them are to be seen ; and the a vas deferens and of a duct of the vesi
mucous membrane is of a yellowish tint cula seminalis, enters, in close proximity
from their paucity in this situation. In with its fellow of the opposite side, at the
front of it, however, numerous finevessels base of the prostate, about three or four
course forward, side by side, for the most lines below ( the prostate removed and
part in the axis of the urethra, but with placed for examination as last described)
a slight oblique divergence outwards,right the opening which transmits the urethra.
and left of the pale line of the verumon . There is a well-marked depression, in form
tanum , prolonged into the membranous pyramidal with the apex directed inwards,
portion. The mucous membrane is there in the base of the organ , which indeed
fore redder in tint anterior to the emi- corresponds with the apex of the notch
nence ; and on examining it with a separating the two lateral lobes. This
magnifying -glass, it is seen to be due to depression penetrates the substance of the
the minute and longitudinally branching posterior portion or middle lobe, about
vessels just described. three - fourths of the mass lying between
The utricle, or vesicula prostatica, is the ducts and the urethra, the remaining
one- fourth forming a thin layer between !come to a similar conclusion . His paper,
the ducts and the under surface of the communicating the results he volume arrived
prostate. This proportion varies in differ- at, is published in the thirty -ninth
ent subjects; in all, however, the greater of the Transactions of the Medical and
part of the mass lies between the ducts Chirurgical Society ( 1856 ), and is illus
and the urethra . A thin stratum of ſtrated by drawings of his dissections."
tissue, i to z of an inch in thickness, Kölliker's latest account is to be found
6
separates the two ducts, as they perforate in the Manual of Human Microscopic
the organ side by side. They then pass Anatomy,' published in 1860 by Parker,
directly to the utricle, and continue their London. It confirms his own original
course embedded in the walls of that description, as well as the views of the
cavity, one on each side; their little slit- observer above mentioned.2
like orifices opening on the anterior part A description has already been given
of the verumontanum , at the mouth of of the anatomical arrangement ( p. 12 ) of
the utricle itself. By carefully making a the fibres which immediately underlie the
longitudinal section of the utricle, exactly mucous membrane of the prostatic ure
in the median line, the course of the duct thra, a layer of intermingled muscular,
may be easily traced. connective, and elastic fibres, lying in the
The ejaculatory duct, from its place of direction of the axis of the urethra. And
entry at the base of the prostate to the it has been shown that these are sur
orifice at the utricle, is about six lines in rounded by a layer of fibres transversely
length . It is composed of a mucous or circularly disposedround the axis, and
lining, or inner coat, some pale muscular consequently disposed at right angles to
fibres surrounding it, with connective the preceding. And lastly, that thislayer
tissue intervening ; the coats are much is thicker than the first named, especially
thinner and less firm than those of the vas at its vesical extremity, where it becomes
deferens. The muscular fibres are ar- continuous with the circular fibres of the
ranged longitudinally in the axis of the bladder itself. The other tissues which
duct, and are continued into those which enter into the construction of the organ ,
underlie the urethral mucous membrane,
close to the mouth of the utricle, and 1 The prostate is essentially a muscular body,
consisting of circular or orbicular involuntary
which have been already described. fibres, with one large central hole for the passage of
the uretbra ; and another smaller oblique opening,
directed upwards below the former, for the trans
THE MINUTE ANATOMY OF THE PROSTATE .
mission of the common ejaculatory seminal ducts to
the central urinary canal. The few longitudinal
fibres on the upper surface of the prostate, which
COMPONENT TISSUES AND THEIR AR- | are derived from the external layer of the bladder,
can scarcely be said to form part of that body.
RANGEMENTS. — It has been already seen " Its circular fibres are directly continuous be
that the pale or unstriped muscularoffibre hind, without any separation, with the circular,
of the
fibres one
enters largely into the composition the about bladder ; andin front a thin stratum
-thirtieth of an inch thick, is prolonged
prostate. This has been affirmed by forwards from it around the membranous part of
numerous independent observers, among the urethra, so as to separate this tubefrom the
the earliest of whom was Dr. Handfield surrounding voluntary constrictor muscle.
Jones, whose statement of the fact was Within and quite distinct from the circular fibres
lies the tube of the urethra, encased by its submu
6
first recorded in a paper in the Medical cous layer of longitudinal fibres. Towards the
lower and outer aspects, the fibres are less firmly
Gazette,' August, 1847 . applied together, especially where the vessels enter ;
In the following year, Kölliker , the and they appear to be superadded tothose which
well-known German histologist, now Pro- join the coat of the bladder.
fessor of Anatomy and Physiology in the As only so small a portion of the prostate is
glandular, the propriety of calling that body a
University of Würzburg,published anac, giand is rendered doubtful; for the small secreting
count in the "Zeitschrift für Wissenschaft' mucous
glands contained in itarebutappendages of the
membrane, which project amongst themus
(Leipzig) of his examination of thepro- cularfibres in the sameway as the other glands of
state, in which he declared that the larger the urethra extendinto the surrounding submu
portion of the organ was constituted by cous tissues.'— Trans. Med . Chir . Soc., vol.xxxix.
the pale muscular tissue, and that the pp .330-1.
? The prostate, according to my own obser
smaller portion only consistedof glandular vations, which areconfirmed by V.Ellis,and partly
tissue. More recently, Professor Ellis, also by Jarjavay,is a very muscular organ , the
glandular substance scarcely constituting wore
ofUniversity College, has closely in than one-third,or the half of the entiremass.
vestigated the same subject, and has |pp. 439-40, et seq.
and which Ihave subjected to an extended circumferential parts of the prostate, the
and careful examination in various ways, muscular and allied fibres are partially
will now be considered in detail. continued into the capsule of the gland
First of all, then, the two layers of itself, into the structure of which they
muscular and other fibres just enumerated enter .
are perforated by many gland-ducts, from The interstices alluded to above are
the gland -structures presently to be de- occupied by the glandular structures,
scribed. These gland-ducts, passing in a which , in the lateral portions of the organ ,
concentric direction, open in the sinus on form a large proportion of the prostatic
either side of the verumontanum in the substance, and give it a parti-coloured
urethra . Next, among the outer or cir- appearance to the naked eye. When a
cularly disposed layer of fibres, may be longitudinal section is made of a lateral
found a few small and simple gland -crypts, lobe, they are easily distinguished by their
attached to excretory ducts in their course yellowish colouring, and by this character
to the urethra. These small glands are, their situation, line of direction, and their
for the most part, situated under the proportion in relation to the fibrous stroma
urethra, near to where it joins the neck may be approximately estimated when
of the bladder, behind and not in front of sections of the organ are made. An
the verumontanum . antero -posterior section in the median
The structure of that part of the mass line is well represented at fig. 4, which
which lies without and beyond these two delineates a section in the median line of
layers ofmuscular fibre, and which forms a healthy prostate, natural size, accu
the lateral lobes, is that portion which rately drawn from a fresh average speci
mainly gives distinctive form and charac- men, taken from a subject aged fifty -four
ter to the prostate — that, in fact, which years ; weight of prostate, 4 drachms
constitutes it an independent and a male
organ .
We find here aa combination of muscu
lar and allied tissues, i.e. the mixed pale
muscular, connective, and elastic fibres
( the first-named predominating ), and of
the glandular structure.
The muscular tissue has no longer any
very defined form of arrangement. Bands
of it appear to take their rise from the
outermost of the circular fibres, and to Fig. 4. - Healthy Prostate ; a median section,
pursue a direction outwards towards the
capsule. In doing so they proceed some- 48 grains. The utricle is laid open , as
what irregularly, as if interwoven loosely well as the ejaculatory duct of the left
with each other, and thus they leave side, seen to traverse the wall ofthe utricle,
numerous interstices. Kölliker says, that slit up to show its situation there. The
these bands or bundles radiate outwards, right duct, previously in contact, is re
in all directions, from the sides of the moved with the right half of the organ .
verumontanum . I cannot distinguish any- Both ducts lie closely together in the
thing quite so precise as a general radia- centre of the median portion of the organ ,
tion ; certainly not a regular radiation and there is no sign of the existence of
without interlacement: but perhaps he any natural separation of a part of it in
does not mean this. There is a general this place,to indicate a "third or middle
diverging of these bands from the centre lobe,' as a distinct formation. The agglo
to the circumference ; but there appear meration of glands which occupies the
6
also to be some bands having a different situation of the median portion ,' the
direction, so as to cross and coalesce with ejaculatory duct beneath it, and, next,
>
the others, at angles more or less acute- the glandsofthe lower and posterior parts,
bands which do not partake much of the are easily distinguished, the line of their
diverging or radiating character,but which divergence outwards, backwards, and
interlace among the elements of gland- downwards from the verumontanum being
structure next to be described ,which bind marked by the gland -tissue above men.
them together, surrounding and packing, so tioned ; their lower margins, somewhat
to speak, the lobes of that structure. In the rounded, may be seen reaching to within
16 THE ANATOMY OF THE PROSTATE,
about a line of the circumference of the are not crowded upon it so as to form :
organ, this portion being the capsule and compact mass, as in other racemose glands,
associated fibrous tissue. but are scattered upon it with consider
The glands themselves are, by their able and irregular intervals. Hence the
structure, somewhat peculiar to, and cha- tissue is more loosely aggregated , and
racteristic of, the prostate. They are it is on this account more difficult to
classified with the multilobular or com- isolate, trace, and observe with accuracy.
pound racemose glands, of which the sali- 3. The minor ducts are extremely
vary and pancreatic are typical examples; numerous. Each follicle, or small col
but they differ somewhat from these. After lection of vesicles, has its duct, which is
>
carefully examining them , chiefly by often long, and pursues a straight course
unravelling fresh specimens under the to the main trunks, and these, uniting, 1
microscope, as well as by obtaining fine finally form a single excretory duct from
sections of hardened preparations, the the entire lobule. The smaller ducts lie
following appears to bethe arrangement nearly parallel to each other, and slightly
of the prostatic gland -structures. converge as they approach the principal
It will be desirable, for the sake of duct. Their walls are easily seen by
precision, to name the terms employed sectionunder the microscope to be made
to denote them , commencing with the up of fibres circularly disposed round the
extreme terminal portions of the gland axis ofthe tube.
structures, and proceeding in order to 4. The term lobule is held to imply
their excretory orifices, viz., 1 , vesicles any aggregation of these crypts which, by
or crypts ; 2, follicles ; 3, ducts ; and, 4, means of subordinate ducts, is united with
lobules. the one excretory duct of that series,
1. By vesicles or crypts are denoted which then passes on, unjoined by the
the smallest recesses of all ; cavities of a duct from any other lobule, to the urethra.
partially spheroidal form , and varying in Each lobule is a complete and indepen
size, during the prime of life, from zoo to dent glandular structure, like a sweat
do of an inch . Sometimes only one or two gland, and is equally entitled with the
of these exist at the end of a minor duct, latter to the term " gland. The custom ,
butmore commonly several are associated, however, of applying that term to the
6
the size and number being very variable, entire organ, 'prostate gland ,' renders it
to form a group, having a central cavity preferable to use the term lobule in the
common to allor some of them . The vesicles case before us. All these different parts
are more or less spheroidal or ovoid in are lined with epithelium of different
form ; sometimes they appear asmere cup- characters, as may be verified with great
shaped depressions in the surrounding ease .
tissue, while others are even flask -shaped First, the walls of the vesicles and
or pedunculated . The size given above crypts are covered with an extremely re
is the range usually met with during early gular epithelium , the cells of which show a
adult life. In old age, and, indeed, in dlsposition to be ovoid , but apparently !
middle life, they become larger, and ap- become polygonal under the influence of
pear as if dilated. lateral pressure. The epithelial cells are
2. The cavities, more or less compo- very adherent to each other, and тау be
site, and formed by a group of vesicles removed in masses of convex, or even of
in the manner just referred to, may be tubular form .
termed follicles, and their size is also very As regards the cells themselves, each
variable. Ordinarily, they reach about contains granular matter, and a nucleus
the tho or too of an inch in diameter. a little more elongated, in proportion to
As age advances they become larger, often its size , than the cell itself. There is no
reaching three or even five times that size. well-marked nucleolus. Viewed in a
Each follicle has either a duct of its own, mass, the cells have a yellow or tawny
as most commonly happens, or it opens at tint, derived from the granules in their
once into aa duct commonto several others, interior, though one cell or a single layer
but leading to the single excretory duct will not generally exhibit it. Their size
of the lobule to which it belongs. It is is from the boy to the zody of an inch.
peculiar to the prostatic glands that the In the minor or subordinate ducts, the
follicles are of very varying size, and are lining cells are prismatic, a fact which I
irregularly placed upon the duct. They am perfectly satisfied of, although some
descriptions represent them as spheroidal A question naturally arises, and one

only . In the largest ducts the same is which we believe has never been satis
found, and the epithelium , I believe, atter factorily answered, inasmuch as different
much observation, to be ciliated. observers make very different statements
The vesicles themselves are sometimes respecting it, viz., Is every part of the
empty, occasionally they are packed with prostate pervaded by glandular structures ;
epithelial cells. Sometimes they contain and if so, are they distributed in equal
the liquor prostaticus, and not infre- proportion throughout ?
quently some maybe seen filled with a There are two ways of examining the
yellowish, semi-solid, jelly - like, trans- organ with a view to obtain a satisfactory
parent matter, containing the epithelial answer. The first is by carefully making
cells, although sometimes without them and small slices of it by means of Valentin's
homogeneous. Sometimes they contain the knife, examining each part ofthe prostate
concretions which are so familiar to all who in turn, and submitting the slices so ob
have examined the prostate, and which ap- tained to the microscope. Another, which
pear to be always present in the adult organ. is perhaps preferable, consists in making
The ultimate gland -vesicles are held an incision with a perfectly clean scalpel
in place and united together into follicular into each part of the organ successively
masses, and these again are aggregated into or corresponding parts of several organs,
gland-lobules, chiefly by means of con- to speak more accurately, as several are
nective tissue mingled with a small pro- requisite for the exanıination of the ques
portion of pale muscular fibre. Con- tion ), taking great care not to press with
siderable intervals, filled by these tissues, the fingers near to the part in which the
are found between many of the secondary incision is made, lest Auids should be
portions of the lobule. The true gland forced into the opening from adjacent
structures may, however, be isolated, or sources ; then to remove successively from
nearly so, with great care and patience, the exposed surface, at various parts of
by dissecting them under water with a the section, minute portions of tissuewith
pair of needles. a scissors, or knife and forceps; finally,
The connecting tissues just alluded to to submit each portion separately to a
as surrounding the gland-elements support microscope with a good quarter-inch ob
also a fine but rich network of capillary ject-glass. Nothing is to be added except
blood - vessels, ramifying closely upon the pure water, and after an examination of
outside of the vesicles. The vascular the untouched portion its tissue is to be
supply is considerable, judging from the unravelled under the lens with a couple
amount and freedom of capillary inter- of fine needles.
communication . Now, in the direct median section of
The gland -lobules, each made up, as the anterior part of the organ in front of
above described, of an assemblage of the urethra-in other words, through the
vesicles and follicles, are about forty or anterior isthmus or commissure — I have
fifty in number. Each sends its excretory never found , and after repeated examina
duct to open in the urethra near to the tions, any glandular elements, provided the
verumontanum . Sometimes two such in- section is made strictly in the median
dependent ducts will open by a common line. Advancing about the eighth of an
orifice ; sometimes also they do not open inch on either side of that line, in some
directly into the urethra at the point instances, at a smaller distance from it,
where they arrive at it, but continue a secreting cells and small crypts make their
submucous course until they arrive at the appearance, and with them often small
usual place for opening above named. concretions. In every other part of the
Sometimes they traverse a considerable prostate the cell-structure is to be found,
distance in this manner, occasionally as but it is most abundant in the outer and
much as three-eighths or even half an inch. posterior parts of the lateral lobes, and in
6 6
The middle- sized and largest ducts the centre ofthe ' middle lobe ' or ' median
have well-marked fibrous walls; they are portion .'
composed of both longitudinally and cir- It appears then that the true gland
cularly disposed fibres of the connective structure from one lateral lobe does not
tissue, mingled with aa small proportion of meet that from the other in the middle
the pale muscular fibre. Elastic fibres line anteriorly, i.e. in the anterior isthmus,
are not found here. and that an interval occupied by simpler
structure, and varying in amount in dif- |during the fourth month of intra - uterine
ferent subjects, exists there ; it is worthy life. During the succeeding month an
of remark also that in that interval I have intermediate portion unites them behind
traced a few voluntary muscular fibres (rectal aspect) in the situation of the
reaching down nearly to the urethra. A median portion, and of the commissural
section removed from this spot and un- part below, to which latter the name of
6 >
ravelled will frequently show somestriped isthmus ' or ' posterior commissure ' has
fibres, although in small proportion . This been already applied.
want of continuity of the gland-structures At birth the organ is very small, and
in front seems to indicate a persistence of it continues comparatively so until the
the originalbilobed condition well marked time of puberty . According to the re
in foetal life, and obtaining for the organ searches of Dr. Gross, of Louisville, it
the plural name of prostates ' among the weighs only thirteen grains at the time of
older anatomists. But gland -elements are birth : his report on the size, form, and
found in abundance in the middle line weight of the prostate from that period up
behind the urethra . to adult age is very complete, and may be
The proper capsule of the prostate given here.
:losely covers in the whole organ except * The prostate at birth . Width, at base, 4
at the base and apex, where the ret lines ; a little above middle, 5 lines ; at apex,
enters and issues, and the enveloping 2 lines ; length along the middle, 4 lines, and
structure is there continuous with the at the edge 4 *; thickness at base, 2 lines ; at
adjacent parts respectively, as described middle, 3 ; andat apex,1 }. Weight, 13 grains.
The prostate at 4 years. Breadth at base ,
at page 3. This capsule is distinct from 6 lines; just above the middle,7 ; and at the
the sheath given to the prostate by the apex, 24 ; length along the middle, 6 lines ; and
recto -vesical fascia, and is an integral 7lines at themarginand; thickness at base, 2 lines ;
portion of the organ, not to be peeled off at the middle, 4 ; at apex, 2. Weight, 23
or separated otherwise than by cutting. grains.The prostate at 12 years. Width, 8 } lines
6
It is composed of densely applied fibrous at base ; 9£ above the middle, and 3at apex ;
tissues, viz., the pale muscular fibre, the length along the middle,8 lines, and 84 at the
connective tissue, and a little elastic tissue, edge ; thickness at base, 3 ; middle, 4 } ; and at
and bands of these enter the substance of apex , 2 Weight, 43 grains.
The prostate at 14 years. Width at base,
the prostate itself in great abundance. In 11 'lines ; at middle, 9} ; at apex, 4 ; length 2
fact, the capsule is continuous in structure along the middle, 8 lines, and ten at margin;
with the stroma of the organ ; much in- thickness, 3} at base, 5 at middle, and 3 at
terlacing of fibre exists, and minute vessels apex. Weight, 58 grains.
accompany the entering fibres from with- The prostate at 20 years. Breadth at base,
out, and anastomose freely with the rest along14 lines; at middle, 16 ; at apex, 5.1; length
of its vascular system .
middle,15lines, and at edge 16 ; thick
ness at base, 8 lines ; middle, 10 ; and apex, 54.
THE PROSTATE IN SUBJECTS UNDER Weight, 4 drachms and 1 scruple.' '
ADULT AGE. — In a very early stage of Mr. H. Bell, in an inaugural thesis,
fætal development, after the rectum has which he published in Paris, made ob
become separated from the bladder, this servations, which have been copied by
6
latter and the genito-urinary organs in Malgaigne in> 2 his " Traité d'Anatomie
front exist in the form of a channel Chirurgicale,' 2 resulting from a dissection
6
known by the name of the ' sinus uro- of upwards of forty subjects ranging be
genitalis . Into this , in the male, enter tween two and fifteen years of age. They
the ureters and vasa deferentia , the latter, are as follows :
at first by one opening, and subsequently
the vesiculæ seminales are developed from Diamètre Rayon Rayon Rayon
a portion of the sinus uro-genitalis ad- Ages Transverse
Postérieur P rieur térieu
Oblique Direct Direct
jacent to the opening ; and each vesicula
becoming connected with its neighbouring ans mm . mm . mm . mm .
vas, two independent orifices appear in the 2 à 4 12.40 à 13 5 4.5 à 5 2.25 1.
5 à 10 135 à 17 5. à 7 4 5 à 5.6 1
place of the single one, and between them 10 à 12 16 . à 19 : 6. Å 8 4.5 å 5.6 2.25 à 34
the utricle is developed from an original 12 à 15 19 å 22 8. 4.5 å 5.6 3-4
portion of the sinus itself remaining.

Around this are aggregated the prostatic
glands and fibrous structures, in two dis 1 Gross on the Urinary Organs, 2nd ed. p.70.
? Malgaigne's Traité d'Anat. Chir. &c. Paris,
tinct masses or lobes, visible as such 1859. Tome ii. pp. 483-4 .
FACTS OBTAINED BY DISSECTING THE PROSTATE . 19
I dissected one specimen at twelve are those of importance in reference to
years, which forms a preparation at the this subject.
College of Surgeons, and the weight co- The position of the prostate in children
incides very closely with that of one at differs from that in the adult subject. It
the same age in Dr. Gross's series. is more vertically placed in the pelvis than
in that of the latter. The bladder has a
At twelve years ; weighs 40 grains. corresponding position, its lower fundus is
Length an inch .
Breadth three -quarters. less depressed, less sessile on the rectum
Thickness three- eighths. (so to speak ) than it becomes ļater in life.
The peritoneum comes very near to its
We must not overlook the researches of base ; but as the fundus is developed in
Deschamps made Traité
on a great number of later life, the peritoneum becomes further
bodies.In his Historique et removed, and a well-marked space, or
‫ ܕ‬1
Dogmatique de la Taille ' ' he reports as portion of the bladder ( carefully noted
follows : both by the anatomist and the surgeon ),
1. ' In subjects from three to eight remains uncovered by it beyond the
years of age the anterior tl: ickness of6 the prostate.
1
prostate ' (anterior to the urethra) • is a The form of the gland is more rounded
line and three -quarters; its posterior part in childhood, and has less of the distinc
two lines and a half ; and its lateral parts tive characters and outline which mark the
three and a half lines.' ... 2. 6 In sub- adult organ and its lobes.
jects from eight to sixteen years the thick. Its consistence is soft, the capsule is
ness of the anterior part is about two easily torn, the glandular structures are
lines; of the posterior part three lines ; simple, and slightly developed , being
of the lateral parts four or five lines.' apparently little more than simple follicles,
The following general considerations tubular and crypt-like, and ducts.
CHAPTER II.
FACTS RELATIVE TO WEIGHT, SIZE, AND MORBID CONDITION, OBTAINED BY DISSECTING

THE PROSTATE.
Dissections by the Author — Dissections subsequently made by Dr. Messer - In all, 194 Examples of
Dissected Prostate, presented in the form of a Table.
At the conclusion of the foregoing portion in researches by dissection which are

of this work, and therefore occupying a tabulated below . I have made numerous
position intermediate between that which other dissections for the same purpose ;
relates to the normal anatomy of the pro- but these having necessarily resulted in
state, and that which relates to its diseases, destruction of the organ are not recorded
appears to be the most appropriate spot here ; every one of those reported here as
for placing the data from which many of my own having been preserved and ex
the conclusions given respecting both sub- hibited as wet preparations,
jects have been drawn. These consist
A Tabular View of the Facts observed in 194 Dissections of the Prostate.

1st Series. — Thirty prostates removed and carefully dissected by the author, from the bodies o
individuals at and above the age of 60 years, as they consecutively appeared in the dead -house
of a large metropolitan institution, and exhibited at the Royal Medical and Chirurgical Society
in 1856, together with twenty others, for the purpose of showing that hypertrophy was the
exceptional and not the prevailing condition of the prostate in advanced age. (Trans. vol.xl.)
2nd Series.-One hundred prostates , similarly treated by Dr. Messer, at the Royal Naval Hospital,
i Paris, 1796, vol. i. pp. 39-40,
C 2
Greenwich ; the account of which appeared at the Royal Medical and Chirurgical Society in
1860. ( Trans. vol. xliii.)
3rd Series.— Thirty- four prostates, presented to the Royal College of Surgeons, by the author, in
illustration of the Essay on the Healthy and Morbid Anatomy of the Prostate, which obtained
the Jacksonian prize for the year 1860. These were removed by Drs. Fisher and Davis, of the
Royal Naval Hospital, Greenwich, and transmitted to the author, by whom they were dissected
and examined.
In treating the above 164 examples of prostates, from subjects at and above the age of 60, no
selection whatever has been made; the object having been to obtain them from average lives ,
occurring in that class of the community which is met with in such institutions.
4th Series.- Twenty prostates, from persons mostly of middle age, all being below 60. These
were also dissected and exhibited by the author, at the Medical and Chirurgical Society, in
1856 ; and they furnish part of the data from which the size and weight of the healthy pro
state were deduced .
5th Series. — Ten prostates, removed by the author from healthy subjects in middle age - 35 to 57
years inclusive--not furnished consecutively from any one source, and therefore not classed
with the foregoing series. They were examined by division in the middle line, to elucidate an
anatomical question discussed at page 12.
1st Series.—Nos. 1 TO 30.
No. Age Weight Remarks Length Breadth Thickness

OOON
drs. grs .
79 4 48 | Healthy 1.4 1.45 .85
OOO
85 4 44 Ditto . 1.25 1:55 .95

OO
63 4 35 Ditto 1.35 1.7 • 75

90 4 58 Ditto 1.25 1.85 .85
5 66 4 27 Ditto 1.4 1.5 .65
6 63 4 83 Ditto . 1:35 1.5 .65
7 79 2 Ditto 104 1.6 .55
8 70 4 55 Ditto 1.4 1.8 •7
9 66 4 56 Ditto 1 :4 107 • 75
10 74 Ditto . 1.3 1.6 7
11 61 16 Ditto 1.3 1.6 .8
soos
12 64 5 2 Ditto 14 1.75 9
13 73 4 48 Ditto 1.6 1.8 6
14 66 4 35 Ditto 1:5 1.75 .6
6 Ditto is
15 66 4 1 :5 1.65
16 65 4 24 Ditto 1.4 2.0
17 61 4 54 Ditto . 1:3 1.75 75
18 71 6 40
Hypertrophied ; affecting the whole organ 1.65 1.9 9
1 pretty equally
19 72 5 Left lobe larger than right ; not hyper
18 1.3 1.7 9
trophied
Hypertrophied, described in Chapter V.,
20 62 7 15 showing commencing enlargement of 18 1.7 .85
medianportion
d De - 7
21 74 12 30 ŞHypertrophie ; full of tumours. 2.25 2:4 1.75
scribed in Chapter VI.
B14698288
22 73 7 15 Hypertrophied 1 :5 20 .8
23 7 25 Ditto . 1.5 1.9 1.0
24 6+ 6 20 Ditto, small tumours 1.5 19 .75
25 75 9 50 Ditto, full of small tumours 1.7 2: 1 1.0
26 79 4 36 No hypertrophy; but full of small tumours 1 :3 1:75 .8
27 65 6 18 Small tumour, developing in median portion 1.5 1.7 10
28 6 5 Ditto, and in lateral lobes 1.4 1.9 1.0
29 73 2 58 Atrophied 1:1 1.8 6
30 60 2 57 Ditto . 1.2 1:45 .55
FACTS OBTAINED BY DISSECTING THE PROSTATE. 21
2ND SERIES . - Nos. 31 to 130.
No. Remarks
Age Weight
drs . grs.
死死 6828
31 76 3 35 Tumours present
32 76 3 20 Ditto
33 71 3 50 Ditto
34 87 3 30 Ditto
35 79 2 30 Abscess
36 80 3 Median portion enlarged Dr. Messer has placed these, from 31
37 67 3 20 to 50 inclusive, as prostates under
38 69 2 40 4 drachms, and therefore to be regarded
39 85 2 40 as atrophied. I think there is scarcely
40 77 3 40 evidence for so considering them ; and
41 78 3 20 can regard only Nos. 35, 36, 38, 39, 46,
42 82 3 20 49, and 50, as unquestionably atrophied,
43 71 3 40 judging from the single6 fact of Weight.
44 75 3 50 See Chap. XIV., on ' Atrophy of the
的名仍和 % 83 % 8 89 % 88
45 76 3 40 Prostate .'
46 67 2 20
47 70 3 20
48 75 3 20
49 2 5
50 74 3 0
51 81 5 0 Tumours present
52 82 5 Ditto
53 68 5 50 Ditto
54 78 5 30 Ditto
55 82 5 0 Ditto
56 71 5 30 Ditto
57 69 5 0 Ditto
58 87 5 10 Ditto
59 85 4 30 Ditto
60 81 6 Ditto
61 71 4 30 Ditto
76
% 9 的 29GB86846446 似
62 5 30 Ditto
63 82 5 50 Littlo enlargement of median portion
64 85 5 30 Ditto
65 72 4 30 Abscess
66 80 4 20 Ditto
67 67 5 40 | Healthy
68 78 5 0 Ditto
69 76 4 0 Ditto
70 76 4 40 Ditto
71 5 20 Ditto
72 5 0 Ditto
73 85 4 30 Ditto
74 74 4 40 Ditto
75 5 0 Ditto
76 75 4 30 Ditto
77 61 4 20 Ditto
78 81 5 20 Ditto
79 76 5 30 Ditto
80 84 5 20 Ditto
81 81 4 20 Ditto
82 76 4 10 Ditto
83 64 4 0 Ditto
84 81 5 0 Ditto
885682888
85 8+ 4 40 Ditto
86 4 50 Ditto
87 75 5 15 Dittc
88 60 5 0 Ditto
89 73 4 30 Ditto
90 71 5 30 Ditto
91 73 5 0 Ditto
92 4 0 Ditto
93 70 4 0 Ditto
No. Age Weight Remarks
drs. grs.
94 68 5 () Healthy
95 77 6 Ditto
96 72 28 0 Hypertrophied. All lobes enlarged. Tumours present.
97 77 9 20 Ditto ditto ditto
99 63 14 Ditto ditto ditto
108 72 17 0 Ditto ditto But no tumours.
109 79 12 0 Ditto ditto abscess
110 81 6 35 Ditto ditto tubercle
111 79 30 Ditto ditto Tumours present.
113 78 30 Ditto Lateral lobes chiefly enlarged. ditto
77858458

124 30 Ditto ditto ditto
ON
125 60 14 0 Ditto ditto Tumours and abscess

OOO
126 81 12 0 Ditto ditto No tumours

127 67 17 0 Ditto - left lateral and middle lobes only enlarged. ditto
128 7+ 10 Ditto—right lateral lobe chiefly do.tumours and abscess.
129 81 8 30 Ditto-left lateral lobe only do .--generally hypertrophy-abscess.
130 80 8 30 Ditto -- middle lobe chiefly do.-- tumours present.
3RD Series.—Nos. 131 to 164.
drs , grs .
131 85 5 40 Healthy
132 76 6 Ditto
133 83 5 25 Ditto
134 79 45 Ditto
135 80 6 0 Ditto
136 75 6 0 Ditto
137 82 6 10 Ditto
138 84 6 40 Ditto
139 61 6 20 Ditto
140 64 5 0 Ditto
141 68 6 10 Ditto
142 65 5 30 Ditto
143 62 5 10 Ditto
144 80 6 15 Ditto
145 87 3 50 Ditto
146 93 4 7 Ditto
147 80 3 18 Ditto
148 75 5 25 Ditto
119 74 4 46 Ditto
150 90 2 50 Atrophied - died of carbuncle.
151 78
245 | Atrophied - died of phthisis.
FACTS OBTAINED BY DISSECTING THE PROSTATE . 23
drs . grs .
152 80 10 0 Hypertrophied Of these thirteen specimens :
153 81 8 10 Ditto
154 83 9 15 Ditto In three, hypertrophy affected the whole organ pretty
equally .
155 80 8 30 Ditto
156 79 9 Ditto In three, it affected the lateral lobes, mainly and
157 equally .
84 18 Ditto
158 73 10 18 Ditto In four it affected both lobes ; but the right more than
the left.
159 80 7 Ditto
160 77 8 50 Ditto In two, it affected both lobes ; but the left more than
161 75 7 30 the right.
Ditto
162 76 7 50 Ditto In one, it affected all parts ; but the median portion
163 78 11 17 Ditto chiefly.
164 72 12 45 Ditto Five were the subjects of tumour .
4TH SERIES.—Nos. 165 to 184 .
No. Age Weight Remarks Length Breadth Thickness
drs . grs . inch

VW
inch inch
生生生
165 42 3 37 Healthy 1 :3 1 :4 .6
166 47 4 57 Ditto . 1.8 1.7 .65
98D67
167 47 5 33 Ditto 1.4 1•7
168 50 4 34 Ditto 1 :5 1.7
169 54 4 8 Ditto . 1.25 108 75
170 52 4 13 Ditto . 1 5 1.75
171 54 4 37 Ditto 1.5 1.75
172 54 4 50 Ditto . 1 5 1.7 .7
173 56 3 56 Ditto 1.25 1.75 .75
174 21 3 34 Ditto 1:3 1:4 •7
175 40 4 30 Ditto . 1:55 1.6 .75
176 50 5 20 Ditto . 1:55 1.75 .8
177 50 4 46 Ditto . 1.4 1.9 • 55
178 46 5 Ditto . 1 :5 2.0 : 55
179 55 5 30 Ditto 1 :3 1.8 .85
180 54 4 48 Ditto 1 :4 1.75 •7
181 56 5 22
182 56 6
Small tumours, not hypertrophied 1:55
1.3
1.75
1.8
-75
1 :0
Slight general enlargement .
183 50 5 50 1 :3 1.8 1.0
184 21 2 46
Small tumour developed in median portion 1 :3 • 55
Atrophy --- emaciation from phthisis 1.25
5TH SERIES . — Nos. 185 to 194.
drs . grs .
185 35 4 30 Healthy
186 39 4 36 Ditto
187 41 4 50 Ditto
188 44 4 10 Ditto
189 45 5 6 Ditto
190 45 Ditto See page 12 .
పాలుని
4 40
191 51 56 Ditto
192 52 4 50 Ditto
193 53 5 36 Ditto
194 57 5 0 Ditto
PART II . - THE DISEASES OF THE PROSTATE .
The diseased conditions to which the Secondary Results of the Inflammatory

prostate is liable will be considered in the Process :
orderpresented below. All the deviations Suppuration.
from health are enumerated which an ex Diffuse.
tended study of morbid anatomy, as well Abscess.
as that of the signs and symptoms mani Ulceration .
fested during life, indicate as liable to Hypertrophy of the Prostate.
affect the organ. Simple Tumours and Outgrowths.
Atrophy.
Inflammation of the Prostate : Prostatitis. Cancer of the Prostate .
Acute . Tubercle of the Prostate,
Chronic. Cystic Disease (?)
Calculi of the Prostate.
CHAPTER II.
INFLAMMATION OF THE PROSTATE : ACUTE AND CHRONIC .
Acute Prostatitis - Causes - Morbid Anatomy - Symptoms — Treatment- Chronic Prostatitis - Causes
Morbid Anatomy - Symptoms— Treatment, in its various Forms and Stages.
Acute inflammation of the prostate is by The alleged causes may be arranged
no means a cominon affection, if regarded for consideration in three classes, as
as distinct and unassociated with inflam- follows:
mation of the urethra or bladder. When (a. ) Undoubted causes of acute pro
the latter organ is inflamed, the prostate statitis.
sometimes suffers in a secondary manner The pre - existence of acute inflamma
and degree . But acute prostatitis more tion of the urethra of any kind, but
commonly arises from thecommences
extension of especially the gonorrheal, by continuity,
inflammation which dyalluded
as as alrea Urethral stricture,
to .
gonorrhea . in an aggravated form, tending as it does
Sometimes, however, the prostate is to the production of inflammation and dis
inflamed apparently as a purely idiopathic organisation of all the parts posterior to it,
occurrence, and not from continuity of especially those more immediately ad
tissue with adjacent parts. This, except- jacent, as the prostate and bladder. The
ing the cases produced by violence, as by direct application of irritating agents in
instruments, &c., is probably extremely the shape of strong injections, cauterisa
rare . tion, and mechanical violence of various
CAUSES.—Systematic writers on this kinds. Inflammation of the bladder
subject enumerate many circumstances as sometimes. Calculi of the bladder and of
giving rise to acute inflamination of the the prostate itself. The application of
prostate ; but relative to many of them, cold and damp to the perineum, as by
evidence is wanting in respect of their sitting for a long period on moist ground.
claim to be regarded as causes. Urethritis has been referred to as a proxi
INFLAMMATION OF THE PROSTATE . 25
mate cause, but it may also be the remote |bable that want of exercise and a torpid
cause in the circumstances last enume- state of the bowels tend to produce an
rated , as well as in some of those which obstructed circulation in the veins of the
come under the next head . pelvic organs, as seen in piles ; but that
(6. ) Circumstances which cannot be this condition can occasion acute inflam
stated with absolute certainty to be causes, nation, it is not easy to believe.
but which may, with some amount of pro MORBID ANATOMY.-An opportunity
bability, be so regarded. of studying the morbid anatomy of acute
Horse -exercise is constantly said to be prostatitis, when it forms the primary or
a cause of acute inflammation in the the chief affection , is very rare, especially
organ , by means of the concussion occa- during or immediately after the acute stage.
sioned. That it may aid in producing it It is much more common to meet
when some inflammation of the urethra with the organ when chronic inflamma
already exists is quite possible. But it tion or suppuration is present, and when
cannot be said that hard riders, such as it is presenting none of the phenomena
huntsmen, jockeys, or cavalry soldiers, are indicating the presence of acute inflamma
in any notable degree more subject to it tory action .
than other men equally exposed to other Nevertheless, these phenomena have
and better recognised causes. Cantharides been • seen and noted . I have observed
affects the bladder and not the prostate andrecordedthem myself in one instance.
particularly . Alcoholic drinks, especially They will be regarded under two
when mixed with acids, as punch, may heads.
induce prostatic inflammation, gonorrhea a. The pathological changes which
already existing, not otherwise. Inordinate take place in the early and middle
sexual intercourse, under the last-named stages of acute prostatitis ; con
circumstances, may probably be assigned ditions which do not necessarily
also to the present category . tend either to extensive suppuration
(c. ) Circumstances stated to be causes or to disorganisation , but which
by numerous authors, but respecting which may, and often do, end in resolu
there is either little or no evidence to tion .
render it probable that they are so. The organ is swollen to double or even
Diuretic medicines, copaiba, cubebs, quadruple its natural size, and feels tense
and turpentine, even coffee and highly and firm to the hand. The external
seasoned dishes, are said to cause inflam- blood-vessels are loaded with dark blood.
mation of the prostate . Drastic purga- On making an incision from the front
tives are similarly regarded by some. aspect into the urethra, the mucous mem
Irritations in the rectum, by ascarides, brane is seen to have a somewhat deeper
hæmorrhoids , &c. , are enumerated as tint than natural, although there is less
causes .
All these may , and do un change here than onemight expect; the
doubtedly, sometimes induce an irritable cut surface is redder also than in health.
condition of the bladder, and some of Pressure causes to exude a reddish , semi
them , perhaps, even some degree of in- turbid fluid, a mixture of effused lymph
flammation of the viscus ; but I am not and serum , of blood from loaded capilla
aware of any case of acute prostatitis ries, of prostatic secretion, and a very
directly or indirectly occasioned by any small quantity of pus ; that is to say, if the
of these agents. The morbid condition of Auid is examined under a microscope,
the organ which exists in the presence of some pus-globules will be observed .
carcinomatous infiltration , or of tuber. Making an incision through the lateral
culous deposit, cannot be regarded as by lobes, the same fluids exude, but in some
any means identical with theaffection now what greater abundance than from the
under consideration . Nevertheless, the anterior part just examined . As the in
diseases referred to are commonly enu- flammation advances, the fluid contains a
merated as causes ; a practice which is larger admixture of pus, and a section of
misleading and obviously erroneous . thelateral lobes especially shows several
Sedentary habits are spoken of as a cause minute spots of thickish pus, not abscesses
of the affection, but without the slightest apparently, strictly speaking, but the
shadow of evidence to support the asser- gland - crypts, whose lining cells are now
tion . The same may be said of the secreting pus, and whose cavities are dis
alleged influence of constipation. It is pro- tended with it.
26 THE DISEASES OF THE PROSTATE .
B. Pathological changes which occur in size and tension , complete retention of
in the later stages of acute inflam- urine may occur and continue for some
mation of the prostate . days. In these circumstances a finger in
The continuance of inflammatory troduced into the rectum encounters much
action leads to the formation of small opposition, however quietly it is carried
abscesses in the substance of the prostate. through the sphincter : the anterior wall
These are from the size of a grain of of the bowel is prominent, hard, and hot,
pearl barley to that of a pea, and a few and the outline of the prostate may be
may be larger than the preceding : they traced, not, however, without causing
occur from the coalescing of the smaller suffering to the patient. An attack of
deposits, and the destruction of partitions piles may be induced, the close contiguity
of intervening tissue. It has been ob- of the hæmorrhoidal and prostatic veins
served that the pus of a prostatic abscess appearing to favour this result. At a
has a peculiar glutinous or adhesive later stage, if suppuration has taken place,
quality, differing from the creamy cha- the rectal swelling is softer, local throb
racter of ordinary healthy pus. Some- bing is experienced, and should a catheter
times clots of blood are found, the result be passed, the patient will complain of ex
of small hæmorrhages into the diseased cessive pain when the instrument reaches
gland -crypts or other cavities. Portions the prostatic part of the urethra. General
of the organ may become softened and fever, in a greater or less degree, manifests
even gangrenous. The mucous membrane itself after the accession of the earlier
of the prostatic urethra is reddened, or local symptoms, rigors often accompany,
has patches oforganised lymph on its sur- ing the onset. Pains in the back and
face, the product of inflammatory action ; loins, as well as in the glans penis, and
or portions of the membrane may be de- running down the thighs,are experienced,
stroyed by ulceration, and form the orifice and not unfrequently a sensation of con
of a cavity or cavities already described stant desire to go to stool. The mucous
as occupying the substance of the prostate membrane ofthebladder participates some
itself. times, not always, in the inflammation ;
All these conditions I have observed the urine is febrile in character, and con
at autopsies, after the existence of ad- tains mucus to some amount, occasionally
vanced acute prostatitis, usually, though in considerable quantity, if the last-named
not invariably, consequent on disease structure is implicated . Besides this, there
primarily occurring in allied and neigh- may be pus in the urine to a greater or
bouring organs, and implicatingthe pro- less extent, from which it is deposited as
state secondarily. They will be traced a sediment on standing.
further in describing, hereafter, the patho- The chief signs upon which a dia
logical anatomy of prostatic abscess. gnosis depends may be noted as follows:
SYMPTOMS. - At the outset, a sensation enlargement of the prostate, ascertained
of weight and fulness about the rectum by rectal examination, with acute pain
and perineum is experienced , with pain complained of when pressure of the finger
or uneasiness referred to the neck of the is made upon any part of the swelling
bladder. The patient passes water more there. The act of defæcation is painful,
frequently than natural, and the act is that of micturition still more so, complete
painful, especially at its close. These retention often supervening. If a catheter
symptoms increase; the pain becomes is introduced, exquisite suffering is caused
severe, then lancinating, throbbing, and when it arrives at the prostatic part of
almost continuous ; a sense of tension and the urethra. Added to these, there is con
swelling is experienced, and the anus and stant and deep- seated, often throbbing,
perineum are tender when pressed upon. pain felt about the fundament. These
Movements of the body become difficult symptoms alone,but especially when asso
on this account, as does also the sitting ciated with a history of recent urethral
position. The act of relieving the bowels discharge, which may have previously
at stool produces considerable distress : ceased or not, will suffice to determine
still more so does the act of micturition ; the nature of the case.
the stream of urine being generally small, TREATMENT. — It is unnecessary to enter
and its passage necessarily prolonged, much Some exceedingly well detailed cases of acute
strainingaccompanies it, and the painis prostatitis are given by Vidal de Cassis, who has
paid specialattention tothis affection, in the Annales
exquisitely acute. As the organ increases de Chirurgie.Paris, 1844.
INFLAMMATION OF THE PROSTATE. 27
here into the full detail of that which con- One of the most troublesome condi
stitutes the ordinary constitutional treat- tions met with is retention of urine caused
ment of inflammation. In general cases by the barrier which the swollen prostate
the antiphlogistic regimen and diet, as offers to micturition. The stream dimi
commonly understood,should be observed. nishes, at last ceases, and it is then abso
Small doses of antimony combined with lutely necessary to pass a catheter as
potash may be given frequently ; while many times in the day as the comfort of
the bowels should be freely opened at the the patient requires, probably four times
outset, and a gentle action maintained at least in the twenty -four hours. The
afterwards. best instrument, as a rule, is a soft coudée
The local treatment demands a more catheter of rather small size, say No. 6
special notice. Bleeding from the neigh- or 7. It is to be removed as soon as the
bourhood of the affected part often affords bladder has been emptied ; and its em
greater relief than any other single agent, ployment must be continued, more or
and in most cases the application of leeches less, after the function of micturition
is the most available means. They should begins to re -establish itself, and as long
be employed freely, say ten or twelve, on as the bladder is not emptied by the
the perineum and around the anus. An natural efforts.
expert cupper may obtain eight ounces It is not uncommon that instant relief
of blood from the perineum ; but in the is afforded by a sudden escape of pus, and
absence of such a one the leeches will this may happen during the employment
certainly be preferable.. Leeches to the of the catheter ; an abscess in the gland
rectal surface of the organ , introduced by giving way, and the symptoms, both
means of tubes devised for the purpose, general and local, rapidly diminishing in
have been recommended by some; but intensity. In a few instances it is neces
the effect to be produced in this way sary to make an incision for the exit of
must be small, as only one or, at most, pent-up matter, and this may be done by
two leeches can be applied at a time. rectum if fluctuation is felt there very
The bleeding over, a hot hip - bath should distinctly ; it is less commonly necessary
be taken, then a large poultice or hot to incise by the perineum , true abscess of
flannel placed on the perineum , and the the prostate rarely producing in that
patient be wrapped up warmly in bed. direction sufficient signs of its progress to
The hip -bath may be frequently repeated warrant the introduction of the long bis
with advantage in the course of the treat- toury. Still it may be occasionally
ment, but should not be applied at any necessary, although abscesses opened in
one time for a lengthened period. From that situation are rather deep perineal or
eight to ten minutes suffices for the bath, periprostatic than collections of matter in
which should commence at about 100° , the prostate itself.
and be raised to about 105° or even up to The extreme pain and the difficulty
110º during the period named. Such a in passing water may be, throughout the
method of using this valuable agent ap- case, considerably alleviated by the free
pears to me more advantageous than pro administration of opium or morphia, both
longing the sitting to fifteen or twenty by mouth and by suppository or enema.
minutes. The object of the bath is not In the course of a few days, the
to induce a flow of blood to the pelvic severe pain and the frequent micturition
viscera, but, on the contrary, to expand gradually subside, as a rule,sometimes,
and fill the vessels of the skin by a smart however, not without the occurrence of
impression quickly made upon it, one an occasional relapse for a day or two, as
which is also participated in to a certain after some indulgence on the part of the
extent by every part of the cutaneous patient, especially after exercise too freely
surface. And it is by using the bath in taken or at a too early period . Hence it
the manner described that a general dia- is necessary to restrain with firmness the
phoresis is effected, and a temporary con- activity which a young and generally
gestion of the pelvic surface produced, hearty patient is ready to display as soon
with the result of relieving that of the as his complaint beginsto recede. Mode.
deeper parts. ration in diet, with total abstinence from
1 The instruments which have been employed
alcoholic stimulants, must be enjoined for
for this purpose are described and figured in the a time ; convalescence should be watched,
Lancet, vol. xxxix . p. 645, and vol. xl. p. 299. and means may be taken, not merely to
28 THE DISEASES OF THE PROSTATE.
restore the general health on the ordinary commonly manifested by symptoms before
principles of nutritive and tonic regimen, the fifty -seventh or fifty -eighth year.
but to reducethe bulk of the organ, enlarged Inflammatory enlargement is almost in
as it is prone to remain from the effect of variably preceded by some urethral in
inflammation. Speaking in general terms, flammation . Urethral discharge of a
the prostate willbe found, on examination purulent nature, numerous flocculent
after the lapse of about a month from the shreds in the first urine passed, and pain
subsidence of the acute symptoms, still during and after micturition, have been
swollen and tender. More than the or still continue present. Associated with
natural amount of exertion is required in these, there is often an impaired condition
order to enpty the bladder, and the of the general health . All these signs
stream is propelled with less than the may be, and usually are, absent in hyper-,
usual degree of force. Such are the only trophy during its earlier stages. Finally,
effects remaining when the acute affection inflammatory enlargement is due to the
terminates in a healthy resolution . effusion of morbid products, lymph, pus,
CHRONIC INFLAMMATION OF THE Pro- &c., into the substance of the organ ;
STATE.—The affection here described under while a hypertrophic enlargement is due,
this title is not very uncommon even in as the term implies, to simple over-pro
its simple uncomplicated form ; and when duction of the normal elements of the
it appears as a secondary condition to prostate gland itself.
existing disease of the bladder and ure- Causes. The most fertile cause of
thra, it is one of frequent occurrence. chronic prostatitis is gonorrheal inflam
Nevertheless, its existence is barely recog- mation, which has extended backwards
nised by some of the best known writers and affected, more or less acutely, the
on prostatic disease,and by some it is not prostate. Local cold and damp must be
even named . recognised as occasionally producing it;
Chronic prostatitis is met with in more rarely still it is due to mechanical
three different phases ; but the symptoms injury inflicted on the urethra or on the
and pathological characters are much the perineum . Long-continued indulgence in
same in each , and differ in degree rather venereal excesses of any kind is undoubt
than in kind. It may solely originate in edly a cause. That form which results
an attack of acute prostatitis, and show from long-standing and severe stricture of
little disposition to diminish after the the urethra, ofchronic cystitis, of calculus,
acute symptoms have subsided ; or, either vesical or prostatic, is common
secondly, there may be a tedious resolu- enough and needs no separate considera
tion, leading, by slow steps,to the re- esta- tion ; it is the mere result of existing
blishment of healthy action ; and, finally, adjacent disease, upon which it altogether
the condition may commence in the depends.
chronic form , independently of any acute MORBID ANATOMY . — I have examined
attack, in which case it may be the several prostate glands which manifested
primary or sole existing complaint, or it a pathological condition resembling that
may be dependent on disease of adjacent which, when observed in other organs,
organs. obtains the name of chronic inflamma
It is common to meet with instances tion ; such , for example, as occurs in
in which simple chronic inflammation of lymphatic glands , superficial and deep , in
the prostate, producing enlargement, is the mesenteric glands and in the tonsils,
regarded as an example of hypertrophy. &c. The prostate so affected may be
Yet nothing can be more distinct than the found larger, or even smaller , than the
two affections, if we compare their patho- natural size ; for there is no necessarily
logical history and characters. Chronic constant deviation in this respect ; the
inflammation , however, does not neces- consistence , if any difference exists , is
sarily cause enlargement of the organ ; less firm , the texture is more open and
indeed, this is an exceptional condition, spongy . The colour of the cut surfaces
all varieties considered. But when in has a more dusky hue, sometimes with a
flammatory enlargement does exist , it is redder tint. More fluid than natural is
almost invariably in the early or middle found in the gland -tissue, and freely
periods of life; while hypertrophy never issues on being pressed. This fluid is of
occurs before the fiftieth, very rarely a dirty hue, and, if firm pressure is made ,
before the fifty - fifth year, and is not is stained slightly red. In advanced cases ,
INFLAMMATION OF THE PROSTATE . 29
deposits of pus are found, varying from muco -purulent matter, and masses of
the size of a grain of pearl sago to that epithelium , which have their origin in
of a pea, but they are few in number, the prostatic ureth ra and not in the bladder,
perhaps only one or two are seen, thus as may be ascertained by desiring the
contrasting with the numerous dissemi- patient to pass water into two glass vessels ,
nated small abscesses met with in the the first ounce or so into one, the remainder
later stages of acute inHammation. The into the other, when the purulent matter
mucous membrane may be thinned and will be found in the former portion , while
more vascular than natural, with the latter clear. This mode of ex
duct -orifices large ; this being the case if amining the urine is one to which I attach
there has been dilatation of the prostatic considerable importance. It separates
urethra, as sometimes happens behind a purely urethral products from the deposits
stricture : on the other hand, it may be which come from the bladder or from the
coated in places with organised lymph, kidneys, and which are otherwise likely to
giving it a roughened and opaque appear- be attributed to the latter sources, or at
ance . Or its own structures may be all events to be misunderstood. For all
thickened , not reddened as in acute in- purposes of urine examination this pro
flammation , but presenting after death a ceeding ought to be pursued . In well.
dull ashy grey, or even slaty hue, the marked cases, there appears at the end of
last-named marking long persistence of micturition a drop of blood, sometimes
the unhealthy action. Pus is, in such more than that, tinging the last portion of
cases, often found filling the sinus pocu- urine passed : an occurrence often leading
laris and the gland -ducts around ; and to a suspicion that calculus exists. This
sometimes a cavity filled with pus com- sign , as well as the simultaneous pain ex
municates with the urethra, forming a perienced ,and the fact that the symptoms
chronic abscess in the prostate; while it are increased by much exercise, often
is not uncommon to find an abscess or renders sounding necessary in order to
abscesses surrounding it, in other words, determine the question. Indeed I know
peri-prostatic abscesses depending on fore- no other complaint in which the symptoms
gone disease of the prostate itself. so strongly resemble those of stone in the
SYMPTOMS.-- A patient who suffers from bladder in a mild form .
simple uncomplicated chronic inflamma- Further inquiry will frequently dis
tion of the prostate complains of a little cover that the patient has little or no
undue frequency in making water, some- sexual desire, and he may or may not be
times of muco -purulent discharge from the subjectof frequent involuntary seminal
the urethra, of a sensation of weight and emissions during sleep . The health is
fulness, sometimes of dull pains in the mostly somewhat impaired, and general
perineum and about the anus, occasional debility is complained of.
or persistent, but which are almost always TREATMENT OF SIMPLE CHRONIC PRO
increased by exercise ; often of pains in STATITIS. - When the weight and dull pains
the thighs and legs, or in the sacralregion : about the perineum are pretty constant,
sometimes increased, butnot invariably, and there is obvious tenderness of the pro
by sexual intercourse. There is usually state, both of these conditions being in
no pain in micturition until the end of the creased by exercise, nothing is so service
act, when it is occasionally, but by no able as counter - irritation at the surface of
means always felt, and then it is not acute the perineum, continued for a period of
like that of calculus. There may be four, six, or eight weeks, and if thus
tenderness in the perineum, sometimes persevered in , benefit is almost certain to
felt in the sitting posture ; tenderness in follow . It may be accomplished by apply
the prostate itself to rectal examination : ing to the part strong acetum cantharidis '
6
an irregularity in form is sometimes de- or ' liquor epispasticus ; ' the soreness to
tected by the finger, but this is excep- be kept up by occasional repetitionsof the
tional ; and there is not necessarily any process. It may occasion slight trouble
enlargement. The passing of a catheter to the patient at first, but by applying
gives more than usual pain when it daily simple ointment, the inconvenience
traverses the prostaticurethra and neck of is lessened. In using the blistering-fluid,
the bladder. The urine is aa little cloudy, care must be taken not to allow it to run
but on examination this condition is found downwards to the margin of the anus, nor
to be mainly due to shreds of tenacious should it come into contact with the
30 THE DISEASES OF TIIE PROSTATE.
scrotum. The most efficient mode is to much pain being felt when an instrument
paint a surface of the skin of the perineum reaches the prostatic urethra, nothing acts
about half an inch wide and one and a more beneficially, in many cases, than the
quarter inch long, say, on the right side application of a solution of nitrate of
of the raphé, and in three or four days a silver, commencing with about five grains
similar portion on the left side ; so alter to the ounce, and increasing it to twenty
nating the application every three or four grains if necessary, by means of a per
days, which permits to each spot about a forated catheter containing a piston , by
week to heal before a renewal of the which the fluid can be set free at the
painting is made. A very small quantity
proper spot, and its action mainly limited
of the blistering - fluid suffices ; it is not
to it; a matter which it is important to
necessary to produce a very sore surface,
accomplishpretty accurately . In perform
or any degree of irritation sufficient to
ing this little operation, the following
interfere with freedom of movement on course should be pursued. The bladder
the part of the patient. The common should first be emptied ; and the opportu
error is to apply it too freely. nity of doing so should be employed to
While thus treating the local condi- determine the exact length of the urethra,
tion, the digestion also must be improved, in the usual manner, while the urine is
the vigour of the system promoted, and flowing. The instrument containing the
exercise is to be permitted and increased caustic solution should then be passed
by degrees as soon as the power of taking immediately, the solution being discharged
it without inducing pain is acquired. as soon as the perforated extremity has
The digestive organs being in toler- arrived within the prostatic urethra, the
able condition, the use of iron is mostly situation of which may be correctly in
attended with benefit. The sulphate, ferred from the known length of the
combined with sulphate of quinine, and urethra, as well as by the undue sensi
made into pills, with some extract of bility which the part possesses. The im
rhubarb and a little extract of nux vomica, mediate results usually are, repeated wants
is an advantageous form of tonic for these to pass water, which are painful, and
cases, in which it is desirable to maintain sometimes attended with slight bleeding ;
regular action of the bowels, impaired as these subside in twenty -four hours, and
it usually is by inability to take much possibly are succeeded by a little purulent
exercise. A little of the watery extract discharge for a day or two. During the
of aloes can be combined, if it is necessary first few days it is not uncommon that the
to employ more decided aperient action. symptoms originally coniplained of in
The tincture of the sesquichloride of iron crease, but afterwards they gradually
is also an efficient remedy, provided the diminish. Should this, however, not be
bowels are not permitted to become un- the case, no fresh application of the caustic
duly constipated . should be made until two or three weeks
A common source of complaint among have elapsed, as it is impossible to ascer
young men is the occurrence of unduly tain the effect in aa shorter period of time.
frequent nocturnal emissions. These may If necessary, it may then be again applied
be associated with chronic prostatitis, but as before, or with a stronger solution. A
far more commonly they have no such third or a fourth application may be neces
cause, are the natural and necessary con- sary ; but it is rarely desirable to employ
sequence of continence, and are not the it again if not successful on the fourth
result of any morbid condition of the occasion. Its success mainly depends on
prostate at all ; so far only as they are applying it freely and accurately to the
thus related do they come under our con- prostatic urethra, and when this is en
sideration here. When, however, with sured, it generally proves a valuable
the group of symptomsalready described, remedy.
the patient complains of involuntary In these cases also alterative and tonic
nocturnal emissions, occurring irregularly treatment, such as that just described, and
but with great frequency, an instrument generous but non -stimulating diet are
may be passed through the urethra. mostly required .
Ordinarily,however, in chronic prostatitis, When there appears to be little active
the contact of a foreign body only in- disease of the prostate, and we have only
creases the existing irritation. The symp- to deal with the sequel of a severe acute
tomis referred to being predominant, and attack , in which convalescence is pro
ABSCESS OF THE PROSTATE. 31
gressing but very slowly, there is less | irritating, character. If the enlargement
indication for counter-irritation , and pro- is considerable, it is desirable to employ
bably none for the employment of caustic also local blistering. I have had recently
in the urethra. One of the most prominent under my care two patients, one at
conditions in such a case is the persistence twenty -eight, the other at thirty - five
of enlargement and induration of the organ, years of age, with enlarged prostate ; in
due to inflammatory deposit which took the former it was very considerably so,
place during the acute stage. This is the and was caused by a severe attack of
enlargement which belongs to the period acute inflammation, which he experienced
of youth, and differs totally from that three years ago ; in the second the en
which occurs in advancing years, and is largement from the same cause is so ex
known as senile hypertrophy . treme as to render a rectal exploration
The general health being vigorous, even somewhat difficult from the great
those internal remedies which appear to projection of theorgan into the bowel. In
possess a specific power to promote ab- both cases, the latter especially, the fre
sorption of the effused matters may be quent occurrence of symptoms of irrita
employed. Such are the iodide and bility of bladder, and of pains in the
bromide of potassium . They may be perineum and loins, appeared to be due in
administered conjointly or separately, the great measure to this abnormal condition.
latter agreeing with the stomach some- Respecting chronic inflammation of the
times when the former will not. Either prostate, resulting from prior disease in
agent may be combined with fifteen or associated organs, as stricture of the
twenty grains of the acetate or bicarbonate urethra, calculus, organic disease of the
of potash twice a day, or with two or bladder or of the rectum , &c. , it will be
three scruples of the tartrate of potash, if unnecessary to say more than that treat
there is a constipated habit of body. ment which is suited to the primary
These are the more indicated if the urine complaint will embrace all the necessities
presents an unduly acid, and therefore
7 arising from the prostatic complication.
CHAPTER IV .
SUPPURATION OF THE PROSTATE . - ABSCESS, ACUTE AND CHRONIC.
Results of Inflamation . - Abscess. - Diffuse Suppuration . - ACUTE AND CHRONIC ABSCESS . — Morbid
Anatomy of Acute. - Of Chronic. - Symptoms.— Treatment of Acute.—Chronic Abscess. — Cases. -
ULCERATION . - Pathology of.
An attack of acute inflammation may be of acute inflammation affecting the bladder

followed not merely by chronic inflam- and prostate, and following long unre
mation and induration, varying in degree lieved retention of urine from organic
and in tendency to persist , but, especially disease, or surgical operations upon the
when neglected or occurring in a natu- urethra or bladder.
rally weak or delicate constitution, in MORBID ANATOMY OF ACUTE AND
suppuration of the organ . And suppu- ChronIC ABSCESS. It has been already
ration may take place either as an acute mentioned that the prostate may be the
action at a very early period in the case, seat of numerous small abscesses, ap
or subsequently after a long persistence of parently commencing in suppuration of
chronic inflammation ; constituting in the the glandular crypts ; that these may
first acute, and in the second chronic dilate, coalesce with neighbouring crypts,
abscess : it may also occur in a diffused and so lead to the formation of cavities
manner among the tissues of the organ. varying from the tenth to the fifth of an
The existence of suppuration in a inch in diameter. But abscess may form
diffused form , and not in that of localised in the prostate by a different course of
and limited deposits, is rare, and occurs events.
only, as far as I have observed, in cases Acute abscess of considerable size
sometimes forms rapidly in acute pro- 2nd. Abscess, never acute in its cla
statitis, and rapidly discharges itself, most racter, may slowly form in the prostate
commonly by the urethra. It is exceed as the result of chronic inflammation in
ingly rare to have an opportunity of dis- it, or in the neighbouring parts.
secting such a case, because resolution 3rd. A tubercular deposit in the pro
takes place, or, at all events, the patient state may soſten and be discharged , a
does not succumb, or, if he ultimately chronic abscess resulting.
does so, almost never during the acute 4th . Abscesses may occur from the
stage of the complaint. Consequently, it irritation of a foreign body, such as cal
is mainly from explorations made during culus, embedded in the prostate; or in
life that we can ascertain anything of its the midst of malignant growths.
morbid anatomy. The prostate examined In examples of the first and second
by rectum feels full, tense, and much kinds I have seen , in a few instances, a
larger than natural. Suddenly, a dis- cavity capable of holding from two to
charge of matter by urethra taking place, three drachms of fluid , situated in the
it becomes somewhat smaller, and much prostate gland , and occupying either
less tense. Other signs, both objective lobe, or, partially, both . The walls of
and subjective, but not anatomical, exist- the cavity are composed of a thick
ing to confirm the diagnosis of prostatic layer of organised material, with ragged
abscess, the fact of its existence in the Hocculent surface, and pusadhering. The
substance of the gland is established ; and colour is grey or grey -slate, the same tint
its healing is equally so, since I have pervading a thin layer of the prostatic
examined subsequently patients who have structure itself lying adjacent to the
been so affected , and have verified the fact abscess, then shading off into the natural
of recovery, some undue hardness and aspect. Sometimes a large proportion of
increase of size usually existing for a long the proper structure of the prostate has
period of time afterwards. disappeared , as the effect of the abscess ;
Recently, however, the rare oppor- indeed, occasionally, almost the entire
tunity of dissecting a case offered itself in organ has been destroyed under these cir
one of the metropolitan hospitals. A man , cumstances. I possess two examples, in
aged twenty -five, was admitted as a me- which , nearly the whole of the prostatic
dical patient, with fever and pain in the substance being thus removed, the ure
loins, coming on within fourteen days thral canal traverses the hollowed gland ,
from the commencement of a severe go- being continuous, nevertheless, with the
norrhoa. He was unable to pass urine, membranous urethra on the one hand ,
and his water was removed by the catheter. and with the bladder on the other. This
He gradually sank on the eighth day after condition is shown at fig. 5, drawn from
his admission. At the autopsy pus was one of them when recent: the subject of it
abundant in the urethra ; the mucous being that of a man under my care at the
membrane, however, was only moderately Marylebone Infirmary. The case is re
injected in places. A large abscess was corded in the ' Pathological Trans.' vol. v.
found between the rectum and bladder, p. 208, and also at p . 77, together with
and continuity ofpassage existed between it another example of the same disease. An
and the floorof the prostatic urethra, where excellent example of this somewhat rare
it opened by two large orifices close to condition exists also in the Museum of
the verumontanuin . It had produced de- the College of Surgeons, Edinburgh,
struction of a considerable portion of the No. 2090, XXXII. c.
a
prostate gland itself, but parts not de- In an example of the third kind, the
stroyed seemed tolerably healthy. Whether, walls of the cavity present similar appear
however, this abscess was truly prostaticat ances, and it occupies usually portions of
the outset, or periprostatic, it would still be one or both lateral lobes ; but portions of
difficult to decide. It largely involved pale yellowish, or greyish -yellow, curd
the prostate, however, and is therefore like matter, mixed with a little pus, may
illustrative of the present subject. adhere to the walls, or may, indeed, fill
Prostatic abscess may assume a chronic the cavity if not discharged during life.
These conditions are of rare occurrence
condition in a variety of ways. :
1st. The acute abscess above described see Chapter XVI. , on Tubercle of the Pro
may not heal, but may assume, and con- state .
tinue in, the chronic condition . Fourthly, abscess may be associated
ABSCESS OF TIIE PROSTATE. 33
with prostatic calculi from the irritation urine, giving rise to fresh collections of
produced by the foreign body. The matter around, from the inflammation so
membrane -like envelope which lines the produced. Extravasation rarely, if ever,
cavity in which the calculus is situated has to be feared, the parts exposed to
may become with inflammation a pus- urine being defined and thickened by
secreting structure. Small collections of exudation matter.
pus are commonly met with in making TREATMENT.—This mainly consists in
sections of encephaloid tumours of the watching the course which the abscess
prostate ; but these need no special de- takes, and evacuating the matter, when it
scription. presents itself either in the rectum or in
SYMPTOMS. — The occurrence of sup- the perineum, the latter circumstance
puration, as has been before stated, may being very rare. In the rectum, if a fluc
be suspected when after the first six or tuating tumour is manifest, it is easily
seven days the acute symptoms do not punctured. But the deep perineal abscess,
subside, when the pain and difficulty of often formerly regarded as prostatic in its
micturition and defæcation increase, if origin, is probably rarely so; but rather
rigors occur, and the patient is very rest- the result of extravasation of urine behind
less and feverish, complaining of great the deep fascia. If, however, deeply
tension and of a pulsating sensation in the seated abscess in this position is manifest,
perineum and at the neck of the bladder. it should be opened without delay.
The fact is determined if, by rectal ex. The incision requisite must be made
amination , the swelling there increases, with boldness, in the median line, in the
and communicates to the tip of the finger known direction of the prostate. The
a sensation of softness and elasticity, in forefinger of the left hand having been
place of the firmness and resistance which introduced into the bowel, aa long, straight,
were noted before. The act of examina- and narrow bistoury, the cutting edge of
tion also, although necessary, is exces- which is upwards, should be thrust into
sively painful, and should be very gently the raphé, about three- quarters of an inch
and slowly performed. Pressure in the anterior to the anus in the known direc
perineum may also reveal tenderness
fulness in that situation .
and tion of the swelling, and the incision en.
The natural larged in a straight line upwards, to a
course of abscess in the substance of the slight extent, so as to give a free opening
prostate is generally spontaneous evacua- for the discharge of matter. The depth
tion by the urethra , often immediately to which such an incision must be carried
after the passing of a catheter, rendered
cannot be less than an inch and a half, it
necessary by the patient's condition. may be two inches ; less than the former
Occasionally the matter is evacuated by will be probably useless, and if so, un
the rectum , as in the case of a gentleman
necessary and injurious.
recently under my care, when two ounces But it must be sufficiently obvious
of healthy pus were suddenly evacuated that the surgeon should be well satisfied
while the patient was at stool , a smaller that there is a collection of matter in the
a
quantity being evacuated every day for situation referred to, before he decides
some time after from the opened cavity of on making this attempt to evacuate it by
the abscess. In this case the enlargement, artificial opening. In cases of doubt,we
which was very considerable, was due to must await the result, confining ourselves
a previous attack of prostatitis, compli- to palliating the symptoms which arise,
cated with obstinate and narrow stricture and not unfrequently nature will clear up
of the urethra. The spontaneous evacua- the case by discharging the pus through
tion of matter by the rectum is perhaps the urethra. Under the various circum
less favourable, generally speaking, than stances met with, it must be confessed
by the urethra . It may be followed by a that occasionally a case will present itself
troublesome urethro - rectal fistula, but not in which the indications for action are not
necessarily, or even usually so. On the very marked or decided.
other hand , although the opening of the Occasionally, a prostatic abscess has
prostatic abscess into the urethra may been observed to come forwards spon
soon close, the walls of the cavity having taneously by the perineum . Such, at
granulated and united by adhesion, yet, if least, is stated to be the case. It is con
this does not take place, the sac may re- trary to the principle understood generally
main open, and become a receptacle for to hold good with respect to the course of
D
matter confined in all parts of the body, side, will generally aid materially the
viz., to seek exit in the direction of least progress of the case. Chronic abscess very
resistance ; for in the case supposed, the rarely calls for an incision from the peri
matter must find its way through the neum, and the less instrumental interfe.
deep perineal fascia. It is not improbable rence by urethra also thebetter . Itmust
that in some of the alleged cases this generally heal very slowly, since, after it
barrier was behind the abscess, and not has broken , urine is apt to pass into the
between it and the surface at all, a dis- cavity, maintaining irritation and pain ,
tinction not always easy to establish . and hindering the reparative process.
Very rarely prostatic abscess may burst
into the peritoneal cavity. Mr. Adams CASE No. I.
gives an example of this in a case of ProstatITIS AND CYSTITIS AFTER INTEMPERANCE
tubercular prostate . It is probably a AND EXPOSURE TO COLD, RESULTING LV
very rare occurrence under any other cir- ABSCESS OF THE PROSTATE.
cumstances. J. P. Aged 54. Oct. 1854 . А man of
CHRONIC ABSCESS.—The discharge of intemperate
or three
habits since twenty years of age.
attacks of gonorrhoea
matter from an acute abscess ofthe pro- Two
For some years when young.
past hashad occasional pain
stateis sometimes followed by long-con- when passing water , but nothing which he con
tinued suppuration. Chronic abscessmay sidered serious.
arise also by itself, though not very fre- Six months ago exposed severely to wet and
quently ; and it may occur as the result cold ; followed by retention of urine, and was
of confirmed or neglected stricture of the relieved by the catheter. He was unable to pass
water without an instrument after
this , and be
urethra ; in the former case either with
came an in-patient of St. Mary's Hospital. Some
or without any existence of tubercular time after he was discharged, passing his urine
deposit. It is by no means always easy, by the catheter, which he had been taught to
or even possible, to diagnose the existence pass for himself.
of a chronic abscess of the prostate during Dec. 23 , 1853. Hewas admitted under my
care at the Marylebone Infirmary, requiring to
life; in some instances, however, it may pass waterovery hour,which he can do only by
be recognised by rectal examination . A means of the catheter ; and he suffers severe
part of the prostate may yield sensation pains about the perineum, pubes, and loins if
of Auctuation to the finger in the rectum ; the relief is not afforded . No tenderness in
and if this is obvious in a case where the hypogastric region ; nothing particular noted
history and symptoms have been such as after rectal examination; no tenderness within
reach of finger there . General condition weak.
to render the occurrence of chronic abscess No. 8 catheter passes easily into his bladder.
there probable, it is advisable to take After several observations it is noted that some
means for evacuating it. This may be urine flows before the instrument passes quite six
done by passing a grooved sound into the inches; after passing it farther , more can be
bladder, and making an incision into the drawnoff;ofno
condition thecalculus,
bladder but a tender and rugose
is detected.
spot detected. It by no means necessarily During the following three months, he pot
follows that we are to open the urethra in ably improved after injecting the bladder with
these cases, although it has frequently solutions of nitrateof silver, increased from halt
been done without producing any mischief a grain to 1 grain to the ounce. He retained
the mucus disappeared,
his urine three hours,
in the shape of fistula afterwards. Some and the pus greatly diminished.
interesting illustrations of this fact have In April, 1854, he succumbed to an attack of
been given by Mr. Meade, of Bradford.2 pneumonia. Autopsy fourteen hours after
When we are in doubt as to the wards.
On removing
physical signs of abscess, and only suspect kidneys the layingopen
entire, and penis, bladder,the
ureter, and
urethra
its presence , the indications are almost from above, it was found healthyas far asto
solely those which relate to the patient's the prostatic portion. Here a large cavitypre
general health, and this, as in almost all sented itself, capable of containing 10 or 12
cases of chronic abscess in other parts of drachms of fluid. It undermined the mucous
the body, requires the greatest care. The membrane of the urethra, opening into the
canal by an aperture the size of a florin, situ
digestion must be strengthened , and then ated on the upper part: thus the floor of the
generous diet administered — cod -liver oil, urethra alone remained , forming a kind of
tonics, and pure air, especially at the sea- bridge through the cavity, which extended be
low , above, and on either side of it (see fig . 5).
1 Anat. and Dis. of the Prostate, 2nd ed., p. This cavity is bounded by the capsule of the
128. prostate, the substance of the organ having
2 Med. Times, Oct.20, 1860. A paper on In- disappeared. Passing through the cavity is the
flammation and Abscess of the Prostate Gla nd. right ejaculatory duct found to be dissected out
ABSCESS OF THE PROSTATE . 35
entire. It is dilated , admitting a No. 9 cathe- | communicating with either. There is, never
ter until it leaves the prostate, when it opens theless, a free communication between thiscavity
into the sac of an abscess . The left duct has and the urethra by means of the right ejacula
disappeared, but the opening by which it entered tory duct, for the catheter above mentioned
the urethra remains. On examining thebase passed directly into it. This cavity is capable
of the bladder, a sac is seen occupying the of containing about 6 drachms of fluid, and may
entire interval between the two vasa deferentia be either the sac of an abscess in the cellular
and the vesiculæ seminales, but apparently not tissue, or one originating in the right vas de
Fig . 5. - Abscess of the Prostate.
ferens itself. The latter supposition seems to and bright crimson arborescent injection in
be more probable from the appearance of the patches. The ureters are a little above the
parts. natural size. The kidneys are above the usual
The walls of the bladder are much thickened , size, and present the appearance of interstitial
and the mucous membrane is much injected, ex- deposit, with much tat, under the microscope.
hibiting reddisb, brownish, and greenish tints,
D 2
30 TIE DISEASES OF TIIE PROSTAATE .
Case No. II . the subjacent tissues. It may be occa
Long- STANDING URETHRAL OBSTRUCTION , IN sioned during urinary retention and ex
CONTINENCE. ABSCESS OF PROSTATE AND travasation . I have seen cases in which
RIGHT VESICULA SEMINALIS . ulceration of the prostatic urethra and
neck of the bladder has occurred from
J. T. Aged 73. Admitted to Marylebone maintaining a catheter in the urethra and
Infirmary, under my caro, May 23, 1854. For bladder during too long a period, for the
many years he had much difficulty in micturi.
tion,and incontinence ; beyond this no informa- sake of treatment. An example of this
tion can be obtained, as he is evidently fast may be seen in the Museum of the Royal
sinking, apparently exhausted by disease . College of Surgeons, London ; No. 2551 :
His uring passes constantly, and he keeps a it is described by the catalogue as a ' patch
vessel in bed accordingtohis habit There is oflymph where a catheter rested.' ul
a large opening in the scrotum , which.
gives exit
to much pus. The man is almostpulsele ss and ceration may occasionally be found exist
evidently dying ing after any long - continued vesical dis
Autopsy. Bladder much thickened ; very ease in the elderly and enfeebled, and
rugose; mucous membrane exhibits fine reddish- especially in paralysed patients, from cere
brown and few slatishtints . On laying open bro-spinal disease or injury. It may go
the urethra a
part in the bulb
was found with
thickened walls, narrowed, and much lymph de- on to sloughing, with considerable de
posited on the surface, partially fixing two struction of prostatic tissue in any of these
calculi , each about the size of a smallpea . In cases .
the prostatic part was seen an opening into the After all, there is nothing special in
sac of an abscess, formed by the capsule of the
prostate, precisely like that justdescribed in the these forms of ulceration as affecting the
preceding case ; with the floor of the urethra prostate ; it is a morbid action alike af
bridging over it. Behind it was another abs- fecting its tissues and those of all other
cess, involving the right vesicula seminalis. soft parts in the organism when their
Both kidneys
large cysts much diseased, and containing vitality is impaired by certain morbid
. As far as the abscess of the pro- conditions local or general.
state is concerned, fig. 5 represents the condi
tion very correctly. There is no specific forin of ulcer
affecting the prostate ; nothing peculiar
ULCERATION OF THE PROSTATE.—The to it as an organ, as there is in the stomach,
urethralmucousmembrane of the prostate for example. There is no ground either
suffers ulceration as a consequence of for believing it to be the subject of any
previously existing lesions, Pure idio- specific chancrous ulceration, except in
pathic ulceration is probably extremely those very rarely observed instances in
rare. Thus, when an abscess opens into which such an affection has made its way
the urethra, the tissues around become along the urethra, and even into the blad.
ulcerated, and the opening remains during der.
a certain space of time ; such cases have Further, as ulceration almost never
chiefly furnished the examples of ulcera- exists apart from some other morbid con
tion described by authors. A like condition of the prostate, bladder, or urethra ,
dition exists in the discharge of tubercle, and never except as a consequence of
or in the sprouting of malignant growth . some prior lesions there, it is manifestly
A slight tubercular deposit into the mu- impossible to offer any description of the
cous membrane of the prostatic urethra symptoms characteristic of it. Neither
has been noted as leading to ulceration in relation to symptoms nor to treatment
there : more commonly it affects the lin- of ulceration in the prostate, is there
ing of the bladder and the vesical orifices any specific indication beyond that of
of the ureters. So also, after the impac- treating the general and local symptomsas
tion of a calculus, either entire or in the they arise, in accordance with principles
form of a fragment, ulceration may take already laid down under the head of acute
place. After long-continued and aggrava- and chronic inflammation, in the preceding
ted stricture of the urethra, followed by chapter ; and by removing the cause , if
dilatation of the canal, passing through it be a removable one, such as stricture of
tie prostate, and thinning of its mucous the urethra, or calculus of the bladder or
membrane, I have not unfrequently ob- of the prostate, which has given rise to
served chronic ulceration affecting it and the ulceration.
37
CHAPTER V.
HYPERTROPHY OF THE PROSTATE.- ITS ANATOMICAL CITARACTERS .
External Characters of Hypertrophied Prostate - Parts chiefly affected - Amount of Enlargement

produced - Changes in Urethra and Neck of the Bladder which result- Internal or Structural
Changes produced — Varieties of Hypertrophy.
HYPERTROPHY OF THE PROSTATE.— Among as always abnormal . Absolute proof of
men who have passed the prime of life, this appears to be wanting, but I think
or, to speak more definitely, those who that seven drachms may fairly be con
bave passed the fifty -fifth year, or there. sidered as indicative of hypertrophy when
about, as far as the most carefully pro- found in a subject of about 60 years of
secuted researches tend to show, a peculiar age. I have never seen a prostate of that
affection of the prostate is commonly, but weight which did not present other indi
by no means generally, met with . The cations either of external physical, or of
organ enlarges by a slow and gradual pro- internal structural changes, corroborating
cess, and mostly produces more or less the suspicion aroused by thefact of weight.
obstruction to the discharge of urine from On the other hand, I have seen a pro
the bladder. This enlargement, as will state weighing less than six drachms, which
be seen when we consider the details of afforded unmistakable evidence of the
the subject, is not a product of inflam- existence of hypertrophy in the conforma
matory action, nor is it caused by any tion, &c. The possibility of this can be
results of inflammation corresponding easily understood when we recollect that
with those which constitute inflammatory in some individuals a prostate of less than
enlargements in other organs ; that is, the four drachms is of normal size.
albuminous, fibrinous, or other exuda- The first external character generally
tions, such as occur in lymphatic glands, observable in an hypertrophied prostate is
for example ; but it is due to an increased undue fulness,and an unnatural tendency
formation of the normal tissues of the to rotundity. Almost always the gland
prostate, and is therefore to be classed as thicker than natural . Neither the
an hypertrophy. length nor the transverse measurement
MORBID ANATOMY. — It will be con- may be necessarily increased, while the
venient to study the morbid anatomy of measurement from before backwards(erect
this affection under the following heads : - position) is almost invariably increased.
I. The external physical characters Hence the fulness remarked. The sur
belonging to the hypertrophied Prostate. face markings described in the section re
II. The parts of the Prostate chiefly lating to healthy anatomy disappear ; the
affected by Hypertrophy. external indications of bilobular forma
III. The amount of enlargement pro- tion diminish. If a section now be made
duced by Hypertrophy . through the anterior part (anterior com
IV. The anatomical changes in the missure), so as to lay open the urethral
Prostatic Urethra and neck of the blad- canal longitudinally, the lateral lobes ap
der, induced by the Hypertrophied Pro-
> pear fuller than natural, and to protrude
state . a little into the passage, so that their
V. The internal or structural changes opposed sides press lightly upon each
observed in the Hypertrophied Prostate. other.
I. EXTERNAL PHYSICAL CHARACTERS . In a more advanced stage, the enlarge
It has been already seen that it is ment is more considerable ; either lateral
scarcely possible to describe, in exact lobe may predominate , or the portion
terms, the limits, in respect of either behind the verumontanum , ' medidan por
weight or size, of a healthy prostate, any tion ,' may be largely develope . The
addition to which must necessarily and form or outline of the gland may be very
consequently be regarded as indicating irregular and unsymmetrical from the
hypertrophy. By some observers a weight presence of projecting portions, which
exceeding six drachms has been regarded | may result from two conditions — first
either lobe may protrude greatly beyond this subject, and these are now numerous,
the others, as just alluded to ; or inde- show that no one portion of the organ
pendent tumours may be found embedded exhibits any marked predominating ten
in it, or partially so, springing from the dency to enlarge above the remaining
surface, and forming very salient projec- portions, either in point of early mani
tions in any direction, most commonly, festation, rapidity of growth , or extent of
however, towards the cavity of the blad- development.
der. When these are present and largely Writers, and surgeons generally, seem
developed, the original form of the pro- to attribute to the median portion (“middle
state is often obscured, and a mass of lobe ' ) the earliest tendency to enlarge, as
rounded prominences, sometimes nume- well as to regard this as the source of the
rous, and generally irregularly placed, most considerable development in point
surrounds the neck of the bladder. See of size. As regards the locality of com
fig. 16, p. 56. In any oftheseconditions mencing enlargement, I do not think the
2
the urethra, as it passes through the pro- median portion exhibits the change at an
state, may be diverted aa little right or left earlier period than the lateral lobes, but,
of the middle line through pressure by as regards the rate of development, the
the most enlarged part ; the prostatic former, perhaps, progresses more rapidly
portion may be increased in length (neces- than the latter. At the same time, most
sarily with the increased length of the of the preparations contained in four of
prostate itself ), and the antero-posterior the principal museums of London, includ .
diameter of the canal is often much in- ing that of the Royal College of Surgeons
creased by reason of the enlargement of each one of which I have carefully ex
the lateral lobes. To all these changes amined, and possesswritten notes respect
the capsule accommodates itself, and in- ing) , amounting to a total of 123 speci
creases commensurately with the increas- mens, exhibit about an equal development
ing gland. in size of at least three portions of the
In external colour there is no dif- organ ; that is, of the lateral lobes and
ference ordinarily observed ; unlike to median portion, while in many the anterior
malignant enlargement, in which hetero- commissure is correspondingly enlarged.
logous formation and increased vascularity I have classified the preparations referred
are accompanied by marked yellow, red, to in distinct groups,marked by the direc
and violet tints in some variety of shade. tion or situation in which the enlargement
In consistence, there is usually some is chiefly manifested, a method which will
change ; the hypertrophied prostate is afford the means of obtaining a compre
commonly more firm and dense to the hensive view of the question under con
touch than the healthy : one experiences sideration . The first group consists of
a sensation suggestive of structures firmly the four varieties of form which most
bound within a tight or stretched envelope, commonly occur ; the second group of
the tru fulness of which is apparent if a three varieties of form which are deci
section is made, when the contained parts dedly rare.
protrude, or the containing parts recede,
I. General enlargement of pro
affection
so that the cut surfaces become more or r

less convex. In a few exceptional ex- state, that is, both lateral lobesand
forms
the
amples this does not occur, but it is un- median portion pretty equally en
of
.
doubtedly the rule. larged, is present in 74 preparations

II. The parts of the prostate which of the 123 .
are chiefly affected by hypertrophy. II. General enlargement of
There is no part of the prostate which prostate, but the median portion
may not be affected by hypertrophy. enlarged in greater proportion ; in
The lateral lobes, the median portion, or 19 preparations.
middle lobe, the anterior and posterior III. General enlargement, but
commissures, are all capable of exhibiting the right lobe predominating, and
this change, although in different degrees very decidedly larger than the left ;
Comm
of extent, as regards both their several in 8 preparations.

liability to be affected, and the extent IV. General enlargement, but
which development may attain when the the left lobe predominating, and
affection has taken place. decidedly larger than the right; in
The data for forming a conclusion on 11 preparations.
Uncommon
HYPERTROPHY OF THE PROSTATE. 39
affection
forms V. The lateral lobes only en- III. The amount of enlargement pro
the
of
.
larged ; in 5 preparations. duced by hypertrophy.
VI. The anterior commissure It bas been shown that a weight of
only , or chiefly enlarged ; in 3 pre- about 400 grains, or nearly 7 drachms,
parations. must be regarded as an example of hyper
VII. The lateral lobes and an- trophy, the average weight of a healthy
terior commissure enlarged, not the prostate being about 270 to 300 grains,
median portion ; in 3 preparations. or 44 drachms. Now the weight may be
The several series of preparations considered a very fair index to size, and
tabulated in Chapter II. furnish results is sufficiently so for all conceivable practi
very closely corresponding with the fore- cal purposes, since the amount of increase
going, including two series of 64 pre- in one corresponds (on trial) very closely
parations by myself, and another, con- with the amount of increase in the other.
tinuing my own observations, by another The proof of this can be made by calcula
observer, Dr. Messer, formerly of the tion from the amount of water displaced
Royal Naval Hospital, Greenwich. These by immersion , an experiment very easily
results are more valuable than those ob- applied to a few cases. Where, as often
tained from museums, because they con- happens, the structure is denser than in
and not of selected speci- the healthy prostate, a slight increase may
sist of average
mens. Among 100 prostates from sub- be allowed in calculating the true amount
jects of 60 years old and upwards, Dr. of hypertrophy. However, it is scarcely
Messer found 35 which were enlarged . conceivable that such exactness can be re
He reports, that in 17, or about one-half quired in any given case.
of the number, all these lobes were
pretty equally enlarged ; ' that in 14 both
lateral lobes were chiefly affected ; that in
one case the left lateral and middle lobes
were mainly affected ; that in one the
right lateral lobe was niostly ; that in
one the left lateral lobe was alone ; and
that in one the middle lobe ( median por
tion ') was chiefly affected ; in all 35.1
The general inferences which must be
drawn from all the facts adduced are Fig . 6 .
(a) That the lateral lobes and the
median portion, or middle lobe, Taking weight, then, to correspond
are equally liable, or nearly so, to with the amount of hypertrophy, and as
be affected with hypertrophy. very fairly indicating the increase in size
(B) That the posterior commissure is in all cases, it is unnecessary to record
generally involved with the pre- rectilinear measurements of so irregularly
ceding enlargements, and in pro- formed a body as an hypertrophied prostate
portion to the extent which they most commonly is, but to furnish, under
manifest. the topic here considered, the amount of
(y) That the anterior commissure is augmentation in weight which the hyper
not frequently affected, but never- trophied prostate does ordinarily attain,
theless is so in rare instances. and that which it may occasionally and
(8) Lastly, that development takes extraordinarily exhibit.
place at about an equal rate in My own dissections (see table) afforded
each of the three principal divi- 20 examples of hypertrophied prostates,
sions ; in some cases the lateral from persons at and over 60 years of age.
lobes appearing to enlarge more Those only are reckoned to be so which
rapidly than the median portion ; presented physical evidence of the change,
in others the contrary effect is without regard to weight. These 20
found, and perhaps in a rather ranged from 6 drs. 20 grs. to 18 drs.
larger number of cases than in the The mean weight is about 9 drs. 15 grs.
preceding. The most common weight is from 7 drs.
1 See a valuable report on this and other questo 10 drs.
tions
the prostate, Dr. the
connectedbywith anatomy
Messer.— Trans. diseases
and Med of
. Chir. A very good example of the earliest
Soc. vol. xliii. p. 153. stage of hypertrophy is shown at fig. 6
it was taken from a subject aged 62 years ; mean weight was 15 drs. 2 grs. The
weight of prostate, 6 drachms 5 grains. most common weights ranged between
The portion lying above the duct is pro- 7 drs. and 14 drs.
truding upwards. A small fibrous tumour From these data it may be inferred
was found in each lateral lobe ; and one of that the most usual weight for an hyper
them may be seen projecting a little into trophied prostate which has existed some
the urethra, and rendering the mucous ten or twelve years, is between 9 and
membrane slightly prominent (indicated 12 drachms, or more than double the
in the figure by an asterisk ). natural size. Nevertheless, many cases
Dr. Messer's dissections afforded 35 exceed this limit considerably. The
examples of hypertrophy from persons at largest example of hypertrophy known is
and over 60 years. The 35 ranged be- 9 or 10 ounces, or about 75 drachms.
tween 6 drs. 15 grs. and 48 drs. The The size of such a mass, forming a pre
Fig. 7.-A good example of Extreme Hypertrophy. ( From a preparation in the

Museum of University College.)
paration now in the museum of University is not thought necessary to allude further
College, is nearly that of a cocoa-nut ; here to their statements respecting it. A
but such an example is extremely rare. large orange is the simile furnished to
In malignant disease even these limits are describe the largest example observed by
exceeded. Other observers, including Mr. Howship . Sir Charles Bell speaks of
John Hunter, Sir E. Home, Mr. Howship , one'as a monstrous enlargement of the
Sir Chas. Bell, Sir B. Brodie, Mr. Staf- prostate gland, probably the largest in
ford, Dr. Gross, Mr. Adams, Dr. Hodgson , this country.' 2 This is now in the museum
MM . les Drs. Civiale, Mercier, Leroy of the College of Surgeons, Edinburgh
d'Etiolles, and Rokitansky, have estimated ( No. 2071 , xxxii. B), and may be de
the extent of hypertrophy in general, but
not in precise terms; and as it does not 1 Diseases of the Urinary Organs. Howship
London , 1823. p . 299.
appear that they have pursued any exact 2 Treatise on the Diseases of the Urethra, 8.C.
rosearches in relation to this question, it p.423. London, 1822.
IIYPERTROPIIY OF THE PROSTATE . 41
scribed as having the volume ofaa medium. | which I have examined, the uretlıra has
sized cocoa-nut. Dr. Gross describes a measured three inches from the orifice of
specimen as weighing 9 ounces. the bladder to the membranous portion,
I have once operated for retention in a instead of one inch and aa quarter, which
case which was at least as large as a full- is the normal length.
sized cocoa-nut, but had no means of The next effect is aa deviation from the
making any exact estimate of it after natural direction ; and this varies with
death . each form of enlargement noted. Thus,
IV. The anatomical changes in the where there is enlargement of, or out
prostatic urethra and neck of the bladder, growth from , the median portion , the form
induced by the hypertrophied prostate. of all kinds most generally present, a
The most important result of enlarge- change in the direction usually commences
ment, at all events in any of its four common about the middle of the prostatic urethra ,
forms, is obstruction to the flow of urine. its posterior wall being carried upwards,
Very rarely is it otherwise, although there or upwards and forwards, in the erect
appear to be some cases, few and excep- position of the body , producing a more or
tional, in which the condition of the Fig . 8.
vesico -urethral orifice is so altered, that
the bladder is unable to retain the urine,
which consequently runs off as fast, or
nearly as fast, as it enters the viscus from
the ureters; a subject which will be more
fully discussed hereafter. Admitting, then,
that the result almost uniformly met with
is obstruction , producing more or less re
tention in many instances, it is obviously
one of the most important parts of the
present inquiry to ascertain the influence less angular curvature in the place of a
of enlargement upon the form, size, and nearly straight line. Examples of this
direction of the urethra.
deviation are shown in the adjoining
The first effect to be noted is one figures, which, although diagrams, repre
which is common to all the first four
forms of enlargement : viz . , increase, Fig . 9.
sometimes considerable, of the antero
posterior diameter of the prostatic ure
thra . Associated with this is diminution
of its lateral or transverse diameter ; so
that the canal becomes a narrow or chink
like passage, instead of one which, when
distended , is of about equal diameter in
every direction . The lateral lobes, in
creasing, not only encroach laterally upon
the canal itself, but gradually carry up
wards that portion of the urethral wall
which is constituted by themselves, and
that to such an extent that I have seen sent in profile the form of the actual
the slit-like opening produced by the specimens from which they were taken
antero- posteriortransverse section in such after death.
a case measuring three-fourths of an inch . The direction , in early stages of en
The length of the prostatic urethra is largement, is usually more or less that of
algo materially increased by the same a simple curve, but in more advanced
forms of enlargement. The increased stages it may be almost angular, so that in
magnitude of the encompassing body in some instances a complete step has to be
every direction involves an addition to the surmounted at the neck of the bladder
length of the passage which passes through before an instrument will enter the cavity
it. But it is often rendered tortuous also, ( figs. 8 and 9). Now, when associated
which further contributes to the augmen- with this undue development of the
tation of its length. In some preparations median portion, there is a predominating
Urinary Organs, 2nd ed. p. 688. enlargement of either lateral lobe, it is
obvious that the lateral direction of the absence of any predominance of a lateral
canal will be also changed. Thus, if the lobe, where the median portion is largely
right lobe predominates, there will be a developed, a similar kind of deviation is
lateral curve of the urethra, the convexity often met with, only it is not necessarily
of which ispresented to the left, and vice confined to one side, but may exist equally
versâ. And as the predominating lateral on both . The vesical end of the urethra
lobe is almost always found in connection being divided by a large median out
with a large median portion, and is usually growth of pyriform shape, a passage is left
more or less blended with it, the direction on either side of it, giving to the canal
of the urethra will be upwards and to the there the form of the letter Y ( figs. 11
right, or to the left, as the case may be and 12 ). In these diagrams, drawn, like
( fig . 10). Sir E. Home, up to the date of the foregoing, from actual specimens, the
publication of his first volume on the line which the catheter must take is indi
prostate gland, had never seen predomi- cated by dotted lines. And the degree of
nating enlargement of the right lateral lobe, vertical direction associated with it fre
and he inferred, as a rule of someimport- quently depends upon the amount of
FIG . 10. mucous and submucous tissue drawn up
by the growth, on each side of which, at
the vesical orifice, it forms a kind of semi
circular bar. It is hardly necessary to
C Fig . 11 . Fig . 12 .
a
3
3
a
a. Right lobe.
a. Right lobe of prostate, considerably enlarged. b. Left lobe.
b. Left lobe , less so . c. Median portion
c. Tumour from median portion blended with left (“middle lobe ').
lobe, and consequently deflecting the urethra
to the right side. Thecourse which an instru- allude to the importance of calling to
mentmusttake in such a case is indicated by mind, when instrumental aid is required,
dotted lines.
the frequency with which lateral deviation
ance in relation to the introduction of is found to exist in largely developed
catheters in enlarged prostate, that such forms of prostatic obstruction.
an enlargement, and by consequence, that The next deviations are those to be
a deviation of the canal to the left either observed in the form of the internal mea
did not occur, or was extremely rare. He tus, or vesico -urethral orifice, which in its
met with an enlarged right lobe,however, healthy condition is too well known to
before the publication of a second volume require description. When, however, the
on the same subject, but still regarded it posterior median portion is predominant,
as uncommon, and in this light it has been the vesico -urethral orifice acquires a cres
viewed, I observe, in the latest works on centic form , the convexity of which is
this subject.. There is, however, no directed upwards. When the right lobe
ground for supposing that there is any considerably exceeds in size the left, the
difference in the liability of either lobe to crescent has its convexity to the left side,
the affection, since among the existing and so on . In some preparations, where
specimens the predominating lobe is to be two or more irregularly enlarged lobes
found in nearly equal numbers to the are combined , the orifice is very much
right and left respectively. But in the distorted, presenting an elongated and
HYPERTROPHY OF THE PROSTATE . 43
tortuous 'outline. Sometimes it appears the internal meatus the same result takes
to be overlapped altogether, when an out- place ; thus in the instance represented at
growth from the posterior median portion fig . 14, where it was extremely so, the
affects a valvular form , or has a narrow patient was almost incapable of passing
peduncle. In these circumstances, which water by his own efforts.
however, are not very commonly met It occasionally happens, but very
rarely, that one result of prostatic enlarge
ment is undue patency , and not obstruc
tion of the urethro - vesical orifice ; and
this circumstance, erroneously regarded ,
indeed, as not infrequent, is supposed to
explain the occasional occurrence of
genuine incontinence, the bladder being
empty, in the place of retention of the
urine. Submitted to the test of extended
anatomical research , the following facts
appear :—First, it is very rare to find ex
pansion of the internal meatus. Secondly,
when it does occur, it is almost invariably
associated with distended and hypertro
phied bladder, proving incontestably that
obstruction was present during life, and
that retention, not incontinence, was the
result.
The expansion of the vesico - urethral
orifice, which prevents the bladder from
FIG . 13.- Partof the bladder and the prostate, retaining urine, is accounted for in the
from a man aged 65. The lateral lobes are following manner :-The lateral lobes
about equally hypertrophied. The enlarge being considerably enlarged, the tumour
mentattheneckofthe bladder was constituted of the median portion, instead of project
by three or four small tumours originating in
the median portion. Obstruction to the outflow ing backwards into the bladder in the
of urine during life was very considerable. usual manner, enlarges between the hinder
parts of the two lateral lobes themselves,
with, the valvular portion appears to be and opens them out as by the action of a
forced against the neck of the bladder by wedge, giving to the meatus an expanded
the effort of micturition , and the obstruc- and triangular appearance. I have care
fully examined the histories attached to
preparations exhibiting this peculiarity,
and where these have been wanting have
verified the existence of an hypertrophied
and distended bladder, and in no instance
have I been satisfied that real inconti
nence, 'that is, unassociated with reten
tion , existed during life. Anterior to the
vesical orifice, it may further be added,
there is usually a sufficient degree of en
croachment of the lateral lobes upon the
canal to produce considerable obstruction
and habitual retention of urine. I am
Fig. 14 .-— Internalmeatus of urethra as seen from quite aware that the condition and its
the bladder: two or threesmalltumours pro- alleged result sometimes co -exist; but
ducing nearly total obstruction. that such cases are frequent I have no
hesitation in denying.
tion rendered still more complete. Figs. The following is an example of it.
13 and 18 show this condition on a small A man who died at the Royal Naval
scale, not unfrequently met with, but in Hospital, Greenwich, at the age of 84
both cases the effect was almost complete years, did not suffer from any retention
obstruction. Occasionally the tumour of urine during life, yet at his post
may be very small, yet if it is engaged in mortem examination Dr. Messer found a
prostate weighing no less than 26! thicker portionsof the mass presented by
drachms ; it contained many tumours. a considerably hypertrophied prostate,
Dr. Messer makes the following remark such being usually one of the lateral
respecting this question : lobes, certain peculiarities of appearance
' It may be remarked that, in cases are observable. These may be noticed
where the hypertrophy is advanced, and under two heads : viz., first, those com
the tumours tend inwards, the urethra mon to all hypertrophied prostates ; and
becomes greatly expanded , and the inter- secondly, those which are met with in
spaces between the rounded sides of the only some of them.
projections into it serve as channels for First.- Characters which are common ,
the urine to pass away by. This condi- although in greater or less degrees of pro
tion will frequently explain, I have no minence, to all hypertrophied prostates.
doubt, the occasional absence of symptoms When a section of the gland is made,
of obstruction in cases where the pro- (a. ) The surface bulges irregularly ;
state is known to be considerably en- (6.) It is, also, more or less parti
larged .''1 coloured ; and
But there is another point of view (c.) It is striated in places with small
from which the development of the en- tortuous blood-vessels.
larging prostate may be regarded. The (a .) IRREGULAR BULGING.—There is a
tendency is, in some instances, strongly general protruding of the cut surface of
manifested in a direction towards the the prostate, above the level of the
centre of the organ, or the neck of the border of the divided capsule, a condition
bladder. In others, it appears to affect not seen in section of the normal organ.
an opposite direction, to become de- It is obvious, also , that portions of differ
veloped very largely at its periphery. In ent size, and sometimes of spheroidal form,
the fornier, which may for brevity's sake are more tumid and prominent than the
be denominated centric hypertrophy, the rest ; these are by no means always in
outflow of urine may be very materially dependent tumours, as we shall presently
obstructed before the prostate has in- see.
creased much in the matter of weight and (6.) PARTI-COLOURING . — It is equally
size. In the latter, which may be de- obvious that the shades of colour affecting
scribed as eccentric, or peripheral, a very the cut surface have a greater range in the
large development may take place, and an hypertrophied than in the healthy pro
enormous prostate may be encountered in state. Always parti-coloured to someex
the rectum, and yet little obstruction to tent as the latter is, the former is more so ;
the course of the urine will be mani- varying from pale dingy yellowish - grey
fested. This, it is almost unnecessary to and buff to yellow , the last sometimes
remark, is a form far more favourable for deep in tint. Red patches sometimes
the patient than the other. It lately oc- intervene between paler portions ; and
curred to me tohave the opportunity of small black spots, collections of dark con
examining a striking example in the case cretions, are seen interspersed in follicles
of an elderly gentleman lately seen in or in ducts.
consultation .
He expelled his urine very (c.) The redder portions just referred
frequently, and with difficulty, but emp- to are generally easily resolved by the
tied the bladder completely . There was naked eye into fine arborescent vascular
no residual urine on introducing the cathe- injection ; deeper in tint than that seen
ter after the act of micturition ; a fact in the healthy organ .
verified, not only by myself at the time Secondly. -Characters which are met
referred to, but by his ordinary attendant with in some hypertrophied prostates, but
on numerous occasions. Nevertheless, the not in all.
prostate formed an enormous tumour in In some glands, the spheroidal promi
the rectum, presenting an unusually nences displayed on section are easily enu
marked example of enlargement there cleated : they are then firm , pale, and
7
when digital examination was made. destitute of much moisture. These are
V. The internal or structural changes simple tumours , contained in the struc
observed in the hypertrophied prostate. ture of the prostate ; formations so com
A. The naked- eye characters. monly met with, and playing so important
When we make a section of one of the a part in connection with the pathology of
1 Op. cit. p. 153 . the prostate, as to demand a separate con
IIYPERTROPHY OF THE PROSTATE. 45
6
sideration. (See Chapter VI. relating to small proportion of liquor' or fluid
Tumours.) medium .
Other prominences are loose in tex- B. The structures of hypertrophied
ture, partially separable from the surround. prostate, as examined by the microscope.
ing structure, but by no means to be enu- Regarding the elementary fibres of
cleated. These have often quite as much different kinds, of which the normal
of the yellow tint as the surrounding prostate has been shown to be composed
parts ; and they have a moist succulent (see Healthy Anatomy), we may com
character. They are single gland -lobules, mence by affirming that the hypertrophied
which seem to have become larger than prostate, when submitted to the closest
the neighbouring"gland-lobules ; and they microscopical scrutiny, presents no new ,
are much larger than those found in the or other elementary, structure whatever
normal prostate. than those there described . The existing
This condition is by no means un normal structures are simply augmented
commonly met with. It seems to indicate in quantity. They may , however, al
that a true hypertrophy may affect a though not necessarily, exist in different
portion of the organ, while adjacent por- relative proportions to each other, or they
tions are normal or but slightly affected. may be arranged in a form differing from
Thus one lateral lobe may be consider that which obtains in the normal state.
ably hypertrophied, while the other is These structures are, as we have
scarcely altered in size. When single already seen,
lobules are affected in this manner , it (a. ) Fibrous structures; viz., pale
suggests the existence of a condition in- muscular fibre, connective tissue , and
termediate between general hypertrophy elastic tissue ; and -
and isolated tumour, and furnishing a (6.) Glandular structures ; viz. , base
link between them . ment membrane forming recesses and
There is another very marked differ- excretory ducts ; both lined with epithe
ence observable in examining hypertro- lium , polygonal and prismatic, and con
phied prostates, which separates them taining secreted matters.
into two somewhat distinct categories. The former (a) have been termed the
A typical example of the one kind basic or stromal part of the organ ; the
exhibits, on section, an abundanceof fluid latter (6) the glandularpart.
exuding from the cut surface, and slight Structurally regarded, the prostate
pressure greatly increases the quantity exhibits abnormal development in four
issuing. Similar fluid issues freely from varieties or types, all of which are fairly
the orifices of the prostatic ducts in the included by this term hypertrophy.
urethra . Such, at least, is the result of an
A typical example of the other kind examination of very numerous specimens,
shows no fluid on section, neither on which, being necessarily destroyed by the
pressure is there any, or scarcely any, process, were not included the tables.
from the orifices just named. The four varieties of hypertrophy,
These conditions are easily explained structurally considered, may be defined
by the varying amounts of active gland- as follows:
tissue present in the two cases, as will be 1. Simple increased development of
seen under the next division of the subject. all the component tissues of the
Again, in some instances small cavities organ in about equal ratio.
are disclosed by section ; these are some- 2. Excess of developmentin the stromal
times empty, and sometimes give issue to portion over the glandular portion .
a drop of thick yellow fluid, exactly like 3. Excess of development in the glan
pus to the naked eye. These are by no dular portion over the stromal.
means necessarily abscesses, and are not 4. Re -arrangement of the structures,
so unless some inflammatory action has stromal and glandular, in the
been present, a condition studied under its form of tumour.
appropriate heading. We may so far an- The first form of hypertrophy is that
ticipate the next section ofthis chapter as which is generally observed in those
to say that this yellow matter is, when not examples in which the size of the organ
pus, the prostatic concretion in a more is not very greatly increased , although
concrete state than natural, and containing the morbid action may have continued
the cell and allied elements, with a very for a long period of time. The normal
relative proportions of different parts are small quantity. The larger portions of
not greatly disturbed ; there is general stromal tissue, unmixed with glandular ,
fulness ; increase of weight, to perhaps are situated usually near the periphery of
about double that of a healthy organ ; the organ , in the lateral lobes, lying be
and, generally speaking, there is no single yond the glandular lobules, and forming
portion of it which much predominates sometimes a thick stratum between them
Neither and the capsule.
in size over the other portions.
on section nor by pressure does any It is hardly necessary to observe that
undue amount of secreti on appear, neither this form is to be distinguished from that
does there seem to be any deficiency. enlargement which results from inflam
Under microscopic examination, such matory action, and which is considered
a specimen shows few characters differing by itself in the Third Chapter. That
from those observed in the normal organ. action occasions a deposit of its own
There is some dilatation of the gland- proper products ; but there is no reason
follicles, a condition present in all hyper- to believe that it has any power to gene
trophied prostates that I have examined. rate any of the natural structures of the
Many of these are blocked up with yel- prostate. Their overgrowth is a true
lowish semi-fluid contents, which appear hypertrophic formation ; while the lymph
to be the prostatic secretion in an inspis- of inflammation is the result of a morbid
sated form , and the well-known prostatic effusion, and as such becomes in course of
concretions. This semi- fluid matter, time in part removed by the unassisted
1
although often resembling exactly pus to efforts of nature.
the naked eye, is resolved by the micro- It is common to find, especially in the
:
scope into the following constituents :-a larger specimens, cavities measuring one
clear liquor, loaded with epithelium ; or two lines in diameter, lined with
both prismatic and ovoid or polygonal smooth membrane, often empty, some
(the former from the ducts, the latter times containing several concretions.
from the vesicles) globules of highly re- Abundance of these latter are commonly
fracting matter resembling fat, but pro- found in and among the glandular parts
bably not so ; much amorphous granular of the organ , where also may be found
matter ; and small amber -coloured semi- some collections of the yellowish semi
transparent concretions. These concre- | Auid matter described above.
tions are also found lodged in the ducts, 3. Excess of development in the glan .
and very often at or near their orifices in dular structures over the stromal.
the urethra. This condition is exceedingly rare . I
2. Excess of development in the have examined certainly one, if not two,
stromal portion over the glandular portion . such specimens, and record them here in
This is no doubt the form in which consequence. The gland, in the first
hypertrophy most commonly exists. It instance, weighed about 14 drachms, and
has been said to be the invariable condi- hypertrophy appeared to affect each part
tion which constitutes hypertrophy of the in a pretty equal degree. When cut,
prostate ; this, however , is certainly not muchº fuid exuded , the structure was
the case . In the larger, and in the very extremely succulent, and the yellowish
largest examples — we may say those glandular parts obviously predominated
weighing from 2 ounces upwards — this over the greyish stromal part.
form of hypertrophy is almost the only Under the microscope, gland-structure
one met with ; that depending upon a
considerable formation of tumours (class i Dr. C. H. Jones appears to have been the first
4) being sometimes excepted. to point out the fact that senile hypertropby was
frequently due to increase of the tibrous element
Under the microscope, we meet, in ratherthan of the glandular.- Medical Gazette,
well-marked specimens of the class now August 20, 1847.
under consideration , with large portions ternt parenchymatouofs enlargement
It is this form
6 hypertrophy'tohasbeen
which ap
the
of stromal structure, unaccompanied or plied, and particularly by Dr. Hodgson, of Glasgow,
not penetrated by any glandular structure. in hisworkon the prostate gland,
Dr. Messer regards
London,1856.
enlargement
the as pro
Portions of thegreyish material which duced principally by hypertrophy of thefibrous
pervades the mass may be unravelled tissue which naturally exists in the organ.The
under water on the glass slide, and no gland-follicles also
gland- structures be found in it : in other numerous, but do notbecome enlarged , and more
affect the size of the organ to
the same extent as the fibrous development.
portions these latter are found in very Op. cit. p. 150.
TUMOURS AND OUTGROWTHS OF THE PROSTATE . 47
was seen to abound throughout the organ, of arrangement ; rounded masses, often
and gland products pervaded almost every quite isolated from the adjacent prostatic
part . The gland-follicles were a little structure, by which , nevertheless, they
enlarged , that is, to about double their are surrounded , are found in all parts of
average size ; besides these, several the organ . Some of them are adherent
cavities, containing the yellow semi-fluid to the adjacent parts, continuity of struc
matter, were present. There can be no ture being evident at limited portions of
doubt that in this case the glandular their periphery.
structures existed in a larger proportion If we examine microscopically one of
to the stroma than that which is met these bodies , the stromal tissue of the
with in the normal prostate. A second prostate is at once identified, and is found
specimen was examined, the condition of forming almost the whole of the mass ;
which approximated to the preceding, although some small proportion of glandu
but it was not quite so well marked . lar structure is generally discoverable also ;
4 . Re-arrangement of the normal but this, unlike the fibrous stroma, differs
structures of the prostate, fibrous and usually from the corresponding elements
glandular, in the form of tumours. in the healthy organ, by being less com
As before stated, we have here to pletely developed, exhibiting often an im
deal only with the elementary constituent perfect or aborted condition of the gland
tissues of the organ ; but they no longer vesicles and follicles. These tumours, so
exhibit the primordial arrangement, as frequently associated with hypertrophy of
they do in those forms of hypertrophy the prostate, are peculiar in character ;
which have been already described. In their full consideration, therefore, will be
these cases, the tissues assume new modes deferred to the succeeding chapter.
CHAPTER VI.
TUMOURS AND OUTGROWTHS OF THE PROSTATE .
SIMPLE TUMOURS— Frequency of their occurrence - Described by several Anatomists -- Examples

cited — Their Physical Characters and Intimate Structure - OUTGROWTHs - Nature of , Analogy
between these Affections of the Prostate and Tumours of the Uterus — Rare Form of Polypus of
the Prostate - Cases.
SIMPLE TUMOURS AND OUTGROWTHS FROM presence is much more common, I believe,
THE PROSTATE.—In considering both the than is generally supposed ; indeed it
external characters and the intimate cannot be doubted that they are present
structures of the hypertrophied prostate, in a large majority of the cases ofhyper
it has already been necessary to allude to , trophied prostate.
and even in some degree to describe, Thus , in three - fourths of the hyper
certain tumours often met with in the trophied specimens in my own series
organ , as well as the not infrequent tumours were present, as well as in two
occurrence of distinct outgrowths, usually or three which were not hypertrophied ;
springing from that part known as its of the latter, No. 181 is an example; here
median portion. they are extremely minute, although
It may be premised that these forma- quite distinct. Dr. Messer reports the
tions are always of slow growth , and occurrence of isolated tumours in no less
generally of moderate size ; they exhibit than 27 out of 35 hypertrophied pro
benign or non-malignant characters, and states.
are thus wholly unlike any of the can- Of 70 specimens of hypertrophied
cerous formations which will be hereafter prostate in the museum of the Royal
considered as occasionally affecting the College of Surgeons, in seventeen the
prostate. They are found almost al- isolated tumours are so clearly discerned
ways in the hypertrophied prostate, but that the careful observer cannot fail to
are, nevertheless, occasionally met with see them in the preparations as they stand
in the organ of normal size. Their ) in the containing vessels. There can be
no doubt that many more would be found published at Paris about 1833-4, is as
similarly affected if the test of dissection follows. It may first be premised, that
were applied. In a large proportion of the subject of the description was a
the remainder there is an outgrowth, prostate gland considerably hypertrophied
affecting more or less a pyriform shape, taken from a patient who had been cut
projecting from the median portion. for stone by the high operation in one of
It is manifest, from the examination the hospitals, who died soon afterwards,
of all these morbid specimens, that we and had been submitted to a minute post
meet with two distinct classes of new mortem examination,
formations in connection with the pro The tissue of the gland was very
state affected with hypertrophy. easily torn , and in so doing, portions of
A. Tumours which are generally im-an irregular spheroidal form were sepa
bedded in the substance of the prostate,
rated ; the largest of these had about a
but the structures of which are isolated
magnitude of a middle- sized nut. A
from those which surround it. section of the gland exhibited surfaces of
B. Outgrowths which are continuous circular outline, of which each belonged
in structure with the parts of the pro- to one of the spheroids.
state from whence they spring, but which Each of these spheroids was evidently
manifest a tendency to become partially a glandular vesicle or lobule hyper
isolated, by assuming a more or less poly- trophied. The tissue of each lobule pre
poid form and maintaining attachment to sented a cellular texture ' ( to the naked
the parent organ through the medium of eye understood ); " the cells, of unequal
a pedicle only. magnitude, were filled with the prostatic
Both these conditionsdiffer materially liquor. Several of the larger (glandular)
from that already considered as simple vesicles were converted into cells (or
hypertrophy affecting the organ either crypts), and contained a matter, yellowish
generally or partially. The class of out, and thick , like purulent matter.
growths appears to offer examples of a " These large vesicles or lobules, al
morbid formation midway between iso though perfectly independent or isolated,
lated tumour and general hypertrophy. were held together by a framework or
We will study, first, bed of intervening tissue, evidently
A. The isolated tumours of the muscular in its character, and which I
prostate. can compare to nothing so well as to the
The fact of their occasional appear- tissue of the gravid uterus. The prostatic
ance has long been recognised . Sir envelope, very easy to isolate from the
E. Home describes and very clearly muscular fibres of the bladder, was con
depicts them in his work . He believed stituted by a rather thick and whitish
them to be the remains of extravasated muscular layer. . . . Thus we see that
. .
blood -clots in the substance of the gland, the prostate was made up of large vesicles
and he conceived that they were produced or lobules scattered throughout a bed of
by the rupture of vessels, and generally muscular tissue, which furnished aa thick
occasioned by violent exercise, especially envelope for them . Each glandular
by hard riding lobule was cellular in its character .'
Within the last few years the nature Velpeau called special attention to
of these tumours, and their relation to these tumours of the prostate ; and al
the prostate, has been the subject of more though he appears not to have minutely
extended inquiry: examined their histological resemblances
Cruveilhier has carefully examined to other tumours, he pointed out what he
them . This author has a remarkable believed to be an analogy between them
passage, in which he foreshadows some of and the fibrous tumours of the uterus.
the views which some later writers have He says, speaking, in his lectures, of
more completely developed. The original, certain cases of death which had occurred,
which appears in his Anatomie Patho- during the session in his clinique, from
>
logique,' Livraison xvii., descriptive enlargement of the prostate and its conse
letter-press belonging to Plate II., p. 3, quences: '—'When these patients die,
they always present tumours in the
1 Practical Observations on the Treatment of
Diseases of the Prostate Gland, vol. ii . London, | Leçons orales de Clinique Chirurgicale , par
M. le. Prof. Velpeau, tome zie, pp. 478-9. Paris,
1818. Vide pp. 17, 21-25, 273, 277, 285 ; Plates i. 1841
ii . iii. iv , v. vi . and vii.
TUMOURS AND OUTGROWTHS OF THE PROSTATE. 49
prostate. Let us dwell for an instant on the “fibrous tumours of the uterus were
this subject, since it merits particular nothing else than hypertrophy of the
attention. I have attempted to show the normal tissue of the womb.'
relations which these tunours, affecting Rokitansky originally took these
certain individuals, hold to those fibrous tumours to be simple fibrous formations
bodies or tumours which are developed analogous to the fibrous tumours,' loosely
in the uterus. You know that the so called, appearing in other parts of the
fibrous tumours of that organ develop body. Subsequently , when studying the
themselves sometimes very near the subject of bronchocele, and examining
uterine mucous membrane, from which the isolated masses embedded in , and
they soon project ; that they often become situated near to, the hypertrophied thyroid
engaged in the uterine neck , and from gland, which were evidently masses of
thence protrude into the vagina, where gland-tissue like that of the parent gland,
they constitute what is commonly called he remarked a similarity of relationship
7
“ fibrous polypus” of the uterus ; that between the prostate gland and its
at other times they are situated very near tumours, that is to say, those now under
the serous covering of the uterus, become consideration. He found,on examination,
prominent into the abdominal cavity, and that these formations were composed of
give rise to so-called peritoneal fibrous basic structures, identical with those
tumours. If, on the contrary, they are forming the prostate itself, but that the
developed in the substance of the uterine glandular elements were less perfectly
walls, and remain so, they form there the formed, less completely developed, as a
“ fibrous tumours properly so called, rule, than those of the normal and healthy
which sometimes present masses of extra- gland.
ordinary size and weight. He observed also, that the rounded
' I perceive a great analogy between masses were not always confined within
these prostatic tumours
97
and the “fibrous the limits of the prostate gland itself, but
tumours of the uterus . that they were soinetimes found beyond,
' 1. There are some of these 'fibrous as outlying formations, analogous, in his
prostatic tumours, which are developed opinion, to those occupying a like relation
of the vesical
in the directionabsolutely cavity, to the thyroid gland.
pedunculated
which become outlying masses referred
The to are
precisely as do the fibrous polypi of the occasionally met with , although far less
uterus, and become enveloped by the commonly than those which are embedded
vesical mucous membrane. These, with in the substance of the gland. Sir J.
a peduncle more or less extended, may Paget relates a striking example. He
acquire the volume of a nut, or even of writes : Near the enlarged prostate,
6
half of an egg. similar (that is, to those of the thyroid)

2. These fibrous tumours may be detached outlying masses of new sub
developed in the very substance of the stance, like tumours in their shape and
relations, and like prostate gland
prostate, and may acquire a volume tissue, in
similar to that of the preceding.
6
may be sometimes found. A case
( 3. Finally, they may be developed follows of ' a man 64 years old ,who for
at the perineal or at the rectal surface of the last four years of his life was unable
the prostate, and may project towards the to pass his urine without the help of the
perineum, towards the side of the pelvis, catheter. He died with bronchitis; and
or into the rectum . a tumour, measuring 2 inches by 1 },
' Observe, then , a great analogy in was found lying loose in the bladder,
the matter of situation. But there isa onlyconnected to it by a pedicle, moving
great analogy in the matter of structure
also . These
on this like a hinge, and, when pressed
are veritable “ fibrous forwards, obstructing the orifice of the
tumours,” and not mere “ hypertrophy of urethra. Now, both in general aspect
the prostate," as has been said. I do not and in microscopic structure, this tumour
regard these tumours as degenerations of is so like a portion of enlarged prostate
the organ , but rather as new productions. gland, that I know no character by
>
It is notsurprising distinguish them.' ? Speaking

that this (hypertrophy) whichZurtoAnatomie
should be the common idea respecting i des Kropfes, p. 10, von Prof
the prostatic tumours, since for a long Carl Rokitansky. Wien , 1819.
2 Lectures on Surgical Pathology, vol. ii. pp.8-9,
time it has been customary to believe that Iby Jaries-Paget, F.R.S. London,1853. The pre
E:
of the embedded tumours, Sir J. Paget | the tumour was easily turned out ;
says : it was very firm in texture, its
' In enlarged prostates they are not structure consisting of cæcal pouches
unfrequently found. In cutting through filled with epithelium, connected to each
the gland, one may see amidst its gene- other, and surrounded by a fine fila
rally lobed structure, portions which are mentous tissue .' Mr. Gray remarks the
invested and isolated by fibro -cellular analogy which exists between these tu.
tissue, and may be enucleated. . . . They mours and some of the forms ofmammary
lie embedded in the enlarged prostate, glandular tumour ; and he adduces two
as, sometimes, mammary glandular tu. cases in which a glandular tumour existed
mours lieisolated in a generally enlarged within the limits of the external capsule
breast. They look like the lessfasciculate of the prostate gland, which, in its
of the fibrous tumours of the uterus ; but growth, had projected into the cavity of
to microscopic examination they present the bladder, and had been erroneously
such an imitation of the proper structure supposed to be an enlarged lateral lobe.
of the prostate itself, that we cannot dis- The following were exhibited at the
tinguish the gland -cells, or the smooth Society by myself: one, a preparation in
muscular fibres of the tumours, from which several of these tumours, each
those of the adjacent portions of the about the size of a large pea, were em
gland . Only their several modes
1
of bedded in various parts of the prostate.
arrangement may be distinctive. ' These were ' lighter in colour and denser
Several examples of these tumours in structure than the adjacent parts,' and
have been examined and described with appeared to be composed of fibrous struc
care by others within the last few years. ture, and not to contain glandular ele
The following examples will aid us in ments. ? The second was a specimen of
considering the subject, and are therefore partially outlying tumour, which con
quoted. tained glandular tissue,and also the con
At the Pathological Society of London , cretions ' so often found in prostatic
Sir W. Fergusson exhibited two tumours, structure.3 Also a specimen of tumours
one 6the size of a filbert, the other that embedded in the anterior commissure of
of a horse- bean ,' removed from the pro- the prostate, which were made up mainly
state gland in the operation of lithotomy ;2 of the organic muscular fibres charac
and Mr. Shaw showed a similar one, teristic of prostatic structure, together with
6
the size of a moderately large hazel-nut, ' a small proportion of imperfectly formed
developed in the centre of the left lateral glandular elements intermixed. Each was
lobe. The surface of the tumour was isolated by a capsule of fibrous tissue.' 4
very smooth, and it was embedded in a Since that time I have examined
cavity, the sides of which were also numerous other specimens of isolated
smooth, and the connection between prostatic tumour. They corroborate the
them was so slight that the tumour could views which I expressed in a paper on the
easily be enucleated from the prostate, subject at the Medical and Chirurgical
which body it resembled in structure ; Society in the session of 1856–7 , viz.,
the only difference perceived by the that some are almost, if not entirely, made
microscope being that the gland was up of the constituent fibrous structure of
traversed by small wavy fibres which the prostate, without gland -elements, and
were not visible in the tumour .' 3 that these are by no means common .
Mr. Henry Gray exhibited a similar That, generally, there are present, in
tumour, occupying the centre of an en- addition to the fibrous structures, some
larged lobe of the prostate from a man gland -elements more or less imperfectly
aged 62. It was ' circular in form, about developed.
the size of a hazel-nut, contained in a Among specimens sent to the College
thick capsule of fibrous tissue, from which of Surgeons, with the essay on the pro
state, to which the Jacksonian prize was
paration is now in the museum of St. Bartholo- awarded in 1857, I submitted some to
mew's.
1 Lectures on Surgical Pathology, vol. ii. p. 264, 1 Trans. of Path . Soc. vol. vii. p. 252, Nov. 20,
by James Paget, F.R.S., London, 1853. 1855.
2 Path. Soc. of London, Feb. 19, 1849. Vide Re- 2 Trans. Path . Soc. vol. vii. p. 254, Dec. 4,
port in the Proceedings for the Third Session, p. 83. 1855. See fig ., case iii . p. 56.
3 Path. Soc. of London, May 7, 1849. Pro 5 Idem , p . 256, May 6, 1856 .
ceedings, pp. 83-4 . 4 Idem , vol . ix . p. 298, Dec. 1, 1857 .
section and to microscopical examination. The size of the embedded tumours
The latter showed the basic structure to ranges between a tenth of an inch and
be identical with that of the healthy pro- about five- eighths of an inch in diameter.
state, viz., burdles of pale muscular fibre, Their density is rather greater than that
with connective tissue, and a little elastic of the prostatic tissue proper ; they are
tissue ; very little glandular structure firmer to the touch , and more compact.
seen ; a few depressions or pouches, and if divided while retained in their original
some ovoid epithelium (same as gland - position, as when a section made through
epithelium in the normal prostate ), and a a prostate gland passes through one of the
few priematic epithelial cells (same as tumours, its cut surfaces protrude above
exist in the ducts of the prostate ). To the plane of the surrounding surface, and
sum up all that is known on the subject present a slight convexity. They are for
of the tumours in question : the most part paler in tint than the pro
In a considerable number of hyper- static structure proper. Commonly a thin
trophied prostates, rounded tumours are layer of the tissue which immediately
found, which are more or less isolated environs them is a little compressed, so
from the surrounding tissues of the gland. that in some cases the tumour appears to
These tumours do not appear to affect any lie in a kind of cyst,which is occasionally
particular part of the prostate more than very well marked. When not isolated,
6
another,and may be found in any part of but ' outlying' in situation, the tumour
it. Perhaps they are more numerous in may attain a larger size; as in the example
the lateral lobes, especially at their pos- referred to, page 49. Their vascularity
terior extremities, than elsewhere. Oc- is evidently less than that of the surround
casionally they are embedded in an ening prostatic structure.
larged median portion. It often happens Examined by the naked eye, or under
that the small multiple eminences so fre- the microscope with powers of different
quently seen at the neck of the bladder, degrees, we can discover no structural
in the site of the uvula, are due to these peculiarities as compared with the pro
small tumours there, situated under the state itself ; they possess all the elementary
mucous membrane and aa few submucous tissues common to the normal prostate,
fibres, there being no enlargement of the and they possess no tissue not belonging
median portion. When the swelling is to it.
large and single, it is more commonly Respecting the arrangement of these
hypertrophy or outgrowth of the part. tissues, the basis of the tumours appears
Rarely they are found in the ' anterior to be the fibrous basis or stroma of the
commissure' of the prostate. Sometimes prostate itself, a structure already de
they appear just under the capsule, and scribed under the head of “6 Normal Ana
so spring from the surface,, carrying, in an tomy ;' an admixture of unstriped soft
outward direction, the capsule as a cover- pale muscular fibre and connective with
ing, but nevertheless escaping altogether a little elastic tissue, closely interwoven.
the contour of the gland, and looking Interspersed with this, there are present
almost like an independent or outlying in most cases small cavities containing
formation. Occasionally they are really Hattened polygonal or spheroidal epithe
outlying, i.e. separated by an interval lium, like that seen in a pouch at the
from the prostate itself. A space of half extremity of a prostatic gland-duct, and
an inch has been seen to intervene be sometimes,also ,some prismatic epithelium .
tween such a tumour and the adjacent These cavities are sometimes solitary,
gland ; a narrow line of duct, with other sometimes slightly branched, and some
vessels, and a little tissue alone connect- times of an elongated or tubular form .
ing them. In aa few instances there is very little, or,
When embedded in the substance of perhaps, no such glandular tissue to be
the prostate, as most commonly happens, found ; generally , however, a careful
they occasionally appear to be almost un- search will discover it. In some of the
connected by continuity of tissue with outlying tumours the glandular structure
the adjacent structures, and they may be is more perfectly developed - in some it is
easily enucleated. Most commonly some quite so -and a duct is furnished which
fibres exist, uniting them to these, and in evidently carries secretion to the appointed
a few instances the uniting tissue is con- destination.
siderable in quantity . With such a mode of formation , all
E 2
that is known respecting their slow mode | It has its own special ducts, which traverse
of development, and their indisposition to the pedicle to open in the urethra, and in
manifest any morbid or other changes its substance may be almost invariably
whatever, except that of simple increase detected those concretions which are found
in size, it is quite certain that they possess in the adult prostate. It may vary in
none of the characters of malignant size from that of a pea to that of a mid
growths, but are simple or benign in their dle-sized pear, and at the outset exerts a
tendencies. perceptible influence on the neck of the
There can be no doubt that the em- bladder, the lower or posterior border of
bedded tumours occur both in the hyper- which is gradually elevated as it increases.
trophied and non -hypertrophied prostate, Ultimately it finds its way into the cavity
though much more commonly in connec-
There
the viscus, where it is truly poly poid
of shape.
tion with the former condition. in
appears to be no ground whatever for the Occasionally this pyriform mass is
theory suggested by Velpeau, that an connected to the main body by so long
hypertrophied condition of the prostate is and slender a pedicle, that it appears at
altogether dependent on tumour-forma- first sight to be a separate or outlying
tion . There may be, as already shown portion . Such was the condition in a case
under the subjectof Hypertrophy,' simple I recently examined.
hypertrophy of the prostatic tissues with- The glandular structure of these out
out any tumour -formation at all. But growths is generally ,as might be expected,
there is, at the same time, no doubt that more perfectly developed than in the
their presence is more common than their isolated tumours. Concretions, as just
absence in the hypertrophied prostates stated, are commonly found in various
of elderly people. stages of progress embedded in the former,
It may be that there is a tendency to but I never found this to be the case in
the production of these tumours in the any of the latter ; and the reason appears
prostates of all, or nearly
n all, elderly sub- obvious. In the one case there is an
jects; and that when the disposition to actually secreting structure with ducts of
hypertrophy exists also, the tumours par- exit in a state of activity ; in the other
ticipate in the disposition equally with the structure is rather an imitation, or
the rest of the tissues, and thus become imperfect development, of a secreting
objects of attention to the pathologist. apparatus, and consequently it cannot be
B. Outgrowths which are continuous supposed that any functional office is per
in structure with the parts of the prostate formed by it.
from whence they spring, but which The occurrence of outgrowth, although
manifest a tendency to become partially most common in the part described , is not
isolated, by assuming a more or less poly- invariably confined to it. A projecting
poid form , and maintaining attachment to growth may occasionally spring from the
the parent organ through the medium of posterior part of either lateral lobe,and has
a pedicle only. been even observed to arise from that part
We have already seen that any one of the prostate which lies above or ante
portion of the prostate may exhibit un- rior to the internal meatus of the urethra .
due development, while surroundingparts It must not be overlooked thatgeneral
are either but slightly or not at all affected hypertrophy of the tissues of the prostate
by any such action. The outgrowth from may, and commonly does, coexist with
the median portion is the most familiarly tumour or outgrowth - almost invariably
known example of this. It is then gene- with the latter . And, doubtless , the out
rally composed for the most part of the growth is only a more marked expression
ordinary structures of the prostate, of the same disposition which pervades
although sometimes containing a smaller the organ, in somemeasure, perhaps deter
proportion of the secreting elements than mined by the form and nature of the
belongs to the organ in the normal state, cavity towards which the protrusion is
and it appears to enjoy activity of func- directed ; the existence of the cavity of
tion in common with the rest of the pro- the bladder probably permitting a deve
state. It assumes a pyriform shape even lopment which would not be possible in
in its earliest stage, and is always con- other directions, where masses of solid
tinuous in structure with the adjacent structure oppose such extension .
prostatic tissues from which it springs. A consideration of the facts exhibited
TUMOURS AND OUTGROWTHIS OF THE PROSTATE . 53
under the subject of tumours and out- state, then , although not of itself the abso
growths serves as an appropriate intro- lute equivalent of the uterus, contains it
duction to the remark that analogies of a in the utricle, situated as this cavity is in
very remarkable kind exist between the the very centre of the organ .
characters and relations of these two Secondly.—The point, however, on
forms of tumour and those which affect which I would lay greater stress is, that
the uterus. We have already seen that the prostate and uterus are organs whose
Velpeau suggested the idea some years bulk is constituted by the same tissue,
ago, and that he rested the analogy upon namely the organic muscular fibre. No
the correspondence which he assumed to other organ in the body besides these two
exist in the two sexes between the uterus is similarly constructed by thick masses of
and the prostate, from a belief that the this structure ; elsewhere it is distributed
two organs originated from the same in membranous layers. This analogy of
centres of development in the early con- structure is, perhaps, in relation to the
dition of the ovum, coupled with the fact pathological question before us, stronger
that both are liable, in after life, to ex- than that of identity of origin in early
bibit tumours presenting similar external fætal life, since it has more influence,
characters. doubtless, in determining the appearance of
The ground of analogy, which is de- tumours and outgrowths of similar cha
rived from regarding the uterus of the racter, than any other circumstance.
female and theprostate of the male as the Thirdly.-- The two organs thus simi
morphological equivalents in the two larly constructed are very frequently the
sexes, is not, perhaps, the strongest that subjects of tumours, identical both in ex
might be adduced. I shall indicate one ternal and histological characters. Thus,
which I think is still more conclusive, as in the uterus we find these formations
well as other points of analogy, the com- nearly or completely isolated, made up of
bined result of which will render the cor- organic muscular fibres, with connec
respondence more obvious. tive tissue, embedded in the substance of
Firstly.-In studying the typical plan the organ , or standing out in relief from
on which the entire genito-urinary appara- either surface . In the prostate we meet
tus of the two sexes is constructed, the most with precisely the same tumours,and they
recent laboursof modern philosophical ana- are similarly disposed . Although , on the
tomists confirm the view that the analogue high authority of Rokitansky before re
of the uterus, or rather of the uterus and ferred to, an analogy has been pointed
vagina combined, in the male, is the pro
static vesicle or utricle. This is the view different opinions have been expressed as to whether
taken by Leuckart, in the Cyclopædia of it morphologically representsthe vagina, or the
6
uterus, or both . H. Meckel at one time, and in

Anatomy and Physiology .' It was main opposition to almost all other authorities, suggested
tained by Sir James Simpson in an exhaus- and maintained that it was the analogue of the
Weber con
tive Memoir on Hermaphroditism and vagina, rather than of the uterus.
sidered it as the male prototype of the female uterus;
Sexual Malformations generally,' which and still more lately Bimbaum and Leuckart have
first
was appeared in therepublished,
subsequently same work, with
but which shown
con- the that this organ may be more truly heldas
morphological equivalent of the whole sinus
siderable additions. An extract from this genitalis,
opinion 'nowbothgenerally
the uterus and the vagina - an
shared in by those who
is appended in a note below . The pro- formerly took a different view of the subject.
Huschke has sometimes found the lower or vaginal
1 ' Few , or indeed none, of the eminent anato- portion of the male utriculus separated from the
mists who have in later years studied the subject upper and dilated end by a constricted point, as if
of the prostatic vesicle or utricle, as Huschke, indicating its division normally into uterus and
Leydig , Rathke, Leuckart, Bischoff, Arnold, Wahl- vagina. Indeed , it is only in accordance with this
grew , Kölliker, Duvernoy, Goodsir, and Allen last doctrine that we can understand the relative
Thomson, have at all doubted that this organ is a positions and modes of junction of the genital and
representative or analogue, in the male organisa- urinary canals in some monstrosities, and the fact
tion, of the genital canals of the female. * But of the great variety of forms and shapes which the
*
male uterus or prostatic vesicle assumes when it is
• Some of the variousdiseased states attributed found — as so often happens - preternaturally en
to enlargement, & c., of the third lobe of the pro- larged and disproportionately developed in different
state glandwill be yet found, I believe, to be morbid kinds of hypospadiac and hermaphroditic malforma
states of this prostatic vesicle. To the minds of tion .'
some “ The Investigation of the Diseases of the i Vogel established this fact in relation to the
Male Uterus' would appear to be almost a paradox structure of the so-called fibrous tumours of the
in thought and words.'— Obstetric Memoirs and uterus in 1843, and it has been confirmed by Dr.
Contributions, edited by Drs.Priestley, ofLondon, and Oldham , Dr. Robert Barnes, Dr. Bristowe, and
Storer, of Boston, vol. ii. pp. 318, 319, London, 1856. others.
out as existing between these embedded these outgrowths and tumours, among the
tumours of the prostate and those of the latter especially those of the fibrous kind,
mammary gland, I confess that the may remain of so small a size, both in the
grounds of that analogy appear to me less uterus and in the prostate, that the bulk
complete than those which indicate their of the organ is not sensibly increased, and
relation to the fibrous tumours of the no signs indicating their existence during
uterus as just suggested. The prostate life are produced ; while on the other
differs very materially from the mamma hand they may increase to an enormous
(and , in a corresponding degree, resem- extent, so as to exceed by very many
bles the uterus) in being mainly consti- times the natural size and weight of the
tuted by tissue, designed to exert a organ in which they originated,and
, give
mechanical power ; while the mamma is rise to the most important derangements of
simply a secreting organ, or gland. The function .
prostate is a muscular organ, but per- Fitthly.—The two organs are subject
meated by glandular tubes and follicles. to considerable hypertrophic enlargement,
Were the small glandular tubes found in mainly consisting of their constituent
the inner wall of the uterus prolonged fibrous elements. And in both , this con
more deeply into its substance than they dition may be associated with some
are, the analogy between the uterus and tumour-formation , or it may exist inde
prostate would be complete. The organic pendently of it. In the latter case , the
muscular tissue appears to have a ten- hypertrophy may be general or local,
dency to become the nidus of isolated affecting the whole or certain parts of the
masses of like tissue, in structures formed organ ; and, when thus local, affecting
by it ; the type of these being found in particular spots more commonly than
the uterus. In the prostate we have the others. These remarks apply equally to
same phenomenon, plus certain imper- the prostate and to the uterus.
fectly formed gland- tissues, but the addi. Sixthly.—The two organs are liable
tion may be fairly regarded as an accident, to these changes after the prime of life
depending on the presence of glandular has passed. Bayle, whose observation is
elements in the muscular organ in its quoted by Rokitansky, and verified by
normal state. Hence the amount of Dr. Robert Lee, says that 20 per cent.
gland-tissue so intermixed with the tu- of women, after 35 years of age, have
mour is extremely variable in different fibrous tumours of some size in the
specimens. The fibrous tumour, we uterus. I have found prostatic tumours
know, in whatever part of the body it in 30 per cent. of males after 50. In
occurs, is very prone to imitate in some women , however, the tendency to this
measure the tissue in which it is placed. formation declines after 50, although it
Thus, as Sir J. Paget remarks, spiculæ of cannot be said to cease. Nevertheless it
bone may be frequently observed, when it is exceptional after that period. It is
is situated in bony structures ; ' a disposi- generally regarded as most active during
1
tion which accounts for the intermixture the term of uterine functional activity, or
of some gland -elements when it appears rather during the latter moiety of the
in the prostate. time. The age at which the reproduc
Fourthly.—In the uterus we are tive function of man is most vigorous is
familiar with another form of tumour, certainly not that at which a like tendency a
which, springing from the interior, and in the prostate is evinced ; but on the
forming a polypoid growth there, is much other hand, it may not be forgotten that
more intimately connected with the the term of productiveness is not limited
uterine structure than the variety just in the case of the inale, as in the opposite
described, perfect continuity of tissue sex, And still further, it may, I think,
cxisting between it and the polypus. So be fairly admitted that our acquaintance
from the median portion of the prostate with the prostatic function is not at pre
we meet with an outgrowth ,tending to sent sufficient to forbid, but on the other
become polypoid in form , which continues hand rather to encourage, the supposition
its development in the direction of least
resistance , and exhibiting complete con- 1 Rokitansky makes the age still later. Fibroid
tumours
tinuity of structure with the prostate itself. the of the uterus, he says,i are unusual up to
thirtieth year, and present themselves most
It may be further observed that all frequently shortly after the fortieth year.'- Manual
Lectures on Surgical Pathology, vol. ii. p. 136. I of Patholog. Anat., Sydenham Soc. vol.ii. p. 298.
that it is possible that its activity may breadth, springing from the verumon
not diminish during the middle and later tanum in a child ,and directed backwards
years of life, when the hypertrophic dis- towards the neck of the bladder. The
position is manifested. One thing is second is mentioned by Rokitansky, but
certain — the prostatic secretion, whatever not described, as a solitary case which he
its purpose, does not appear to be at that had seen."
time less plentiful, judging from the staie The third occurred in my own prac
of the organ after death, than at any tice, and was exhibited by me at the
previous age. Pathological Society of London in 1856.2
There is one form of tumour, or It was about five-eighths of an inch
rather of outgrowth from the prostate, in length, soft in consistence, and at its
the occurrence of which is extremely rare, base was continuous with the apex of the
but which may be mentioned before verumontanum , lying in the urethra,
closing the chapter. It has no relation to which it appeared to fill, and reaching to
any of the preceding varieties. It is a the neck of the bladder. It was com
polypus springing from the verumon- posed of the elements of fibro- cellular
tanum . I know of four instances only. tissue, with a few organic muscular fibres
The first is in themuseum of St. Thomas's intermingling at its base. In some parts
Hospital, No. BB. 8, a small polypus were seen, near the centre of the growth,
about half an inch long, and two lines in some minute crystal-like bodies, having
Fig . 15 .
very much the appearance of uric acid, past he has had the ordinary symptoms of
yellowish in tint, and rhombical in form , chronic cystitis. Now, thereis much irrita
with a few octahedra. They proved to be bility10 ofcatheter
bladderpasses
; noretention or incontinence.
with perfect
crystals of some earthy carbonate (seefig. No.
bladder slowly empties itself ofpus ease. The
and mucus
15, a a). The tumour was covered with after urine is drawn off. No calculus. Urine
mucous membrane and columnar and thick, opaque, mixed with much pus, slightly
spheroidal epithelium . acid on several occasions, no renal casts or
The only point in the history of the crystals.
Only a slight degree of enlargement of the
patient which related to the presence of prostate is recognisable from the rectum. Pa
the polypus, was, that he had for some tient suffers very little pain, but is extremely
time been in the habit of passing water weak, and appears to be gradually sinking .
with greater frequency than usual. Not Death occurred on November 7.
long ago I met with another example andPost-mortem
part of urethra hours after
, six removed death .The
entire . - Bladder
former
resembling the preceding case, but more is elongated , and projects upwards behind the
vascular in structure .
pubic symphysis ; the walls are thicker than
natural. Projecting into the cavity, at its meck,
is a lobulated tumour about the size of a small
CASE No. III . walnut, of yellowish colour and smooth aspect,
ENLARGEMENT OF THE PROSTATE DUE TO Iso - contrasting surface
corrugated strongly withlining
of the the crimson
membranehueof and
the
LATED FIBROUS TUMOURS : DISEASED AND
SACCULATED BLADDER. bladder (fig. 16). The cavity was contracted ,
J. P. , aged 74, admitted to the Marylebone | Path . Anat., Syd. Soc., vol . ii. p. 235.
Infirmary, October 27, 1855 , under the care of 2 Trans. Path. Soc. vol . vii. p . 250, with en
Mr. Herry Thompson. Two or three years | graving.
and corresponded with about two-thirds only of On cutting into the left side of the prostate
the organ removed. The upper third proves to the section of a rounded body embedded in the
be a sac, opening by a very small orifice into the gland is seen. This body is four -tenths of an
bladder proper , and an opening made into it inch in diameter, is isolated from the surround
ing tissues, separable from them in places with a
blunt probe, but in others closely adherent, or
united by prolongations of tissue common to
both. It is lighter in colour, and apparently
denser in structure than the adjacent parts.
Several other similar bodies correspond with the
protuberances seen in the prostate before making
sections of it. Three of the largest of them are
dissected out ( fig. 17). The mucous membrane
was first divided over them and turned aside ;
then a few longitudinally disposed fibres, which
in places peeled off from the rounded bodios like
a capsule, but which at other times appeared to
run into their substance, and to be continuous
with it. One of these bodies, corresponding
with a protuberance on the right side of the
gland seen in both drawings, is isolated in the
preparation, and bands of fibres appear to unite
it with the fibrous constituents of the gland
behind . Small portions of tissue detached from
b any part of the bodies of which section has been
made, exhibit under the microscope the elements
of the organic muscular and connectire tissues,
closely packed in bands. Acetic acid developes
a number of the rod - shaped nuclei lying longitu
dinally among the fibres.
Fig . 16. — Enlargement of prostate from fibrous An isolated mass of the true glandular
tumours; bladder diseased and sacculated ; elements of the prostate may be seen in one of
showing section through anterior part of blad- the sections — that on the right side. It is
der and prostate. The enlargement of the obvious to the naked eye by exhibiting a yel
prostate is seen obstructing the vesicalneck, lower tint than the surrounding parts. Under
and projecting into thecavity of the bladder. the microscope it presents the ordinary glandu
A rounded eminence occupied by one of the lar elements as well as some of the minute
tumours is dissected out in fig . 17.
" concretions," so called, often seen in the pro
states of elderly people. None of these struc
gave exit to about
The tumour springsanfrom
ounce
theof prostate,
pus and which,
mucus. tures are found in the rounded bodies before
described.
though not enlarged towards the rectum , bulges A large proportion of the bulk of the organ
is made up of a whitish, fibrous-looking tissue,
which intervenes between masses of the gland
structure, almost surrounding and isolating
them. This tissue, under the microscope, is
seen to consist chiefly of the connective fila
ments, intermixed with organic muscular fibre.
ENLARGEMENT OF THE PROSTATE : NUMEROUS

TUMOURS : SEVERAL CALCULI IN THE
BLADDER .
A gentleman, aged 65, who had experienced

some difficulty in micturition about twenty
years. Marked symptoms, amounting some
times to retention, had existed about six years.
In the commencement of the year 1857 he
came under the care of my friend, Mr. Sampson,
of Ipswich , who suspected the existence of cal
culus in addition to organic obstruction of some
kind. In May I saw him in consultation , and
Fig. 17. - One of the above small tumours we found considerable prostatic enlargement;
dissected out. but the bladder was at that time far too irri
table to admit of any operative proceedings for
into the urethra considerably, and also into the stone. There was more or less retention of
vesical carity . urine requiring daily catheterism , and the
Both kidneys are diseased, and contain patient was very weak.
several small collections of pus, besides somo Death from exhaustion took place at the end
ordinary rysts of June. At the autopsy the prostate was found
enormously enlarged , the anterior or pubic por- | the size of a kidney bean. On examination I
tion being that which exhibited by far the found these to be made up of fibrous material
greatest increase,a most unusual circumstance ; containing a considerable proportion of the
this portion formed an irregularly shaped nodu- glandular elements of the prostate. Nine small
lar mass , about the size of a hen's egg, and con- calculi were also found in the bladder, lying in a
a
tained numerous embedded tumours, each about deep depression behind the enlarged prostate.
CHAPTER VII.
THE CAUSES OF HYPERTROPITY OF THE PROSTATE.
The Sulijcct of Causes obscure-Its Investigation extremely important - Most circumstances alleged
to be Causes - Cannot be so regarded - Present Views stated - Inflammation not a Cause-nor
Stricture nor Calculus — nor Venous Stasis-Gout, Rheumatism, and Syphilis not Causes - Sexual
Excess — Prostatic Enlargement not analogous to Glandular Hypertrophy, nor to Hypertrophy of
other Muscular Organs depending on Increased Function - Enlargement of Prostate andUterus shown
to be Identical in Nature and probably in Causation , Perhaps a Necessity of their Common Structure
Ascertainable Conditions under which Enlargement occurs - Analysis of Results arrived at in relation
to Age.
Next in importance to the discovery of only to be obtained by collecting all the

some unquestionably successful means for suggestions and speculations that areto be
the cure of hypertrophied prostate , would found in the literature of the past ; and
be a recognition of those circumstances rather be careful not to admit too much ,
which stand in the relation of causes , re- than to appropriate every line resembling
mote and proximate , to this remarkable a contribution , under the semblance of
affection . While some authors acknow- offering information on the subject. No
ledge that a considerable degree of ob- thing would be easier than to swell this
scurity attaches to the subject , others do chapter into a volume, and for the simple
not hesitate to express decided opinions in reason that so little is known of its subject,
reference to it, confidently enumerating so much conjectured. But that the reader
many things as undoubted causes ; and may possess a sketch of the opinions of
most appear to agree in reference to some some of the most experienced authors in
few of these , or, at all events, as to the reference to it up to the present time,
existence of a strong probability in favour these shall be stated as briefly as possible
of so regarding them . It appears to me, by way of quotation , before attempting to
however , that in order to accept the etio- enter upon an independent examination
logical views of this affection which are at for ourselves.
present current , a good deal must be taken John Hunter says nothing directly in
for granted ; and that if we require a fair relation to causes , but states that he has
amount of evidence that they are correct , seen hemlock of service in several cases .
we shall probably reject them all, or very It was given upon a supposition of a
nearly so . However discouraging such a scrofulous habit . On the same principle
result may be deemed by the student, we I have recommended sea-bathing,' & c.
may rely upon it that it is the necessary It should be remarked , however , that the
and important preliminary step, if true, distinction between the enlargement of
to a better state ofknowledge on this sub- the prostate in earlier years, usually con
ject. The admission of a single circum- sequent upon inflammation , especially
stance into the list of causes which cannot gonorrhea , and the senile affection at
be sustained there by something better present under consideration , was not then
than aa fanciful belief, conventional custom , made . In the chapter quoted , these two
or by, it may be, the impression ' or the widely differing conditions are spoken of
7
conviction of an author,unsupported by indifferently : yet, on the authority of

testimony, must assuredly becomea stum- this passage, hemlock has been largely ad
bling -block in our progress towards truth. ministered in the last-named complaint.
Better is it to sacrifice the completeness Sir E. Home, who enjoyed large op
which often seems to be thought essential " A Treatise on the Venereal Disease, 2nd edit.,
to a pathological treatise, if that quality is p. 174. London , 1788.
portunities for the observation of these | an obstruction to the emission of urine by

cases, was of opinion that the chief pre- the vesical neck .
6
disposing cause consisted in the slow Sir A. Cooper says, " The enlarged
return of the blood from the neck of the prostate is the consequence of age, and
bladder, arising from the disadvantageous not of disease .' ?
situation of the veins respecting the heart,' Sir Benjamin Brodie regards enlarged
including habitual congestion of those prostate as an almost invariable accom
vessels ; and that this was rendered more paniment of advanced age, assigning it a
powerful by the undue indulgence in the place in that category of phenomena
pleasures of the table, or in any habits which marks the decline oflife. Thus he
6
which ' increased the circulation of the says, “ When the hair becomes grey and
blood in those parts. The most common scanty, when specks of earthy matter
and influential proximate cause he con- begin to be deposited in the tunics of the
sidered to be
6
the effects of horse exercise, arteries, and when a white zone is formed
producing ' rupture of vessels in the in- at the margin of the cornea, at this same
ternal parts of glands,' establishing thus period the prostate gland usually - I
' a great analogy between this complaint might, perhaps, say invariably - becomes
and apoplexy .' At the same time he increased in size.' Hence no other cir
believed prostatic enlargement to be one cumstances or conditions than the general
of the changes natural to old age. one of declining life are mentioned by
Mr. Wilson, in his lectures at the him in the light of causes.3
College of Surgeons, in 1821 , having stated Mr. Samuel Cooper, in his Dictionary ,
that he has ‘ met with several cases which after reviewing various statements, sums
>
confirm the justness of the observation ' up with the following opinion : --' It seems
of Sir E. Home, respecting the liability of to me better to confess that the etiology of
individuals of full habit to the disease, ob- this complaint is unknown .
. ; ' but he
6
serves , that it appears to occur most fre- adds, ' I have known several persons
quently in those persons who, either from afflicted who had led very sedentary lives.:4y
living a life of strict celibacy, have not Mr. Coulson states , on the authorit
used the genital organs so much as nature of others , the usually recognised causes,
seems to have intended , or who have in- but expresses no decided opinion in favour
jured both the genital and the urinary of any one of them .”
organs by a life of excess. Finally , he Dr. Groes, of Louisville, doubts the
adds that many persons have suffered influence of some of the agencies usually
much from the enlargement of the prostate assigned as causes of hypertrophy of the
gland who have lived a moderate and prostate, but thinks there is no doubt that
quiet life, without approaching to either it may be induced by the following :
6
of the above - mentioned extremes .' 2 ' Habitual engorgement, protracted and
Sir Charles Bell gives no opinion as to frequently repeated sexual intercourse,
the remote or predisposing causes, but irritation resulting froin thepresence of a 6
believed that a predisposition to prostatic vesical calculus. Finally,' he says, ' the
enlargement existing, one of the most fre- protracted or frequent use of stimulating
quent and important exciting conditions diuretics, of wine and alcoholic drinks,
would be found in any source of irritation exposure to cold, the repulsion of cuta
to the bladder, inducing repeated contrac- neous diseases, gout and rheumatism , ex
tions of the organ . Whatever the occa- ternal violence, the frequent introduction
sion of these, which was indifferent as re- of the catheter, and habitual straining at
6
gards the ultimate result, the muscles of stool, as in chronic diarrhea and other
the urethra ' were set in constant action, affections of the bowels, may all be enu
the effect of which, according to his view, merated as so many exciting or predis >
was to draw backwards the middle lobe or posing causes of this affection .' 6
median portion, to which he stated them
to be attached, and thus to produce the pp. 2 171-189.
Medico -Chirurgical Transactions, vol. ii. 1812,
Illustrated by three Plates, showing
elevation so frequently observed to form dissections of these muscles.
2 Lectures in I.ancet, vol. iii. 1824, p. 239.
1 Practical Observations on the Treatment of the 5 Lectures on the Urinary Organs, 4th edit.,
Diseases of the Prostate Gland, vol. ii. pp. 9, 10. pp. 163–166 and 186, 187.
London , 1818. 4 7th edition, p. 1122.
2 Lectures on the Structure and Physiology of 5 Diseases of the Bladder and Prostate Gland,
the Male Urinary and Genital Organs, pp. 331, 332. 5th ed., p . 589.
London , 1821 . 6 A Practical Treatise on the Discases, &c., of
THE CAUSES OF HYPERTROPHY OF THE PROSTATE. 59
Desault speaks of enlarged prostate as Mercier, who discusses the subject at
being " very common in elderly people, length, regards as predisposing circum
and in those who have had many attacks stances all those which most favour stag
of gonorrhea ; nevertheless, it is not al. nation of the blood. Persons of soft and
ways a result of venereal taint.' He be- lymphatic habit, with the cellular and
lieved that it might sometimes arise in adipose systems largely developed, possess
the scrofulous and other cachectic habits.'' generally very lax and unresisting venous
Amussat adopts the older views, which tissues ; and observation shows that such
had long been current among continental are most frequently the subjects of pro
surgeons ; and these his opinion may be static engorgement.' ... ' I believe there
regarded as well and briefly expressing. is a certain relation between weakness of
Syphilis, the presence of a foreign body the inferior veins and hypertrophy of the
in the bladder, the existence of strictures prostate ; this explains why the affection
in the urethra, are its most ordinary appears sometimes to be hereditary .' He
causes. It is observed especially in considers sedentary habits to favour greatly
elderly persons who have long used prostatic enlargement, stating that shoe
sounds or bougies, which they introduce makers have formed one-third of his cases
themselves. In this case, the swelling of in hospital practice ; after these come
the prostate is occasioned by chronic in- house-porters, weavers, and tailors. He
flammation produced by the contact of adds that it is no less true that active men
instruinents .' 2 are also victims to it, and questions whe
Civiale devotes a section to the special ther a vertical position of the body, much
consideration of causes, in which he de- prolonged, may not produce the same
clines to consider speculative questions effects as a sitting one. Finally, admitting
relating to the supposed analogy between the effect of blood stasis, he inquires, does
the prostate and the uterus, or the resem- this act by rendering nutrition more
blance which has been suggested to exist active, just as a limb which is much exer
between its enlargement and that of the cised acquires great development, or does
&
thyroid gland or liver, &c.; and enu - it rather retard the process of decomposi
merates those which he believes to be tion , rendering less easy the separation of
proximate or exciting causes ; placing elements which otherwise would be elimi
first in order of influence the presence of nated ? ' He confesses
1
his inability to
calculus in the bladder. Next come or- answer this question ."
ganic strictures of the urethra and the In considering this subject for our
difficult micturition which results. Much selves it will be desirable first to examine
stress is laid upon this, and Cruveilhier's the alleged causes of senile enlargement
remark that stricture and prostatic en- of the prostate, and show why many of
largement rarely coincide, is quoted for them have no title to be so regarded.
the purpose of refuting it ; Civiale stating And first, inflammation must be elimi
that numerous facts exist attesting the nated from the category. Let us contrast
accuracy of his view of the question. On distinctly the enlargement of youth or
the other hand, he admits that the influ- middle age with that of advancing years.
ence is not constant, since urine, arrested Nothing can be more calculated to
by the stricture, may hinder, by means of originate erroneous views than the habit
the pressure reflected backwards, the pro- common to most authors of disregarding
state from becoming enlarged. The im- this important distinction . Thus, the 6
proper use of instruments in the urethra complaint ’ is said to be very common
is placed next on the list. He combats among elderly persons, but occasionally
the notion that venereal excesses have any met with also in early manhood . But
intimate relation with the prostatic affec- no two affections can be more different
tion ; and believes that authors have been than those which are thus confounded .
far too ready to admit their influence One category cannot be made to contain
without examining the question .”3 them both . In youth, the organ becomes
the Urinary Bladder, by S. D.Gross, M.D., 2nd ed., Génito-Urinaires, par le Dr. Civiale, édit. 3 , pp.
pp. 688–691. Philadel., 1855. 244 et seq Paris, 1858.
| Euvres Chirurg. de P. J. Desault, édit. 3e, Recherchés Anatomiques, Pathologiques et
t. iii. p. 238. Paris, 1813. Thérapeutiques sur les Maladies des Organes Uri
2 Leçons sur les Rétentions d'Urine, par Dr. naireset Génitaux, considérées spécialement chez les
Amussat, pp. 199, 200. Paris, 1832. Hommes âgés, par L. Auguste Mercier, chap. iv.
3 Traité pratique sur les Maladies des Organes pp. 218-233. Paris, 1811 .
enlarged by interstitial plastic effusion, held by many as among the best- esta
the result of inflammatory action. In age, blished causes of enlargement. In this
there is an unnatural development of the manner, sedentary occupations are con
prostatic tissue itself. Histological exami- sidered as predisposing causes. Anything
nation of its elements, already sufficiently which tends to obstruct the return of
considered, shows that the redundant venous blood from the pelvis, such as
parts areprocess,
matory in no in
wayanydueoftoitsthemodifica-
inflam- mesenteric or hepatic
like, is ranged obstruction,
under this head. or the
Great
tions. There is no proof that the en- stress is laid by some writers upon the
largement which is constituted by undue venous enlargement and stasis which
production of the fibrous and muscular elderly persons in particular are not un
elements, whether in the diffused form or commonly the subjects of. Undoubtedly,
in that of tumour or outgrowth , is a pro- hæmorrhoidal swellings are thus pro
duct, direct or indirect, of inflammation duced, and most frequently. But is
in any part of the canal. The newly there any analogy between this effect and
formed tissues are not the result of morbidthat observed in enlarged prostate ?
deposit dissimilar to the organisation to between congestion and thickening of
which they are added, but of an im- tissues, by exudation from overcharged
moderate development of the ements od - vessels, and the new formation of
proper of the part. The action of inflam- normal structures ? Do varicose veins
mation, and the deposit of its products in lead to the latter result in any other part
a tissue, so far from favouring growth , is of the body ? Assuredly not. The effect
directly antagonistic to such a process. A of venous stasis in the leg may often be
prostate, therefore, which has been en- seen in thickening of the integuments,
larged by inflammatory effusion, cæteris and distension of the capillaries from
paribus, might perhaps be considered less which the veins arise, in the occasional
likely subsequently to exhibit an hyper occurrence of inflammatory action and
trophic tendency, nutrition being rather consequent exudations or deposit into
impeded by the process, not encouraged. interstices of structure, but never in
Inflammation must, therefore, be excluded the increased production of pre-existing
from the list of causes. Stricture of the normal and healthy tissue. True hyper
urethra , and calculus of the bladder, are trophy, outgrowth, or tumour - not one
frequently stated to give rise, probably by of them has venous congestion for a cause.
irritation, to hypertrophy of the prostate. Venous congestion impairs structure,
Respecting the first, the fact, as deter- diminishes its vitality, and, often enough,
mined by numerousobservations of the predisposes to ulceration the tissues
dead body, and careful examinations of the affected by it, so that a slight injury pro
living, is, that a coexistence of stricture duces the destructiveprocess, but it never
and senile enlargement of the prostate is augments the vital force, or stimulates
certainly not common. Obstruction to a growth. On these grounds, then, it must
catheter encountered beyond the stricture, be dismissed from the list of causes of
and produced either by enlarged lacunæ, hypertrophy of the prostate.
dilated urethra, or undue development of Gout and rheumatism have been
the muscular structures of the neck of made to perform a part in the category of
the bladder, constituting more or less of causes in this, as in that of almost every
a barrier there, is common enough, and other obscure affection ; but without the
has often been attributed to the complaint smallest foundation in observed facts.
Calculus Elderly people often have rheumatism ,
in the
of question
bladder mayerroneously.
— but , in a similar manner, and are subject to enlarged prostate. I
induce the last-named state, which arises confess, after a careful investigation of
under circumstances of prolonged irrita- the subject, that I know of no closer rela
tion, whatever its cause (see Chapter tion between the two affections. Nor can I
XIX .), but not the hypertrophied pro- say more of gout. That either diathesis
state. Were the latter a result, we should has any causal relation to the prostatic
surely sometimes meet with it in child complaint there is not the slightest ground
believing.
hood and youth, periods of life at which for There
stone is prevalent. is not the least foundation for
Habitual engorgement of bæmorrhoidal regarding syphilis as a cause. Perhaps it
and prostatic veins is very confidently is not possible to speak with the same
degree of confidence in regard of sexual structure and position of the prostate has
excess, Much influence in producing suggested that its function is partly a
hypertrophy has been attributed to the mechanical one, and, so far, analogous to >
effect of habitual indulgence of this kind ; the two organs just named . It has been
but, from the fact that the affection has regarded as an important portion of a
been observed to occur in individuals muscular apparatus bearing pretty nearly
known to have been remarkable for the same relation to the seminal Auids, as
chastity, the opposite extreme of conti- regards the act of propulsion, as the
nence has been, therefore, regarded as exer- bladder does to the urine.
cising a similar influence. In regard to But that the enlargement of the pro
the first, it appears reasonable to believe state is not a mere muscular hypertrophy,
that repeated use may induce hypertrophy induced by increased action, and corre
here as elsewhere; while without entering sponding with the degree of augmented
upon the question of the prostatic func- function excited, is proved by the facts
tion, it is impossible not to associate the just adduced of its non -appearance during
organ with the sexual act ; and, admitting the terms of youth and prime manhood.
these, it appears not to be easy to escape Nevertheless, viewing the phenomenon
the inference that hypertrophy may pos- as involving an hypertrophy of the in
sibly result from sexual excess. Yet voluntary muscle, a condition the existence
facts do not favour this view ; hyper- of which cannot be disputed, whatever be
trophy does not exist when the function the opinion held as to the function of the
is in greatest vigour, and is not called into organ, we may inquire whether the causes
immediate existence by the most licen- of such hypertrophy in other parts of the
tious excesses indulged during the prime body, similarly constituted, have been
of life. And it must be admitted that, ascertained ; and if so, whether anything
when in any part of the body an hyper- may be gained by analogical reasoning
trophy is developed, it is coincident with , in elucidation of the subject before us.
or, at all events, immediately follows, the There is but one other organ in the .
increased action which induced it. Such body which is similarly constituted as
is the universal law, and illustrations of regards the nature of its structures, and
its action must be familiar to all . in the manner of their aggregation, a fact
Supposing, for argument's sake, that enlarged upon in the preceding chapter.
we regard the prostate as a secreting The uterus, like the prostate, is composed
gland in the fullest sense of the term , its of the inorganic muscular tissue distri
enlargement cannot be considered as buted in thick strata, so as in either case
affording a parallel, or even a very similar to form a thick mass, not in thin planes,
pathological result, to that which occurs as found in all the other organs in which
in hypertrophy of other such glands. All this tissue appears. The tendency to be
its component tissues are not augmented come the seat of local and general hyper
in their relative proportions. There is no troph of isolated tumours , and out
analogy between its enlargement and that growths of a special character, which both
of an hypertrophied kidney, for example. organs equally manifest, has also been
Considerable augmentation in bulk may demonstrated. Starting from this re
take place in the prostate, when the
glandular elements appear not to be | It is no partof the design of this work to enter
increased at all, or verylittle, and that in upon the difficult subjectofthe function of the pro
state. In mywork on stricture of the urethra, which
either case, whether defined tumour be gained the Jacksonian prize of the Royal College
present or not. It is also true that occa- of Surgeons for the year 1852, I stated my belief
sionally hypertrophy is associated with that its function was partly that of a muscle,that
it was an important element in the apparatus de
increase of true gland structure also. signed to expel the seminal fluids - vide pp . 31 and
On the other hand, suppose the pro- 47- and further investigations have but confirmed
that view.
state to be regarded as a muscular organ , Professor Ellis says, in a paper already referred
which is permeated by a glandular to: *It( the prostate) may be considered as only an
apparatus, and that its hypertrophy may advanced portionofthe circularlayer of thebladder,
though
be compared to that of the uterus or denily ofit must have the power of acting indepen
the vesical fibres, as, for instance, in the
bladder,both of which , when in that con- propulsion of the seminalfluid . Its chief officewill
dition, maintain the glandular tubes and probably be to hurry on the semen, and deliver this
follicles which belong to their lining mem into the grasp of the voluntary muscular fibres of
the constrictor urethræ .'- Med. Chir . Trans. vol.
brane unaltered . A consideration of the xxxix . p .332. 1856 .
markable fact, it is difficult to resist the not increase beyond a certain very
inference that this tendency to over- limited size, and do not interfere with the
growth , this disposition to generate fresh performance of any known function in
elements identical in character with those either sex, but which, in exceptional
proper to the structure of the organs, has instances, continue to be developed, for
à source common to both , and perhaps the most part only, during a certain
inherent as a kind of structural, or per- limited period of life, say , in general
haps functional, necessity. The capability terms, between thirty -five and fifty in the
of this structure for exhibiting rapid and female, and between fifty and seventy in
enormous increase under certain circum- the male ; in the one case appearing in
stances is admirably exemplified by what the form of uterine hypertrophy or
happens to the gravid uterus. A dormant tumour, in the other in that of prostatic
force is awakened through the presence hypertrophy or tumour. Whether the
of the impregnated ovum , and the weight formation of these products is anything
and bulk of the organ are in aa few months more than a contingency of structure,
increased tenfold . Active determination that is, whether it be connected with any
of blood is coincident, and doubtless functional action common to the structure
supplying the materials of nutrition, but in both cases, is more doubtful.
not venous congestion, nor any one of the Anatomical examination of the en
numerous alleged causes of prostatic larged organs, prostate and uterus, demon
hypertrophy already referred to. But strates the arteries and veins to be both
the uterine function having ceased tem- enlarged, the latter, probably, as a result
porarily or permanently, the organ of the former. An increased supply of
diminishes and returns, sooner or later, arterial blood is coincident with the
nearly to its original size. During the increasing size of the organ ; but whether
latter moiety of the term of reproductive the vascular determination precedes or
activity, the uterus is exceedingly prone closely follows the commencing develop
to develop formations, identical in struc- ment it would not be easy to affirm ,
ture with its own, but more or less Are there any circumstances in the
isolated from the parent tissues, either in mode cf life, or of pre -existing disease,
the form of tumours or outgrowths, and which we are warranted by reasonable
these are associated with general develop- evidence in considering causes of pro
ment of the normal parts of the organ. static hypertrophy ? I know of none.
These phenomena are observed , perhaps, The fact that almost all known causes of
with greater frequency in the virgin than diseases in general have been alleged to
in the impregnated female, showing that be so , of this one in particular - what is
they do not depend upon any forcecalled it, in reality, but a tacit expression of the
into play by pregnancy, but on one irre- same opinion ? Every diathesis - gouty,
spective of it, and possibly inherent in rheumatic, tubercular, syphilitic — has been
the structure of the organ , or associated arraigned as the offending cause. Every
intimately with some function peculiar to form of local excitement possible to the
it. pelvic viscera has been similarly held
It is an interesting circumstance that accountable. Thus it follows that the
the prostate, male homologue of the bearing of any single circumstance be
uterus, should exhibit analogies in many comes neutralised in the concourse of
points of view with the latter organ in numbers. Every proposition finds its
regard of its tendency to overgrowth. refutation in the presence of some other
The most obvious explanation, and the one among the multitude.
conclusion which, after a careful examina- The origin of hypertrophy being thus
tion of the subject, is that which appears attributed to a necessity of structure, no
to me better supported than any other, doubt all circumstances which tend to
seems to be offered in the simple fact now induce active determination of blood to
completely established, that the structure the locality may aid in its develop
in both is exceedingly prone to development. Thus we find emotional excite
(as already shown, Chap. VI.), among its ment of a sexual kind, and actual 1
component elements, minute independent excesses, over-stimulating food, sedentary

or
isolated formations, possessing an habits, horse exercise, and many other
organisation identical with itself; which conditions having a like tendency, enu
formations, in the majority of cases, do merated among the causes of this affection.
But the initial step in the causation of fourths, tumour and hypertrophy co
hypertrophy is, I believe, independent of, existed .
and probably uninfluenced by, any of these Of the 56 cases of hypertrophy,
of
circumstances, although they doubtless nearly one-half made no complaint
tend to increase already existing disease. respecting symptoms during life. It is
And perhaps something may be done by to be recollected , however, that it is
judicious treatment to retard the progress exceedingly common for slight deviations
of enlargement, since the tendency to be- from the normal function to take place in
come hypertrophied is an exceptional elderly persons without complaint being
condition in the prostate, and not a neces- made ; it is not, therefore, to be inferred
sary or frequentoccurrenceeven among that no symptoms of the existing enlarge
men of advanced age, as will now appear. ment were present. Most probably, an
All that tends to diminish the local inquiry would have elicited the fact, that
supply of arterial blood to the organ it was the habit ofmany of these patients
may be held to favour the condition to rise two or three times during the
of status quo, or slow increase. This, night to relieve the bladder, and that
however, is not the place to enter during the day their frequency of mic
further on the subject of treatment ; the turition was greater than that of the
allusion made is sufficient to illustrate the healthy subject.
question under consideration. With the present data, therefore, it
We have now to inquire what are the appears that actual hypertrophy of the
peculiar conditions, actually ascertainable prostate exists in about 34 per cent. of
by inquiry, under which hypertrophic men at and above 60 years of age.
enlargement of the prostate, or tendency That it produces manifest symptoms
thereto, is developed. in about 15 or 16 per cent.
It never appears but in advanced The following results of this investi
years. But it is not, therefore, a natural gation are extremely interesting.
or necessary concomitant of age. It is, on The average age of the 108 individuals
the contrary, a condition which a very unaffected with hypertrophy was 75.02
large majority of elderly men escape. years.
Contrary to the generally received opinion , The average age of the 56 individuals
its occurrence is not normal but excep- affected with hypertrophy was 75.03
tional, An analysis of various particulars years . For all purposes the two amounts
given of the dissection of 164 prostates must be regarded as identical.
from individuals at and over 60 years The average age of those in whom
of age ( see Chap. II.), presents an oppor- the enlargement was considerable, 26 in
tunity of determining with tolerable accu- number, was 74:46 years.
racy the average proportion of cases The average age of those in whom
in which, after that year has been the enlargement was less considerable,
reached, the organ may be expected to 30 in imber, was 75.53 years.
become the subject of hypertrophic and It must be borne in mind that all
atrophic changes. these cases were placed in favourable
Of 164 individuals, ranging between hygienic conditions, and had the benefit
60 and 94 years of age, in 97 the proof constant and careful medical super
state was unaffected by either change. vision. Had they wanted both or either
Of the remaining 67, eleven were af- of these advantages, the result must have
fected by atrophy, and 56 by hypertrophy. been greatly different. Prolongation of
Of the 56 cases of hypertrophy, life in the later stages of the affection
26 were marked specimens, i.e. examples depends mainly on the concurring exis
which weighed 10 drs. and upwards tence of the two conditions named . This
( 10 drs. to 48 drs. ). The other 30 were fact is one of considerable importance,
slighter but undoubted examples (54 drs. and ought to beknown to those who are
to 93 drs. ). the subjects of this complaint, since they
Of the 164, 57 were the subjects are often prone to regard it as necessarily
of isolated tumour in the prostate. In tending to shorten the natural term of
about one-fourth of these cases the organ life. They are entitled to the benefit
did not exceed the natural weight, they which a more cheering view of their con
are therefore not ranked with hypertro- dition and prospects cannot fail, in most
phied prostates ; in the remaining three- instances, to impart.
Among the 108 unaffected by hyper- | altogether unknown, however, rare
trophy, were individuals of greater age examples having been met with at a much
than any among the affected portion ; more advanced age. Dr. Beith has placed
for example, three above 90 , and many on record a case in which prostatic en
above 80 years of age. But among the largement, and sacculated bladder as its
56 hypertrophied, there were no less consequence, formed the only abnormal
than 14 of 80 years and upwards, one conditions observable in the body of a
reaching 87. man who died at the age of 103.1
Besides the 164 cases thus analysed, It may then be regarded as established
there were 20 specimens below 60 years by these facts, that hypertrophy of the
of age, which formed part of my first prostate, so far from being a change
series of 50. Among them were 13 invariably, or even usually , present in
cases between 50 and 60 years ; only old age, is an exceptional condition . And
one of these exhibited any signs of it may be further regarded as highly
hypertrophy ; the age was 56 years ; probable, that a slight tendency thereto,
the enlargement was slight, evidently in almost, if not quite, unrecognisable during
the early stage, and affecting pretty life, may occur in about one out of three
equally the whole organ . individuals after 60 years, and that
The period of life between 55 and appreciable enlargement may be met with
65 is that during which the affection in one out of seven or eight, at that age
most commonly begins to be developed. and upwards.
I have never been able to meet with an It is germane to this subject to re
instance of its occurrence at so early a mark here, that, on the other hand,
period as 53 years of age. On the other atrophy does not appear to be an effect of
hand, it appears rarely to commence after old age when hypertrophy is not present,
70. Where it exists, the disease has as has been alleged . This subject will be
generally made considerable progress be- further examined in aa subsequent chapter,
fore 70 or 75.. Consequently, it is met devoted to the consideration of Atrophic
with but unfrequently in later years, and changes in the Prostate.
is exceptional after 80 or 85. It is not i Trans. Path . Soc ., 1850-51, p. 124.
CHAPTER VIII .
THE SYMPTOMS OF HYPERTROPHIED PROSTATE.
Onset of Symptoms sometimes very gradual — Sometimes sudden - Phenomena first noticed - Those
which subsequently occur in their order - Incontinence or OVERFLOW - Characters of Urine
Nature of Ropy Mucus '-Complication with Calculus - Bladder often much distended before
existence of the Complaint is discovered— Last Stage.
In the earliest stage of hypertrophy of the the character of the enlargement itself;
prostate, there are no symptoms suffi- and secondly, upon the constitution of the
ciently marked to attract the attention of patient. In respect of the first condition,
the patient. It is probable, indeed, that we shall see hereafter in what degree the
a very considerable period, varying in nature of the enlargement influences not
different cases from a few months to some only the severity, but the kind of symp
years, is passed between the actual com- toms produced ; and learn also how it is
mencement of enlargement, and the that even a considerable enlargement of
occurrence of anything which is observed one portion of the organ may produce
to be unusual in the act of micturition, or little or no inconvenience for a long
of any kind of derangement arising from period , while a much slighter increase,
the organic changes which are taking otherwise situated, may be the cause of
place. The length of time which elapses great disturbance,
disturbance, both locally and
between the onset of disease and the generally. Secondly, there is in these
manifestations of symptoms, depends cases, as in all others, that natural idio
mainly upon two conditions: first, upon syncrasy of the individual patient, which
TIIE SYMPTOMS OF HYPERTROPHIED PROSTATE . 65
in one instance enables him to withstand groins, testicles, and thighs are sometimes,
the inroads of disease, and to a great but by no means commonly, complained
extent adapt his constitution to altered of at an early period. A sense of weight,
circumstances, and in the other disposes fulness, or uneasiness about the perineum,
it to yield, without much attempt to rally, rectum , and hypogastrium is felt, which
to the morbid influences to which it is the patient soon , almost instinctively as it
subjected. were, learns to refer to the neck of the
Taking into account the variations bladder. He is often annoyed by an un
which are thus encountered in the obser-pleasant odour in the urine which is new
vations of numerous cases, the symptoms to him , a symptom which to some men is
exhibited may be described as taking particularly repulsive. As the expulsive
generally the following form and order of
efforts to pass water become more fre
appearance , quent, irritation of the rectum is expe
It occasionally happens, as will be rienced in a greater or less degree; the
hereafter shown, that the occurrence of contents of the bowels are more frequently
complete retention after some obvious passed from inability on the part of the
exciting cause, as exposure to cold, &c., is patient to prevent the act of defæcation
the first announcement of the existence of accompanying that of micturition ; and
prostatic enlargement. When, however, tenesmus, protrusion of the mucousmem .
this is not the case, one of the earliest brane or prolapsus, and hæmorrhoidal
signs generally observable is a manifest swellings, are apt to result. The asso
diminution in the force with which the ciated action of the bowel is, perhaps,
urine is ejected . The urine also makes more likely to take place , if the enlarge
its appearance less quickly than natural ment of the prostate is developed in a
after the effort to expel it has been made , direction backwards into the bowel,
and a certain hesitation or uncertainty is rather than forwards into the bladder .
experienced before a stream is fairly In this manner , a constant sensation of
established . The size of this is not neces- the existence of some matter in the bowel
sarily much smaller than it was in health , requiring removal is occasioned , and un
but it cannot be projected so far by the availing efforts are made to obtain relief at
ordinary amount of effort , neither can its stool. Much stress has been laid by some
force be much augmented by additional writers, following J. L. Petit1 , who seems
effort, a circumstance which is unlike to have originated the idea, on the ap
to that which is observed in stricture of pearance of Aattened stools, as an indica
the urethra, where , however feeble the tion of this form of enlargement, but, as
stream , increased action of the bladder far as I have been able to judge, without
almost invariably tells to some extent sufficient grounds. I do not doubt that
upon it. Indeed, there is no doubt that, in some cases the motions may be passed
in some forms of prostatic eniargement, in the form described , but should rather
increased efforts to make water do but believe this to be an effect not of the pro
augment the difficulty in micturition . truding prostate, but of some action of the
A powerful contraction on the part of sphincter ani, which exercises a much
the bladder appears in such cases to add greater influence upon the form than the
to the obstruction at its neck, a result organ in question can do. Of this I am
which it is not difficult to understand certain , that in several patients under my
when we observe the form which examina- own observation, whose prostates largely
tion of the parts sometimes reveals . The occupied the rectum , a condition veri
desire to pass water becomes more fre - fied by myself, this appearance has not
quent than natural, not greatly so at first, been presented . Again, Ihave not less cer
andthere is notthe satisfaction following tainly observed it in others who have had
it which is ordinarily experienced in a neither stricture of the bowel nor en
state of health . Frequently the want larged prostate to occasion it. As the
occurs again in a few minutes, especially disease advances , pains directly associated
after the first effort on rising in the morn- with the condition of the bladder begin
ing , when the bladder has become dis- to be complained of. The constant
tended during sleep. In course of time, aching sensation behind or about the
however, the act must be more repeatedly pubes which usually attends on distended
performed , and night is often disturbed 1 Traité des Maladies Chirurg. tome iii. p. 24,
by calls to pass water. Pains in the par J. L. Petit ; ouvrageposthume. Paris, 1790.
F
bladder or severe chronic inflammation of length the same thing happens by day
that organ , is a trying symptom . Sore- also, and the condition of the sufferer be
ness in the urethra is frequently felt ; comes painful in the extreme, his person
and an aching or shooting pain extending and clothes exhaling an offensive odour
to the glans penis, in which it is acutely of the decomposed secretion, his participa
perceived. At the same time some muco- tion in society being impossible,while the
purulent discharge sometimes appears by consciousness of becoming a source of
the urethra ; this varies with circum- annoyance to others is a painful addition
stances, appearing after exposure to cold to his own sufferings. The condition
or damp; or with an attack of retention ; described is generally spoken of as incon
or with exacerbation of all the symptoms, tinence, a misapplication of the term, as
depending, perhaps, on a constipated state we shall hereafter see, which has been
of the bowels ; and then subsiding rapidly productive of fatal errors in practice. A
under appropriate treatment. At such much better term is that employed by the >
times it occasionally happens that the French surgeons, namely, regorgement'

testicles become unusually tender, and (overflow ) ; as aptly indicating a condition
slightly swollen ; while the urine is ex- which, so far from being one in which
pelledwith greater difficulty, or requires the bladder cannot retain , is one in which
to be drawn off for a few days by the it retains too much. For this reason , in
catheter. Vascular excitement of the my work on · Stricture of the Urethra ,'
penis, producing frequent erections, is published in 1853, I employed the phrase
also at times a concomitant symptom . retention with incontinence ' to designate
And as the complaint has thus been the condition described, from the inappli
gradually progressing it is obvious that cability of the word referred to . But the
the bladder is less easily emptied, al- shorter term of overflow is certainly pre
though the efforts to obtain relief have ferable, and I shall make no apology,
become painfully frequent,and wearing to therefore, for seeking to naturalise the
the constitution. While in very rare cases, term in this its English form .
exceptional to the general rule,the effect of A sign which should be looked for in
growing enlargement is to open the neck such cases is the existence of dulness on
of the bladder, and thus permit a real in- percussion about the pubes, and the
continence, so that the viscus is unable to degree, if present, to which it extends.
contain more than a small portion of Frequently in chronic retention the blad
urine, the general result is , that the der may be felt as a rounded body, and its
urethro -vesical outlet is more firmly closed, limits defined by a dull note even as high
and requires a preternatural amount of as the umbilicus,although more frequently
contractile effort in order to drive the to the extent of three or four fingers'
fluid through it. Hence the bladder is breadth above the pubes.
never emptied, its contents not being ex- As the complaint advances, it becomes
pelled below a certain level : the act of difficult to commence the act of micturi
expulsion requiring the weight of a tion, much straining taking place before
quantity of fluid adequate to distend it, the obstruction at the neck of the bladder
conjoined with some additional pressure is overcome, and the urine begins to issue.
derived from the elasticity of the vesical The patient is sometimes compelled to
walls under these circumstances, and lean forward in order to increase the
the action of the abdominal muscles, pressure on the abdomen and so exert
which tells with greater force in propor- more force on the bladder. Indeed , so
tion as the size of the bladder is increased. forcible are the exertions which patients
It is not difficult to see that distension of undergo in these circumstances, that an
the viscus, if unrelieved , must inevitably abdominal hernia is not unfrequently so
increase ; its capacity yielding to the con- caused. In some instances the general
stantly augmenting demand. Hence the health suffers much from pain and broken
bladder becomes at length habitually rest. Slight chills, capricious appetite,
filled, and a little surplus only flows off decreasing strength ,andliability to illness
at each act of micturition, and thảt even after slight exposure, manifest the steady
not by a stream, but by a succession of progress of organic disease. The kidneys
drops. At night, when voluntary control are liable to become impaired through the
is suspended by sleep, urine drains away, long- continued impediment to the dis
to the great discomfort of the patient. At charge of urine. Hence uræmic poison
THE SYMPTOMS OF HYPERTROPHIED PROSTATE. 67
ing, inducing coma and death, is one of | before such matters are observed in the
the modes by which the fatal event some- urine, or long after their appearance, the
times takes place, more especially when urine may be darkened in colour from
the sufferer has been a victim of the admixture with blood. The tint is not
disease unchecked in its course, and unnecessarily red, except from recently
relieved by art. effused blood, and then arising, perhaps,
The occurrence of hæmorrhage to a from the employment of instruments. It
trifling extent is a frequent accompani- is often of a reddish brown or dirty hue,
ment of the complaint. Undoubtedly it which the colouring matter of the blood
sometimes relieves congestion, and may assumes after mixture with urine, espe
be to a certain degree salutary : often it cially when somewhat decomposed.
occurs after exposure to cold , sexual ex. The chemical reaction of the secretion
citement, or other circumstances which is at first neutral, then alkaline in various
tend to produce a vascular determination degrees of intensity. The odour is pun
to the pelvic viscera. Sometimes it re- gent, ammoniacal, often fætid, sometimes
sults from the imprudent use of the extremely so . The quantity often varies
catheter ; and it may then happen to an considerably in the same patient from day
alarming extent. to day ; the measure being sometimes
The characters presented by the urine below, but more generally much above,
should be noted. They are such as the natural or healthy standard . But it
arise from decomposition of some of its is worthy of remark that urine is fre
constituents from abnormal retention, quently secreted more rapidly during
mixed with the products of chronic the night than during the day.
inflammation of the bladder. Accordingly Under the microscope may be ob
the first deviation from health noted by served tesselated and spheroidalepithelium
the naked eye is that it is no longer in abundance, blood corpuscles, and pus
transparent, but a little cloudy, often pale, corpuscles. Besides these, there are
with a few shreds or flocculi suspended usually many of the prismatic crystals of
in it. More or less of mucous deposit the triple phosphate of ammonia and
slowly appears at the lower part of the magnesia in great variety of form and
vessel containing the urine after standing . size, and the amorphous phosphate of
A thin pellicle forms on the surface, more lime. Other crystalline forms may be
or less whitish and opaque, sometimes present also, such as uric acid and oxa
iridescent. In later stages the mucus lates, but the first -named constitute the
increases in quantity, and appears as the typical forms which are present in the
glairy, tenacious, slimy, adhesive matter urine of these cases. Albumen is not
so well known to be associated with present until introduced either by the
chronic inflammation of the bladder ;‫ ܪ‬not admixture of blood or pus ; and then, of
that
miscible with the urine, it adheres to the course, it has no significance beyondselv es
side of the vessel, and follows the urine as which the blood or pus them
it is poured out from one to another , in a possess . It may occur in later stages, from
mass which it is difficult to separate . In chronic inflammation of the kidney s them
advanced cases this mucus sometimes selves, as a result of the disease of the
contains traces of calculous, generally bladder, and interference with excretion
phosphatic , matter , in the form of small so occasioned , or from other causes. In
amorphous greyish or whitish masses of these latter circumstances casts may be
soft consistence . When the mucus has detected , and albumen may be thrown
subsided, there is sometimes deposited down in larger quantities on application
upon it an opaque creamy-looking layer, of the usual tests. But it is not common
which is unaltered pus, mixed with that degeneration of the kidney is asso
crystals of the triple phosphate in varying ciated with enlargement of the prostate,
quantity. In any stage of the complaint sufficient only to neutralise the alkalinity of the
1 The so-called mucus, which is frequently fluid , to be made up almost entirely of corpuscles,
passed in very large quantities from the bladder, is with multiple or irregular nuclei : in such cases, I
usually a compound of pus and mucus, in variable presume, itis altered pus, and little else. In other
proportions. It has by some been considered as instances the proportion of the corpuscles is very
merely pus rendered viscid by the addition of alkali . small in quantity when compared with that of the
After repeated careful observations, cherical and amorphous or very faintly striated viscid fluid in
microscopical, I find that its composition may be which they are suspended, which appearance leads
very different in different cases. In some it ap- me to conclude that the secretion proper of the
pears, after the addition of very dilute acetic acid, mucous membrane is the chief component.
F2
68 TIIE DISEASES OF THE PROSTATE .
nor, indeed , that the local condition has ticular effort, although more frequently
any influence in producing any form of than natural, who is conscious, it may be,
Bright's disease . of some little escape involuntarily during
As a result of long - continued disorder sleep, or even in the day on making any
in the urinary apparatus, and of the strong muscular effort, is very apt to think
changes in the urine itself, which have that his urine passes perhaps too freely ;
been thus described, it is not surprising but does not suspect the existence of any
that the formation of calculus not uncom- obstruction in the urinary outlet. The
monly takes place. Its presence will be condition of such a patient, too, is some
suspected if there is much pain during times overlooked, even by his medical
and after the act of passing urine, if attendant, and no specific investigation is
pain at the end of the penis is severe, if made. The apparent freedom of micturi
blood is frequently seen , and if these tion has masked the real malady, and the
signs are manifestly increased by exercise. treatment is directed only to those symp
Furthermore, small fragments of calculous toms which have been productive of most
matter may from time to time be passed. discomfort or anxiety to the patient; it
But it is also true that the existence of may be, only to the general malaise, or
calculus is sometimes masked by prostatic some febrile condition , not uncommonly
disease ; in the first place because many resulting from the hidden cause. The
of the symptoms are common to the two march of events, however,must ultimately
disorders ; and secondly , because the con- arouse suspicion as to the state of the
formation which the neck of the bladder bladder ; a catbeter is passed, and greatly
assumes in the latter affection tends to to the astonishment of the patient, and
prevent the occurrence, in some measure, sometimes scarcely less so to that of his
of the most distinctive symptoms of stone; attendant, some thirty or forty ounces of
inasmuch as the foreign body is less urine, or even a much larger quantity, may
liable to be engaged in the vesical neck, be drawn off, notwithstanding that the act
but lies back deeply behind the enlarged of micturition has been just performed.
prostate. Hence, the pain immediately Now, it is during the prevalence of such a
following micturition may be lessobvious state of things that unaccustomed exposure
in this condition, and yet a calculus may to cold or damp, or undue indulgence in
be present, and be the source of irritation alcoholic drink, or the like, may suddenly
of which the calculus, and not the prostate, produce congestion of the already enlarged
may be in greater part the cause . prostate ; and a condition of complete re
The same absence of symptoms is tention may be the first occasion of dis
favoured by atony of the bladder, the covering the existence of the affection.
coats of the viscus not closing upon the After this the habitual distension may be
calculus, and so not producing the pain lessened by the daily use of the catheter,
occasioned by the contraction which fol- but the bladder rarely regains the power
lows the act of micturition from a healthy of evacuating its contents completely when
bladder. unnatural retention has existed for some
But , although such is the ordinary months or for a year or two.
course of unrelieved hypertrophy of the The last stage of the complaint may
prostate, the earliest signs of this affection be indicated more by the signs of a gradual
are not always observed in the order of decline of the powers of life,than by those
progression here presented. On the con- of advancing obstruction ; on the other
trary it is by no means uncommon for an hand, the final symptoms are sometimes
attack of complete retention first to reveal those of depression , consequent on acute
the presence of the disease. Its progress cystitis, and frequent hæmorrhage, with
may not have been rapid in these circum- or without the infliction of instrumental
stances; but the impeded function, al- injury ; or of gradual exhaustion, from
though, probably, of long duration , has constant discharge of pus and mucus from
not excited any very obvious symptoms. the bladder and ureters; or, lastly, of
The impediment has often long existed uræmic poisoning of the system , from the
when its presence has been least suspected. failure of the eliminating function of the
A patient, for example, who passes a suffi- kidney.
cient quantity of urine daily ,without par
69
CHAPTER IX.
THE EFFECTS OF ENLARGED PROSTATE IN RELATION TO THE FUNCTION OF MICTURITION
RETENTION— INCONTINENCE - ENGORGEMENT AND OVERFLOW .
Retention of Urine , more or less considerable, the general result of Enlarged Prostate - Contrast between
Retention and Incontinence - Retention due to Obstruction , not to Paralysis — True Paralysis of the
Bladder extremely rare, except from Lesion of a Nervous Centre - Overdistension andAtony of the
Bladder - Tabular View, showing various degrees of Obstruction and corresponding Results - Engorge
ment and Overflow - Importance of last-named Symptom - Commonly confounded with Incontinence
-When does real Incontinence exist ?—The Effects on the act of Micturition produced by the various
Organic Changes in the Bladder, Ureters, &c., which occur as the Result of Enlarged Prostate.
MECHANICAL obstruction, which may be patent and incapable of contracting, and
situated either at the neck of the bladder that the urine flows off as fast asit escapes
or in the urethra, is the chief cause of from the ureters, while the bladder itself
chronic retention of urine ; that is, a state remains empty. The term Incontinence
in which the patient, being unable by his has been employed to designate this con
natural efforts to empty the bladder, re- dition also, although it presents a state
tains there a certain portion of urine, which is the exact reverse to that already
which varies considerably in quantity, so described . But in this case, whether
just as the amount of obstruction itself a nervous lesion be the cause of the phe
varies. By far the most common cause of nomenon or not, the term is appropriate,
this condition is enlarged prostate ; and because the bladder is unable to retain ;
when the obstruction is considerable, it the condition might, therefore, be accu
may be that no urine at all is passed by rately described as incontinence of urine.
voluntary effort. The bladder then be- On the same theory, also, retention of
comes permanently distended, and the urine is supposed to be caused by the con
fluid gradually increasing in quantity, at verse form of paralysis of the bladder,
length opens the orifice, and flows off that is, when the neck retains its nervous
spontaneously. To designate this phe- supply, and the body losing it, becomes
nomenon the term incontinence was ori- unable to expel its contents. Thus it will
ginally applied, and is still employed by be seen that the term Incontinence comes
many, although it is incontestable that the to be frequently applied to precisely oppo
condition so described is in reality the site states of the containing function of the
very reverse of incontinence, since the bladder. Hence the misunderstanding,
bladder already contains too much, often the difficulties, and the grave errors in
much more even than its capacity, in a practice which sometimes occur, especially
state of health , would admit, and it is to the student, in connection with this
the surplus only which is forced out. The subject.
bladder is in fact engorged , and the urine Now , without discussing here at length
overflou's. the question already raised, as to whether
The phenomenon of involuntary mic- these local deprivations of nervous influ
turition in elderly persons is very fre- ence do, or do not, take place — in the one '
quently accounted for, not on the ground case affecting only the neck of the bladder,
of existing obstruction, but on the sup- at other times the body alone—I have no
posed presence of paralysis affecting the hesitation in affirming that in a great
bladder. It is held that either the neck majority of the cases of habitual retention
or the body of the bladder may be sepa- of urine, with uncontrollable overflow of
rately paralysed, the remaining portion re- a portion, the cause is palpable and physi
taining its normal supply of nervous influ- cal, and not impalpable or dynamical"; a
ence - a pathologicalstate the existence of fact which in each individual case may be
which it would be very difficult if not im- ascertained by examination ; in other
possible to prove, and which, if it be an words, there is an organic obstruction in
actual occurrence, is certainly extremely some part of the urethra , situated either
rare .
On this theory, however, it is said at its commencement in the neck of the
that when the neck is paralysed and the bladder, where it is usually constituted
body unaffected, the vesicaloutlet becomes by enlarged prostate ; or in a portion of
the canal anterior thereto, where it usually result is retention and overflow of surplus
takes the form of permanent or organic urine,—the very condition, it may be
stricture . remarked, which is affirmed on the local
We are, I believe, indebted to Mercier paralysis theory (as above shown) to be
of Paris for first calling attention forcibly the result of paralysis of the body and
to the important fact that organic obstruc- non -paralysis of the neck . Under certain
tion, not local paralysis, or impaired circumstances, paralysis of the bladder
nervous supply , is the great, and almost may be produced by reflex action, no
universal, cause of the various states organic lesion of nervous centres being
which are described as retention and in- present; as in severe shock following
continence, when existing in elderly injury, and the like.
individuals who present no sign of im- The second exceptional case is that in
paired nervous power in other parts of the which a healthy individual voluntarily
body. To his able treatment of the retains his urine for a considerable period
„subject I would refer my readers for the of time, in spite of urgent desire for
arguments in favour of this view . It is relief. The not unfrequent result is that
not entered upon here, because I have the muscular expelling apparatus of the
preferred regarding it as a question of bladder is overstretched, loses its tone,
fact, rather than as a theme for discussion . and is more or less unequal to perform
The obstruction is, or is not present ; if contraction in a normal manner . More
the former, it may generally be verified. or less chronic retention results, and will
Experience alone has led me to reject the probably continue unless relieved in the
impalpable cause, and to appreciate the ordinary way. To this state also the
material one, and to an extent sufficient to term paralysis has been applied ; but
warrant me in referring to the factalonefor as there is no evidence whatever that the
corroboration of the assertion made above. lesion consisted in any loss or impairment
In nineteen cases out of twenty, exclud- of the nervous force transmitted to the
ing two classes of cases which will be im- viscus, it conduces to a better apprehen
mediately named, the symptoms described sion of the case to call it simply as it is,
are invariably associated with permanent Overdistension, or, if preferred, Atony of
obstruction of some kind, as may gene- the bladder. It is perfectly gratuitous in
rally be verified during life, or, more such an instance to imagine a lesion in
perfectly, after death . The exceptional any part of the nervous system to account
cases referred to are, first, those in which for the phenomenon, and it is, therefore,
there is cerebral or spinal lesion of an undesirable to speak of it as produced by
organic kind, which paralyses more or a paralytic condition of the bladder.
less completely the nerve-functions of The phenomena produced by obstruc
motion, voluntary and involuntary, of tion at the neck of the bladder caused by
sensation, or of sensation and motion enlarged prostate, in connection with the
combined, of the whole body, below the function of micturition , may be briefly
situation of the injury. In such cases recapitulated as follows, and connected step
the body and neck of the bladder are by step with the organic changes which
alike affected ; still the almost invariable arise in the progress of the affection.
OBSTRUCTION AT THE NECK OF THE BLADDER
ORGANIC RESULTS .
FROM ENLARGED PROSTATE, PRODUCES
a. Increased efforts to expel urine
Corresponding Hypertrophy of
giving rise to the muscular coats of the Blad
through obstructed orifice ; der.
b. Inability to effect a complete ſ Dilatation of the Bladder corre
contraction of the Bladder ; sponding with the increasing
amount of residual urine, the
and consequent Retention of result of augmenting obstruc
a portion of urine ; tion at the neck .
See Recherches Anat. Path. et Thérap. sur les The local paralysis theory was defended by Civiale,
Maladies des Organes Urinaires et Génitaux, con- in a reply to the above, in the Moniteur des Hôpi
sidérées spécialement chez les hommes âgés, Part II. taux, Feb. 8, 1855. Mercier's rejoinder appeared in
chap. i ., par L. Aug. Mercier. Paris, 1841. Also, the same journal, April 10 and 12. See, also, these
Recherches sur les l'alvules du Col de la Vessie, two memoirs, with some additions, in his latest
chap . iv., by the same. Paris, 1848. And more work, Recherchessur le Traitement des Maladies des
recently , by the same author, a paper, Sur l'Inertir, Orgunes Crinaires, Sc., Paris, 1856.
ou Atonie de la Vessie,' & c.,Gazette Médicale, 1851. |
ENLARGED PROSTATE IN RELATION TO MICTURITION. 71
OBSTRUCTION AT THE NECK OF THE BLADDER ORGANIC RESULTS .
FROM ENLARGED PROSTATE , PRODUCES
c. Increased inability to effect
contraction of the Bladder
from increasing dilatation and giving rise to Their more or less complete
overstraining of the muscular Latony.
coats ;
d. The Bladder becomes engorged Organic changes in the mucous
with urine, the neck is dilated , lining of the Bladder ; saccula
and a portion overflows, irre
spective of the will of the tion of the outer coats, and dis
tension of the ureters, &c.
patient ;
Thus we arrive at an appreciation of that when the enlargement of the organ
terms which , when applied to the morbid is uniform , so that each lateral lobe and
states described, simply and clearly denote the median portion (middle lobe) are
their meaning :-Retention, Engorgement, pretty equally augmented in size, the
Overflow . The term Incontinence is to last-named part acts as a wedge, that it
be employed solely to denote that con- separates the two lateral lobes, and opens
dition in which the bladder is organically out the neck of the bladder , so as to pre
incompetent to contain urine , which vent the bladder from retaining the urine.
therefore issues soon after its entrance by He gives particulars of four cases under
the ureters. his own care, in each of which, at an
On the other hand, when from any examination of the body after death , the
cause the bladder is inflamed, it has little bladder was found empty, and contracted
retaining power, and empties itself with in size, while the prostate was enlarged
undue frequency. To this condition the considerably, but equally, so that the
term Irritability of the bladder is gene- internal meatus was patent and of a tri
rally applied, as indicating a condition angular form. During the latter part of
of activity, and therefore one very dis- life, incontinence had been present in
tinct from Incontinence, which , as we each case, and there had been no retention
have seen, always implies the presence of of urine.
a passive condition, in which the urine As has been observed in a preceding
dribbles off, being neither retained nor chapter on the morbid anatomy of the affec
expelled . tion , I have not seen in the extensive
Real Incontinence, then, is a rare collections which our museums afford , a
parallel instance to these cases of M.Mer
occurrence in the adult male. That it is
so is one of the most salutary and im- cier, and must, in consequence, believe it
portant lessons which the student can to be a rare result. On the contrary, in
learn. It should be held as an axiom, prostates similar to those described by
the importance of which it is impossible him , the bladder is generally much dilated ;
to overrate, that AN INVOLUNTARY FLOW OF at all events, is not less than the natural
URINE INDICATES RETENTION , NOT INCON- size. Most rarely is it contracted ; nor on
TINENCE . How often has the overflow of examining the numerous recorded histories
surplus urine from an engorged bladder attached to these preparations, does it
concealed the real evil from an inex- appear that real incontinence had been
perienced practitioner, and induced the verified during life. It may be remarked
patient to believe that " his water was further, also, that the equal development
>
too abundant, or passed too freely,' and of the three portions does not necessarily
wanted repressing rather than withdraw- produce the opening out of the internal
ing ! And what has been his astonish- meatus, since the outgrowth from the
ment, when, the true state of matters posterior median portion is almost always
being recognised by his attendant, the directed backwards towards the cavity of
introduction of a catheter has given exit the bladder, and presents no appearance of
to a pint or more, it may be, of retained acting as a wedge between the laterallobes,
urine ! from which, on the contrary, it seems
But does Incontinence, that is, or- rather to diverge, as if forced out by their
ganic inability on the part of the bladder lateral pressure. Since the publication of
to retain urine, ever occur as the result the first edition I have had two or three
of enlarged prostate ? M. Mercier states
that he hasnot infrequently found it so dies1 des
Recherches Anat. Path , et Thér . sur les Mala .
Org. Urin . et Gén. par L. Aug. Mercier ,
occasioned, in this manner . He believes pp . 261–273 . Paris, 1841 .
72 TILE DISEASES OF THE PROSTATE .
opportunities of verifying the existence of the length or the curve of the catheter is
the condition described, but the infre- required for the case. These conditions,
quency of its occurrence corroborates the which are undoubtedly exceptional, I have
statement previously expressed respecting nevertheless not unfrequently observed
its rarity. during life and verified after death. (See
A resultwhich almost uniformly occurs figs. 10 , 15, and 20. )
from considerable hypertrophy of the We have thus a condition distinct from
a
prostate, is elevation of the urethro- general hypertrophy, but liable, like it, to
vesical orifice above the floor of the produce obstruction to the outflow of
bladder. The entire neck of the organ is urine, and chronic retention and engorge
pushed up behind the pubes by the en- ment of the bladder, in elderly subjects
larging mass, so that what had been a condition which requires similar man
originally the most dependent portion of agement also , in all respects. The prac
the cavity is no longer on a level, or nearly tical lesson is one which relates to dia -
a
80, in the standing position of the indi- gnosis ; and it is simply this, that we are
vidual, with the outlet bywhich the urine not to affirm the absence of obstruction of
has to pass ; and a depression exists behind the neck of the bladder, and infer the ex
the neck, in which urine may remain, even istence of true paralysis affecting that
after it has ceased to flow through a cathe- viscus, when it is unable to empty itself
ter lying just within the bladder. Hence voluntary efforts, because we discover
the posture of the patient will sometimes no enlargement of the organ by rectal or
affect the flow of urine; and accordingly, by urethral examination. The obstruction
he finds that when kneeling, or in the may be, and in these circumstances it not
prone position of the body, he is able to unfrequently is, due to the existence of a
pass water after ceasing to do so in the small rounded tumour developed in the
upright posture. In some few instances, prostate, but projecting into the urethral
the outgrowth from the median portion canal, and usually, although not invariably,
having become pyriform , and possessing in or near to the situation of the uvula
but a narrow pedicle, the mass is so move- vesicæ.
able as to fall forwards upon the vesico- Other circumstances may be briefly
urethral orifice in the manner of a valve, named as results of enlarged prostate, and
and close it very effectually when the affecting the function ofmicturition : viz.
individual is in the upright or in the prone those arising from the hydraulic pressure
positions. Thus a patient finds by expe- exerted upon the entire urinary tract,
rience that urine passes more freely when behind the point of obstruction . I shall
he is lying on his side or back, than by merely name them here,as thewhole sub
any other method. Such a circumstance, ject is treated at length in my work on
which , by the way, is one of rare occur- Stricture of the Urethra,' chapter the
6
rence, may suggest the presence of this second. The changes thus produced in
form of enlargement, and this may be the containing and excreting organs are, in
verified by means of an exploring sound the main, almost the same, whether the
(see the following chapter Diagnosis
on ). obstruction to outflow is situated in the
Sometimes, however, when there is not course of the urethra (stricture), or at the
much hypertrophy, obstruction may occur neck of the bladder ( prostatic ).
from the presence of simple tumours in Hypertrophy and dilatation of the
the prostate. While, as we have seen, a bladder are the commonest, indeed almost
prostate may becomelargely hypertrophied the invariable, results of prostatic enlarge
without causing obstruction to the outflow ment. Hypertrophy and contraction, on
of urine, one of these small tumours de- the other hand, are more common in stric
veloped at the neck of the bladder may ture of the urethra. Sacculation of the
produce complete inability to micturate. bladder often follows, being produced by
The small firm rounded projection which it protrusion of the mucous membrane out
constitutes, fills up the internal meatus, wards, through small interstices between
closes it almost entirely against the natural the enlarged fasciculi of the muscular coat.
efforts to relieve the bladder, and renders The sac, commencing as a mere indenta
necessary the aid of the catheter. At the tion , becomes pouch-like, and, in the course
same time, little or no enlargement of the of long-standing disease, is distended into
prostate may be present or ascertainable a spheroidal cavity, capable of containing
by rectal exploration, and no difference in several ounces of urine. ( See fig. 18. )
ENLARGED PROSTATE IN RELATION TO MICTURITION . 73
The presence of these sacs may be sus- | the presence of a sac was proved by the
pected during life,when , after the bladder occurrence of what he denominated the
has been completely emptied by a catheter, fluttering blow of the bladder,' communi
cated through the catheter to the hand of
B the surgeon. The phenomenon thus de
scribed I have repeatedly experienced in
circumstances in which there was no evi
dence of the existence of sacculi, and,
indeed, every reason to conclude they were
not present ; I cannot, therefore, admit it
to be a diagnostic sign. The ureters may
also become dilated to a considerable
extent, and their walls at the same time be
hypertrophied. The ureter has even been
known to serve the purpose of a subsidiary
bladder ; in one well-known case it formed
a tumour, easily recognised during life
when distended , which reached from the
pubes to the lower ribs, but which dis
appeared after catheterism . Dilatation of
the pelvis of the kidney follows, and some
times to such an extent that an organ so
affected presents the appearance of a cyst,
al
or congeries of cysts, a condition in which
irreparable injury to the renal structure
FIG . 18.- Thebladderand prostate of a man aged itself has been inflicted. Indeed, the kidney
seventy -six years, drawn when fresh , andshow- may ultimately almost disappear under the
ing a tumour embedded in the interior part of influence of such fluid pressure when long
the organ ,divided into nearly two equal hemi: continued. Add to all these effects the
spheres by an incision into the urethra.
the neck of the bladder another eminence is noxious action of decomposed urine upon
seen, which produced almost total obstruction the whole extent of the mucous lining in
to the outflow of urine ; it consisted of a
spheroidal tumour, carrying before it a thin volved ; the consequence of which is
layer of prostatic tissue. On the leftcavity
sac communicating with the proper is seenaof chronic
and
inflammation,proc
leading
esses toinulcerative
various
the bladder by a small opening, in which a gangrenous
slender bougie is placed . parts.
Such are the principal effects of pro
certain changes of position in the patient's static obstruction,and the organic changes
body, in the course of a very few minutes, which take place in the organs behind its
set free some three or four ounces of very seat, as the results of retained urine, not
turbid urine. Mr. Guthrie believed that removed by artificial means.
.
CHAPTER X.
THE DIAGNOSIS OF PROSTATIC AND OTHER OBSTRUCTIONS AT THE NECK OF
THE BLADDER .
Examination by Rectum - Method of conducting i ;—Points to be verified - Examination by Urethra

By catheter - By sound adapted for the purpose - Ordinary methods of using it - Rigorous deter
mination of Size and Form of Tumour often possible — Diagnosis of Prostatic Enlargement from
Stricture of the Urethra- From Calculus of the Bladder - From Tumours of the Bladder - From
uncomplicated Chronic Cystitis – From Atony of the Bladder – From Paralysis of the Bladder.
ALTHOUGH an observation of the ordinary | the nature of the complaint, still its exis
symptoms of prostatic enlargement, in an tence cannot be asserted without a physical
elderly patient, affords good ground for examination.
entertaining a pretty correct surmise as to Just as in the case of suspected stone
in the bladder, the sound must reveal the either side; it may then pass further
presence of the foreign body, so, in this backwards in the median line, until the
case, must the finger, and occasionally the firm prostate is no longer felt, but the
sound, recognise the existence of prostatic more yielding tissues of the bladder be
enlargement, irrespective of the evidence hind its base, especially in the centre, at
which may be derived from the existence the interlobular notch , which is readily
of any symptoms whatever; and they reached in the natural state of the parts.
should also define, as far as possible, what Once familiar with the normal con
are its nature and extent. ditions thus presented, deviations will
The test which is chiefly depended on easily be recognised ; but without such
by the surgeon is an examination , by previous knowledge, it is impossible to
means of the finger, in the rectum. It is appreciate any but considerable develop
so familiarly known and commonly em- ments of disease. It is desirable to pursue
ployed, that it might be deemed super- a methodical plan in conducting these
Auous to enter into details respecting the examinations. For example : the first
method of applying it. The student, step of the inquiry should have for its
however, or any one unpractised in such object the deviations in size and form .
explorations, will learn little by employ- The first- named is almost always in the
ing them , unless he has attained some direction of enlargement. Is it general,
previous knowledge by experience, of the or partial ? affecting one, or both lobes ?
size and form of the prostate in health, and to what extent ? Affecting breadth
and his study will be facilitated by some mainly, or forming a rounded protrusion
preliminary hints. into the bowel ? It is so prominent some
The patient should, as a rule,lie on his times, that the tip of the finger encounters
back upon a couch, and the surgeon stand the swelling the moment it enters the
on either side, so that the forefinger of rectum, and has to be depressed con
one hand may be employed in the rectum , siderably before it can be carried beneath
while the other hand is free to use a the tumid organ . Again, instead of find
catheter if required, since by concerted ing the yielding coats of the bladder in
movements of that instrument in the the middle line, when the finger is carried
urethra, and of the finger in the rectum , up to its fullest extent, an increasing ful
more accurate information may sometimes ness and firmness may be encountered,
be obtained than by either exploration due to an enlargement or outgrowth from
conducted separately. The nail of the the median portion ( middle lobe') oc
index finger should be short, and should cupying that situation , and defying any
first be soaped and then well greased. attempt to define it. Then the form of
The patient's knees being drawn up and the enlargement may not be uniform or
separated from each other, the finger spheroidal; it may be irregular, knobbed,
should be made to glide very slowly and or mammillated ; a condition which it is
gently through the sphincter, and when very important to note.
introduced as far as possible, so that two Secondly, the consistence of the parts
phalanges are free to move in the bowel, is to be ascertained. Is the tumour soft,
the limits of the prostate may be defined. hard, or unequally so in places ? Is there
The healthy prostate may now be de- fluid in it ? And - often a question of
fined ; but the student may first endeavour vital importance — can we appreciate
to define immediately within the ring of fluctuation distinctly beyond it ? In the
the sphincter, through the anterior wall latter case, the right hand should be
of the bowel, which recedes at this point, applied to the hypogastric region, and
the termination of the bulb of the urethra, firm pressure made there, with the view
or, at all events, themembranous portion. of ascertaining if a large body of Auid,
Next the apex of the prostate is distin- such as a distended bladder, can be pressed
guished , and gradually widening out, the down upon the apex of the finger, in the
body, which is firm to the touch, with an rectum below ; then gentle but sudden
outline distinctly suggesting that of a taps should be made on the same region,
flattened chestnut; the finger will readily for the purpose of imparting the wave
appreciate a slight depression marking the like impulse which, under such circum
line of the urethra , between its two lateral stances, will be communicated. This is
lobes, and may glide over the outer an important mode of verifying the con
borders of the latter, into a hollow on dition of the bladder, and the proper
DIAGNOSIS OF PROSTATIC ENLARGEMENT. 75
position for the trocar, when the operation patient. It should notbe small, nor very
of puncture by the rectum is about to be large; a number 8, 9, or 10 (English
performed , or its applicability to the case scale) French coudée catheter being suit
in question has to be determined. At the able for most prostatic cases. If the
same time, the situation of arterial branches urine flows when the catheter has passed
is learned ; one or two of considerable about 61 to 7 inches, no considerable
size may generally be felt a little to the hypertrophy can exist ; but the converse
right or left ofthemiddle line, and, some- position is probably present, ifthe catheter
times crossing it, branches of the hæmor- passes 7 to 9 inches before urine appears.
rhoidal arteries. The presence of prostatic If a silver catheter, or a sound, is used,
calculi may sometimes be thus ascertained, the handle will require to be depressed
when large or numerous, lying in one or more than in the healthy subject. In ad
more cavities of the prostate , with very vanced cases the ordinary silver catheter
little tissue intervening between them and is inadequate to reach the bladder, or does
the wall of the rectum . ' so only when it has passed further than
Thirdly. We seek for the degree and usual, 'and another instrument may be
locality of tenderness on pressure; making necessary. This is generally from two to
firm pressure distinctly with the point of four inches longer, and possesses a larger
the finger in three different spots ;-on curve than the ordinary catheter; while
the centre of the prostate, on the extreme some instruments describe also a larger arc,
right and left borders, consecutively, per- a third, for example, instead of a fourth ,
mitting an interval of a few seconds to of the circle. A medium prostatic silver
elapse, that the patient may clearly dis- catheter (see fig. 24, 6, Chapter XII.) has its
tinguish each separate movement, the beak at right angles to the shaft, the re
sensation occasioned by which he is re- collection of which makes the direction
quired to describe. if inflammation is and even the exact position of the beak
present, the pain will be extreme, and theobvious at once to the mind's eye, the
mere introduction of the finger will be axis of the shaft being, as it always is, in
very distressing to the patient ; in this view. In some few cases, while the beak
case, heat and tension will be remarked passes through the prostatic part of the
also.
urethra, the handle will be distinctly de
Lastly, supposing a sound or catheter flected to the right or left, from which
to have been previously introduced, we fact, if verified by two or three trials, a
may, while holding it in the right hand , greater degree of enlargement may be
and communicating to it gentle move- suspected to exist on the side towards
ments downwards, estimate the thickness which the handle turns.
of the tissue intervening between it and At all events, by one or other of these
the finger in the bowel, also the situation courses we may obtain approximatively cor
and direction of the instrument, &c. , in rect views of the size and mode of develop
event of there being difficulty in introduc- ment of the prostatic enlargement. The
ing it. Its presence there is occasionally progress of the complaint may be noted
useful, for the purpose of furnishing a from time to time, and I am not aware
solid body of known size and form over that much advantage can be obtained by
which the exploring finger may pass ; the possession of more exact knowledge
and by the aid of which most of the respecting the tumour, attainable, perhaps,
above -mentioned inquiries can be pro at the expense of reiterated and more
secuted with facility . painful applications of the instrument
Having learned, relative to these diffe- than those at present alluded to. But it is
rent points, all that can be attained through desirable to be familiar with the manner
the rectum, the urethra is to be explored. of accurately determining the condition of
This may be done either with a silver or the prostate, of the bladder and its con
* flexible ' catheter ; the latter being easier tents, especially in relation to the question
for the student, and less irritating for the of calculus or tumour, and for such a
1 I have more than once had patients with em purpose the instruments with a large curve,
bedded calculi in the prostate. The grating from already described, are wholly useless.
these is very perceptible to a finger in therectum, Hence it is necessary to employ that now
when a catheter lies in the urethra, and is gently
pressed downwards. A few months ago I removed
usually
u adopted in sounding the bladder,
several thus felt,of rather large size, by the fer- viz., a sound with a very short curve at
ceps, in a patient I saw with Mr. Savory . its extremity, or possessing a beak rather
than a curve, which is much shorter and / ployed, but their use for sounding the
more angular than that of the ordinary bladder, and more especially for examining
the condition of the prostate, has, during
the last fifty years, been more particularly
advocated by those among the French
surgeons who have bestowed special atten
tion on maladies of the urinary organs.
The short beak is of course for the pur
pose of being carried into the bladder, in
which cavity it can with care be turned
freely in any direction, provided a small
quantity of urine or other fluid is retained.
In this manner not only can every part
of the bladder be searched for calculus,
but information respecting the form and
degree of obstruction at the neck, what
ever may be its nature, can also be ac
quired. After the bladder has thus been
traversed, the instrument should be gently
withdrawn until the beak lies just within
the urethro -vesical orifice, when, by turn
ing it round to the right and left, the
Fig . 19. - Short -beaked sounds for exploring. natural condition, if it exist, of that part
can be ascertained ; or, on the other hand,
catheter. Instruments somewhat resem- the presence of tumour, or of stone, the
bling this description have long been em - 1 depth of the fossa behind the prostate
which
Fig. 20.
( fig. 20), and other relative points, can be which our French brethren have em
determined. It is occasionally advanta- ployed, it may not be unprofitable to
geous to use a hollow one, so that the notice briefly the methods by which exact
quantity of fluid in the bladder can be information respecting it is sought. And
augmented or diminished, without remov- since I object to the practical end for
ing the instrument; and lest this should which such manæuvres are designed, viz.,
impair its solidity and weight, I employ the destruction by mechanical or chemical
one made in steel,of which the extremity meansof obstructing portions of the pro
is aa little bulbous and solid ; the channel state, there is additional ground for doubt
opening about half an inch or more short ing whether the employment of many of
of the extremity on the convex surface. them can conduce to any beneficial result.
(See fig. 21.) Without giving my ad- I shall, therefore, describe only one ortwo
hesion to a practice which requires the of the simpler means in use for diagnose
performance of the extremely numerous ticating tumours of theneck of the bladder,
and varied maneuvres for the purpose of premising that the instrument employed
arriving at a diagnosis respecting the pre- is always one similar to those delineated
cise terms of a prostatic enlargement, I at figs. 19, 20, or 21. For the more com
DIAGNOSIS OF PROSTATIC ENLARGEMENT. 77
plicated proceedings of this kind, the been jyst seen , cannot be accomplished
reader is referred to the practice and when it is a case of tumour of the median
writings of the authors themselves, par- portion of the prostate, and not a simple
ticularly those of Mercier. bar. In withdrawing the instrument from
1st. Means of recognising tumours the bladder, the beak being turned down
which rise into the neck of thebladder. wards to the basfond, if the prostate is
The sound having been introduced, it healthy, it will come back into the urethra
is slowly and gently, but completely, ro- easily, but if there isan enlargement there,
tate on its axis in the cavity of the it will hook against it, and not leave the
bladder, and close to its neck . If the bladder in that position.
prostate is healthy, this is done without 2nd. In order to recognise an en
any elevation of the instrument, and the largement of the prostate projecting into
shaft retains an almost horizontal position the urethra , Mercier proceeds as follows:
(the patient of course being recumbent) . After having explored the bladder, I draw
But supposing that there is a tumour at the instrument gently back into the pro
the neckof the bladder, thebeak must be static region ofthe urethra, pressing lightly
arrested in the movement of rotation, and upon it, at the root of thepenis' ( its upper
it will be necessary to elevate it propor- aspect), “ just under the pubic symphysis,
so as to press the angle of the sound or
salient part of its curve against the pos
terior wall of the prostatic urethra ; then
I draw it forward without elevating its
shaft towards the abdomen, as in ordinary
catheterism , and without making it deviate
much from the axis of the patient's body
( 15 ° to 25° ). When there is a simple
eulargement of the prostate in the antero
posterior diameter, the beak traverses it
easily without inclining either to the right
or left. If, on the contrary, there is a
projection of one of the lateral lobes, the
beak , in passing the spot, inclines to the
opposite side : the handle indicates this
movement and the direction in which it
is made .' '
This portion of the subject may be
appropriately closed with a few remarks
on the diagnosis of prostatic enlargement
as against stricture of the urethra, vesical
Fig . 21 . calculus, tumour of the bladder, simple
atony or inertia of the coats of the bladder,
tionately to the height of the eminence, and paralysis.
after which it will descend again, the In Stricture of the urethra, the stream
movement of the handle indicating ap- of urine is invariably small, in a confirmed
a
proximatively the size and form of it. If, case extremely so ; in the prostatic affec
in introducing the instrument through the tion, though diminished in force, itis often
prostatic part, the beak is found to rise less so in volume than in the previous
gradually , the handle being depressed be case . The use of a full -sized sound, how
low the horizontal line, there is probably ever, marks the distinction clearly. In
spheroidal enlargement of the median stricture, obstruction is encountered al
portion. But if the beak abuts upon an ways before six, mostly before five, inches
obstacle there, and has to be lifted over it ofthe instrument have disappeared ,always
in a direction upwards,entering the blad- before it arrives at the prostatic urethra.
der with somewhat of a jerk , there is In enlarged prostate, obstruction is not
probably an enlargement of the same por- encountered until seven or eight inches
tion, affecting the form of a bar, with a have passed , and not necessarily then, for
deep sinus of the prostatic part of the provided that the instrument be suffi
urethra. But in this case the instrument ciently long, it may pass into the bladder ;
can be rotated with facility, which, as has i Recherches Anat. &c., pp. 361, 365.
but the handle, supposing the instrument a foreign body, to some form ofobstruction ,
to be a metallic one, has to be depressed to atony, or to paralysis, depriving the
between the patient's legs in a manner patient of the power of expelling the con.
not required in the normal state. Lastly, tents of his bladder, a condition which is
stricture almost invariably makes its ap- tantamount in its effects to obstruction.
pearance before middle life ; prostatic hy- We may rely upon it that in most of the
pertrophy never before fifty - four years of obscurer cases, there is a material cause,
age. not infrequently calculus; the presence of
In regard to Calculus, while many of which needs a more than ordinarily search
the symptoms are common to both coming examination to verify. In very rare
plaints, the occurrence of severe pain at cases, it may be encysted, or otherwise
the close of micturition, at the end of the rendered difficult of detection by the
penis ; the exacerbation of symptoms, es- sound. The absence of all the physical
pecially of pain and of bleeding after signs of enlarged prostate, by rectal and
exercise, may be looked upon as strongly vesical exploration, will, of course, prove
indicating the presence of stone in the the non-existence of that complaint as a
bladder. Nevertheless, calculus may exist
cause .
in the absence of most of these signs, tlie Single or repeated acts of voluntary
two first-named especially, from the cir- over -retention of urine are sometimes fol
cumstance that it is sometimes situated lowed by Atony or inertia of the muscular
behind the enlarged prostate, and does parietes of the bladder, and a state of
not approach the more sensitive region of chronic retention follows from their con
the internal meatus. The fact of small sequent inability to expel the vesical con
quantities of blood being occasionally tents. The condition resulting resembles
passed after exercise, more closely ap- much the retention produced by enlarged
proaches in value to a pathognomonic prostate, and requires frequent relief by the
sign than any other. A persistent dis- catheter in the same way, at least for a
charge of slightly bloody mucus, or of pus, time. Here the absence of physical signs,
in the urine, should also arouse suspicion. the history of the attack, its connection
The use of the sound, however, can alone with a cause generally recognised by the
clear up this case also satisfactorily. patient, and the diminished power of dis
The existence of Tumour of the blad- charging the urine in the recumbent
der is less easily affirmed. Compared position, after a catheter has been placed
with prostatic enlargement there is more in the bladder, help to distinguish this
pain, and there is more tenderness on the affection. In enlarged prostate, the urine
introduction of instruments, the urine is often flows with considerable force when
frequently or generally mingled with sani- the influence of the obstruction is removed
ous discharge and flocculi or shreds of by the introduction of a catheter, and the
organic matters. Examination of these current can be accelerated materially by
under the microscope may reveal the pecu- the will of the patient, unless there be atony
liar structure of villous growth, or, which is also, as there may be from undue distension.
almost equally significant, may demonstrate But when the cause of engorgement and
that they consist of growing organised retention is not obstruction, but complete
structures, not of merely pus cells or de- atony of the bladder, the urine runs out of
squamated epithelium . Exploration by the catheter, and is not propelled, neither
rectum sometimes detects a firm mass occu- can the flow be much influenced, by any
pying some portion of the walls of the efforts of the patient.
bladder, especially if malignant disease be Lastly, there is Paralysis of the bladder,
present, of which other signs willalso be a condition in which its nervous supply is
ascertainable (see Chapter XIV.) ; but either impaired or destroyed. It is almost
neither soft fibrous nor villous tumour is always associated with a similar condition
appreciable by such, or by any other ex- of the lower extremities, and this may re
amination ; the most characteristic symp- sult either from disease or injury of the
tom of the latter being almost constant encephalon or spinal cord. There is no
admixture of blood with the urine. evidence of the existence of true paralysis,
Simple uncomplicated chronic Cystitis, that is, a removal or impairment of nervous
with catarrh, is by no means a common affec- influence, limited to the bladder ; never
tion. The series of symptoms thus denoted theless, the term paralysis is constantly
is almost invariably due to the presence of applied, but most inappropriately, to de
TREATMENT OF PROSTATIC ENLARGEMENT. 79
note inability of the viscus to expel its , of the parts around, the will of the patient
contents, whether the cause be obstruction exerting no influence upon its flow unless
at the neck , or over -stretching (atony) of the abdominal muscles should be in a
its muscular walls. The bladder is not normal condition, as in cases of injury
deprived of nervous force, and thus ren- (rare) occurring to the spinal cord between
dered paralytic, except when there is lesion the sources of nervous supply to those
of some nervous centre involving numer- muscles and to thebladder, in which case
ous other parts in the same predicament, a slight influence is perceptible. Other
any more than is the stomach singly para- wise no impulse is noticeable, except
lysed, the intestines, or any other viscus through the agency of acts unassociated
see
( preceding chapter ). There can then with micturition ; such as deep inspiration ,
be no doubt respecting its presence ; and coughing, sneezing, and the like, by which
the indication which catheterism presents, a momentary pressure is communicated to
when it does exist, is also singularly cha- the paralysed bladder, and the stream is
racteristic . An instrument being intro- momentarily accelerated .
duced, the urine is propelled by the weight
CHAPTER XI.
THE TREATMENT OF PROSTATIC ENLARGEMENT, FROM HYPERTROPHY AND SIMPLE TUMOUR .
1. TREATMENT for the purpose of obviating the results of Obstruction caused by Enlarged Prostate
-Necessity for removing retained Urine - Question of patient relieving himself - Instruments to
be used – Of permitting a Catheter to remain in the Bladder - Evil results of not relieving the
Bladder - Treatment of ATONY OF TAE BLADDER-Of CHRONIC CYSTITIS - Injections — Counter
irritation - Baths — Buchu - Pareira brava-Uva ursi - Triticum repens— Matico - Lythrum Sali
caria — Alchemilla arvensis — Epigæa repens — Chimaphila - Wild Carrot — Copaiba - Cubebs- Ben
zoin — The Demulcents — Indications for use of the foregoing — The Mineral Acids - Alkalies
Benzoic Acid- A Case - IrrITABILITY OF BLADDER - Value of Opiates - Injections — HEMOR
RHAGE-Its Treatment - INCONTINENCE of Urine- Treatment — Recurring Attacks of Congestion .
—2. THE GENERAL TREATMENT and Management of patients with Enlarged Prostate - Dietetic,
Regimipal, and Moral.-3. SPECIAL TREATMENT againstEnlargement itself - Hemlock_Mercury
-Hydrochlorate of Ammonia-Iodine,Mr. Stafford's Method - Bromine — Kreuznach Waters
Compression - Depression - Electricity - Division and Excision - Crushing, &c.
The topic presented for consideration in In considering this subject, it will be
this chapter is one of great interest and found convenient to make three distinct
importance, and is worthy to be the sub - divisions of it, and to regard them sepa
ject of prolonged and careful study. Its rately, as follows:
interest for the practical surgeon consists 1. Treatment for the purpose of ob
in the fact that,notwithstanding the gene- viating the results of obstruction caused
rally admitted intractability of the com- by enlarged prostate.
plaint, much may be done to palliate its 2. The general, or constitutional , treat
most distressing symptoms, and something, ment and management of patients with
perhaps, to retard its progress; but in enlarged prostate.
addition , there is the knowledge that the 3. Treatment directed against the en
attainment of any means capable of arrest- | largement itself.
ing that progress, or of curing the disease, First,— Treatment to obviate the re
would be one of the greatest boons ever sults of urinary obstruction caused by an
bestowed by the science of medicine upon enlarged prostate.
suffering humanity . The importance, To provide for the removal of retained
therefore , of the subject is equally mani- urine is generally the chief indication
fest. No wonder, then, that the search for presented by a patient so affected, when
remedial treatment should constitute an first applying to his surgeon for advice.
alluring subject of inquiry for students of Unaware of the nature of his complaint ,
the healing art ; and that much research he seeks to be relieved from some discom
and experiment have been devoted to this fort produced by an obstacle to the free
department of pathology, course of urine, such as undue exertion
80 TIIE DISEASES OF THE PROSTATE.
necessary to perform micturition, the un- appears to be aggravated by the very

natural frequency with which the want is frequent use of the catheter, however
experienced, some degree of involuntary gently it is introduced, it will be neces
micturition, or, perhaps, an alteration of
> sary to make some compromise between
some kind in the character of the urine the conflicting indications which are thus
itself. #
presented . So, also, the condition of the
A diagnosis having been made by the urine itself, and the amount of mucus
employment of the catheter and rectal with which it is charged, must be taken
exploration, the methods of arriving at into account in determining the question :
wbich are fully considered in the pre- if the secretion is very acrid from de
ceding chapter, and the fact being disco- composition, or much loaded with depo
vered that a certain quantity of urine is sits, more frequent removal is necessary ;
habitually retained in the bladder, how- and an injection, as hereafter recommen .
ever frequently or forcibly the efforts to ded, may be also desirable. In the majo
evacuate it have been made, the first rity of cases, however, in which these
great principle of treatment is this : that states are not present, the removal of the
it is necessary to empty the bladder com- urine night and morning suffices to main
pletely at least once a day. It may be tain the reservoir in a tolerably sound
very desirable to do this even three or and healthy condition, and it is undesi
more times daily, the necessity depending , rable to resort to artificial aid with
in great measure, upon the amount of greater frequency than is necessary to
residual urine. In general terms, if only accomplish this.
two or three ounces are left after the act With regard to educating a patient
of micturition is performed, once a day to the use of the catheter, it should be
maybe sufficient; if it amounts to double done systematically on the part of his
this, twice will probably be better. If a medical attendant, as
a soon as the for
much larger quantity of urine is retained mer has become somewhat familiarised
than that passed by the natural powers, to it by observation . The patient should
it is not unlikely that the instrument will be taught to note accurately how much
be required three times in the twenty -four of the catheter remains projecting from
hours. And if the power of urinating is the urethra and its line of direction with
almost or quite lost, it will be necessary regard to the body, at the moment when
to employ it as often as a decided want the urine flows, so as to accustom his eye
to micturate is experienced . There are to judge correctly as to the point at which
certain modifying circumstances which he may expect the appearance of aa stream
must be taken into account . Such are the when the instrument is in his own hands
facilities which exist for passing instru- a moment always of some anxiety to the
ments, and the condition of the urethra inexperienced performer. In using the
itself. If the patient possesses the ability catheter for himself, he should generally
to pass a catheter easily, and it is very stand with his back against a wall , the
I are indeed that he cannot do so after reeeiving vessel being placed conveniently,
practice, he complies with the demands so that no unnecessary movement of the
of his case . But when the ability has body be made during any part of the
not been attained , the difficulty may, in time at which the instrument is within
some circumstances , be serious , as when the urethra . As to the kind of instru
the operation is required to be performed ment to be recommended , I have seen
every few hours, and the surgeon is un- silver and flexible instruments used with
able always to afford the regular attend- equal facility by different patients, the
ance which is desirable . It is, however , nature of the case, and the result of trials
generally imprudent to entrust this duty with both , deciding the question in each
to any non -professional attendant; and particular instance . Unquestionably , flex
the patient should be made to understand ible instruments are, in the great majo
that, having his own sensations to guide rity of cases, the better and safer kind .
him, he may soon attain considerable dex- If the metal catheter is used , the direc
terity in the management of an instru- tions for its employment are those which
ment, at all events in the one passage apply to the passing of instruments by
with which he will become familiar. But, the surgeon , detailed in the succeeding
again , if the urethra and bladder are chapter,modified only by the fact of the
extremely sensitive, and this condition operator having himself for the subject
of his skill. This very fact ought to in- Respecting elastic instruments, two
spire him with confidence, for he possesses varieties may be employed, each of which
an important advantage over his attend has its own peculiar advantages, appli
ant in one respect, which will compen- cable in different cases . The English
sate largely at first, and altogether ulti- brown gum catheter, mounted on a stilet,
mately , for his want of varied experience but used without it, has the advantage of
on others which the surgeon possesses. taking almost any amount of curve which
It consists in his being able to regulate can be desired , by giving it the required
the movements of his instrument , not form in hot water and plunging it at once
onl y by the sense of touch in common into cold, when the form becomes fixed ,
with any other operator, but by his con- for at least a considerable time. The
sciousness of the sensations produced French black flexible catheter, with a
by it in the urethra, which the surgeon bulbous extremity ( see fig. 23, in the
cannot possess. On this ground it is un- next chapter), has the advantage of ex
doubtedly true that, after long practice, treme flexibility, so that in many instances
few men can pass a catheter for the patient the mere pressure of it in the horizontal
so well as himself, provided that his direction carries it easily and safely into
senses are acute, and that he possesses or- the bladder. The same material may be
dinary intelligence. Accustomed also to made in aa form long ago utilised here in cer
follow but one track, he knows intimately tain cases of obstruction , but now adopted 6
every portion, and learns some little ma- systematically, and known as " coudée ,'
6
næuvre adapted to meet any difficulty or elbowed ;' see fig. 22. Undoubtedly, >
which may be presented. it is one of the most valuable catheters
Fig. 22. - Coudée catheter.
for patients with enlarged prostate ; the stilet is withdrawn. It should then be
little beak, which, of course, is introduced oiled, but not warmed , and used without
pointing upwards, keeps close to the roof
of the canal all the way, and owing to
the flexibility of the entire instrument,
which follows the curve of the urethra
whatever it is, the extremity slides over
any prostatic obstruction with great ease.
If more curve is required for any given
case, it may be attained by making the
instrument with a fixed curve instead of
straight, as is usually done, or a second
elbow may be made in the stem — the in
strument known as ' bicoudée,' a form
which need not be further described
here,
The English catheter, depending for its
efficiency on its curve, requires a special
manipulation, which must be acquired by
practice. Generally, however, when this
instrument is employed, the curve is
always required to be greater than it
naturally possesses as supplied by the
makers. Hence when used the patient
should be furnished with several, and
these should be kept for some time be Fig. 23.-English gum catheter mounted
fore they are wanted, each mounted upon on overcurved stilet.
a well - curved stilet ( fig . 23), so that
when required it may retain as much of delay, as the curve soon lessens in the
the curve as may be desired after the urethra. Nothing can well be added
G
here respecting the mode of its manipula- | of the bladder, which accrue from not
tion bythe patient, who must be taught completelyemptying it daily, form only a
by his surgeon, and the teacher must portion , although a very important one,of
adapt his instruction to the necessities of the evils which can be obviated by this
each particular case. When the stem is treatment. Associated with these ,and en
too flexible, it is sometimes advantageous tailed by the same cause, is that state of
to introduce into the instrument an iron engorgement and overflow of urine, com
stilet six inches long, which gives firm- monly termed, but inaptly, incontinence,
ness to the stem or shaft, while the whole which will assuredly follow gradually in
of the curved portion remains as flexible creasing retention, when unrelieved, a
as ever. state which necessarily exerts an injurious
It has been recommended for these influence upon the ureters and kidneys,
cases by some, as a mode of treatment, ultimately leading to their disorganisation,
that a catheter should be permitted to re- and thus to a fatal termination . Short of
main in the bladder for some days at a these results are the scarcely minor ones
time. There are two hypotheses on of atony of the muscular coats of the
which the advice is given . The first is, bladder, chronic cystitis, catarrh, decom
that by permitting the bladder to remain posed urine, hæmaturia, calculous deposit,
empty, or nearly so, during a considerable and, always accompanying them , impaired
period of time, we encourage it to regain general health. All these can be, under
its contractility, assumed to be lost or ordinary conditions, avoided , and in most,
impaired by overstretching. Atony is, kept in abeyance by the persevering use of
however, very rarely the essential condi- the catheter. It is impossible to overrate
tion which causes retention in these cases. the benefits arising to the patient from
There may be some loss in the muscular this means ; and the responsibility which
power of the vesical coats, but it is not is incurred by overlooking or failing to
much except in old and unrelieved cases. impress his mind with the necessity which
The material obstruction at the neck generally exists for the use of the catheter,
caused by the enlarged prostate, and not should not be forgotten by thesurgeon in
by any local paralysis,' as it is commonly dealing with any signs of irritability of
termed, is the sole, or almost sole, occa- bladder, and incompetence to retain urine
sion of the urinary difficulty ; as has been by persons in advanced years.
explained in the previous chapter. Con- Supposing, however, that our atten
sequently, the inlying catheter can avail dance is required for a case in which,
nothing, and on this ground the practice from neglect or otherwise, the urine has
referred to gains little support. The been long permitted to accumulate, and
second hypothesis is, that the constant the amount of residual urine has reached
pressure of the catheter promotes absorp- a pint, or even two. If we evacuate the
tion of the substance of the tumour, bladder two or three times daily, great
and so tends to the material improvement relief will undoubtedly be at once afforded
of the patient's condition . But the fact to the patient ; his frequent calls to pass
is, that the tendency is much more to water, the constant dribblings from a dis
ulceration of the tissues than absorption, tended bladder, will be removed, but the
after the manner supposed. It will , of sudden change made by catheterism fre
course, be understood that there is no quently acts prejudicially on the consti
reference here to cases in which urgent tution . If we continue it, some febrile
urinary retention has existed, which has symptoms often show themselves, the
been relieved with difficulty by the patient will become low, and even finally
catheter, or to those in which great pain sink, his end being sometimes perhaps
is produced, or unusual obstacles are accelerated if the injunction to empty the
encountered in passing the instrument. bladder completely two or three times
In such circumstances, as we shall see daily be invariably followed. Sir B.
when discussing that subject in the fol- Brodie, was the first, I believe, to point
lowing chapter, we may be justified in out the consequence of such treatment in
permitting the catheter to remain in the these cases ; and observation has de
canal for a considerable period. monstrated to me the justice and the
The consequences of enlarged prostate value of his remarks. Following a general
already alluded to, viz., the increasing re 1 Lect. on the Urinary Organs, 4th ed . pp.
tention of urine and habitual distension 203-5.
law which forbids the making of rapid or Ordinarily, they partially recover their
extreme changes in the conditions and tone and power, when retention has not
habits of the human economy (familiarly existed long, and the bladder has been
exemplified by the dangers known to regularly emptied once or twice a day for
accrue from sudden exposure to heat a few weeks. But this does not always
after extreme cold, or from appeasing, happen, and then, partly from disuse and
without stint, the cravings of the almost over-distension, and partly from inflam
starved ), the surgeon should commence matory deposit in the vesical membranes
his treatment by removing only a portion impairing their contractility, the organ
of the urine, not exceeding half the con- still continues in a state ofatony.
tents of the bladder, and in the course of This state is occasionally partially re
two or three weeks, perhaps, by gradually mediable -- sometimes entirely so ; and it
withdrawing a somewhat larger propor- is extremely desirable, for many reasons,
tion , and slowly accustoming the atonied to resuscitate the lost function . Cold
coats of the viscus to their new condition, affusion suddenly made on the abdomen
he may venture to empty it entirely. should be applied twice a day . Cold
And ifthe urine becomes very cloudy, as water injections into the bladder itself
it often does, he is to be in no hurry to are sometimes of service, and may be
wash out and thus disturb the tender and employed on alternate days, and after
irritableorgan . More barm than good wards every day. These failing, a cur
is often done by undue mechanical inter- rent of electricity may be passed by
ference with the washing bottle and in- applying one pole to the lumbar region
jections in these particular conditions. of the spinal column, and the other to
Subsequently, when the first stage has the perineum and hypogastric regions
been passed , and any fever which may alternately. Or a mild current may be
have arisen has completely subsided, the passed, by applying the latter pole to
cleansing of the bladder may be useful. the interior of the bladder, through the
In directing all this part of the treatment urethra.
he must exercise great caution, watching The constitutional remedies are strych
for symptoms, and doing all he can to nia, in moderate doses, such as the oor
invigorate the patient, by improving his 16 of a grain two or three times daily,
a long period of time ;
digestive organs, and by administering but employed for and
such nutritious food as he can digest, tincture of steel, ergot of rye : all
with as much tonic and stimulant as he combined with tonic regimen .
may require. Another very important 2. CHRONIC Cystitis — a consequence
principle to be carried out in such cases of prostatic obstruction—is generally en
is to keep the patient strictly within doors countered at some time or other in most
for the first week or ten days, when com cases. Its presence is manifested by the
mencing the use of the catheter, keeping appearance to the naked eye of pus and
him warm , much in the recumbent posi- mucus in the urine, by undue frequency
tion, even in bed, and forbidding all of micturition, and dull pain in the region
exercise. This regimen is applicable of above the pubes. It is generally very
course only in cases where the residual amenable to treatment, and often dis
urine is unusually large in quantity, and appears under the habitual use of the
is unnecessary in those common examples catheter above described. But when this
where eight to ten ounces only remain is not the case,if the symptoms are not
after an act of micturition . severe, and the discharge of viscid mucus
In the management of these, or indeed which accompanies it is not mixed with
of all, cases of hypertrophied prostate, blood, much benefit may be obtained by
there are other difficulties and emer- simply washing out the bladder once a
gencies which may be still encountered day with warm water, with a single, and
at some time or another. These it will never with a double current catheter;
be convenient to consider separately. the temperature should be about 100%
1. ATONY OF THE MUSCULAR COAT OF Fahrenheit. After the mucus and puru
THE BLADDER .— The bladder having for a lent matter have been removed , which
long period of time been unable to empty may be assumed to be the case when the
itself, the muscular fibres sometimes lose water flows clear and untinged from the
the power of perfectly contracting, even cavity, decided benefit is in some cases
where the cavity is artificially emptied. obtained by using mild astringent injec
G2
tions, at intervals of two or three days the most value in chronic cystitis. A
always commencing with extremely weak short notice will be devoted to each prin
solutions-- whether of the mineral acids, cipal agent, so that the special indications
the acetate of lead, or the nitrate of silver. which should determine the selection for
A small quantity of fluid only should be any particular case may be inferred .
employed at first, and it should be thrown The infusion of Buchu ' is somewhat
in very gently and gradually. This treat- stimulant and tonic ; its activity in regard
ment will be further considered hereafter of its action on the bladder seeming to be
( see page 91 ) . due to a volatile oil , which communicates
Depletion of any kind is never ad- its odour to the urine. From one to two
.missible. Counter -irritation is difficult or three ounces may be given from two
to employ, and often occasions much dis- to five times in the twenty -four hours ;
comfort. Perhaps benefit is occasionally and it may be strengthened by adding to
derived from the application of irritating each dose thirty to sixty minims of the
plasters over the pubes, as a burgundy- tincture. It is useful in many cases of
pitch plaster, upon which 15 or 20 irritable bladder, arising from stricture
grains of tartar- emetic have been equably and prostatic obstruction. It is diuretic,
sprinkled . But the eruption produced by but seems to exert a beneficial influence
the latter is apt to be sometimes more de- on the mucous membrane of the bladder,
veloped on the scrotum and perineum and to lessen mucous discharges from it .
than on the locality of the plaster itself, Perhaps it disagrees with the stomachs of
to the great annoyance of the patient. a few patients, in which case it is worse
Another method of making permanent than useless to administer it. In conse
counter-irritation is that of rubbing a quence of the varied opinions which are
moistened stick of nitrate of silver on the
BOCHU.--The leaves of the Barosma crenata
skin above the pubes, first removing a
portion of the hair. This is to be sub- and others ; a rutaceous plant, from the Cape of
Good Hope, introduced into practice in this
sequently
But nothing good simple
is so with
dressed ointment.
as a hot linseed country, about sixtyyearsago, by Dr.Reece.
Dr. Prout says, ' In chronic affections of the
poultice, the surface of which has been mucous membranes of the urinary organs,
sprinkled with flour of mustard, and ap- among remedies of the balsamic class, the
plied to the same region : this may be mildest, as wellas one of the most efficient, is
the buchu.' - Stomach and Renal Discascs, 4tlı
regularly repeated every day, or every ed. 1848, p. 403.
other day, for some timewith advantage. Mr. Coulson writes, • In my experience,
Hot hip-baths, by which is intended however,no medicine hasbeen so generally suc
a temperature ranging from 100 ° to 108°, cessful in irritability of the bladder, as the in
fusion of buchu . I could cite several cases
or even higher, according tothe patient's where it has succeeded after other medicines
ability, natural or acquired, to sustain it, had failed !– Diseases of the Bladder, 5th ed.
are among the most useful means. The 1857, p. 85.
patient should remain in the bath about Sir B. Brodie believes the use of buchu to be
ten minutes, the object being to make a mainly limited to that class of cases in which
smart impression on the skin, and fill its the bladder affection does not depend on obstruc
tion at the outlet, but on renal disease, and
vessels, and not to weaken or sweat him states,' Inthese I cannot doubt that I haveseen
unnecessarily. When removed, he should it productiveof the most beneficial effects.' He
be rapidly dried, wrapped in hot flannels, advises its continued use for a long period , if
and placed in bed, or in a recumbent tried at all, and in doses of one and a half to
position. two ounces three times a day . - Lectures, 4th ed .
1
The hot bidet, or basin of hot water, p . 15Dr.. Gross thinks its use is occasionally
is in some circumstances as useful, inas- attended with benefit, but has nevor derived
much as the application can be made much advantage from it.' --Anatomyand Discascs
hotter than the preceding, since it is of the Urinary Organs, 2nd ed. p. 228.
directed to a much more limited surface ; the mucous membrane
Dr. Pereira says, “ In ofchronic inflammation
the bladder, attendedof
the effects are even more advantageous with copiousdischarge of mucus, it frequently
for some persons. Besides, it does not checks secretion, and diminishes the irritablo
induce weakness by repeated use, as hip- patient
conditiontoofretain
the bladder, thereby enabling the
his urine for a long period ;
baths are liable to do .
Respecting the internal administration but I have several times seen itfail to relieve,
and in some cases it appeared ratherto add to
of medicines there is some difference of thepatient's sufferings.'-— Elements of Mat. Med .
opinion , at least as to those which possess 3rd ed. 1853, p. 1913.
expressed respecting the relative value check the muco - purulent discharge from
and properties of these several agents by the bladder, which is so commonly pre
different authorities, I shall cite several sent as the result of irritation of its
of them in notes at the foot of the page, mucous coat by decomposing urine. It
to present at one view the collective exis said to be contra -indicated when any
perience of those who should be among degree of inflammatory action is present,
the best able to judge of this subject. being highly astringent from the large
The decoction of Pareira brava ! is amount of tannic and gallic acid which it
largely prescribed in this country, chiefly, contains. The dose is from two to three
it is probable, on account of the strong ounces three or four times in the twenty
commendation it formerly received from four hours. If it is desired to strengthen
Sir B. Brodie. He advised thatit should the preparation, ten or twenty grains of
be made in a more concentrated form , the extract may be added to each dose of
and given in larger quantities than for the decoction . It tends to check mucous
merly employed. The dose of decoction discharge and allay irritability when the
should be from two to four ounces three preparations previously noticed have
or four times in the day. It may be failed .
rendered more powerful by an addition An infusion of the underground stem
of the liquid extract; such as of from of the Triticum repens (dog's grass, or
half a drachm to two drachms to each couch grass ') is an agent from which I
dose of the decoction . The indication
itsr,use
for dde
bla is noth simp
so muc le pres
as the encelity
irritabi of the
of visc id excitement, ratherthan byvascular activity , or
by organic disease.'-p. 403.
mucus in large quantity . Sir B. Brodie says, The Uva ursi has the
6
The decoction of Uva ursi ? has also reputation of being useful as a remedy for
obtained a reputation for its power to chronic inflamma tion of the bladder. I'must
that this remedy has generally
say, howerer,
PAREIRA BRAVA.–The root of this plant disappointed me in these cases, and that I have
has been prized by different nations for some not seen those advantages produced by it which
centuries as an antidote to calculous disorders . the general reputation of the medicine had led
Sir B. Brodie says, ' I am satisfied that it has me to expect.? — Op. cit. p . 112. Again , in
a great influence over the disease (chronic cystitis, depending on renal disease, he states
cystitis) which is now under our consideration, that it may, in some instances, be employed
lessening very materially the secretion of the with much advantage.'-- p. 150. But fuller
ropy mucus, which is in itself a very great evil, doses than usual are advised.
and, I believe, diminishing the inflammation in Mr. Coulson speaks well of it , but thinks
the bladder also .'— Lectures on the Urinary more highly of buchu. — Op. cit. p. 96 .
Organs, 4th ed. p. 112. Dr. Gross says, ' I have used it a good deal
Dr. Prout states, “ Of the remedies of a in the treatment of cystirrhæa, and have occa
tonic and astringent character, the Pareira sionally experienced the best effects from it. I
brava is undoubtedly one of the best we possess have found it particularly serviceable in cases
in catarrhal affections of the bladder .'— Op.cit. attended with excessive morbid sensibility of
P. 403 . the neck of the bladder.'— Op. cit. p. 228 .
6
Mr. Coulson speaks of it as adapted to Dr. Pereira writes, “ My own experience of it
irritability of the bladder associated with pain, amounts to this, that in some cases the relief
for which he regards it as an excellent medi- obtained by the use of it was marked ; whereas
cine,' adding, that it may be combined with in other instances it was of no avail.'-- Op. cit.
6
nitric or nitro-muriatic acid , or dilute phosphoric p. 1514.

acid to lessen the secretion of mucus.' — Op. cit. Dr. Wood, of Philadelphia, believes “ the
6
p. 173 . credit which it now enjoys is scarcely equal to

Dr. Gross has never seen any good effect its merits,' and adds that, “ in cases of cystir
result from its use.—Op. cit. p. 227. rhea, persevered in for a long time continuously,
2 ARCTOSTAPHYLOs Lva URSI. - An ericaceous for several months if necessary, I believe that it
plant, the leaves of which have lorg been em- will occasionally effect cures even unaided, and
ployed against calculous diseases. will often prore a serviceable adjunct to other
Dr. Prout writes, “ When the kidneys and measures.'--— Treatiseon Therapeutics. Phil. 1856.
5
bladder are more

early stages than usually
of organic irritable, (in theI Vol|. i . pp. 129, 130.
renal disease) TRITICUM REPENS. — James, in his Medicinal
doubt ifany remedy surpasses the Ura ursi Dictionary, Lond. 1743, thus speaks of it :The
when judiciously directed . -
n
Op. cit. p . 159. decoctio of the root drank is effectual aginst the
gripes, difficulty of urine, and ulcersof the bladder ,
Again : ' In chronic affections of the mucous and breaks the stone. Vide Dioscorides , 1 , 4, c. 30.
membranes of the urinary organs, next to It is also moderately aperient and lenifying.' The
the Pareira brava, rank theUva ursi, and the lithontriptic virtue of this plant has also been
Lythrum Salicaria. These last are , however, taken notice of by Boerhaave , and confirmed
more especially beneficial to those forms and by abundance of experiments. JohnGerard, in
stages of the affection marked by irritative his famous Herball, Lond. 1623, speaks of it in
have derived much advantage. For | Prout, ' a strong infusion, taken fre
many years I have used it largely , both quently, sometimes gives great relief.' '
in private and in hospital practice, in The solvent power for phosphatic de
cases of constant and severe irritation of posits, for which this plant has enjoyed a
the bladder from any cause. It has long credit, was believed by Dr. Prout to be
been prized in these circumstances in due to the malic acid which it contains.
some country districts; and it is officinal I have largely employed it during the
as a diuretic, and as a diet drink ' last fifteen years, and regard it as one of
among the French. My first knowledge the best of the agents we possess in deal
of it was derived from a country patient ing with doubtful or obscure cases of
suffering from severe stricture, and the chronic cystitis, and among them those
frequent and painful micturition of which co-existing with chronic pyelitis. But in
he was the subject was more effectually all forms of disease producing frequent
subdued by this remedy, which he had and painful micturition, it demands an
long taken for the purpose, than by any early trial. It never disagrees with the
medicinal means I could devise. Ac- stomach , and is not unpleasant to the
cordingly, I have tested its powers as palate. The formula is as follows: In.
above stated ; and my belief is, that it is fuse one ounce of the herb in one pintof
of more value in the cases described, and boiling water for an hour; strain, and
in those of renal calculus especially, than take three or four ounces of the liquor
in prostatic irritation . Nevertheless, in three or four times daily, Another
these cases also , where the indications are remedy I have tried is the Achillea Mille
to lessen the frequency and the pain of folium (common Milfoil) : an infusion is
micturition, it is unquestionably useful; made of the same strength as the fore
often affording relief when buchu, pareira, going, and the dose is the same. I can
uva ursi, and other infusions, have failed. not at present speak of it with the same
The mode of administering it, which I confidence as I have done of the last
have adopted, is the following. From named remedy. 2
two to four ounces of the dried under- Matico, well known as a powerful
ground stem, popularly called root, are astringent, appears to have been advanta
slowly boiled in two pints of water until geously employed in a form of cystitis
reduced to one pint, the liquid is strained frequently accompanying prostatic en
and taken when cool ; a third part three largement. Dr. Neligan says, “ I have
times in twenty-four hours. Like the found the tincture very useful in the
rest of these agents, it should be given, as treatment of catarrh of the bladder in the
a rule, alone, with the view of observing aged.'3 The infusion may also be em
its effects, although it may also form a ployed, either with or without the tinc
vehicle either for acids or for alkalies, ture, in doses of from one to two ounces,
when desired. It is somewhat diuretic, It possesses a volatile
le
principle, which
and
and perhaps slightly aperient. appears to resemb that of cubebs,
A decoction of the Lythrum Salicaria to have a similar action.
was employed by the late Dr. Prout, and The Decoction of Senega perhaps
considered by him to be very nearly exercises a beneficial influence on the
allied in its properties to the Uva ursi mucous secretion of the bladder ; and has
( see note on p. 85). It was formerly been used on account of its reputation for
officinal in the Dublin Pharmacopæia. controlling the bronchial catarrh of elderly
The dose is from two to three ounces. ' people. The dose should be one ounce
On the same authority was recommended and a half or two ounces, two or three
an infusion of the Alchemilla arvensis , times a day.
when the urine is alkaline and phos- 1 Alchemilla arvensis : an indigenous plant.
It is astringe
phatic, in which circumstances, says Dr. reputation nt, curehasofhad
for theand
an ancient popular
gravel and calculis,
The infusion is made of one ounce of the dried
similar terms. Among the ancient authors it leaves with a pint of boiling water. — The Nature
enjoyed a great reputation ; Paulus Ægineta names and Treatment of Diabetes, 2nd ed. p . 185.
it more frequently than any other remedy in 2 Matico belongs to the natural order Piperacex ,
urinary diseases. from which are obtained the cubebs and other
1 Lythrum Salicaria , thespiked purple Loose- peppers. The infusion, which is generally pre
strife. It has been employed chiefly in diarrhea scribed, is prepared with an ounce of matico to :
and dysentery , being mucilaginous and astringent. pint of boiling water.
For the decoction, one ounce of the root is boiled in 3.Medicines, their Uses and Modes of Admin
one pint of water. stration , 4th ed. Dublin, 1854, p. 76.
Dr. Gross quotes cases illustrating the may occasionally ameliorate the symp
value of the Epigæa repens, in chronic toms. If beneficial at all, the result is
cystitis with catarrh . It is administered soon apparent; and there is therefore
in the form of decoction , the dose being nothing gained from pushing it, either by
two ounces, frequently repeated. Similarly increased doses or by long administration
related to the Uva ursi, andpossessing nearly of the remedy. Indeed any increase of
equal claims to utility in the complaint the dose beyond 7 or 8 minims appears to
just named, is the Chimaphila, or winter diminish the beneficial effect. It may be
green. It is employed in the form of de- given with 15 or 20 minims of liquor
coction, in two or three ounce doses, which potassæ , and a little acacia, and an ounce
may be strengthened, when necessary, by and a half of camphor mixture, or some
the addition of extract. The infusion of bland vehicle; or if preferred, inay be
wild carrot seeds" must not be overlooked, administered in a capsule. In whatever
as exercising a sedative influence in some way it acts, the patient frequently ex
irritable conditions of the bladder. It periences relief when micturition is diffi
has been supposed to be chiefly used in cult and the urine is loaded with and pus
relieving the strangury occasioned by mucus.
blisters. The Chios turpentine has been recoin
All the foregoing act probably, to m
mended, in doses of 4 or 5 grains, by Sir
some extent, by means of their diuretic Benjamin Brodie. Both this and small
properties ; inducing a flow of watery doses of Cubebs pepper, 10 to 20 grains,
urine, and so reducing any irritating have been found useful in checking in
qualities in that fluid ;, while a certain ordinate catarrh. The volatile oil may
amount of astringent action may possibly be substituted for the powder if preferred,
be exerted directly upon the mucous in doses of 10 minims, on sugar or in
membrane , and so avail to repress the un- mucilage ; or, better still, the preparation,
due discharge of its secretion. In some, known as “ liquor cubebæ ,' which is ai
of which the buchu is the most marked more manageable and efficient form .
example, the volatile oil contained may, Another balsamic remedy has been re
besides acting as a diuretic, exert some commended, viz., the compound tinctureof
influence, so -called specific, upon the benzoin in drachm doses three times a day.
vesical mucous coat, of a calmative kind , Another class of useful agents is the
when that membrane is in that state of Demulcents. These are, for the most
irritation or excitement commonly known part, simply mucilaginous or starchy solu
as chronic inflammation with catarrh. tions, which form an agreeable means of
That this is probable appears indicated by diluting the urine, at the same time that
the known similar result of administering they furnish some little nutriment to the
some of the balsams under the same cir- body, and in some instances, perhaps,
cumstances, all testifying to the value of some special therapeutic influence. They
small doses of copaiba in chronic catarrh are, therefore, often useful vehicles for the
of the bladder. It is worthy a trial, and administration of the acids and the alka
! Op. cit. 2nd ed. p. 228. Epigæa repens, the lies, when these are required ; but al
Trailing Arbutus — diuretic and astringent. The
decoction is made with one ounce of the dried though originally given on account of
leaves boiled in a pint of water. This plant ap certain soothing and sheathing qualities to
pears tobenearlyrelated to the Uvaursi. An- the urinary tract, which, by virtue of
other American remedy is the Phytolacca decan- their mucilaginous character, they were
dra, or Virginian Pokeberry, employed in order to
alleviate simple irritability of the bladder. Dr. supposed to possess, there is no ground
scribing, withDr.
Grosssays, Physick
decided wasininthe
success habitof pre- whatever for attributing their beneficial
this affection, the influence to that quality, which must
saturated tincture of Pokeberries. He gave it in
two-drachm doses, every seven or eight hours .'— necessarily disappear in the process of
Op . cit. p. 262. digestion and assimilation .
Chimaphila umbellata has long enjoyed a
considerable reputation in America,both in urinary Among the most useful are the de
complaiuts and in scrofula, for which latter it has coction of marsh mallow , or of the
been considered a specific. It is diuretic and
astringent. For the decoction, boil one ounce in a common mallow
decoction of in its absence ; the
carageen moss ; the
pint and a half of water to one pint, and strain. - infusion of linseed ; , ortheIrish
decoction of
L, P.
5 Daucus carota, common or wild carrot. An barley, better known as barley -water ; and
ounce of the seeds to a pint of boiling water are
a solution of gum arabic in water. An
the quantities for infusion. Dose, two or three
ounces every two or three hours . 1 As good formulæ for these simple yet useful
American remedy, which has obtained five times daily. To this, when cold,
some reputation , is the inner bark of the tincture of buchu may be added , if de
slippery elm , Ulmus fulva. It has desired.
mulcent properties, and tannic acid, in The indications, then, which I believe
small quantity, is also present. The fol- will best guide us in the selection of the
lowing is the formula employed. Mace- principal remedial agents enumerated, may
rate one ounce and a half of the bark in be briefly pointed out as follows :
one pint of boiling water for six hours ; Chronic mucous discharge from the
press thoroughly and strain. bladder in large quantity, associated with
In regard to the efficiency of each one relaxation and debility , no inflammation
of the principal medicinal agents enume- being present, may be acted upon by the
rated , it should be remarked that the most Uva ursi, by Alchemilla , and also by
opposite opinions respecting them are held Pareira . Chimaphila is said to be equally
by experienced surgeons. It is more than appropriate in this form of complaint. In
probable that either the virtues of these simple irritability of bladder — that is
agents have been overrated, on the ground when the desire to make water is fre
of estimates formed from the observation quent–in the absence of the causes or
of exceptional cases- or that the appro- symptoms of any acute inflammation, the
priate and particular indications for the Triticum repens, Buchu, Alchemilla, and
use of the remedies have not been accu- perhaps Uva ursi , afford the best chance
rately defined, or, indeed , discovered ; so of relief; but the first named is useful in
that the successes havecapablebeen due in inflammatory states also.
part to chance, and are of being When there is some chronic inflamma
multiplied by more skilful adaptation. tion present (not acute), as evidenced by
The latter suspicion is not without irritability of bladder, some little pain
foundation, and it is far from improbable above the pubes, and considerable tender
that the three chief and most popular ness experienced when aa catheter is passed,
remedies in urinary difficulties are some certain kinds of volatile oil , which are
times, perhaps not unfrequently, pre- excreted by the kidney and impregnate
scribed somewhat at random . This opinion the urine, are frequently beneficial. One
is strengthened by the better success which of the mildest, safest , and most easily
is said to result from their employment in digested forms is that found in the infusion
combination, a method which is more of buchu. It may be used alone, or with
popular abroad than in this country. the addition of 20 minims of tincture
Thus the following combination is not un- or liquor of cubebs, or this may be re
frequently a useful one, and may be replaced by a few minims of turpentine or
commended : copaiba, but these are more prone to dis
R Fol. Uvæ ursi. agree with the stomach ; yet they some
Rad. Pareiræ bravæ contritæ āā Zij . times exercise a beneficial influence when
Boil together in three pints of water simple buchu has failed, more especially
until reduced to two, and strain. Two or in cases where much catarrh is present
three ounces to be taken from three to also.
vehicles are often wanted, I subjoin a list of those
In this place may be mentioned an
which, having been frequently employed , can be 1 An illustration of the Transatlantic mode of
depended upon . prescribing these remedies is given by Dr. Gross, in
DECOCTION OF MARSH MALLOWS. - Boil three his work already referred to :-A combination of
ounces in three pints of water until reduced some of the articles above mentioned may often be
to two pints. advantageously employed. Indeed, the effect is
DECOCTION OF Irish Moss . - Clean and wash usually muchº more conspicuous when they are
an ounce of the moss, afterwards boil in a given in this manner than when they are used
pint and a half of water until it is reduced separately. Ihave long been in thehabit ofad
to one pint. Any proportion of the water ministering, with the happiest effect,a combination
may be replaced by milk, when required to of buchu, uva ursi , and cubebs, sometimes in the
be more nutritious. form of an infusion, but more generally in that of
DECOCTION OF LINSEED . - Boil an ounce of a tincture, given several times a day, in conjunction
unbruised seed in a quart of water for an with a small quantity of bicarbonate of soda.
hour. Occasionally a few drops of the balsam of copaiba,
Decoction of BARLEY . — Boil two ounces in the muriated tincture of iron , or dilute nitric acid,
a pint of water for five minutes, andthrow may beadvantageously added to each dose of
away the liquor. Add two quarts of water these medicines.'
to the barley, and reduce by boiling to one Dr. Gross adds, naturally enough, When thus
6
quart. combined, itis of course impossible to determine

GƯM WATER. — One ounce 'of pure gum dis- what merit is due to each respective article.” — P.
solved in one pint of water. 229 .
excellent combination, for which I am ferent result follows administration of the

indebted to Dr. Gross, useful in irritable, alkalies. By their means we can act
and even in some inflammatory states of speedily and powerfully on the kidney
the bladder . One ounce and a half of secretion , and change an acid to an alka
the leaves of Uva ursi, and half an ounce line urine if it be desired . They have
of hops, infused in two pints of boiling long been regarded almost in the light of
water in a closely covered vessel for two specific sedatives to the bladder under cir
hours : a wine glass of the liquor to be cumstances of inflammation or irritation,
taken several times a day. Dr. Gross and are perhaps entitled to more uniform
writes — it often acts like a charm ; confidence in such cases than any other
promptly allaying the pain and spasm at remedies known . ' Such, at least, is, with
the neck of the bladder , and powerfully out hesitation, my own experience .
promoting resolution .' ' T Additional light has been thrown upon
An important point in the employment this subject by the observations of Dr.
of the decoctions and infusions in question Owen Rees. He asserts that, even when
is to give them liberally. The ordinary the urine is alkaline , alkalies are often
doses by tablespoons are, I think, almost productive of a greater benefit than any
valueless. From 10 to 15 ounces must other remedy , allaying the irritation pro
be given daily in order to obtain benefit duced in the viscus by urine of that cha
in most cases. At least, I have obtained racter, aad tending to restore it to its
advantage thus after failing with smaller normal acidity. It appears to Dr. Rees,
quantities. Formerly they appear to have to quote his own language, ó that an alka
been so administered . 2 line state of urine very frequently resulted
But further, it cannot be overlooked from disease of the mucous surfaces over
that some of these infusions and decoc- which the urine had to pass before excre
tions have been generally administered in tion, and that urine which had been se
combination with other agents, and with cereted of healthy acid character was,
the use of other means, which have, per- owing to this condition of the membrane,
haps, really contributed largely to the often passed of strongly alkaline reaction,
favourable result, although from circum- ard containing a deposit of theThearthy
stances they have not been permitted to phosphates as a consequence. e pa
share the credit. The agents referred
are the acids and the alkalies. It has
to tient, in fact, was secreting healthy urine
the variation
.
from the normal state
been by no means common to prescribe consisting in the urine being rendered
the vegetable solutions in question lin . alkaline by disease of the mucous surface
mixed with one or other of the two very of the urinary passages. That the dis
important classes of bodies just named'; charge from the urinary mucous mem
and much observation of their effect when brane, when inflamed, was of a strongly
uncombined will be necessary before their alkaline character, and sufficient in quan
specific properties are known more accu- tity to neutralise the acidity of healthy
rately than at present. urine, I proved by an experiment on the
This remark brings us to the consider- inflamed surfacepresented by the fundus
ation of the influence of these chemical of an inverted bladder which I examined
agents in chronic cystitis. in a case of deficient parietes of the ab
The mineral acids are very frequently domen, a congenital deformity not very
ordered simply because the urine is alka- | uncommonly met with . In confirmation
line, and has a tendency to deposit earthy of the above views, I took the opportunity
phosphates. But even very large doses of adducing the fact that in several cases
by the mouth do not exertany appreciable of alkaline urine I had succeeded in ob
influence over the chemical reaction of taining the secretion of healthy acid
such urine. As general tonics to the reaction by rendering the urine less acid
system , in such circumstances sometimes on secretion and therefore less irritating ;
needed, they may be useful. But a dif- and by perseverance in this plan till the
i Op. cit. p. 186. inflammatory condition subsided, the nor
2 Half-pint doses, two or three times a day, are This view was held by Mr. Adams. Anatomy
recommended of a decoction of Uva ursi and and Diseases of the Prostate Gland, 2nd ed.
Pareirabravacombined, in Blackie's Disquisition 1853,pp.42, 43. He compares theirinfluence on
on Medicines that dissolve the Stone, & c. London, cystitis to that of quinine in neuralgia, giving the
1771 , p. 182. This is but one illustration among preference, among the ordinary alkaline salts, to
several which might be referred to of similar date. carbonate of soda.
mal acid reaction of the urine, as it passed urine is secreted with deficiency of acid,
from the bladder, was eventually ob- and the earthy phosphates are habitually
tained .' 1 thrown down, lemon -juice is, perhaps, one
Proceeding on this principle, Dr. Rees of the most certain forms of acid to affect
recommended those salts in which the the reaction . But the cases with which
alkali is combined with a vegetable acid, we have to do are not in this category :
especially the citrate of potash and the the alkalinity is produced in the bladder,
tartrate of potash and soda; the latter if the urine arriving there from the kidneys
the bowels require a laxative, and the with its normal amount acid, as may
former if this is not the case . Both exer- be easily demonstrated byof the catheter.
cise a powerful influence in neutralising Benzoic acid has a like influence, but is
the acidity of the urine, notwithstanding less easy to administer from its extreme
the aperient action which is associated insolubility in water. When it can be
with oneof them. It is almost needless to taken, and does not disagree with the
say, that the value of liquor potassæ has stomach, it sometimes not only acidulates
been recognised from time immemorial, the urine, but subdues frequent micturi
and that it is still the favourite remedy tion. Twenty grains require a drachm
when an alkali is required. I may add and a half of rectified spirit for solution ,
that it is so with myself, and preferred in al- which may be taken in a wine-glass of
most allinstances to any form of potash salt. water, when it is precipitated in a very
But the citrate is, perhaps, the best neutral divided state , and should be instantly
salt to employ when objection to adminis- swallowed. Or it may be given in pow
tering the pure alkali' exists ; and in a ders, rubbed up with a half or equal
series of papers on Irritability of the Blad- weight of white sugar ; or it may be sus
der, which appeared in the Lancet'aslong pended in simple syrup, or in the mucilage
7
ago as in 1854, I stated that it was far pre- of acacia. Perhaps a better form still is
ferable to Vichy water (vol. i. p. 439) . that of pill, made by compounding 3
Its value in this respect was observed and grains with 1 minim of glycerine, two or
pointed out at the commencement of the three to be taken three or four times
present century.2 On the other hand, daily.
alkalies do not invariably exert a bene- 3. Irritability of bladder, with pain
ficial influence in these cases ; the alkaline increased during the repeated efforts to
state of the urine is sometimes increased make water, is one ofthe most distressing
by their moderate use. And it occasion- accompaniments of the affection . The
ally happens that alkalies in full doses patient becomes worn and exhausted by
augment the irritability of the bladder ; loss of rest and sleep, if these are not
especially in the form of citrates or bicar- ensured by sedatives and opiates ; the
bonates, by their diuretic action, which latter, especially, being usually of great
rarely if ever happen from liquor potassa . value. Opiates by rectum agree with
In reference to Vichy water, mentioned patients, and may be administered either
above, my opinion is unchanged - namely, in the form of suppository or enema..
that undesirable
it is an form of alkali in From one and a half to three grains of
urinary complaints, and in all circum- the extract of opium, or the same quantity
stances inferior to potash. of powdered opium, or half a grain to a
In those very rare cases in which the grain of morphia, made up with twenty or
2 :On the Pathology and Treatmentof Alkaline thirty of cocoanut butter and properly
Conditi
F.R.S.
onsoftheUrine.By G.Owen Rees, M.D., moulded, are good forms for the purpose.
300, 301 . Reports. Third Series.
, pp.Hospital
Guy's
Vol. i., 1855
A grain of extract of belladonna is some
? It is interesting to observe that it is no new times a suitable addition when much
observation that thesalts formed by a combination spasmodic action is present ; but when
of the vegetable acids with the alkaline bascs are there is already impaired power to empty
capableofcommunicating, when taken by the the bladder, it does harm by paralysing
mouth, an alkaline reaction to the urine, although
it is, comparatively speaking, a recent achievement the muscular fibres of the bladder, and by
of chemistry to explain this. More than seventy entirely depriving the patient of power to
years ago Sir Gilbert Blane was in the habit of
prescribing citrate of potash for the express pur expel his urine . A combination with a
pose of rendering the urine alkaline. See his few grains of hyoscyamus, conium , or
paper ‘On the Effects ot'Large Doses ofMildVege- lactucarium , may occasionally, be made
table Alkali," read Nov 11:808 to Chirurgical
of Medical, and the Society withadvantage. A common form is 10
Knowledge.'— Trans. vol. iii. p. 339. or 12 grains of the pil. saponis cum opio ;
but a better vehiclefor the active drug is |two or three ounces of plain warmwater
the cocoanutbutter just referred to, which are to be injected, never using sufficient
possesses no irritating qualities, the effect to produce a sense of uneasiness, much
of which in the soap is sometimes com- less of pain , from distension of the viscus,
plained of. and after remaining about half a minute
When enemata are employed, they should be permitted to flow out. A solu
should be small in quantity and mucila- tion of acetate of lead having been pre
ginous; as, for example , one or two pared, of the strength of one grain to four
ounces of starch or barley - water, con- ounces of warm water, a small quantity
taining from forty to sixty minims of of this should be slowly injected, allowed
laudanum . The fluid form ensures a to remain about half a minute, and then
more rapid action, when such is required. to run out. This may be used daily.
At the same time we may administer In no case is it desirable to exceed one
by mouth morphia, or some other prepara- third of a grain of the acetate to the
tion of opium , in quantity appropriate to ounce of water, unless the object is to dis
the patient's condition ; and it is usually solve phosphatic matter, in which case one
well borne, and of great value in these grain to the ounce may be enployed : but
cases.
In some cases small doses, such as mechanical means have now superseded
one-sixth of a grain of morphianightly, chemical agents. In addition to the nitric
suffice to check irritability of the bladder; acid and the last -named agent, the follow
usually double or treble this dose is neces- ing formulæ may be employedwith advan
sary. Where, unfortunately, it does not tage as injections in the bladder :—Where
agree, I have found Davenport's chloro- the urine is fetid, two grains of carbolic
dyne very useful; of very little service acid added to four ounces of warm water .
are conium , belladonna, or Indian hemp, or When the patient feels much soreness,
full doses of hyoscyamus, or extract of from frequent micturition, and a little
hop. But when morphia is tolerated no blood appears in the urine with much
mode of giving it is better than that by muco-purulent deposit, the next may be
subcutaneous injection. Its sedative in- :
tried : biborate of soda, a drachm ; gly
fluence takes place with a rapidity and cerine, four drachms ; warm water, four
certainty which no other method of ad- ounces. In the same circumstances, a
ministering ensures. solution of quinineis sometimes employed
4. When there is phosphatic deposit for injecting the bladder, in the propor
in the urine, or there is much mucus, or tion of one to two grains to the ounce
it is ammoniacal or fetid, much benefit of water. It should be used, as all the
may often be derived from injecting the preceding solutions, at a temperature of
bladder. Indeed , these are the circum- from 980 to 100° Fahr. As a rule, not
stances in which this treatment is espe more than one and a half or two ounces
cially applicable. The formula most em- of any fluid should be introduced into the
ployed formerly was the dilute nitric acid, bladder at one time. In this way the
in the proportion of half a drachm to chances of producing irritation are re
the pint of water, which is sufficiently duced to a minimum ,and the best result.
strong to commence with, afterwards gra- from washing out is obtained.
dually increasing to, but not exceeding, 5. A frequent accompaniment of en
two drachms. It is not desirable to use larged prostate is the appearance of blood
any strongly medicated injection when in the urine. It may be simple unpro
there is much purulent secretion with voked hæmorrhage from some part of its
sanious discharge, and when great pain is surface, or it may be the result of passing
experienced. The quantity thrown in must an instrument. In the latter case, it will
depend upon the capacity of the bladder, sometimes take place, although passed with
and will vary from two to four ounces. the greatest care and without pain, so
One of the best injections in cases of ready to bleed is the organ in some states
muco-purulent secretion from the coats when enlarged ; but this is an exceptional
of the bladder is a solution of the occurrence . It may be due solelyto the
acetate of lead. The best mode of use of silver or other inflexible catheters,
proceedinghaving
catheter is thebeen
following
passed: ainto
flexible
the and disappearrubber
vulcanised by substituting
instrument.a coudée or
It has
bladder, the external orifice is to be con- been said that such habitual disposition to
nected with an india -rubber bottle, and bleed is due to some ulceration at the
neck of the bladder. This is a very rare of the bowel, which in this quantity it is
occurrence, but there is often a congested not likely to do ; or better still to intro
condition of the mucous membrane there, duce small pieces of ice, like large sup
and then the occurrence of occasional positories, into the bowel. It is recom
bleedings is readily accounted for. mended that a catheter should be passed
When hæmorrhage is very slight, it into the bladder and the clot broken up ;
requires no special treatment beyond in- and that efforts to remove portions of this
creased care in the use of instruments, should be made by applying an exhausted
and the observance of perfect quiet for a gum-bottle or syringe to the instrument.
short time after passing one. A change I do not approve of this course, unless it
of instrument will sometimes cause it to is rendered absolutely necessary by re
disappear ; or the employment of one that tention of urine, which is rarely occa
is one or two sizes smaller than that which sioned by the presence of the clot, and
has been habitually used. If the amount fresh hæmorrhage may be excited by this
lost is sufficient to threaten or produce practice. Some of the best results I have
any appreciable etfect on the patient's seen have arisen from declining all me
general condition , it may be desirable to chanical interference. In onethus treated,
use internal remedies. The surgeon may the bladder was so distended with clot as to
then select from the following, or try resemble the uterus of a pregnant woman .
them in succession, if necessary:-Gallic The patient was very exsanguine, and
or tannicaacid, five to seven grains, with or had a small and very feeble pulse. Opium
without a few minimsof the liquor opii, was given every hour with gallic acid,
three times a day, or more frequently if until it allayed the painful and spasmodic
necessary : alum, or iron -alum , in ten or straining to evacuate the contents of the
fifteen grain doses ; matico in tincture and bladder, which is usually present, and
infusion ; sulphuric acid in infusion of causes great distress ; and nutriment in
roses ; acetate of lead and opium ; pre- teaspoonfuls constantly ; ice locally ; and
parations of ergot or ten to fifteen minims absolute quiet. Fresh a blood ceased to
of turpentine, suspended in mucilage, and ooze by uretlıra, and in a few hours urine,
frequently repeated.. Sometimes prepara- so thick and deeply coloured as to resemble
tions of iron are indicated, especially the grumous blood, passed. Iu the course of
sesquichloride, and may be given in the forty -eight hours it gradually became
form best . adapted to agree with the lighter in colour, the bladder smaller,and
patient's stomach. Mr. Adams prefers the ultimately the whole of the clot was dis
use of alkalies in these circumstances, solved, and came away in solution ; and
stating that of internal remedies, the an excellent recoveryfollowed . The in.
simple salts of soda and potash, as the dications are exceedingly plain not to
carbonates, in small and repeated doses, interfere, provided there is not absolute
are decidedly preferable to acids.'' Sir B. retention. The breaking - up or otherwise
Brodie speaks of one case in which disturbing the clot is liable to provoke
hæmorrhage ceased during 2
the administra- fresh bleeding; the hasty removal of the
tion of Ruspini's styptic. I have used it, vesical contents is extremely likely to
but without observing any advantage. open orifices of vessels now closed by
If the hæmorrhage is considerable, the plugs of clot within them , and pressed
bladder becomingdistended, and thismay upon by the contained mass, besides afford
happen to an enormous extent, a large ing a fresh cavity into which more blood
tumour being definable, extending mid- may be poured. Moreover, there is no
way towards the umbilicus, or higher, ground for regarding the clot as a great
other means must be adopted. It is usual evil , which must be got rid of at all
to apply ice in bladders to the perineum and hazards ; much less for adopting such
hypogastrium , the patient maintaining the a mode, recommended on no mean antho
most perfect quiet in bed, his person being rity, as injecting several ounces of a
lightly covered, and the bedclothes elevated strong mixture of acetic acid and water
from the body by means of a cradle. into the bladder in order to effect solution.
Two or three ounces of ice-cold water The solvent power of the urine is pro
may be frequently injected into the rec- bably not only the most efficient, but the
tum, if it can be done without disturbing safest of all agents in effecting the object
the patient too much by producing action desired.
1 Op. cit. p. 116. 2 Op. cit. p. 201. It nevertheless happens in a few cases
that some mechanical means must be has received some one, two, or three
adopted to remove firmly adhering co- ounces of urine, it begins to Aow, in the
agula, and the bladder has even been 1
absence of any voluntary efforts on the
opened above the pubes for that purpose,' part of the patient. This may occur,
but such a condition is happily extremely although rarely, as has been already
rare .
It is true that the distress occa- shown in the Ninth Chapter, from peculi
sioned to the patient by urgent wants to arity in the form of the enlargement pre
micturate and uncontrollable efforts to ternaturally opening the vesico -urethral
empty the bladder, with terrible pain and orifice. If, then, the frequent micturition
spasm , indicates that something should be does not depend on a cause relievable by
done for the removal of the coagula . In medicine, such as that occasioned by ir
these circumstances, the use of opium , ritability or inflammation of the mucous
either by the mouth , injecting needle, or membrane of the bladder, but on some
rectum , should be first thoroughly tested organic source of the kind described, a
before resorting to instruments. But if, the proper receptacle ( often useful in the latter
pain and straining being thus subdued, there case also) is the principal remedy, and
is still no urine passing oralmost none, delay should be almost constantly worn. Such
to use mechanical means would no longer are manufactured of india-rubber, and
be prudent. The best thing then to do is they most efficiently provide for the ne
to attach the catheter to a powerful sto- cessity. They are, however, too well known
mach -pump, and then withdraw carefully to render any description necessary here.
a considerable portion of coagulated blood. 7. Another result of obstruction at
A strong aspirator, such as used in litho- the neck of the bladder from enlarged
trity, attached to an evacuating catheter, prostate is a susceptibility to congestion
say No.13or 14, not more, in size, is a most and inflammation in the organ from very
efficient agent in such an emergency slight causes ; and a few hints respecting
Many a good surgeon has relieved a dan- its management will close this section of
gerous retention and saved a life in such the subject of treatment.
an emergency, by applying his mouth to Various circumstances, of which the
the end of the catheter when no other means most common are sitting on a damp or
were obtainable. A small quantity of cold seat, especially out of doors, general
clot removed often gives spontaneous exit exposure to cold, the movements en
to much more, and suffices to afford effi- countered in a long journey, horse exer
cient relief. Afterwards cold, or even cise, indulgence in alcoholic stimulants,
iced, water, infusion of matico, in quan- and sexual excitement, will produce in a
tities of only 2 ounces at a time, may be sudden manner an attack of increased
injected to check further bleeding; and a difficulty in making water ; rarely, there
vulcanised india -rubber catheter may be may be also a more or less profuse dis
left in the bladder subsequently, if no charge from the urethra of a muco
urine can be voluntarily passed. purulent character, sometimes tinged with
6. A distressing result of enlarged blood ; and it may be
prostate is sometinies incontinence of slight attack of fever. accompanied by a
The attack sub
urine. By this I do not refer to the sides with rest in bed, hot fomentations,
overflow from engorgement relievable by hot hip -baths, a mild aperient, and seda
the catheter, usually termed incontinence, tive treatment: warm enenata may also
which has been already fully considered, give relief. The bladder must be relieved
but a real inability on the part of the in the usual manner, but generally with
bladder to retain more than, at all events, a smaller or softer catheter than might be
a small quantity of urine - a condition , otherwise employed, if the urethra is more
therefore, in which the calls to make tender than usual. Occasionally, also, a
water are necessarily frequent, and can- few leeches to the perineum or around the
not be resisted. As soon as the bladder anus are useful. The treatment may not
1 Mr. A. Copland Hutchinson, with the con- be otherwise antiphlogistic, as the age and
currenceofSir A. Cooper,opened the bladderfrom constitution usually met with in these
above the pubes, and removed a pint of coagulum ,
only twelve hours after the occurrence of humor- patients contraindicate depletion. Such
rhage. He felt enlargement of the prostate from attacks are due rather to passive conges
the cavity of the bladder. The patient died three tion than to acute inflammation, and are
days after
made operation,
. Londthe.Ned and no vol.
. Repository, post-mortem was widely different from the acute prostatitis
xxii. p.128.
1824. already considered in the Third Chapter.
II. The general treatment and man- ' ales agree better than any other dietetic
agement of patients with enlarged pro- stimulant. Whatever is selected of this
state is next to be considered . kind should be regarded as the single
It is of great importance to maintain article of use, and variety should not be
all the functions of the body in health, indulged in. During an access of in
since any slight derangement is liable to flammatory symptoms the stimulant
augment the urinary symptoms. A fit of should be withdrawn, if necessary ; and,
catarrh, of indigestion or constipation, is when the patient has not been accustomed
apt to produce increased obstruction and to it, or feels as well or better without it,
irritability of the bladder. The prin- such abstinence should be encouraged.
ciples, then, on which the diet, regimen, The clothing should encourage and
and general management of the patient maintain a due action of the skin .
are founded it is by no means difficult to Flannel or woollen garments should cover
understand and apply. Modifications will the trunk and the limbs, and all changes
be necessary for every individual case ; of temperature should be efficiently pro
but a general plan may be sketched here, vided for. Elderly patients often suffer,
from which material deviations will not as the season of autumn approaches, from
probably be often necessary : a foolish prejudice against unnecessary
First, in the matter of diet, the patient wrapping. The lighter summer flannels
should restrict himself to such plain, should, early in this season, be exchan
simple, but nutritious food as his ex- for a heavier description . Any chillgedor
perience has shown that he can easily check to the transpiration by the skin is
digest. Moderately cooked tender and attended with danger of internal conges
juicy meat, of which the best in most tion of the prostate in the subject of en
circumstances is mutton, may be taken largement. Damp must be avoided, or
once a day, varied by poultry , game, removed after exposure, especially from
and fish, with well-cooked vegetables or the feet, without delay ; the lower limbs
fruit, the former habitually, the latter should be kept habitually dry and warm ,
occasionally ; home-made or whole -meal a habit of the first importance, as freedom
bread, not less than thirty -six hours old ; of circulation and healthy vascular action
milk in moderation , if it agrees with the here is one safeguard against the recur
stomach ; eggs in like manner, alone or rence of congestion elsewhere, and par
as farinaceous puddings, furnish the prin- ticularly at the point which demands
cipal varieties of food from which the especial protection .
diet should be selected. All that tends The healthy functions of the skin
to derange the stomach and bowels, to must be promoted by habitual tepid
tax unduly the digestive powers, to con- sponging, and occasional warm baths.
stipate the bowels, or to over-excite the The warm foot-bath should be frequently
circulation , must be avoided . Pork, and employed, on the principle just alluded to.
salted or dried meats and fish, highly- The question of exercise is one of im
seasoned dishes, greasy sauces, pastry, portance. The subject of enlarged pro
cheese, strong tea and coffee, all unripe state must not be encouraged to believe
and most uncooked fruit, all raw vege- himself too much an invalid, but must
tables and pickles, should be generally exert his physical powers, as far as they
denied. The question of alcoholic stimu- exist, in daily exercise in the open air, of
lants is often entirely an individual one, which walking is decidedly the best form .
for which express rules cannot be given, Riding is often out of the question ; the
except that in no case is more than a movement of trotting is sometimes preju
strictly moderate use of such to be per- dicial ; and I have seen bleeding caused
mitted . There are some, perhaps, of both by it and by a long drive over
these cases in which the withdrawal of rough roads, or indeed after a long rail.
the accustomed two, three, or four glasses way journey, and, at the same time, in
of wine per diem might be a hardship if creased difficulty in micturition . On
not an injury. In such circumstances ordinarily smooth surfaces, carriage exer
light claret or hock is the best form of cise may he added to, but should not
stimulant. Port and sherry are not gene- supersede, that of walking, where the
rally admissible,often wholly to be avoided, latter can be taken ; if not, the former
as are spirits also . There are other cases, must be substituted . No exercise should
perhaps exceptional, in which light bitter be carried to undue fatigue, and after it,
rest in the horizontal position is desirable. III. The special treatment to be di
Neither should the patient withdraw too rected against the enlargement itself.
much from intercourse with cheerful This resolves itself into two distinct
society, as some, under a morbid sense of parts,—The
7 medical and the mechanical.
the gravity of the complaint, are very apt The medical treatme nt has been hither
to do. This, although often encountered to marked by uncertainty, not to say in
at the onset of the symptoms, gradually efficiency, as to any power exhibited in
disappears in most cases ; while in some effecting a reduction in the size of the en
others the complaint depresses the patient larged organ. Nevertheless many agents
for the remainder of his days, and even have been administered for this purpose .
perhaps tends to shorten them . He One of the earliest on record is hemlock,
should be told that there are many men which probably gained its reputation, or
who, on account of prostatic enlargement, rather its introduction into practice against
have long been obliged to remove the enlarged prostate, independently of its
whole of their urine by catheter , being ancient celebrity even from the time of
unable to pass any by their own efforts, Pliny for the reducing of all tumours ,
and who, nevertheless, are so actively from a remark of John Hunter to the
engaged in the pursuits of life, that their following effect : ' I have seen hemlock
:
daily associates are often wholly ignorant of service in several cases. It was given
of their infirmity. The habitual tone or upon a supposition of a scrofulous habit.
temper of mind exhibited by the patient On the same principle I have recommended
is to be noted, since a desponding one is sea -bathing, and have seen considerable
prejudicial; will tend to encourage the advantages from it ; and, in two cases, a
steady progress of disease, and unnerve cure of some standing.'1 There can be
his constitution for resisting its casual no doubt from the tenor of this passage,
attacks. The opposite state must be that Hunter alludes to the enlargement
sedulously encouraged, not merely as an which occurs from effusion after acute in
important therapeutical means, which it flammation in young subjects, and not to
nevertheless is , but as the legitimate the totally different affection now under
result of a proper imate of his com- consideration - a distinction which even
plaint, so susceptible of palliation, so now does not seem to be always sufficiently
slow in progress as it is in the majority maintained. On the next page we learn
of cases, and so little prone to shorten that Hunter had heard of the virtues of
life materially where judicious care and burnt sponge in a single case ; and in
management are exercised. To assist in another , of benefit derived from a seton
producing this healthy and natural state in the perineum, as long as it continued
of mind, occupation of a cheerful cha- open ; the age of the last case, twenty
racter, suited to engross the thoughts and years, being given . It is very evident
energies of the patient, should be found, that these have no bearing whatever upon
if possible. The mental and moral our subject, and there is no reason , there
management of the patient are sufficiently fore, for founding any treatment on the
indicated by these few remarks, which a practice referred to. The reputed efficacy
sense of their importance impels me to of hemlock in the resolution of enlarge
make. Before leaving this subject, the ments, particularly of the lymphatic and
necessity for reminding the patient of the of the mammary glands, may rest on good
evil effects which may result from great evidence, but there is no proof of its
excitement of all kinds, should not be utility in prostatic hypertrophy. One
overlooked. Mental disquiet and anxiety, thing is certain, there is no preparation
when excessive, often exerts an unhappy in the materia medica respecting which
influence upon the urinary function in more care is necessary in order to obtain
these cases. Undue indulgence in sexual it pure than the extract of hemlock ; and
excitement must be similarly guarded this should never be forgotten when it is
against ; it may be even necessary occa- intended to employ it. Further, in order
sionally to advise abstinence from inter- to ascertain its real value, it should be
course, when obviously followed by ill always given alone, and for a considerable
effects; otherwise the moderate exercise period of time. The dose is from two to
of the function is, in some instances, a five grains, two or three times a day.
source of relief rather than the con
1 On the Venereal Disease, 2nd ed. London ,
trary. 1788, p . 174.
Mercury has been written about as a ministering iodine internally by supposi

remedy, and, although never highly re- tories in the rectum , occasionally by the
commended, has been spoken of as ' worthy mouth , and in applying it to the urethral
of a trial . ' If there is one agent more than surface of the prostate in the form of a
another for the administration of which no weak ointment; commencing with one
indication in this complaint exists, itmust grain of the iodide of potassium to the
be mercury. I cannot conceive an elderly drachm of simple cerate, and increasing
patient with hypertrophied prostate being it to ten or twenty grains to the drachm ,
otherwise than injured by a mercurial sometimes even adding to this a small
course, and must protest against its ad- quantity of the pure iodine. He states
mission intoa catalogueofmedicineshaving that his success was complete with nu
the slightest claim to influence favourably merous cases of the complaint in advanced
the disease in question . age, as well as in that form to which young
The hydrochlorate of ammonia enjoyed men are subject.
for a time a considerable reputation in On analysingthe cases detailed, twenty
Germany when Dr. Fischer of Dresden seven in number, eleven only can be re
had claimed for it, in 1821 , the power of garded as examples of the enlargement of
reducing senile enlargement, if taken in old age, and in these the inference depends
sufficiently large doses. Several reported on the evidence afforded by the author's
favourably as to its powers, the dose re- examination, by exploration of the rectum .
commended being at first 15 grains, four In several of the others, an enlargement
times a day, which was increased to double confined to the middle lobe ' was dia
and at last to three times that amount : gnosed, because there had been difficulty
larger quantities produce unpleasantsymp- in introducing an instrument near to the
toms. No result was to be expected until neck of the bladder, no enlargement being
it had been taken four or six weeks; after presented in the rectum. These, of course,
an interval it was to be again administered are rejected — first,because existence of the
for six or eight weekslonger; the full dose difficulty described is no proof that en
of two or three drachms daily being em- larged 'middle lobe'exists ; and secondly,
ployed during the greater part of that because it is not very common to find this
time. Later experience has not proved form of enlargement unaccompanied by
the remedy to possess any value in hy- augmentation of the lateral lobes also.
In other cases confirmed stricture was
pertrophied prostate.
Iodine and its combinations have been present; when, it difficulty in drawing
put in requisition pretty extensively, with off the urine was experienced after the
a view to theremoval of prostatic enlarge- catheter had been passed through the 6
ment, and aa considerable degree of success contraction, enlargement of the middle
has been claimed as the result. The known lobe ' was in consequence affirmed to exist.
power of this substance in effecting the But the co - existence of senile enlargement
resolution of numerous swellings of the with stricture is not common, while diffi
lymphatic glands, of the thyroid gland,.
culties in traversing the posterior or pro

and other tumours, naturally induced a static part of the urethra after a stricture
trial of it in this affection also. The late has been passed, no hypertrophy existing,
Mr. Stafford first called the attention of are familiar to every surgeon of experience
the profession to it with this view in 1840, from other and well recognised causes.
and in 1845 published a second edition Lastly, the remaining cases ranged be
of his work, giving the result of further tween 21 and 40 years ofage; the affection
experience, and theopinion which he formed generally followed a severe gonorrhæa ;
therefrom was expressed in the preface in and they were examples of enlargement
the following terms: -I have very little from prostatitis in early life.
hesitation in saying, in the general cases But eleven cases of success, in indi
of enlargement we meet with,success will viduals ranging between 50 and 80 years
attend the treatment, if it be properly of age, are recorded by the author without
effected and persevered in for a sufficient hesitation, and must be accepted or re
length of time.' jected according to the view which is
Mr. Stafford's plan consisted in ad- taken of his powers of diagnosis, and
accuracy in reporting. It is almost un
tions1 An Essay
of the on theGland.
Prostate Treatment of some
By Ř. Affec necessary
A.Stafford. to call to mind the fact that a
2nd ed. London , 1845. Preface, p. 7. very careful exercise of both these faculties
TREATMENT OF PROSTATIC ENLARGEMENT . 97
is necessary in observing the increase or sitive mucous membrane of the urethra

decrease in size of the tumour, the chief I wholly disapprove. Nothing is easier
evidence respecting which is derived from than to pass down to the prostatic part a
rectal examination, especially if the pro- small portion of ointment impregnated
gress be slow . The reader cannot, how- with some chemical agent, and project
ever, but be struck with the ease and con- it into the urethra there. But that it can
fidence with which the author notes the remain there in any quantity, or for any
effect ofonly two or three suppositories, as time, adequate to the absorption of a part
perceptible to his finger in the diminution of the salt introduced, I do not believe;
of the enlarged prostate; with thegeneral the greater part, if not the whole, is
completeness of thecures vouched for, and speedily removed to the bladder, and the
the rapidity with which they appear to utmost which can be expected to result is
have taken place. From two to four an amount of irritation corresponding to
months is affirmed to have sufficed, in the quantity of the agent employed - an
several instances, to reduce the prostate of effect which, in any degree, is positively
an aged person from the size of a hen's injurious.
egg ' to its natural dimensions (op. cit. COMPRESSION . — The influence of com
p . 101, and elsewhere). All that can be pression in retarding the progress of mor
said further is, that such success was bid growths and enlargements has long
marvellous, and that such results have been recognised , and has been employed
not followed the numerous trials of his with success in discussing tumours and
remedies which were at that period made absorbing inflammatory products. The
by others. And thus it has come to pass question has therefore arisen, can reduc
that the use of iodine in these cases has tion of the enlarged prostate be effected
very_properly been relinquished . by the same agency ? Its solution has
Further, after a trial of other reputed been attempted in various ways, but never,
remedies, including mineral springs, par- it would seem , with any great degree of
ticularly those of Kreuznach, I fear it success, the practical application of ade
must be acknowledged that no thera- quate pressure having been generally
peutical agent is known which has the found to be impracticable, difficult of
power of reducing actual hypertrophy of application, or irritating to the bladder.
the prostate . The volume of the en- It has been supposed, moreover, that the
larged organ may be lessened, so far as its benefit accruing from the use of large
increase of size depends on congestion or catheters in this complaint is in part due
on inflammation ; and as these conditions to the compression which they exercise on
sometimes co -exist with hypertrophy, their the prostate ; and it is not absolutely im
removal may lead to the conclusion that possible that some amount of beneficial
the latter state has been beneficially in- influence may be thus exerted. It does
fluenced. The mode in which Kreuznach not appear, however, to retard develop
water was formerly used is appended in a ment appreciably, although it perhaps
note below. ) tends to maintain a more patent state of
Of the application of iodine in any urethra than would otherwise be found.
form or degree to the surface of the sen- It is evident that a much more powerful
act of compression than that which can
Tepid hip-baths,
the bittern, daily, of
or mother
of water,Kreuznach
to which be exercised by a catheter even of the
springs has been added, -lye,
invaried the
proportions,be largest size, is required, if the volume of
ginningwith half a pint or pound, according to theprostate is to be diminished by it, or
the form in which it is obtained , to four gallons of
plain water at a temperature of 900 to 940, or In 16 ounces of the mother -lye there were,
Chloride of Calcium 1789.97
warmer, if preferred ; in this the patient should Sodium 226 :37
be seated for twenty minutes every morning. 99
168.31
The principal spring at Kreuznach employed Potassium
Magnesium 230.81
for medical purposes is the Elizabeth Quelle ; and Aluminium 1.56
for topical applications, the water of this spring is 99
Lithium . 7.95
strengthened in saline constituents by the addition 2
59.14
of the mother- lye after the elimination of the Bromide of Sodium
Iodide of Sodium 0.05
chloride of sodium at the Salt Works, which exist .
on a very large scale close by the town, at other 2484:16 grains

saline springs . This mother-lye, of which the
specific gravity is between 1.3 and 1.4, contains no Both this and the iodide of potassium were
less thanbetween 2,000 and 3,000 grainsofsolids usedwithsomebland decoction,as an enemadaily,
in 16 ounces. A late analysis gave the following of about three ounces ; to be retained as long as
result : possible .
H
the neck of the bladder rendered more / direction can be exerted by means of a
patent. second portion, which , being glided along
Physick, the American surgeon, at the shaft, and continuing its direction,
tempted to accomplish the object by dis- furnishes two divergent blades, by which
tending with fluid a small bag of gold forcible dilatation can be made . He has
beater's skin, previously rolled up and recorded good results from the proceeding,
introduced, on the end of a catheter, into and believes that these arise not from any
the bladder ; and by then attempting to absorption of tissue produced by the
withdraw the dilated sac through or into pressure, but by a mechanical depression
the vesical orifice; and a successful result of the obstacle which exists at the neck of
is claimed by Parrish . Subsequently, M. the bladder. In one of his cases he
Leroy d'Etiolles attempted by means of reports marked benefit from six applica
metallic instruments to compress the pos- tions of the instrument of about five
terior border of the neck of the bladder. minutes each.2 Some other apparatus
He first of all employed straight, or nearly have also been designed in France, but of
straight, sounds, by means of which ,when so complicated a nature , and so obviously
carried into the bladder, it is not difficult, inefficient for any practical purpose, that
as may be readily understood, to make no description need be given in these
pressure with the hand, after a somewhat pages. The foregoing attempts are only
rude fashion, directly upon the floor of the detailed here for the sake of illustrating
vesical neck . As a modification of this the views which have at different times
method , and owing to the difficulty of been held by various surgeons with regard
introducing straight instruments into the to compression as a therapeutical agent in
bladder'when the prostate is enlarged, he enlarged prostate, as well as the means
devised an instrument having the form of which have been employed in order to
an ordinary prostatic catheter, the curved accomplish it.
portion of which could be rendered After some experience of the employ
straight'at will, after its introduction into ment of compression in its simplest and
the bladder , by means of a stilet made most innocuous form , viz. , by expanding
of artic intod aporti
brought ulate
capable
ons line
right
of bein an india-rubb tube with wate , so as to
through theg exert a consierderable influencer on the
agency of a screw in the handle of the neck of the bladder , I am of opinion that
instrument; and in this manner he suc- the risk encountered of irritating the
ceeded in exerting a certain degree of parts does not compensate for any little
pressure on the same limited portion of benefit attained, and which can only be
the organ .
2
After this M. Leroy proposed regarded as temporary in its character.
to dilate the vesical neck more equably in I tried it fully by means of a special ap 6
various directions, by employing an paratus, described in my work, ' The
instrument with three expanding metal Enlarged Prostate, published in 1858,
blades, and again also with the lithotrite and I found no good result from the
of that period ( 1831-2 ). Other French method, contrary to the hopes entertained ,
a
surgeons have proposed to introduce a and the natural desire to remedy a diffi
large curved gum - elastic catheter, and culty if possible. But I subsequently
afterwards to forcibly straighten it by wrote of all these and similar proceedings
introducing a strong straight stilet. Mer- that they could not be recommended,
cier speaks of having employed this believing that the progress of the disease
method, and states that a flexible exis more certainly checked by good general
tremity to the steel stilet enables it more management and the avoidance of irri
easily to traverse the catheter. But he tation in every form , than by any spe
also has devised a special instrument for cific attempt of a mechanical nature to
dilating the prostatic portion of the reduce the tumour or dilate the neck of
urethra,> or the neck of the bladder. It the bladder. Hence I confess it is some
6
possesses the form of the " bicoudée ' what surprising to find that anyone who
catheter, but with two handles, so con is acquainted with what has already been
trived that pressure in an antero-posterior tried as treatment of the kind described,
should at the present day gravely propose
Surgical Observations, p. 258.
2 Erposé des Procédés pour guérir la Pierre. 1 Recherches, & c. , 1856, pp. 174, 175 .
Paris, 1825, p. 180, et seq. Par Dr. Leroy · Étude sur divers Points d'Anat, et de Path . des
d'Etiolles. Organes Génito- urinaires. Paris, 1860, p . 24.
to repeat it. Certainly, no one who has | One conductor was passed into the rec
had a large experience of the prostatic tum to the rectal face of the organ ;
diseases of advanced years, ventures to use the other was passed to the prostatic
instruments sufficiently large to produce urethra. On examining the details of the
any diminution of the gland or any dila- case, there cannot be a moment's doubt
tation ofthe canal which passes through it, that it was one of mere chronic inflamma
by the agency of compression. He will, if tory enlargement of the prostate, succeed
he has tried such a method, have speedily ing to gonorrhæal discharge : the age of
learned that it is very easy thus to excite the patient was forty -four years, a period
inflammation in an enlarged prostate and of life at which neither dissection nor
in the adjacent bladder, and not very easy careful clinical observation has ever de
to subdue it. He will aggravate his tected a case of hypertrophy of the pro
patient's sufferings, and assuredly he will state. The number of sittings was seventy,
not in the least degree improve the and extended over a period of six and a
mechanical condition of the parts. There half months. In this time, under any
is not the slightest analogy between the appropriate treatment, it is more than
morbid affection known as organic stric- probable that the reduction of such an
ture of the urethra, and that to which enlargement would readily have taken
the same canal is liable when surrounded place.
by an hypertrophied prostate. In the Division of the obstructing portion at
former case the passage can be almost the neck of the bladder has been per
always largely benefited by mechanical formed. Other operations have been also
agents, such as the dilating action exerted attempted for effecting a similar purpose ;
by the bougie. In the latter case the such as the excision or the crushing of a
hypertrophied prostate is never diminished protruding portion, and even the ligatur
by pressure or compression, but almost ing of a polypoid outgrowth. Respecting
invariably exhibits increased vascularity the division of an obstruction, barlike in
and tenderness as the result of the action its form , elevated from the posterior
of the instrument employed. Besides, it border of the neck of the bladder, it is no
is an error to suppose that the inability to doubt a proceeding to be accomplished
micturate, resulting from enlarged pro- without much difficulty , with the exer
state, is due to narrowing of the canal, as cise of ordinary care. If made at all ,
is the case in stricture. The retention is Bottini's mode with the electric cautery
due to closure of the neck of the bladder ; is probably the safest mode of proceed
in the interference with that delicate exit ing. ' In most cases, although not in
and its valvular action,which the pressure variably, the bar is a prostatic develop
of newly formed prostatic growth in and ment, and when well marked may per
about it has occasioned. haps in some cases be incised with advan
Several times during the last twenty tage, and without danger to the patient .
or thirty years, attempts have been made Such was the opinion of the late Mr.
to reduce the volume of an hypertrophied Guthrie. As, however, he introduced
prostate by passing through it a current the consideration of this subject to the
of electricity . It is not difficult to make profession in connection with his views
application of this agent; but, supposing of another affection occasionally met with,
that any advantage could be expected to altogether distinct from enlarged prostate, 6
result from it, the sittings must be very and to which he gave the name of " bar
numerous and extend over a long period at the neck of the bladder,' I shall defer
of time in order to afford it a fair trial in any further remarks respecting the opera
any given case. Were any marked bene- tive proceedings (which must be the
fit likely to arise, there would be good same, or nearly so, whatever be the con
grounds for advising the patient to submit stitution of the obstruction in question )
to the inconvenience even of such a to the eighteenth chapter, which is de
course . Experience, however , does not voted to an examination of that subject.
warrant us in drawing any favourable In that place the various cutting opera
conclusions respecting its employment. tions which have been applied to the
Thus, a case was reported in Paris' of prostate will be considered at length.
marked success following the use of A very few words will suffice for the
faradisation in hypertrophied ' prostate.
6
i di un nuovo cauterizzatore. Prof. Bottini.
i Gazette Médicale, 1861. No. 70, p. 309. Bologna, 18 4 .
1 2
notice of crushing and the ligature. Some, the subsequent effect of leaving a putrid
of our French brethren have performed slough in the bladder, as a result of the
on the living body these procedures, the process. Subsequently he designed an
first named not unfrequently. A portion, écraseur, contained in a canula of the
supposed to be the protruding one, is form of a catheter, for the purpose of
seized between the blades of a lithotomy removing these outgrowths.3
forceps, or an instrument very similar, The reason for mentioning most of
and is torn away, if possible, or crushed, these proposals rests mainly on their his
so as to ensure a state of sphacelus in the torical interest. As examples of practical
part attacked. Jacobson's lithotrite has surgery, or as indications to be followed,
been also used, and is preferred for the most of them have none. But from time
purpose.1 M. Leroy also described an to time such proposals are made as novel
ingeniously contrived apparatus for carry- modes of treatment by persons who are
ing a ligature round the pedicle of a not informed of what has been already
polypoid tumour springing from the tried and has already been found wanting.
median portion of the prostate. It is Illustrations of this practice are by no
engraved in his work , where he states means uncommon ; it is therefore desir
also that he has used it with success.? No able, in a treatise like the present, to
details of the operation are given, although, mention, and even to describe, some forms
it must be confessed, they would have of treatment even if they have become
been exceedingly interesting, both in obsolete, and have been already proved to
respect to the difficulties overcome, and be without value.
CHAPTER XII.
THE TREATMENT OF RETENTION OF URINE FROM ENLARGED PROSTATE .
Urinary Retention from Enlarged Prostate, generally due to Congestion of the Organ ; first indication ,
to relieve Congestion - Baths ; second, to allay Pain and Spasm - Opium ; third, instrumental relief
-Catheters, various — Comparative Advantages of - Modes of passiog solid, flexible, & c. - False pas
sages the great cause of difficulty — Modes of avoiding them - Should the Bladder be emptied at
once ? _Should the Catheter be retained ? —Catheterism unsuccessful, what Means are to be em
ployed ?-Puncture Bladder above Pubes ; by Rectum ; through Symphysis Pubis ; Needle
Puncture and Aspiration - Comparative Merits of Case - Perineal Operation Conclusions.
It has been already premised that the habitual symptoms which constitutes the
term complete retention of urine,' here state in question . In by far the greater
used, does not include or designate that number of cases, exposure of the surface
chronic retention of urine so well known of the body to cold or wet, or to both
as a frequent result of enlarged prostate, combined, is the agent which produces
but is intended to apply only to that congestion in the already enlarged pro
urgent condition in which, from this state, temporarily increases its volume,
cause, the patient has been suddenly and occludes the already embarrassed
rendered unable to relieve his bladder ; urethro -vesical orifice. Whatever the
a condition in which he is in a state of cause, however, by which prostatic con
hourly increasing difficulty and danger, gestion is thus suddenly favoured, this
and from which it is not merely exis, in almost all instances, the essential
pedient, but necessary, in order to save nature of the obstruction . Hence may
his life, that he should be relieved. be inferred the first indication by which
Some external circumstances gene- to direct our treatment, viz., to dissipate
rally give rise to that exacerbation of the as much as possible internal congestion.
1 The mode in which M.Leroy adapted the The second is to allay pain , and quiet
instrument of Jacobson to thepurpose isexplained those involuntary but unavailing efforts
and illustrated in the Gaz, des Hôpitaux, January to pass water, which the patient almost
27, 1849.
2 Thérapeutique des Rétrécissements des En- invariably suffers from to a distressing
gorgements de la Prostate, & c. Paris, 1849, pp. 75
and 77. 3 Bull. de la Soc. Anat. Paris, 1856, p. 420.
TREATMENT OF RETENTION OF URINE. 101
extent ; and thirdly, and mainly , mostly of heat than those who are not so
without delay, to draw off the urine, and, accustomed ; and the duration of the
unless in very exceptional cases, by the bath may be about fifteen minutes, the
natural passage of the urethra. heat being rather increased than di
The first indication may be fulfilled minished during that time. Before this
by employing a hot hip bath , or a bath period has elapsed a full effect is usually
for the whole body. The temperature produced on the skin , and a considerable
should be high, from 100° to 105°. derivation from the internal viscera is
Patients who have resorted to it fre- accomplished. Meantime, however, if
quently require a much higher degree | there be much suffering, and particularly
S
Fig . 24.—a, Gum catheter mounted on a stilet of the proper curve for use ; b, Cc,d,
silver prostatic catheters of different curves, the Nos. 1, 2, and 3 of the
instruments which I employ .
if involuntary paroxysms of straining to employed, and of the best manner of

pass urine are present, some sedative overcoming the varied difficulties which
should be freely administered. Opium is may present. Let me premise, then, that
the best, and may be given by mouth or with the exercise of care, and of ordinary
subcutaneously ; the action of a supposi- skill, there should very rarely be failure
tory being too tardy. to introduce an instrument safely through
With the third and last indication the track of the urethral canal.
comes the question of the catheter ; not are certain circumstances under which
a question as to the propriety of using it this is hardly possible, but such are for
There
forthwith, delay being rarely desirable, tunately of very unfrequent occurrence.

but that of the kind of instrument to be The surgeon should be provided with
102 THE DISEASES OF THE PROSTATE ,
silver and gum - elastic catheters of the for immediately before introducing it it
ordinary prostatic length and curves . is necessary to bend back the handle or
First, respecting silver instruments, a stem of the catheter considerably in order
prostate-catheter should not be less in to unfold temporarily the extreme curve
size than No. 9 or 10 ; it should be from which unfits it for passing ; but the in
10 to 14 inches long from the rings on the strument naturally tends to return to that
handle to the end of its beak or point ; form , and doing so during the process of
and the curved portion should comprise introduction, the best possible chance of
about a fourth to a third of a circle, which succeeding is afforded when the prostate
measures from 41 to 51 inches in dia- is large and difficult to be surmounted by
meter ; the former of these being, per- the common instrument . Further, a
haps, the most generally useful size. gum catheter also may be used, either
Three good forms are shown at fig. 24. with or without a stilet ; in one case
The first is sufficient for most cases, the being a flexible, in the other an inflexible
second and third are necessary only for instrument; so that it possesses sometimes
those in which the organ is very con- an advantage over metallic instruments in
siderably enlarged. Besides these there its capability of being adapted in form to
is a silver coudée catheter, sometimes any curve which the peculiarity of the
serviceable, but usually far inferior to case niay appear to demand .
the flexible instrument of the same As a rule it may be said that in three
6
form . cases out of four, the French coudée '
With respect to gum -elastic instru- flexible catheter is the first to be em
ments, almost any of those made for ployed, and that it will be successful. If
ordinary purposes are sufficiently long not, the English gum elastic instrument,
for prostate-catheters. The size should treated as just described, if oneis at hand,
be about that named for the silver instru- may overcome the difficulty. If such a
ments, It is advantageous, indeed it is one is not to be had, much may be done
necessary , in order to render them effi- by way of communicating the desired
cient, to keep a few of these in prepara- curve and quality by theuse of hot and
tion ; that is to say, the catheter should cold water . The English instrument
be maintained constantly, during a con- possesses this advantage, that the surgeon
siderable period of time, on a strongly can give it any curve or form he pleases
curved stilet, describing almost two -thirds while immersing it in hot water, which
of a small circle-a curve, it is almost curve is rendered permanent, or at all
unnecessary to add, in which it would be events sufficiently so to be available for
impossible to employ it ; but on removing immediate use, by plunging it into cold
thestilet from one which has been so treated water. It should be passed, so that the
for a few months, we possess an instru- curve is maintained, and exists unspoiled,
ment which may be found in some cir- when the point of the instrument reaches
cumstances to possess qualifications of the posterior part of the urethra. This
extreme utility (fig. 23 , p. 81). The requires a little dexterity, easily acquired
value of this method arises partly from by practice. Supposing the patient to be
its ensuring that the beak, or last inch or in the standing position , the well-curved
two of the catheter, is sufficiently curved. gum catheter, previously oiled , is intro
However well curved the rest of the induced with the penis directed rather down.
strument may be, if the last inch be wards, but drawn over the curve of the
straight, it will, almost to a certainty, instrument, while the shaft is kept close
become engaged in the prostate, and will to the patient's abdomen, or, if he is very
not pass over an enlarged median portion. stout, is pressed backwards into his left
This should never be forgotten in giving groin. Nearly two-thirds of the catheter
the intended curve to the iron stilet,which should be passed with the shaft in the
cannot be done with the fingers: the last direction described , so that the point
inch can be well curved only with a pair passes well under the pubic arch, when,
of pliers. The chief advantage, however, if the shaft is brought downwards towards
consists in the fact, that a catheter so the operator in themiddle line, and gently
treated has a tendency to increase its pressed inwards at the same time, the
curve as it goes down
the urethra, instead point will rise over any obstructing pro
of losing it, from the heat of the canal, as static eminence into the cavity of the
occurs with catheters not so prepared | bladder. If the patient be recumbent,
the same principle of keeping the shaft accomplished in any other way. The
close to the body rnust be adopted. If it stilet should be so large that it cannot
fails to pass and has to be withdrawn, the issue from the eye of the catheter in any
curve and proper stiffness must be re- backward or forward movement which
stored by the hand, and by plunging it may be communicated to it.
into cold water before re -applying it to After all it may be necessary to re
the patient. sort to the silver catheter, if success has
In some instances the French bulhous- not been attained with the instruments
ended catheter (see fig. 25) may be just described. As it is desirable to follow
successful. This instrument, which is a uniform manner in introducing it, the
generally straight, although sometimes best mode of doing so may be described
made with a curve, owes its utility to its here. The surgeon, standing at the left
extreme flexibility, having no curve or side of his patient's bed, who should lie
force of its own. It follows the sinuosity on his back in an easy position, takes the
of the urethra, and so frequently finds a catheter lightly between the thumb and
way which the stiffer instrument has fore and middle finger of his right hand,
failed to discover. The delicate soft end, which occupies the supine position , the
surmounted hy a bulbous swelling, which former (the thumb) being, therefore,
prevents it becoming engaged in a lacuna applied to the upper surface of the handle,
or other such obstacle in the urethra, close to the rings; the two latter support
insinuates itself, and the larger body of ing it below, and in aa horizontal direction .
the instrument follows. In em The penis may be either held indifferently
ploying it the penis should be between the thumb and fingers of the left
held out horizontally, the patient hand, or uniformly according to the follow
standing, and the catheter pressed ing method, which is not without a certain
in the same direction from first to convenience. The left hand is in this
last. case applied , the palm being upwards, so
Of course, as a general rule that the middle and ring fingers hold the
all flexible catheters are to be penis just behind the corona glandis; the
used without stilets, since the index fingerand thumb are then at liberty
rigidity so produced destroys the to be applied for the purpose of retracting
very quality which is the source the prepuce, if necessary. — The point is
of their value. Nevertheless, then introduced into the urethra, the direc
there are some exceptions to this tion of the shaft being parallel with the
rule, and the stilet has sometimes line of the left groin, and the instrument
a real value. carried down as far as it will go without
The use of the stilet is two elevating the handle from the horizontal
fold . First, if the silver instru line. This is now gently carried to the
ments are insufficiently curved, median line of the body, and at the same
we possess the means of employ- time a little raised, so that the point
ing an inflexible instrument, al- enters the sub-pubic curve. The penis
though naturally supple, of any Fig. 25. being now merely supported , the shaft of
curve we desire , by first com the catheter is brought to the perpen
municating the form to the stilet, which dicular, and moved slowly downwards to
ought to be stouter and stronger than a wards the interval between the patient's
wire. Secondly, it enables us to put thighs, while at the same time slight trac
in practice a manæuvre of considerable tion is made upon it, so as to keep the
utility, well known as having been beak of the instrument closely along the
originated by the late William Hey, of roof of the urethra and enable it to slide
Leeds. Many have derived an advan- closely under the pubic arch ; after which,
tage from adopting it in circumstances of unless the obstruction be considerable, it
difficulty. It may be thus described : the will soon enter the bladder, gliding over
catheter, nounted on its stilet, having any little prominence at the floor of the
been introduced as far as to the obstacle, vesical neck. Supposing that the diffi
the stilet is then withdrawn about an culty is not overcome by this simple
inch , which has the effect of increasing means, there remain but two modes of
the curve and elevating the point of the manæuvring which afford a reasonable
catheter, so as often to carry it over the 1 Pract. Obs. in Surgery. By Wm . Hey,
enlarged portion in a manner less easily | F.R.S. Lond . 1814, 3rd ed . pp. 399, 400.
chance of success with the silver instru- |laceration of the passagehas resulted. It
ment of the ordinary prostatic curve. is a trite remark of Civiale, that ' a
The first is the attempt to follow more catheter goes properly only when it is
closely, or accurately, the upper aspect, or swallowed by the urethra ; no quicker or
roof, of the urethra, either by withdrawing more forcible movement is allowable
and sooner depressing the handle, or by there. There is a truth conveyed by
employing an instrument with a longer this remarkably appropriate simile, which
and more strongly curved extremity, so as should never be forgotten ; the instrument
to override, if possible, a large tumour of should travel through the delicate, sensi
themedian portion, or other prominence tive, and contracted mucous canal by a
of that part. The second is to incline the slow, continuous, and easy movement, re
beak, when arrived at the prostate, either sembling that by which the morsel travels
to the right or left, so as to pass through from the fauces to the stomach. Forcible
the sinus or hollow which, to a greater or and rapid movements are apt to excite
less extent, exists on each side of such resistance, and to create obstacles which
median projection, entering the bladder would, with opposite treatment, not be
not over, but laterally , as regards the encountered .
obstruction . These are the points which The silver coudée instrument of Mer
experience, as well as our knowledge of cier having been mentioned as occasionally
the pathological anatomy of the organ, offering a chance after failure with other
indicate to be borne in mind . instruments, his mode of using it may be
A combination of the two instruments explained here. He premises that the
is affirmed by some to be occasionally idea of an instrument with a beak nearly
useful. The mode of employing them is at right angles with the shaft, and not
to take a full -sized silver catheter, No. more than three-fourths or seven -eighths
10 or 11 of a prostatic curve, but com- of an inch in length ,takes its origin from
pletely open at its extremity , as if the the peculiar form and size of the urethra ,
point were cut off. A flexible gum -elastic known to be assumed in largely developed
catheter, of a size adapted to fill pretty swelling of the lateral lobes of the pro
accurately the channel of the silver cathe- state. As has been shown in describing
ter, is to be passed through this, just so the anatomy of hypertrophy, the pro
far that the point of the flexible instru. static urethra is sometimes increased con
ment protrudes, forming an obturator ; siderably in measurement from its floor
this apparatus being passed down to the to its roof, and the opening into the
obstruction, and the silver catheter being bladder elongated vertically, so that the
held by the left hand, the flexible one canal forms a long oval in its recto- pubic
may be gently pushed onwards through diameter, instead of a spheroidal section,
the former, and may find its way into the when distended by an instrument ; and a
bladder, when neither the silver nor the kind of elevated step generally exists at
flexible instrument would pass alone . the entrance to the bladder. The adapta
In employing any manipulation hither- tion of the instrument to the formation
to mentioned , the instrument should be described will therefore be seen, and the
held with extreme lightness, and used manner of using it is that directed by
only with gentleness and delicacy. By Mercier, although not precisely in his
no other means can the operator learn to own words . The operator stands in
appeciate the kind of resistance which its differently on the right or left side of the
point encounters ; by the gum -elastic patient, who is lying on a couch or bed ;
instrument especially he may be easily the right being more convenient at the
deceived if he uses an improper degree of last step of the process, in which position
pressure, which , instead of advancing, is, we will therefore now consider him.
perhaps, merely caught into some lacuna, Taking the penis in his left hand, and
or pressed against a fold of mucous mem- holding the catheter in his right, he in
brane, while the instrument, nevertheless, troduces it in the ordinary manner as far
continues to disappear under the band,by as to the bulbous portion of the urethra,
becoming bent within the urethra. No when the shaft is to be raised nearly to a
practised hand, however, can mistake the right angle with the patient's body, but
sense of resistance offered under these not to be depressed between the patient's
circumstances; nevertheless, it has oft- thighs, as this action would tilt up the
times been a source of deception, and beak against the roof of the urethra, and
>
TREATMENT OF RETENTION OF URINE . 105
not cause its advance along the canal, as | urethra to the prostate : precisely accord
in the case of the curved catheter ; but ing to the mode in which an ordinary
there is to be a combination of the two lithotrite is passed. But if there is ob
actions of pressing in the line of the shaft struction of the kind now under considera
and depressing, the degree of the latter to tion, as soon as the instrument has ob
be regulated according to the advance viously arrived at it, and will not advance
which the beak is felt to be making as it farther by the means directed, its shaft is
glides through the deep portions of the to be depressed until it nearly reaches
Fig. 26 —General hypertrophy : patient aged 74 : from a preparation of my own.

Lateral lobes blended with median portion formed a bank or bar nearly an
inch high at right angles with the course of the urethra through the prostate.
the horizontal line of the body along over which the same gentle pressure,with
the interval hetween the thighs, in which slight variation of the direction, may
direction it is to be gently pressed for- cause it to glide directly upwards into the
ward, so that the whole of its short beak, bladder. The adaptation of the instru
and not its point, advances along the ment to this form of the urethra is seen
prostatic urethra, the form of which in by examining figs. 8 and 9, at page 41 ;
advanced cases ofenlargement,as we have as well as by fig . 26.
seen , admits of this action , until arrived at But the circumstances must be very
the step or bar at the neck of the bladder, I unusual indeed in which such an instru
ment is necessary. By careful intelli- | the same extent, and its point, as it is
gent management the ordinary prostatic again carried onwards, is to be pressed
catheters, silver or flexible, will pass safely gently on the right side of the urethra ;
in all cases, however advanced, in which failing in that, it is to be introduced while
no lesion by instruments has been pre- pressing it on the left ; since one sidemust
viously inflicted. The real cause of dif- be unbroken by the orifice of the false
ficulty in these cases is the existence of passage, and guided by the uninjured side
false passages. It often happens that in it is probable that the catheter may be
previously -made attempts the catheter has slipped into the bladder. These ma
perforated the obstruction, has passed næuvres, carefully and systematically
out of the urethra , and has been carried employed, rarely fail in overcoming the
onwards a considerable distance in the difficulty presented by the conditions in
belief that it was still progressing towards question . Mercier makes an ingenious
the bladder, when it has really been proposal in order to avoid a false passage
boring a false route by the side of the of the kind described. The instrument
rectum or the bladder . After this un- consists of aa metallic catheter with an eye ,
fortunate occurrence, it follows that the situated in the convexity, two or three
instrument takes the wrong course much inches from the termination of the in
more readily than the right ; in all cases strument, which is solid beyond the eye.
it is difficult, in some almost impossible , to Having passed this first, theend of which ,
avoid it. Under these circumstances , a as usual, finds its way into the false pas
metallic instrument, the movements of sage and fills it, he slides down the hol
which are susceptible of more complete low of the catheter an elastic instrument
control than the elastic one, should be which , issuing at the eye in theconvexity,,
employed . It should be as large as the above described , avoids the false passage,
urethra will admit ; its point should be and has a good chance of following the
blunt, not tapering , and this should be course of the urethra into the bladder.
1 kept throughout its course close to the ( See fig. 27. ) " In practice, however, the
upper aspect of the urethra by gentle plan of manipulation before described is
pressure of the point upon it, so as to far preferable to this proceeding .
avoid the lower part where the obstruc- The question occasionally arises, is it
tion is generally encountered , and the desirable at once to evacuate the entire
walls of the urethra are the most yielding ; contents of the bladder when retention has
hence it is that the false passage is gene- existed for aa considerable period of time ?
rally found in that situation. Arrived at In very rare instances the removal of a
the pubic curve, the handle should be large quantity of urine, amounting to
depressed in order to elevate the point, several pints,has been followed by faint
and here the fingers placed on the peri- ing and depression,from which the patient
neum , to make gentle pressure on the has never rallied . When the extent of
convexity of the instrument, felt through vesical dulness is very considerable, it is
the tissues, often aid its transit. But if, therefore prudent to afford relief in a
after passing some seven or eight inches, gradual manner, and, supposing that the
it is arrested in its course , the forefinger catheter is retained , this may be easily
should be introduced into the rectum to accomplished. The removal of some
ascertain the situation of the catheter , and 30 or 40 ounces will probably afford
if it is felt too distinctly, the mucous mem- complete ease, and after the lapse of half
brane only appearing to intervene between an hour or an hour another portion may
the finger and the instrument, we learn be withdrawn ; in this manner the blad
that it has left the urethra, probably by der may be gradually brought to adapt
its floor or one of its sides, and has passed itself to the normal condition of contrac
between the bladder and the rectum. In tion, which subsequently, as a rule, must
these circumstances the catheter is to be be insured at least once or twice a day.
withdrawn three or four inches, the finger The preceding paragraph appeared in
being still maintained in the bowel in the first edition, published now some
order to be used as a fulcrum upon which twenty -five years ago. Since that time
to tilt upwards the instrument in the I have met with a striking illustration of
next attempt to introduce it-a method the necessity of adopting the prudent
which often proves successful. If still course there indicated. The case became
failing, the instrument is withdrawn to the subjectof legal inquiry in the country,
and an action at law resulted, at which on the abdominal veins and viscera ; the
my opinion was desired . The circum- patient being, unfortunately, in the worst
stances were these. An aged pauper possible position for meeting the result.
had suffered from incontinence of urine' | Had the precaution above recommended.
for some time, this condition being, in been taken,undoubtedly the sudden cata
reality, as it so commonly is ( see page 71), strophe would not have occurred .
the sign of a greatly distended bladder. A point of some importance remains.
The amount of urine daily passed by . A. catheter having been introduced with
continual dribbling was equal, or nearly some difficulty for the relief of reten
so , to the normal quantity, and the medical tion, should it be permitted to remain ?
officer had concluded that it was unneces- This question is answered negatively and
sary to pass a catheter. Circumstances, affirmatively by different authorities. In
however, brought about the decision to support of the negative it is said that the
employ an instrument; the old man was parts are already in a state of considerable
placed upright against a wall, the catheter irritation, and that it is therefore unde
introduced, and six pints of urine were sirable to permit any chances of adding
withdrawn in full stream ; but the water to it, of which the presence of a catheter
had no sooner ceased to flow than the may be one . On the other hand it is
patient fell, dead, at the surgeon's feet. urged that the bladder, after long reten
Fatal syncope had taken place, doubtless, tion, will very soon fill again, that the
in consequence ofthe rapid removal of so obstruction may again act as before, and
large a body, which had previously pressed that less hazard is incurred by the pre
Fig. 27.—Mercier's instrument for avoiding false passages. It is a silver catheter,

hollow up to the dotted line ; beyond this is a solid portion which enters the false
passage. A small gum catheter is passed along the instrument and issues at the
orifice in its concavity to traverse the urethra in front of the false passage occu
pied by the extremity of the instrument.
sence of the instrument than by a pro- plug is fitted to the external orifice, and
bable repetition of the effort to place it the water is drawn off from time to time
there, the argument receiving additional as may be necessary . In some cases,
force if more than ordinary difficulty was however, it is better, especially when the
experienced in passing it in the first in water is acrid and offensive, to substitute
stance . I have no hesitation in coin- for the plug a piece of light and flexible
ciding with the latter view, as the rule, india - rubber tubing of sufficient length to
reserving the right to make exceptions reach a vessel at some distance, under the
under peculiar circumstances. Great bed for example. Or, if it conduces to
danger may be incurred by the too early the patient's comfort, the tube may be
removal of a catheter which had relieved used long enough to reach to an adjacent
in urgent attack of retention. The indi- room-a plan I have frequently adopted
cation for tying in is strengthened, if the in private practice, with good results in
catheter, which has been introduced with these conditions, the whole of the excre
difficulty, is a flexible and not a metallic one, tion passing off as easily into a vessel
the former being much better tolerated at 12 feet distance as into one placed in
than the latter. În fixing it in its place, it the bed itself. Itis only necessary to be
is necessary to be careful thatits extremity careful thatthe tube is slender and light,
only just reaches the bladder, and does and that it is fixed at two or three points
not project far into it, since the latter in its course, commencing at the side of
position is prone to cause irritation. A the patient's bed, so that no weight or
traction may be made upon the catheter rather longer than the ordinary catheter,
by it. All this is very easily managed by but not possessing the large curve of the
a little contrivance. The employment of full prostatic instrument. The operator
the catheter in this manner is of course to introduces this to the seat of obstruction ,
be dispensed with as soon as the patient's and satisfies himself by means of a finger
condition permits. in the rectum that it lies fairly in the
The well-known vulcanized india- urethra, and is engaged in the prostate :
rubber catheter is in some cases exceed he then steadily carries it onward towards
ingly valuable. From its extremesoftness the cavity of the bladder, by pressing the
and flexibility, its presence is scarcely felt point firmly forwards, and at the same
by the patient, and it has the remarkable time slowly depressing the handle ; and
property of rarely acquiring a phosphatic he desists on feeling that the point is free
crust even after several days' residence in in a cavity, and on finding that the urine
the bladder. It is by no means always flows through the instrument. This, ac
possible to introduce it without a stilet, cording to Chopart, was done by Lafaye
which, if necessary, is of course to be re- on the person of Astruc ; in more recent
moved immediately. When the wants to times it has been done in this country by
pass water are extremely frequent, and Homeland Brodie.? Liston accomplished
the patient cannot relieve himself all it with a cutting stilet carried through a
except by a catheter, one of these may slightly curved and long canula,' and
often be most advantageously retained. practised the operation a few times suc
Owing to its extreme flexibility it is apt cessfully.'3 This rough proceeding must
to be swept out of the urethra with the be considered as a matter of history. The
urine, and is thus sometimes not easy to improved flexible instruments now em
retain. Hence Mr. Holt has devised a ployed have rendered any forcible means
pair of ' wings at its vesical extremity, unnecessary and undesirable, except for
which rather tend to produce irritation. very rare cases, in which skilful manipu
I think a German - silver tube, about 4 lation has failed. For these, puncture of
inches long in the stem , makes it quite the bladder from the part most adapted to
easy to retain, especially if it is tied by a the circumstances of the patient, or, if
piece of soft twine to the bair covering temporary relief will suffice, aspiration,
the pubes — thebest method always of re- which is aa much more simple proceeding,
taining a flexible instrument. Or the may be performed.
shaft may be stiffened by an application Puncture of the bladder is performed
of collodion to produce the same condition in two ways ; above the pubes, through
attained by the metal tube. the rectum , and it has also been done
The next question to be considered is, through the pubic symphysis.
what is to be done when it is imperatively The suprapubic, at one time regarded
necessary to afford speedy relief to reten- as the only possible mode of reaching the
tion, all attempts by ordinary catheterism bladder from the surface in cases of en
having failed ? larged prostate, is performed as follows:
Such an emergency, although rarely The patient being placed in a half sitting,
happening, must occasionally present itself. half reclining position, and the pubes
Evidently some form of artificial opening having been shaved, a vertical incision of
must be made into the bladder ; which the integument is made directly above
may be accomplished by perforating the the symphysis pubis, about an inch and
obstructing portion of the prostate, or by a half in length at the surface; this
puncturing the bladder from some exis to be carried downwards through the
ternal part. The different operations in- linea alba, so as just to admit the tip of
volved by these proceedings shall be first the finger to recognise the distended blad
described, and their applicability to the der. Meantime an assistant, standing
various phases of prostatic retention dis- behind the patient, should press one of
cussed hereafter.
Perforation the obstructing portion 1 Practical Observations on the Treatment of
of the prostate —ofin other words, forcible the Disenses of the Prostate Gland . By E.Home.
London , 181 , vol. i . p . 163.
catheterism - once regarded as a legitimate 2 Lectures on the Diseases of the Urinary
operation, was performed with a strong Organs. By Sir B. C. Brodie. '4th ed. London ,
silver catheter, about No. 9 or 10 in size, 1849,3 Practical
p . 195. Surgery. By Robert Liston . Ath
of somewhat conical form at its point, 1 ed. London, 1846, p. 845.
his hands firmly on either side, against seven or eight inches long, should be car
the abdominal walls, in such a position as ried along the finger, and carefully di
to steady the bladder. A straight, or a rected to the part indicated; the handle
slightly curved, trocar ( if the latter, the is then to be depressed, and the point
convexity of the curve should be up- carried upwards through thecoats of the
wards) is then to be carried , with a very rectum and bladder, until it is felt free in
little inclination downwards
into the blad- the cavity of the latter. The canula is
der. The puncture should be made, not to be carefully kept in its place while the
in a direction dipping down behind the trocar is withdrawn, and afterwards re
pubes, or, as the bladder contracts, by tained there by means of a bandage and
emptying itself the opening will recede too tapes. In order to prevent the liability to
far below the symphysis: nor should the slip from the bladder, which the ordinary
distance above it exceed an inch, else the canula is found to exhibit, Mr. Cock,
peritoneum will be in danger. When formerly ofGuy's Hospital, contrived one,
vesical distension is considerable, this the extremity of which can be made to
membrane is carried two inches or more expand somewhat after its introduction
above the margin of the symphysis. into the bladder, and with which there is
After the operation the canula should be therefore less danger of the occurrence of
exchanged for a silver tube specially that accident. The form is that of the
adapted to slide through it, secured by trocar generally employed , but increased
tapes and a T bandage, which may remain in length and thickness . I have always
a variable length of time, at all events used Mr. Cock's instrument, and have
until lymph has been effused upon the found the canula well retained.
edges of the wound, when it may be with. Lastly, the puncture of the bladder
drawn, and an elastic gum catheter worn through the symphysis pubis may be
in its place, an instrument which is gene- | briefly mentioned.
rally better tolerated by the bladder than This operation was first proposed by
one made of metal. Or a gum catheter Dr. J.а M. Brander, of Jersey ,in 1825,
may be passed through the tube, and the when a student in Paris, and described in
latter be withdrawn when the operation a paper at the Royal Medical and Physical
has been completed . Society of Edinburgh, and at the Medical
The puncture by rectum , commonly and Physical Society of Calcutta.3 Se
adopted in stricture , but which may be veral other cases have been reported.
resorted to in most cases of retention from Dr. Brander directs that the patient
enlarged prostate, may be performed in should recline, and the trocar should be
the following manner. The rectum having introduced , with or without a small pre
been emptied , if necessary , by means of liminary division of the integuments,
un enema, the patient is to be placed on about the centre of the symphysis , reckon
his back, in the position for lithotomy, and ing from above downwards, and in a
firmly held by two assistants, not tied. direction at about right angles to the
The surgeon is then to introduce the fore- vertical axis of the body. Dr. Brander
finger of his left hand into the bowel, and says, ' somewhat obliquely downward and
ascertain the liinits of the prostate, de- backward toward the sacrum , varying the
fining its boundaries, particularly the pos- direction according to circumstances; a
terior one . Fluctuation should be felt piece of flexible catheter is then to be in.
there, communicated through the contents troduced through the canula,' and retained
of the bladder, from a tap, or from mo- by a tape.
mentary pressure made on thehypogastric I once tried it in University College
region ; and the point at which it is most Hospital, and failed to find urine, imme
distinctly perceived in the median line diately afterwards puncturing by rectum.
selected . Any spot within fair reach of The symphysis is in fact, as in the preced
the finger, under the circumstances of re- ing instance, so completely ossified in most
tention and consequent distension of the elderly men, that the point of the trocar
parts, may be considered safe as regards Chirurgi Transactions, vol xxxv.
the peritoneum . Having directed an as 1 Medico - cal .
p. 186.
sistant to support firmly the lower part of ? Séances de l'Athénée de Médecine, 1825.
the abdomen with both hands, so as to 3 Transactions, 1842. Vol. viii. part 2, pp.
208-239 . A paper on the subject, and one case
press down and steady the bladderto read December1839, with a second case inthe
wards the rectum , a well - curved trocar, I appendix.
110 TIIE DISEASES OF THE PROSTATE .
is blunted by the bone, and does not per- | certainly exceptionalexamples ofprostatic
forate the soft tissues beyond ,pushing them enlargement in which the finger is unable
before it, and thus the puncture is rendered to reach the tumid bladder behind, and
nugatory. I have observed this on the detect fluctuation there. It is the more
dead body when making experiments for desirable to make the opening through the
the purpose, and shall not repeat the pro- rectum , if there be any doubt about the
cedure on the living. existence of a distended bladder above the
In reviewing the comparative merits pubes ; for there may be imminent danger
of the two other modes of puncturing the romretention without the presence of this
bladder, it must be admitted that each condition. And further, in a corpulent
possesses in certain cases some special ad- patient, its detection, if present, is not
vantages.. Most surgeons have regarded always satisfactorily to be accomplished,
puncture above the pubes as more dan while in such a person the suprapubic
gerous than puncture by rectum , since, operation is less easy, or, at all events, less
although often affording a relief which has1 advisable . I have only had occasion to
even been continued for several years," puncture the bladder for prostatic reten
there is some risk of extravasation and tion three times in my life, only oncemabove
suppuration behind the pubic symphysis, the pubes , in 1864,with Sir Willia Jen
or beneath the peritoneum . If a somewhat ner and Sir James Paget , in the cas e of a
temporary relief only is required, the rectal gentleman who was the subject of the
is the simpler and the safer operation, largest prostate, the result of simple hyper
leaving the suprapubic to be employed trophy, I ever saw ; the gland nearly filled
only when an enormous prostate forbids the pelvis, and rose considerably above it
the application of the former. But when , anteriorly, so that it was necessary to
on the other hand, it is reasonable to increase the length of the suprapubic inci
believe that the new opening must be the sion upwards in order to reach the bladder ,
patient's only resource for a considerable which was placed little below the umbi
period of time, as in cases where he has licus. No other operation than the one
lost all power of passing urine , and has adopted could have given the patient
depended on the catheter solely , and more relief.
over , where the urethra will probably be The aspirator is aa valuable and impor
difficult to traverse with a catheter in tant addition to our resources for the relief
future, it is incontestable that an opening of retention , when such relief is required
above the pubes forms a much more con- merely for a short time, or in an exigency
venient situation for artificial relief than when the means of adopting more serious
an opening within the rectum . operations are not within reach. It is
The puncture by rectum , which has quite harmless, most efficient, and may be
been employed occasionally to afford relief repeated once a day or so for a short time
in these cases, as our museums testify, is when circumstances render such action
almost universally stated by authors to be necessary. The puncture does not injure
inadmissible when the prostate is enlarged, the peritoneum ; at the same time it is in
an occasional exception being made in variably to be made so as to avoid any
favour of the operation when the enlarge- lesion of the membrane if possible. When
ment is not considerable. It is, perhaps, the bladder has been thus emptied of a
a question whether its applicability to a quantity of urine,and the patient feels the
large proportion of prostatic cases has not full relief which follows, it is quite possible
been overlooked by many. There are that the next want to pass water, if not
1 There is a preparation in the museum of the
partly met by his own efforts, may be suc
RoyalCollege of Surgeonsofthe bladder and cessfully encountered by the catheter ;or
prostate of aman aged 66, on whom the opera- if not, after one or two succeeding resorts
tion was done forretention from prostatic enlarge- to the aspirator.
ment, who lived four years subsequently, resuming
his former business habits ; No. 2043. The late An operation which has been often
Mr. Paget, of Leicester, once showedme a patient practised for the relief of retention of urine
(1867) his
above whopubes,
constantly
upon wore
whoma short fexible tube
he performed in stricture,
this in viz., the
the perineum opening
as near of the urethra
as possible toits
operation fifteen years before, and during the
whole of this period he evacuatedall his urine by membranous portion, and the introduction
means of this tube. He had another patient who of a catheter into the bladder from that
had done the same thing for two years ; both
patients followed their occupations with comfort point, has been recommended and occa.
and regularity sionally performed for prostatic retention
PERFORMANCE OF OPERATIONS. 111
also . I have described the proceeding in , suffices, and should in the first instance be
relation to stricture in my work on that adopted. This should be even repeated a
subject, but it can scarcely be regarded as few times, with a view to subsequently
available in prostatic retention . For if attaining success
6
with a catheter before
false passages have been made, and the resorting to ' puncture ' properly so called .
difficulty in carrying a catheter into the 3. Failure by such means continuing,
bladder arises from this fact, an opening if fluctuation can be distinctly felt within
made into the urethra on an instrument in reach of the finger, in the median line
these conditions offers little promise of behind the prostate from the rectum,
success. the puncture through that bowel is an
Our present experience of the various easy and safe mode of giving exit to the
procedures detailed may be stated in the urine.
following conclusions : 4. That if, on the contrary, fluctuation
1. That the cases of urinary retention cannot be felt by the rectum, or if a tumour
from prostatic enlargement which cannot of enormous size is encountered there, the
be relieved by the introduction of a ca- puncture through the bowel is of doubt
theter of some kind, are extremely rare . ful propriety, and the operation ought
2. That if the condition of the urethra, generally to be performed above the pubic
from the existence of false passages, lacera- symphysis. If the circumstances of the
tion, or other lesion, be such that the case indicate that the artificial opening
operator cannot be certain of his ability to may be required for a long period of time,
carry a catheter fairly along the canal, the this is a more convenient situation for it
bladder must be opened ; and in most than the rectum .
cases, the simple operation by the aspirator
CHAPTER XIII.
ON THE PERFORMANCE OF OPERATIONS FOR THE RELIEF OF VERY SEVERE SYMPTOMS
RESULTING FROM ADVANCED PROSTATIC DISEASE .
Must cases of Habitual Micturition by Catheter do well — A few suffer greatly as the Hypertrophy
advances — Hourly Catheterism sometimes required A Grave Condition - Operation to relieve the
Patient - Suprapubic Puncture, and Tube retained—Method of Performing - A New Method, by
opening the Prostatic Urethra from the Perineum— Temporary Withdrawal of Urine by New Route
-Rest to the Bladder and Urethra affords Permanent Relief to Severe Symptoms—The Procedure
described and recommended.
ALTHOUGH in a large number of cases of obtained, as well as from the cessation of

hypertrophied prostate the daily use of local inflammation. This state often con
the catheter is a necessary duty on the tinues for many years without material
part of the patient, and absolutely essen- change. Numerous cases have been under
tial not merely to ensure his comfort, my care in which a patient, who has com
but to maintain his life, the trouble and menced the habitual use of the catheter
labour involved by the proceeding are not at from 57 or 58 years of age, has con
considerable. He acquires the habit of tinued it without difficulty, and without
using the catheter three times a day, or increased troubles of any kind, during a
even five or six times, if all power to pass period of from 12 to 20 years, and until
urine naturally has been lost, and he life has terminated, often from some
employs it with an amount of ease, and cause unconnected with the derangement
with a security against painful and fre- of the urinary organs. In exceptional
quent micturition often long endured be- instances a much longer term has been
fore the habit of catheterism was attained, passed in comfort in the conditions re
which amply recompense him for the ferred to. I have personally been ac
trouble of acquiring it. Moreover, his quainted with two examples of successful
health generally improves from the catheterism pursued without severe troubles
ability to sleep which has been thus of any kind during a term of thirty years.
In one of these the patient lived to the catheter.

for some in the employment of an inlying
age of 90, the other but little less. To tie in an elastic or india
But in some cases, which happily are rubber catheter is an expedient which
only exceptional, a stage of the complaint may avert the fatal result a little ; but it
arrives, by gradual steps, in which a can be only temporary , and it may even
greatly diminished capacity of the bladder aggravate the malady and hasten the end.
takes place, so that the use of the catheter It is assumed, also, that medicinal agents,
becomes necessary from sixteen to twenty- including especially opium , have ceased
four times, or even more, in the twenty- to suffice for the exigencies of the case.
four hours — a condition of extrememisery The bladder is, indeed, so organically
for the patient, inasmuch as it entails thickened and diminished in capacity that
loss of rest, fatigue, and often also hourly relief has become a physical
increased difficulty in passing the instru- necessity.
ment from injury to the urethra by There are two modes of proceeding
frequent catheterism . At this period, by which we may , I think, hope to afford
too, the augmented volume of the pro- to such patients a considerable degree of
state sometimes makes the canal difficult efficient, and of more or less permanent,
to traverse alike for the patient and the relief. The first is one I put in practice
surgeon ; and if a false passage be made several years ago with a moderate degree
by either at this crisis the result is very of success, and it will be first described.
painful, often extremely dangerous to The second mode is one which I have
life. more recently tried, and with better re
A patient in these circumstances has sult, and this shall be fully considered
reached a position in which he exists for subsequently.
little else than to pass his catheter. No It is now nearly fourteen years ago
sooner has he obtained a half- hour's re- since I adopted for a patient who was
lief than he begins to feel the warning of suffering severely in the condition just
another approaching call to pass urine, described a proceeding similar to that
and on each occasion he experiences some which we employ in the trachea when
minutes at least of suffering in his en- death is imminent for want of air - viz .,
deavour to sustain as lengthened an in- the introduction of a tube beyond the
terval as possible. His powers are tasked seat of obstruction - one which is to be
to the utmost, for continuous sleep is out permanently retained there as the con
of the question, and health steadily de- stant channel for urine, just as the tracheo .
clines. This hourly recurring task and tomy tube has served some patients for
the brief intervalof rest which fall to the the only channel during years of air to
lot of such patients are a test of endurance the lungs ; in other words, the puncture
of the severest kind. Life becomes a of the bladder above, or rather behind ,
heavy burden, for equally by night and the pubes.. The proceeding which I then
day the alternating sufferings produced practised differs from the ordinary punc
by the presence of urine which cannot be ture for retention in not being adopted
retained, and by the exertions necessary when the interior of the bladder cannot
to obtain relief, have to be endured with be reached by a catheter, but, on the
out a single respite or even the hope of contrary, it is performed upon the end of
attaining it. a sound already passed into the bladder
The arrival of this stage, then, is the by the urethra inthe ordinary way. For,
almost certain prelude of death to the in the cases before us, it must be remem
patient. Hence the question naturally bered that the bladder is by no means
arises, * Can nothing be done, by any distended with fluid , but may, indeed
operative measures, for the permanent must be, nearly empty — a widely differ
relief of the unfortunate patient? ' And ent condition, as regards operation, from
I think it will be admitted that, if these the ordinary puncture. Moreover, the
should be somewhat difficult or even be viscus is often altered in position or de
attended with some risk, the gravity of formed by masses of prostatic growth
the situation warrants an attempt, if only rising into its cavity, and sometimes even
a moderate chance ofmaterially improving nearly filling the pelvis. I believe that
his condition appears to be attainable. We puncture has never before been done or
are now advisedly seeking a permanent recommended with this end in view ,
relief,' because a temporary remedy exists | viz., to avert death by establishing a per
OPENING OF BLADDER ABOVE PUBES. 113
manent outlet for urine when the urethra |few instances, so that in these it became
is no longer practicable through disease for years the permanent channel by which
of the prostate and bladder. The late all urine passed. These operations, how
Mr. T. Paget, of Leicester, being called ever, were not performed with that end
upon to relieve retention from stricture in view, nor were they for prostatic re
uprapubic
by suprapubic puncture, thought it neces- tention at all ; but it was the comfortable
.lcSntroduced
operator
stopped
removed
sary to retain the tube altogether in some condition of two of these patients, whom
ollow
opening
guides
elastic
length
whole
Bfsound
which
about
orms
stilet
sound
silver
plate
,wpoint
hen
above
stilet
.pubes
when
with
,i,wtube
gum ith
ong
been
into
bare
AHFig
end
laid
the he
,and
the
end
the
.28.
has
the
t-
24 its
of
of in
of
in
itis
withdrawal
bladder
finding
incision
bladder
7
about
leaves
sound
.Size
tube
last
The
the
the
12
13
or
.in
in
of
,
ulbous
flexible
.-eB,nded
metal
stilet
А
B
I saw , which led me to think of the modified somewhat, according to the case,
analogous proceeding to relieve extreme and it is closed by a bulbous- ended stilet,
prostatic difficulties. B. The instrument is introduced by
The operation, which I have now per- the urethra until the end can be felt just
formed several times, consists in passing behind the symphysis pubis. It is then
a large sound, hollow throughout, with a confided to an assistant to retain in its
strongly -marked curve ; that represented place. The operator now makes an in
at A in the adjoining figure ( fig. 28) is cision not more than three -quarters of an
the best for the purpose, but it may be inch in length, more if the patient is very
I
114 THE DISEASES OF TIIE PROSTATE .
stout, enough to admit the index finger worn a few days in bed until the parts
tightly (since a large opening becomes are consolidated, and the patient can
embarrassing subsequently ), in the median move about with safety. If the tube
line at the upper margin of the synıphysis. escapes during the first two or three days,
The tissues are separated by the finger, it may not be easy to replace it, but when
and the linea alba being ne xt slightly the passage is established it may be re
divided by the point of a bist oury, the moved and replaced easily enough. A
finger is passed down closely behind the very important injunction is to make the
symphysis, and when the end of the wound as small as possible, so as to be
sound is clearly felt, a litt le opening is nearly filled by the tube. A large wound
made so as to expose its point. The is more painful,and is constantly traversed
operator now , taking the handle of the at first by the urine.
sound in his left hand , makes the end In the previous edition of this work I
protrude in the wound, the bulbous stilet gave the particulars of three cases in
is withdrawn , and he passes the tube which this plan had been pursued with
c in its whole length into the hollow more or less of advantage to the patient in
channel of the sound. He now with each instance ; and I think it scarcely
draws the sound completely by the ure necessary to repeat these examples. For
thra, and in doing so necessarily ensures it is quite certain now, that the proceed
the passage of the elastic tube into the ing is capable of mitigating the sufferings
bladder. of an aged and infirm patient to whom
When I first designed this proceeding hourly catheterism is a slow but fatal form
I used aa sound with aa second stilet having of torture. To be useful in the way of
a sharp trocar at the end to take the prolonging a usefulor a fairly comfortable
place of the first, intending to make the life, the operation should be resorted to at
incision for the tube hy merely pushing an early period, that is, at least, before
the trocar from within the bladder out the last painful stage has arrived, or has
wards to the skin, after which the tube even given signs of its near approach.
would be inserted and lodged in its place But the proceeding thus described
by withdrawal as above. I learned, how does not now constitute the only resource
ever, by several experiments on the dead within our reach for the relief of these
body, that, although this was safe and cases. There is another operation which
easy of performance in a distended bladder, bids fair to be on the whole more useful,
the peritoneum was usually wounded and more generally available in most of
when the bladder was empty. Hence the instances in which efficient surgical
my abandonment of what seemed a very relief is demanded.
simple and easy proceeding. The path Having during the last few years on
of safety, therefore, is to make a very several occasions been required to make
small opening directly above the sym- a small perineal opening leading by the
physis, then to find the way close behind prostatic urethra to the bladder, for the
it to the end of the sound there, and purpose of removing a tumour therefrom ,
incise only just enough to allow this to to explore for the presence of sacculated
be pushed up into view. The insertion calculus, &c., it has occurred to me to
of the tube into the hollow of the sound, employ the same incision with another
and the withdrawal of the latter, as object in view. I thought it was not un
already stated, brings the tube into its likely that the extreme irritation ofthe
place. But it may be remarked that the bladder in these advanced cases might
urine may not at first flow through it, be mainly due to the repeated catheterism
for the withdrawal of the sound may necessary to afford relief, and imperatively
carry the tube, not only into the bladder, demanded by an inflamed and hypersensi
hut, when this is 'empty or very con- tive bladder. The cystitis on the one
tracted, even through it into the prostatic hand , and the catheterism on the other,
urethra. If so , the tube has only to be exercisemutually inimical influences; and
withdrawn a little, and the urine flows. the patient becomesthe victim of a vicious
Indeed , I have found that the tube is circle of actions, in which an absolutely
usually improved, especially in the sub- indispensable remedy, the catheter, aggra
sequent progress of the case, by being a vates the inflammation of the bladder,
little shortened. It is then to be fastened which , therefore, in its turn, demands the
securely with tapes and plaster, and to be instrument with increasing frequency.
REMOVAL OF URINE BY PERINEAL INCISION . 115
It occurred to me, then , that, were it | suffering condition which has been de
possible to suspend all action on the part scribed in general terms above.
of the bladder for a few days,—to get rid In another case, but very similar to
of all accumulation of urine from the that above described, I removed, by the same
organ ,—to allay the constant and painful operation, a small encysted calculas which
want to pass urine, and also at the same it was impossible to find by means of the
time to abolish catheterism altogether, sound, and which had been the cause of
with its irritating effect on the urethra, long - continued suffering. In another, in
the inflammation of the bladder might which the section was made for constantly
subside, and its tolerance of urine might recurring very severe and painful par
largely increase. And I hoped that a oxysms or spasms, the result was entirely
state of things might be subsequently successful in relation to the pain, although
brought about similar to that which is the frequent micturition,at first greatly
present in a less aggravated stage of relieved, partially returned in a month or
obstruction, when catheterism is not two afterwards.
needed more than six or seven times in The mode of operating may now be
the twenty -four hours. If, in place of considered . The object to be accom
hourly reliefby the instrument, aninterval plished is the opening of the urethra
of three or four hours could be mostly at about the anterior limit of the
attained , an enormous boon would be prostatic portion, by the simplest and
conferred on the patient. Accordingly I shortest route from the surface of the
seized an early opportunity of making a perineum; making a passage which suf
small opening in the perineum, in the fices to admit easily the index -finger and
manner hereafter to be described, for a no more . There can be little doubt that
patient aged 60, who was passing the a vertical median incision, that is in the
catheter every hour, and whose vital line of the raphé, will fulfil this indication
powers were at the lowest ebb from con- better than any other. In this situation,
stant suffering and loss of rest ; and I the prominence formed by the bended
placed in the bladder, by the new passage, knuckles of the operator, while introduc
an indiarubber catheter, so that the urine ing as far as possible the index finger,
might flow off continuously into a re- lies equidistant between the two nates,
ceptacle as fast as it reached the bladder. and acts directly towards the centre of the
The relief was immediate and most re- bladder. Any incision made right or left
markable. He enjoyed long refreshing of the median line must of necessity lead
sleep, was unconscious of any pain, while obliquely to the centre, and be a longer
the urine itself, which had been charged line, because it commences at a point on
with muco-pus and blood, and had been the external surface more distant from the
offensive in the highest degree, assumed neck of the bladder than is the raphe of
in the course of a few hours a healthy the perineum . Accordingly I prefer the
colour, an acid reaction, and was almost central incision, using a median grooved
clear, In two or three days the patient staff, and a long, straight, narrow -bladed
rapidly regained appetite and digestion, knife, with the back blunt to the point.
became cheerful, and showed a change Having placed the left index -finger in the
for the better which no one had been rectum , the knife may be introduced, edge
sanguine enough to anticipate. On the upwards, about three-quarters of an inch
eighth day I removed the catheter from above the anus, with or without a small
the wound ; during the next two days preliminary incision of the skin (I prefer
urine issued by that route at intervals of the former ), until the point reaches the
some hours ; but the wound, which was staff about the apex of the prostate gland,
very small, rapidly closed, and the catheter where it divides the urethra for half an
was of course again necessary. But the inch or so, and is then drawn out, cutting
passing of the instrument was now no upwards a little in the act, but so as to
longer painful, the bladder was not in- avoid any material division of the bulb .
flamed, and could henceforth retain urine The left index - finger is now removed
three or four hours without inconvenience, from the rectum, and, following by the
while the patient himself, in less than groove of the staff, slowly passes through
three weeks from the operation , was enjoy- the neck of the bladder as the staffis
ing active exercise out of doors, having withdrawn. The interior of the bladder
been before confined to his room in the should first be explored by making firm
12
pressure above the pubes of the patient, 1to be uninterrupted and continuous ; the
who should be very fully under the in- patient lies on his back or side, the tube
fuence of anæsthesia, with the right hand, being made fast by soft string or bobbin
so that every portion of its surface can to a bandage round the waist. The relief
be examined by the tip of the left index, is usually at once very great. Instead of
and the presence of any separate tumour, the periodically recurring necessity for
or ofany calculus, & c.,can be ascertained. exertion and painful catheterism , to re
When the exploration has been completed, strain the agonising distension which has
a large vulcanised india-rubber catheter, been occurring probably every three
say about No. 18 or 20 in size (Eng- quarters of an hour, a long refreshing
Jish scale ), or a tube, should be in- sleep of several hours is at onceex .
troduced with its extremity just within perienced.

the bladder. Here it should be retained The term of treatment by the newly
a few days, according to the circum- opened passage varies according to the
stances, and having regard to the relief results. From seven to ten days usually
and comfort afforded to the patient. suffice : the tube is removed and the
I have now made the 'section de- wound rapidly heals, so that at the ex
scribed, for various purposes, many times, piration of two, or at most four, days
and have never met with any amount of more, the catheter must be used by the
bleeding sufficient to cause meany anxiety. urethra as before. No section of this
A moderate division of the bulb made in kind , nor of any other that I know of,
the middle line is not to be feared as a restores the power to empty itself naturally
cause of hæmorrhage, while an incision to a bladder which has been longdeprived
involving the side ofthe bulb, and nearer of that power by confirmed hypertrophy
to the entry of its artery, is more prone of the prostate, according to my ex
to bleed freely; another reason for the perience. I have performed lateral litho
incision advised. Indeed, the risks, if tomy for several patients suffering with
any, attaching to the proceeding, are large calculus and whose bladders were
exceedingly slight. I have met with only completely prevented from acting by
one instance of fatal issue, which occurred hypertrophy of the prostate. In doing
in a patient completely worn out, whose so, I have removed considerable masses
consent to the operation was given at a of tumoar, without the slightestbeneficial
period too late to ensure a successful influence in this respect. Cases have been
result. At an earlier period, life would, referred to with a different result, but I
I believe, have been much prolonged , as have never been able to meet with one,
well as relief given to suffering ; the nor with any precise details confirming
latter condition having been completely the view that a lithotomy section of any
attained, and the last hours of existence kind has any power to remove the dis
rendered painless and tranquil. ability referred to, and enable a patient,
As already intimated, as soon as the who has for years depended entirely on
opening has been made, and the bladder the catheter, to do without it afterwards.
has been examined, an india rubber ca- On the principle, however, of affording
theter is introduced, so that the end lies rest to the inflamed bladder, I have no
just within the neck of the bladder, the hesitation whatever in advising the treat
other end protruding three or four inches ment now described as an efficientmeans
or more from the wound, so as to be con- of affording very considerable and more
nected with a vessel, into which all the or less persisting relief to the worst of
urine is discharged. The flow of fluid is . these painful and hitherto intractable cases.
ATROPHY OF THE PROSTATE. 117
CHAPTER XIV.
ATROPHY OF THE PROSTATE .
Pathological signification of Atrophy - Kinds of_From exhausting Disease - Senile Atrophy, degree
of - Frequency of - Nature - From Mechanical Pressure – From Local Disease in the Prostate - Con
genital Atrophy - Symptoms and Treatment.
By Atrophy of the Prostate is to be under- II. The Atrophy of old age.
stood a diminution in the bulk and weight III. The Atrophy caused by pressure.
of the organ resulting from a gradual dis- IV. The Atrophy caused by disease in
appearance of some of its constituent struc- the prostate itself.
tures. Regarding solely the results of this V. The Congenital Atrophy.
action , it may be considered as the converse The first is the Atrophywhich occurs
of Hypertrophy. from exhausting constitutional disease, par
Senile Hypertrophy, however, in its ticularly in Phthisis. The extent to which
popular signification as applied to the pro- atrophic change occurs from this cause is
state, is not, strictly speaking, the converse sometimes very remarkable, as I have
of atrophy, since the enlargement of the several times had opportunities of noting.
organ which occurs in the later periods of I have recently had occasion to dissect a
life is not the augmentation of structure specimen from a man 21 years of age,
due to increased function, analogous, for who died of phthisis, in whom the organ
example, to the augmentation of a muscle weighs only 54 grains, or less than 1
by increased use, having no conservative drachm . Another example is No. 151 ,
or compensating design and action ; e.g. , from a man aged 78, who died of phthisis :
hypertrophy of the heart for the purpose the prostate weighed only 2 drs. 45 grs.
of overcoming the increased resistance In all cases of this kind there is very con
offered by a calcified valve, &c. Atrophic siderable wasting of all the structures of
change cannot, however, be regarded as the body, and herein this form of atrophy
resulting from any active pathological in- often differs from the second form . But
fluences exerted in the organ itself. It is the proportion of diminution affecting the
a passive condition rather, and consists in prostate appears to be larger than that
simple wasting of the organ, in the gradual suffered by most other organs in the body.
disappearance of elementary structures. There are other diseases in which the
What is the precise physiological action prostate becomes atrophied ; all wasting
by which atrophy is determined ? Is it diseases produce this condition to a greater
some active process of absorption remov- or less extent, but in none is it so marked
ing the constructive elements of the pro- as in tubercular and scrofulous disease. In
state in thesamemanner, but more rapidly, one example, No. 150 of the table of pre
than that ordinary process, which results parations, the prostate of a man aged 90,
from the effete tissues throughout the who died exhausted by carbuncle,the organ
whole body, in order that they may be, as weighed 2 drs. 50 grs. Now in this form
constantly and gradually, replaced by new of atrophy all the tissues of the organ seem
material ? Probably it is rather the result to be about equally affected : one compo
of failing power on the part of the body to nent tissue does not seem to have been
replace, by new material, the effete tissues diminished in greater proportion than an
removed by the natural process of absorp- other, judging from the appearances pre
rion. It is not that the process of degra- sented on making sections in different parts
dation is much more rapid , but that the of the organ .
powers of supply and re-formation are less The second kind of atrophy is that
vigorous than heretofore. which occurs during old age. A general
Nevertheless, there are undoutedly va- diminution in weight and bulk of the
rious forms of Atrophy of the Prostate, solids frequently occurs in individuals as
which must, for the purpose of pathological they advance in life beyond a certain age.
classification, be considered separately. A mere participation in this conditionis
I. The Atrophy of exhausting general not what is intended by Senile atrophy.
disease . A prostate, which is the subject of this
affection, is one in which the diminution the atrophy of exhausting disease. In
is relatively greater than that which affects the latter, all the constituent tissues are
the rest of the body. It has been said, about equally diminished, so far as dis
but it appears without sufficient founda- section enables us to judge. In senile
tion, that when hypertrophy of the pro- atrophy, on the other hand, the glandular
state is not present in the aged, atrophy element is in smaller proportion to the
will always be found to exist. This state- fibro -muscular or stromal than in the
ment is certainly not borne out by facts. healthy organ. The fibrous is often
Thus, by reference to the table in Chapter hard and tough, and may even have some
II., we find no less than fifty individuals at small tumours of the same material ex
and above the age of 70 years (70 ( to 94 isting in it. This form of atrophy is,
years), whose prostates ranged in weight perhaps, less extreme in its degree than
between 34 and 5. drachms, a great ma- that of exhausting disease. In the case
jority of them being between 4 and 5 of an adult who died from phthisis, the
drachms, and in whom , therefore, neither prostate weighed only 54 grains; but in
hypertrophy nor atrophy could possibly be no instance of senile atrophy was there
present. In none of them was there any one weighing less than two drachms and
sign of urinary derangement during life. a few grains.
The number of prostates unaffected is The third form of atrophy is that pro
much larger, viz., upwards of ninety, it duced by mechanical pressure. No pecu
all the individuals between 60 and 70 liarity can be affirmed to characterise this
years are also reckoned ; the higher age form of atrophy. It is that species of di
was chosen, so as to place beyond a doubt minution, of disappearance of elementary
the statemert that a normal condition of constituents, which is observed in all
the prostate is common at very advanced the tissues of the body under the in
ages . Auence of continued mechanical pressure.
Among the 164 examples at and above Thus the prostate is sometimes observed
60 years, 11 only had prostates weighing to be very considerably diminished in
less than 31 drachms. Organs weighing weight and volume from the action of
upwards of 31 and under 4 drachms can- pressure exerted by adjacent tumours,
not be considered the subjects of Senile which may have fluid contents, as abscess
atrophy from the mere fact of weight; and hydatid ; or by bony and other solid
some of them are certainly normal ; but a tumours ; by calculi in the bladder or
knowledge of their structure and of the size embedded in the prostate itself. Not un
of the individualare data which it is neces- frequently, also, from long -continued and
sary to possess, since, as in other organs, extreme distension of the bladder with
it is not the absolute weight, but, as just urine, and of the prostatic urethra itself,
observed, that which is relative to the when very confirmed stricture exists, a
weight of the body, which must be known considerable pressure is sometimes exerted,
in order to decide the existence of the which in like manner seems to result in
degree of atrophy present in a doubtful marked atrophy of the prostate. In these
case. Accepting the number of undoubted, cases the structures are sometimes thinned
examples of atrophy as eleven, and de- to a very considerable degree, the natural
ducting two as occurring in individuals ducts and cavities are dilated, and nearly
who died of exhausting disease ( phthisis one-half of the organ, estimating it by
and carbuncle ), there remain nine which weight, may disappear in the course of
may be classified here. Consequently, on long -standing and unrelieved stricture of
this calculation, senile atrophy occurs in the urethra .
rather more than 51 per cent. of indi- The fourth form of atrophy is that
viduals at and over 60 years of age. After produced by some local diseases of the
all, the result of the enquiry has no prac- prostate itself. Abscess in the prostate
tical bearing ; nevertheless, possessing the will produce disintegration of a consider
materials, it was desirable to eliminate it, able portion of the prostatic tissue by im
as not altogether without interest. pairing the local nutritious supply of the
Senile atrophy, that is the atrophy adjacent structures through the agency
origin not in exhausting of ulceration
both atrophy and pressure ; and
which but its
disease, has occurs independently in a few thus may be said to occur. А
elderly subjects, is of a somewhat differ- deposit of tubercle will produce similar
con
ent character, histologically regarded, from consequences, and sometimes to
CANCER OF THE PROSTATE . 119
siderable extent. In like manner, malig- signs or symptoms. Neither is it con

nant disease will cause the proper struc- ceivable that it should do so, except by
ture of the prostate to disappear, super- the diminution in size ascertainable by
seding it by its own morbid growth ; and rectal examination and by diminished se
in this sense also the prostate has been cretion. As regards the latter, we know
said to be atrophied . so little of its specific amount in health,
Fifthly. Congenital Atrophy. - The that no conclusions can be adopted re
prostate is sometimes found in a condi- specting the change which atrophy pro
tion at birth, in which it may be said duces. No doubt it is associated with a
never to have been naturally developed— decline of the sexual powers in age.
a condition usually associated with con- Neither does the condition demand any
genital malformation of other portions of notice in relation to treatment. There
the genito -urinary apparatus -in extro- is no reason to believe that we possess
version of the bladder for example ; and any means of restoring an organ affected
it is due rather to want of development, with senile atrophy. When atrophy re
strictly speaking, than to atrophy ; no sults from other causes, such as stricture,
further notice of it therefore will ap- abscess, &c., their alleviation or removal
pear here. will doubtless be a means, and the only
SYMPTOMS AND TREATMENT.-It is not means, of beneficially affecting the pro
known that simple uncomplicated atrophy static affection .
of the prostate declares itself by any
CHAPTER XV.
CANCER OF THE PROSTATE .
A Rare Affection ; but probably less so than generally supposed - W'liy it is so - Analysis of Tanchou's
Tables - Malignant Disease of Prostate almost invariably Encephaloid — A few Cases of Scirrhus
-One of Colloid –Melanotic Deposit - Ages at which Carcinoma appears — Duration - Course
Morbid Anatomy - Symptoms Hæmorrhage — The Urine - Treatment - Eighteen Cases — Tabular
View.
The prostate may be the subject of cancer occurred under my own care, I beg to
either as its primary seat, or when second refer to a case at the close of this chapter.
arily implicated after the primary appear . The morbid parts illustrating the course
ance of the disease in some other part of of disease referred to, were exhibited at
the body. In either case prostatic can- the Pathological Society of London in
cer is a rare affection. It is a question, 1854.
however, whether its rarity has not been In reference to this question of fre
in some respects exaggerated , judging quency, the statistical researches of M.
from the general impression which ap- Tanchou are commonly quoted by writers
pears to prevail respecting it. I am in- on this subject, and in the form com
clined to believe that a certain small pro- prised in the following brief statement.
portion of instances is lost sight of among Among 8,289 fatal cases of cancer, he**
the very large number of cases assigned met with only five affecting the prostate,
to senile hypertrophy. The course of It will be desirable, however, to pursue
malignant disease when well marked , it our inquiries a little further with these
is impossible,, with ordinary care, not to figures, for the simple statement is calcu
diagnose from the last-named affection ; lated at first sight to produce an incorrect
but in more chronic forms, perhaps some- impression respecting the fact. The man
times occurring, but most especially in ner in which the data in question and
those cases in which a malignant growth the statistical summary were arrived at is
arises in a prostate previously the sub- as follows:-M. Tanchou made an abstract
ject of senile enlargement, the cancerous from the registers of deaths for Paris and
character is sometimes, perhaps, over- its suburbs, of every case in which the
looked. For a good example of the co- fatal result was attributed to cancer,
existence of these two affections, which during the years 1830 to 1840 inclusive;
reporting what was believed to be the pri- | In children it appears to be always so.
mary seat of disease in each case, naming In adults, an exception is extremely rare.
one organ only, and classifying the whole Indeed the occurrence of scirrhus there
accordingly, with a view, among other has been denied. After a close examina
objects, to form a numerical estimate of tion of all the cases reported, the opinion
the primary seats of malignant disease expressed by Dr. Walshe in 1846, after a
throughout the body. The total number careful examination of the subject, al
comprised 6,957 females and 2,161 males though dealing with necessarily fewer data
-9,118. In 829 cases, the seat of disease than we now possess, was that the evi
was not originally reported, leaving 8,289 dence of the occurrence of true scirrhus
cases. Of these 1,904 were males, and of the prostate is defective.' ' I have
among these the disease was recognised tabulated eighteen carefully reported cases
as a primary lesion, five times in the pro- at the end of this chapter, having rejected
state, and all in adults. But 72 cases those respecting which the evidence is in
are given of cancer of the bladder without sufficient, and among them at least two
distinction of sex . As a primary lesion well -known cases commonly accepted by
this is, I believe, more frequent in the contemporary authors as examples of
male than in the female. In the latter scirrhus. Granting its existence, the
sex vesical cancer is almost invariably extreme rarity of thisform renders minute
due to extension from a uterine growth. details absolutely necessary to establish
Supposing, then , that fully, or more than, an example. Wanting these, we must not
one -half of these may be claimed for hesitate to deny the admission to a cate
the male sex, it is not upreasonable to gory so designated, of any case not accu
suppose that some of them may have rately observed . Moreover, it is necessary
been prostatic in their origin. The fully to bear in mind that, among the older
developed prostatic encepheloma soon be authors, the term scirrhus has been used
comes vesical, and may often not be dis- with the intention of implying merely the
tinguishable except by careful examina- presence of an indurated structure. The
tion. Thus, in two of my own cases, precision of meaning which modern patho
viz. Nos. VII. and XXII., the bladder logy has assigned to it must not, there
was almost filled by a tumour which, fore, be understood when referring to their
nevertheless, had its origin in the pro- records.
state. In the two cases just referred to, Mr.
Regarding the source from which these Howship and Mr. Travers reported there
figures were derived, viz. from an ordinary was little besides the extreme hard
register of deaths, for the purposes of ness of the prostatic substance to support
which no special examination is required, the allegation of scirrhus. The presence
it is almost certain that error of the kind of encephaloid deposit in other parts of
just named must have vitiated the result the body was noted in one of them. Mr.
in relation to this question. And we are Howship’s patient, aged 70, had a pro
entitled, I think, to believe that the prostate of normal size, but unusually firm
portion of five cases of primary disease in in texture ; the disease causing death con
the prostate, out of 1,004 male cases of sisting of large encephaloid masses, in
cancer, is very much smaller than the volving the vessels, nerves, and viscera in
true number . the pelvis and abdomen, and occupying
The occurrence of secondary is much more than half the space of the latter
Mr. Travers briefly states, re
more rare than that of primary cancer in cavity.2
the prostate. It has most commonly specting a case of his own : ' I found the
been observed that the invasion has then prostate occupied by a tubercle, possess
taken place by extension from the bladder. ing all the characters of scirrhus, upon
I have, once only, seen it succeed encepha- section, in an old nobleman , long subject
loid cancer of the penis, itself a very rare to retention.'3
affection . More recently one case of scirrhus has
As to the form of cancerous disease been recorded by a competent observer.
which most commonly affects the prostate, Mr. John Adams, of the London Hospital,
no doubt exists that it is encephaloid. 1 The Nature and Treatment of Cancer. B
W. H. Walshe, Professor of Medicine in Universit
1 Recherches sur le Traitement Medical des College. London , 1846, p. 414.
Tumeurs Cancéreuses du Sein . Par S. Tanchou . ? Med .- Chir. T'rans. vol. xix. p. 35.
Paris, 1844, pp. 256–261. 3 Ibid . vol. xvii. p. 346.
CANCER OF THE PROSTATE. 121
gives the following account of the case :- obvious symptoms of urinary obstruction.
A gentleman, the subject of urinary de- In such a case it is clear that the period
rangement for the first time at 59 years which elapses between the first appearance
of age, died three years afterwards from of urinary difficulties and the fatal ter
the advance of the complaint . At the mination, is not to be regarded as the
post -mortem , the lumbar and iliac glands duration of the malignant disease. This
were affected with scirrhus, the prostate condition is not easy to verify during life,
gland was enlarged to nearly twice its and is happily exceedingly rare; still it may
natural size ; an ovoid mass, distinctly not be overlooked that the co-existence of
scirrhous, the size of a small nut, pro- the two conditions is possible.
jected into the bladder from the upper In referring to the table of cases, it
surface. The left lobe was occupied by may be observed that in childhood the
a long scirrhous mass ; the right lobe ap- encephaloid deposit was limited to the
peared healthy .' Mr. Adams further single organ, or to it and to the adjacent
added, that the tumour had been ex- lymphatics, although the latter has not
amined by an experienced microscopist, been positively reported, and that it ran a
who had pronounced it to be true scirrhus very rapid course. Whereas in the adult
in every particular.'' cases, the development of disease was
Since the occurrence of that case I slower, and other viscera were usually
have myself once verified the existence of affected besides the prostate. These facts
scirrhus affecting the prostate, and have harmonise with those presented by the
met with two other cases on the authority course of encephaloid generally. Always
of trustworthy observers. Mr. Boyd, of progressing rapidly, its growth seems
University College, has also reported a active in proportion to the youth of the
case of colloid disease, for the first time individual. On the other hand, the ap
noted 2 in the prostate, in a man aged 55 pearance of the deposit in several organs,
years. The extremerarity of such affec observed in adult age, may, perhaps, be
tions of the organ is therefore now fully regarded as an effect of theslower rate of
demonstrated . progress manifested by the disease afford
Melanotic deposit is said to be occa- ing time for numerous local developments
sionally found associated with encephaloid to occur.
of the prostate. Its presence is reported MORBID ANATOMY . — Little can be posi
in two cases, one at adult age, the other tively affirmed respecting the morbid ana
in childhood. It should not be forgotten , tomy of encephaloid in its early stage in
in the examination of these cases, that the adult subject. Anatomical examina
interstitially effused blood in a fungous tion can very rarely be brought to bear
growth may be mistaken for true mela on any specimen which has not already
notic deposit, which to the naked eye it arrived at a late period of its fatal course,
sometimes resembles. the death of the patient having been al
Regarding the other form of recurring most invariably caused by the prostatic
growth, viz., epithelial disease, frequently disease in an advanced stage. There is
ranked as cancer, there is no example yet reason to believe, judging by inferences
known of its occurrence in the prostate . drawn from rectal examination of these
Malignant disease has at present been cases in the earlier stages, some months
observed only in childhood and at advanc- before death, that a deposit takes place at
ing age. No authenticated cases are on one point, from which, as from a centre,
record between the ages of 8 and 41. the disease extends ; this point being
The duration of the disease, from the first usually in one of the lateral lobes. In
appearance of symptomsto the fatal result, the first stage, probably, the smallest
appears to vary from one and a half to five amount of active increase is displayed ;
years in adults, and from three to nine but after the swelling has reached a cer
months in children . It should not be for- tain size, it rapidly enlarges, and often a
gotten that encephaloid deposit may some very considerable mass is formed before,
times take place in a prostate previously through the death of the patient, it can
hypertrophied, and already the cause of become amenable to anatomical analysis.
The conditions then commonly found
1 Report of the Meeting of the Royal Med. are as follows :-The prostatic mass is of
and
vol . i Chir.
. Soc., April 12, 1853. — Lancet, 1853, irregular form ; portions project fromdif
? British Medical Journal, April 15, 1882. ferent aspects of the organ , usually from
its upper and posterior ones, and direct nodules there is an arborescent arrange
their course into the cavity of the bladder. ment of minute blood -vessels.
These are of very unequal consistence ; In some examples there is no outburst
some parts are hard and tense, appearing of fungus from any part of the organ, the
to be firmly bound by the enveloping diseasebeing contained within its limits ,
capsule; but the most projecting parts are albeit these are greatly extended. In
often soft and sprouting, as encephaloid of other instances this is far from being the
rapid growth is observed to be in other case ; the capsule gives way , there is not
parts of the body. The colour varies : only fungous growth, but ulceration or
usually brown and reddish tints prevail, even cavity, from which diseased struc
apparently produced by great vascularity, ture has been thrown off, and from which
or by internal hæmorrhage, the latter being hæmorrhage also has probably taken place
sometimes more clearlyevidenced by the from opened blood vessels.
existence of dark blood -clots, enveloped Under the mucous lining of the blad
by the mass and disclosed by making sec- der adjacent there are also, sometimes ,
tions. Some portions are becoming gan- several nodules of cancerous disease ; and
grenous, and manifest grey and slaty tints, finally, if the prostatic affection is ad
especially in the urethral mucous mem- vanced , the neighbouring lymphatic_ves
brane. On making incisions into the sels and glands are always diseased. Even
tumour, if in the later stage, examination the veins of the prostate have been seen
often shows that most of the prostatic to contain cancerous matter .
structure has disappeared before the in- Such are the appearances I have wit
vading action of the cancerous product. nessed in cases of encephaloid affecting
The most recent portions of the growth the adult. In the child, encephaloid of
are seen to be soft to the touch, slightly the prostate attains a larger size as com
jelly- like , opaline, faintly transmitting pared with the bulk of the individual.
light, and of a pale buff tint, almost Here we witness all the results of more
white ; others are yellowish, and some rapid formation , a softer structure, more
reddish up to deep blackish -red . Some succulent and juicy, of brighter tints ;
parts are seen to be softened, pulpy, and often more vascular. Otherwise the
disintegrated; from some a creamy juice general characters in the adult and in the
exudes — from others sanivus fluid, or child are the same.
fluid containing faky masses of dead SYMPTOMS.— The symptoms of the ma
structure, and here and there are found lignant affection are those common to
small collections of purulent matter. prostatic obstruction of any form , but
On searching carefully for prostatic generally declaring themselves with greater
structure among the deeper parts in the rapidity than in cases of senile hyper
sprouting fungus of course there is none), trophy. These symptoms need not be
to discover the confines of the morbid repeated here. But besides them , there
growth where it runs insensibly into still are distinctive characters, such as more
remaining portions of the organ, it may be severe pain , often very intense ; occasional,,
inferred that the gland structures are first often frequent, hæmorrhages ;; and more
involved in the disease, and that the or less constitutional cachexia . The pain
stroma is less readily invaded ; the pale is felt in the rectum , or in the region of
and shooting down the thighs,
muscular fibres appearing to continue the sacrum , anterior
free from cancerous deposit to a later either the or posterior aspect.
period than the gland - follicles. Occa- In one case of my own, recorded here
sionally, but rarely, theprostate isaffected ( No. V.), the suffering experienced during
9
rather by a general infiltration of all the the early and middle term of the complaint
parts than by a distinct localisation of the was very slight, apart from that produced
growth as a tumour; in one such case by retention of urine, which occasionally
examined, the condition of the stroma just happened, and was relieved by the ca
alluded to was well marked . theter. During the last few months of
The mucous membrane of the urethra his life the patient lost the powers of sen
is generally not entire ; beneath its sur- sation and motion in the lower half of his
face nodules of the diseased growth may body froin encephaloid deposit in the upper
be seen , of which one or more have per- part of the spinal column ;otherwise doubt
haps penetrated, and are commencing to less his sufferings might have been severe.
form a fungous growth ; and around these The prostate is not invariably tender to
CANCER OF THE PROSTATE. 123
the touch in these cases, at least not that they have verified cancer-cells in the
notably so ; an observation which is sup urine. Others have failed to do so after
ported by the foregoing instance, before
close and repeated examinations. A good
the paralysis supervened ; and especially
deal of debris may usually be seen in
by another case very carefully watched by
advanced cases ; its presence appears to
my friend Dr. Armitage, to whom I am indicate thatthe growth has fungated,
indebted for the history forming Caseand throws off more or less of its elements
No. VI. in the condition of sloughy detritus. Cells
Hæmorrhage is a common occurrence may often , but not always, be found ,
both at an early and late period in the which strengthen the already existing
course of the disease, being almost uni- evidence as to the nature of the tumour.
versally present at one time or another, Their persistence and constant character
and sometimes to an alarming extent. should be verified, as error may arise
The blood is usually voided almost pure from mistaking the varied and abundant
or unmixed, and frequently appears with epithelium cells which the urinary pas
or after some attempt to urinate, which , sages afford for those of morbid growth.
from some circumstance, has been at- Regarding the treatment of malignant
tended with greater exertion than usual. diseaseof the prostate, nothingmore can
Much less commonly is the hæmorrhage be offered here in relation to the consti
observed to be continuous for any length tutional affection than applies to it when
of time, or constantly communicating a occurring in any other part of the body.
bloody tint to the urine, as happens The treatment is palliative, and must be
with some tumours of the bladder ; unless, regulated according to the various neces
indeed , that organ should also be im- sities which may arise in the progress of
plicated, or the disease have assumed
the form of a fungoid growth into its its tthe case .
he Thus accumulation of urine in the
cavity. Nor is the urine so liable to be bladder must be provided against at the
mixed with pus or mucus as in the vesical smallest risk of irritating, much less of
affection . injuring, the part. If catheterism can
The enlargement formed by the probe dispensed with altogether, so much the
state itself, when examined by the rectum , better. In no circumstances is it of more
is always hard at first, and may or may importance to be extremely gentle in the
not be irregular in outline or consistence, manipulation of instruments. The pain
although it becomes so in course of time. must be relieved by anodynes adminis
Softening may in the later stages be felt, tered by mouth, subcutaneous injection,
but the patient's powers do not always or by rectum, in sufficient quantity to
sustain him to so late a period as that in afford ease to the patient. This point
which the growth either softens or fun- deserves attention : the last few weeks or
gates. The deposit may be ascertained to months of a patient's career, when affected
affect the whole organ, and most com- by cancer, are for him an almost inter
monly does so, but it may affect one por- minable period of severe suffering, cease
tion more than another. Generally in less watchfulness and restlessness, for want
adults other organs are affected, but by no of sleep ; a terrible existence which he
means invariably. But there are always would often gladly terminate. These
diseased lymphatic glands adjacent, and conditions can be greatly ameliorated by
sometimes the infection reaches more administering opium in some form, the
distant groups. The existence of such best to be discovered by the medical
swellings in the course of the iliac vessels , attendant after trial of various prepara
and sometimes in the inguinal region, tions, in some exceptional cases. No
may frequently be verified by examina- doubt the subcutaneous injection of
tion of the abdomen, and constitutes a morphia is generally the most efficient
valuable sign in relation to the diagnosis , and the most manageable. It should be
and, consequently, to the prognosis of the freely supplied, and an increasing quan
case . tity permitted, as the effect diminishes.
The urine should be closely examined , The greatest kindness we can now bestow
in cases of a doubtful nature, for the pre- is the mitigation of suffering, and it is
sence of cells which may be regarded as always to be accomplished. The effects
malignant, from inspection of their forms of opium on the bowels are to be guarded
and constitution . Some observers state against by the necessary aperients, ene
mata , &c. Hæmorrhage must be treated | loid. The same appearance was found in tho
on principles already fully illustrated in glands, in the interspinal mass, and in the
nodular deposits beneath the mucous membrane
a preceding chapter (page 92) . The of the bladder. I exhibited this specimen at
powers of life are to be supported by the Pathological Society, March, 1851.'
every means in our power. Nutritious
food, both in the solid and fluid form , CASE No. VI.
with some alcoholic stimulant if desired ,
must be supplied in accordance with the J. B. Aged 65. A sawyer by occupation ;
digestive powers of the patient. with good health until one year and ten months
before his death. He first suffered from pain
in the sacral region, which gradually increased,
CASE No. V. but he did not give up work entirely until four
teen months before death . At the date named
J. A. Aged 60. Came under my care in he passed blood in his urine for some days.
1851 , for frequent and difficult micturition, May and June, 1856, he passed in St.
with general enlargement of the prostate ; po George's Hospital. Soon after leaving, he
tenderness on rectalexamination . After a time voided a considerable quantity of blood by
he was relieved by the use of the catheter and urethra during a period of six days ; and on
medicines . Subsequently he attended fre
other occasions subsequently, but in smaller
quently at the St. Marylebone Dispensary, that quantity.
his bladder might be relieved. He suffered
About
little pain or inconvenience, except at periods under Dr.the middle ofcare,
Armitage's September, he came
who reports his
when the retention became almost complete. complexion sallow ; body emaciated . Complains
His symptoms becoming worse, he was ad- of very severepainin the region of the sacrum ,
mitted to the St. Marylebone Infirmary, Dec. 9, and passing down theback of the thighs. Passes
1853.
About one month previous to admission he urine twice or three times in the night, rather
more frequently
had gradually become paraplegic. He had now pain , when muchin ropythe day ; occasionally with
mucus is present, and
entire loss of motion and sensation as high as appears to block up the urethra .
the hips, and soon after sensation disappeared Urine is generally alkaline, with tenacious
up to the armpits. The fæces passed involun mucus and earthy phosphates ; no blood . A
tarily, and theurine during sleep. There was full-sized catheter passed easily. The bladder
no pain in the back ; no history of any injury ; did not completely empty itself, and the patient
nor were there any facial signs of cerebral passed the instrument for himself twice a day
lesion. for relief.
Under the use of the catheter, &c. , he im Examination by rectum verified the existence
proved at first, but in Feb. 1854, the urine be- of a largeandvery hard tumour in the situation
came blcody, contained much phosphatic de- of the prostate, apparently about the size of a
posit, and he died, greatly emaciated , on the large duck's egg, but more prominent on the
23rd .
P.M. The bladder was not large, somewhat left than on
No pain onpressure
the right
. side of the median line.
thickened , and its mucous membrane was cor In the right inguinal region, there were
rugated, exhibiting dark red andslaty, tinte, several enlarged and hard glands, and on pres
and adhering
nodules of a calculous matter.
light colour, Several
isolated from little
each sure, others were felt in the courseof the iliac
other, were seen bepeath the mucous membrane.
vessels. The same was observed , but to a less
Theprostate was uniformly enlarged, and about extent,on theleft side.
the size of an orange. These conditions altered very little before
The adjacent iliac glands were enlarged . death , which occurred on March 17 , 1857. The
patient had become a little jaundiced, more
The right kidney atrophied ; its pelvis dilated, emaciated ,and weaker. The glands exhibited
and containing three or four ounces of pus. The no manifest change. The tumour continued
lower end of the corresponding ureter was com- much the same in size, and as hard as ever,
pletely obstructed by an enlarged gland press- until about a month before death, when it
ing upon it. The left kidney enlarged, and con became much softer, especially on the left
taining a little calcareous deposit. side.
On removing the posterior arches of the Autopsy. The prestate enlarged, evidently
spinal column, a fiattened patchof encephaloid thesubjectofmalignant disease, as were the
matter was found adhering to the arch of the lymphatic glands described. No appearance of
first dorsal vertebra,and smaller portions were any similar disease in any other part of the
seen lowerchange,
marksof down. except,
The cord itself exhibited
perhaps, someundueno body, which wasclosely examined. Dr.Armi
injection of its substance. There was no cere tage having kindly presented me with the pro
bral lesion , nor was there any malignant state and adjacent parts in the fresh state, I add
the following notes made at the time.
tumour discovered in any other part of the Bladder enlarged, thickened, and fascicu
body. mucous lining shows marks of inflamma .
tion. ; Several
On making section of the prostate, the lated small bodies,isolated, and about
enlargement appeared to be mainly due to the
displacement of the true prostatic tissue by 1 Transactions, vol . v, p. 204 , which see for
deposit of matter, which , to the naked eye and further particulars, and a detailed report on it by
microscopic examination, was obviously oncepha- | Mr. Hutchinson.
CANCER OF THE PROSTATE . 125
the size of hemp-seed, are seen underlying the in the Museum of Geo. Langstaf, Esq. Lond.
mucous membrane near its neck. 1842, p. 362.
Between the orifice of the left ureter and the
prostate is a mass of oblong form about the size CASE No. IX .
of a large almond, evidently formed by some A gentleman, aged 59, in whose case Mr.
deposit in the muscular substance of the Adams was consulted. Enlargement of the left
bladder,
The prostate is four times its natural size. lobe of the prostatewas detected nearly at the
The general nutline is somewhat uneven, and outset ; irritability of the bladder, and inability
slightly nodulated ; the left lobe larger than the to empty the viscus, being the earliest symptoms.
of life complete control
year regained
the last was over
For bladder
right. From itsrectal surface, a soft fluctuating the . The main symptoms
swelling extends backwards , nearly in the were, excessive pain in the lumbar and pelvic
course of the left vesicula seminalis, which, on
regions, and in the thighs
being opened, gare exit to yellowish fluid of a andswellinginthe and legs, with pain
testicles. Duration of
thick consistence, containing débris of tissues.
The resicula is much thickened, and loaded disease about three years and a quarter.
P.M. Prostate
with deposit in its structure ; the right vesicula leftlobe gland twice
being occupied with itsa carcinomatous
usual size, the
also in aless degree. A section of the mass tubercle , right healthy. The adjacent glands
showed the tissues to be infiltrated with soft much enlarged andsimilarly diseased, but no
pale matter,from which a creamyjuice abun- other abdominal viscera affected. Other cavities
dantly exuded when pressure was applied. This not examined.— Adams on the Prostate, 2nd edit.
under the microscope exhibited numerous p. 119 .
nucleated and binucleated cells, large and small, This case formed the substance of a commu
characteristic of malignant growth ; so also did nication to the Med.Chir. Soc. April 12, 1853,
the other deposits described . at which Mr. Adams stated that the tumour
had been examined by an experienced micro
Case No. VII. scopist, who had pronounced it to be true
MALIGNANT TUMOUR OF THE PROSTATE , scirrhus in every particular.'-- Lancet, 1853,
vol. i . p. 394.
I. B. Aged 68. Had symptoms of diseased
bladder five years. He suffered excessive pain CASE No. X.
in the back, bladder, and rectum , especially
during the last six months of life. Rectal A gentleman, aged 67. Severe vesical irri
tation occasionally
examination showed theprostate to be diseased ; urine for a considerable
bloody ;time excruciating
pain; no retention .;
and catheterism was extremely difficult. There
was at least very frequentand painful micturi- The left side of the prostate presentedtumour
tion, and on one occasion considerable hæmor- of an irregular knotty hardness. Indurated
rhage. He died comatose . glands appeared in the groin, The whole pelvis
P.M. The right ureter had sloughed and became filled with cancerous growths, which
given way, admitting a large quantity of urine after death were found to have pushed up the
to be effused between the peritoneum ; "three bladdertowardsthe umbilicus. The left iliac
pints
almostof filled
fluid being
with measured.
a The bladder was vein was obstructed by pressure, the left ureter
fungous tumour of loose also. The disease was nearly limited to the
coagulated blood, mixed with a white pulpy parts named.
substance, A case related to the Hunterian Society by
back part ofwhich derived its origin
the prostate,'and from the
hadplugged up Mr. Cock, and quoted by Mr. Adams. - Op. cit.
both ureters as well as the urethra . There pp. 147-149.
were several small masses of the same matter in
the lungs and liver .--- Trans. of Med . Chir. Soc. Case No. XI .
vol. viii . 1817, p. 279 . By G. Langstaff, C. F., aged 75, under the care of Sir William
Esg. Fergusson . Duration of symptoms four years.
He was admitted in a sinking condition, and
Case No. VIII. died in the course of three days. P.M. The
A man, aged 45, had suffered five years with prostate was of the size of an orange; and both
symptoms ofdiseased bladder, from obstruction. kidneys exhibited the presence of the same
Šis urine was loaded with mucus, and some deposit, which in each instance was encephaloid.
times was tinged with blood . During the last six Lancet, 1853, vol. i. p. 473.
months of life he had voided pus and blood per 1 A man, aged 63, had been afflicted with
anum ,
disease in the urinary organs and prostate for
At the post-mortem , the bladder was found several years.' The symptoms increased in
to be contracted and hypertrophied. On open- severity considerably for sometime before death .
ing it a large tumour was seen ' produced by At the post-mortem the prostate gland was found
the prostate gland , which was converted into a to be affected with melanosis and fungus hæma
fungoid and carcinomatous tumour resembling todes,and thewhole of theurethra is in a mela
melanosis.' The kidneys were inflamed . • The noid state.' But nothing is said of deposit in the
absorbent glands in the pelvis and abdomen | lymphatics, or in anyother organ.- Idem , p.330 .
Three or four other casesare reported in the
were converted into medullary and carcino - above catalogue as similar to the foregoing ; but
matous matter, and the veins in the pelvis were the accounts given are not sufficiently complete to
filled with fungoid deposits.' There was cancer place their nature beyond doubt, and they are,
of the stomach also.-Catalogue of Preparations / therefore,not included here.
backwards from one and a half to two inches .
CASE No. XII. The prostate was disorganised and softened at
A gentleman, aged 59, under the care of Mr. this part, whence by pressure escaped a cerebri
Haynes Walton. Duration of symptoms between form substance.
eight and nine months only. Hæmorrhage Reported as an illustration of cancer of the
occurred several times . The tumour was so prostate. - Civiale, Traité Pratique, deux partie,
large at a late period in its course that the Paris, 1850, p. 503.
6
finger could not be passed between it and the

sacrum .'
CASE No. XVI.
P.M. “ The true pelvis was entirely filled by
a tumour ' of an encephaloid character. There A man, aged 70, at Hôtel-Dieu , May 1839.
was a cavity in the diseased mass, with irregu- Urinary symptoms had existed about 18 months.
larly ulcerated walls, containing unhealthy pus; Urine had been thick, loaded, and lately dark
there wasno trace of urethra, the bladder ened by blood . Attempts at catheterism appear
opened directly into it.' The adjacent lym- to have been unsuccessful. He gradually sank,
phatic glands were affected . — Path. Trans. and died on the 13th day after admission.
vol. ii. p. 287. P.M. Bladder contained urine dark from
blood ; walls thick ; mucous membrane slate
CASES Nos. XIII. AND XIV. coloured. The prostate was the size of an ostrich's
B., aged 41 , was an out-patient of St. Tho- egg, and presented throughout the tissue of soft
mas's Hospital for some weeks with symp- ening encephaloid, with blood clots in it ; a
toms of stricture, and occasional retention of cavity containing one of these opened into the
urine . Much disposition to bleed when catheters bladder. Encephaloid existed also at the lesser
were passed . Subsequently, complete retention curve of the stomach . - By L. Aug. Mercier,
occurring, he was, on March 19, admitted to the Recherches Anat. Path. fc., Paris, 1841, p. 169.
hospital, under the care of Mr. Simon. Very
sallow , not emaciated, bladder irritable, urine
passed with effort ; testicles swollen and tender. CASE No. XVII.
Rectal examination showed an enlarged prostate.
He suffered much pain, but was relieved by ENCEPHALOID DISEASE OF PROSTATE IN A CHILD ,
occasional catheterism and opiates. In April W.M., aged 5 years. Mr. Stafford was called
he died from sloughing of the urethral aspect to see this child in the Marylebone Infirmary, on
of the tumour, and consequent extravasation of account of abdominal tumour, Norember 1838.
urine. It reached two inches above the umbilicus, and
P.M. " showed the prostate converted into proved to be a distended bladder, 25 ounces of
an encephaloid mass the size of a small urine being drawn off by the catheter. No pain
orange .' 6
was complained of ; and no abdominal tender
Mr. Simon adds, “ The nature of the tumour ness appears to have existed . Prostatic disease
had been fully recognised during life by thepre- was not suspected, therefore no examination by
sence in the urine of granules and flocculi of rectum was made. Eight days afterwards he
animal matter, which under the microscope died .
showed the large coherent nucleated cells of P.M. All the viscera appeared to be healthy,
encephaloid cancer.'-- Lecture by Mr. Simon. excepting theThe
bladder and prostate; the kidneys
mucous membrane of the blad
Lancet, 1850, vol. i. p. 291 . were large.
Mr. Simon illustrates this case with a der was thickened ; in other respects the organ
second. A man , aged 63, sallow and anxious. was sound. The prostate was equal in size to
The chief symptom was irritability of bladder, the largest walnut, was somewhat globular in
which had existed more or less for about three form , and from its back part projected a tumour
years, with occasional bleeding during two of the size of a small hazel-nut. Examination
years, and twice, retention . No tumour in proved the mass to possess the colour, consist
rectum . Flocculent matters passed , indicating ence, and texture' of encephaloid; melanotic
the disease to be encephaloid. A few weeks matter appearing to be intermixed.— Trans.
after he died. Med .- Chir . Soc ., vol. xxii. p. 218, 1839. By
P.M. showed an abundant growth of soft R. A. Stafford, Esq. Now forms Prep. No. 17,
cancerous vegetation from the mucous membrane series xxix. Mus. Barthol. Hosp.
of the prostate.' In both cases the neighbouring
glands were enlarged . CASE No. XVIII.
CASE No. XV .
A boy, aged 8 , 'had experienced for a consider
A man , aged 54, admitted under Civiale's care able length of time great difficulty in voiding
for calculus, 1837.' Urine had long been thick, urine. He was sounded for suspected stone,
foetid, and loaded with mucus ; and the passing after which there was much hæmorrhage ; and
of it painful. Symptoms aggravated during last subsequently swelling in the perineum , supposed
five months. On sounding a stone was detected, to be abscess, which was punctured, but nothing
but his condition forbade any operative measures, escaped but blood , and soon after a fungous
and he soon died . growth. At the post-mortem the prostate was
P.M. Large calculus in the bladder. A con- fonnd to be converted into a medullary sarcoma.'
siderable tumour at the neck of the bladder There were also several fungoid tumours in the
reaching to the membranous portion of the ure- liver.'— Catalogue of Preps. in the Museum of
thra, where was a large excavation extending | Geo. Langstaff, Esq. London, 1842, p. 357.
CHANCER OF THE PROSTATE . 127
Case No. XIX . CASE No. XXI.
A child, aged 3 , having been ill for some A child, aged 3 , under the care of Mr. Solly .
time, was observed to have difficulty in passing Among the earlier symptoms was retention of
water, and subsequently retention. It was then the urine, which was relieved with some difficulty,
brought to the London Hospital, and both cathe- nearly one and a half pint being withdrawn. The
terism and suprapubic puncture were resorted presence of stone was suspected . The child died
to, but without success. Death occurred shortly of peritonitis three months after the first accession
after, and the post-mortem revealed a bladder of the symptoms.
distended with a large cancerous mass, which had P.M. The prostate was enlarged by encepha
originated in the prostate gland and made its loid deposit to the size of a hen's egg.-- Path .
way into the bladder .'— Adams on the Prostate Trans., 1850-51, p. 130.
Gland , 2nd ed. 1853, p. 145.
CASE No. XXII .
CASE No. XX .
A. C., aged 9 months, was placed under the
A child, aged 3. Symptoms of vesical dis. care of Mr. Bree, of Stowmarket, March 9, 1843,
ease during six months; then retention, relieved for retention of urine of 24 hours' duration. A
with difficulty by the catheter, which was fre- pint and a half of urine was removed by the
quently employed afterwards,until theobstruction catheter. A tumour was felt per rectum in the
rendered itimpossible. Puncture of the bladder situation ofthe prostate. Obstruction increased,
was performed above thepubes. About three or and ulceration took place through the sphincter
four weeks afterwards, the child died from ex- ani in a few weeks. Death occurred April 22.
haustion . On dissection, the prostate was ' en- P.M. The bladder was highly inflamed and
larged to the size of a hen's egg, and completely thickened, and the tumour proved to be a very
transformed into medullary matter.'- By Pro- large encephaloid growth from the prostate.
fessor Bush, in Gross on the Urinary Organs, Viscera generally healthy . — Prov. Med . and Surg.
2nd ed. p. 719. Journal, 1846, p. 76.
TABLE OF FOREGOING CASES OF MALIGNANT DISEASE OF PROSTATE.
Case No. Age Duration Character Other Organs
Adults.
5 Mr.Henry Thompson 60 2 years Encephaloid Spine and adjacent
lymphatics
6 Dr. Armitage 65 11 Ditto Lymphatics only
7 Mr. Langstaff 68 5 9 Ditto Lungs and liver
8 Ditto 45 5 Ditto with mat- | Lymphatics and
ter resembling Vessels adja
melanotic de- cent ; stomach
posit also
9 Mr. Adams 59 34 , 99 Reported scirrhus Adjacent lym
phatics only
10 Mr. Cock 67 Not stated Probably ence- Adjacent lym
phaloid phatics
11 Sir Wm . Fergusson 75 4 years Encephaloid Both kidneys
12 Mr. H. Walton 59 Ditto Adjacent lym
phatics
13 Mr. Simon 41 Some months Ditto Ditto
14 Ditto 63 Rather more than Ditto Ditto
3 years
15 M. Civiale 54 Not stated Ditto Not stated
16 M. Mercier 70 i ) year Ditto Stomach
Children .
17 Mr. Stafford . 5 Few months Encephaloid and | No other viscera
melanotic
18 Mr. Langstaff . 8 A considerable Encephaloid In liver also
length of time
19 Mr. Adams . 3 Not stated Ditto Not stated
20 Prof. Bush . 3 7 months Ditto Ditto
21 Mr. Solly 3 3 Ditto Other organs not
examined
22 Mr. Bree . 9 ms . About 3 months Ditto • Viscera generally
healthy .'
* Other cases of malignant disease involving the prostate are reported in the journals and elsewhere, but
are excluded for want of sufficient particulars by which to form a fair conclusion respecting them . At least
30 cases instead of 18 might have been adducerl, had I not been careful to reject those in which the evidence
was incomplete.
CHAPTER XVI.
TUBERCULAR DISEASE OF THE PROSTATE .
TUBERCLE.—Rare in Prostate ; almost invariably associated with Tuberculous Kidney or Testicle

Morbid Anatomy - Symptoins - Diagnosis — Treatment_Tabular View of eighteen cases.
TUBERCLE OF THE PROSTATE . The pro- takes place by urethra. A space remains ;
state is very rarely the seat of the tuber- and several such coalesce and form a
cular deposit, and when it is so, appears cavity of larger size ; pus is formed from
generally to be somewhat increased in the lining membrane, and a considerable
size, until the later stages of the complaint portion of the prostatic substance is de
are reached, when, after suppuration and stroyed. But there is no reason to sup
discharge, its volume may become smaller pose, when such cavities are found in the
than natural . prostate after death, that their origin has
It would appear that at no period of been tuberculous, unless the presence of
the disease is the prostate affected alone, such action or deposit can be distinctly
some other part of the genito -urinary tract verified in some other part of the urinary
being the primary seat of the affection . In or genital organs.
niost cases the depositappears to take place Tubercular deposit appears to be more
first in the kidney, or, at all events, to be prone to affect the outer than the central
present there in an early stage. The parts of the prostate, occurring in the
organ next in order of liability to the lateral lobes chiefly. By microscopic ex
disease, among the genito -urinary group, amination it may be inferred to commence
is the testicle. Thus in eighteen cases in the glandular structures of the organ ,
collected by myself, and forming a table and not in the fibrous stroma.
at the end of this chapter, in which the SYMPTOMS.–From all these circum
results of post-mortem inspections have stances it follows that there are no symp
been recorded, tuberculosis of the kidney toms which are, strictly speaking, proper
is reported in thirteen,and of the testicle to this affection of the prostate. Undue
in seven . The state of the lungs has, I frequency and pain in making water, occa
suspect, not always been recorded, but in sionally blood in the urine, and at times
ten of these cases they are stated to have the signs of cystitis, are experienced.
been diseased. Pains in the back and pelvis, and in the
MORBID ANATOMY.— The form which region of the bladder and urethra, are
the deposited tubercle assumes in the pro- complained of ; while wasting and extreme
state is, at first, that of minute yellowish debility slowly show themselves in the
points, like millet seeds. These become system at large. The local complaint is
larger, and numerous rounded collections to be regarded but as a part of the de
of cheesy or curd -like consistence may be velopment of tubercular disease existing
found, distributed throughout the sub- in other portions of the genito -urinary
stance of the organ . The processes of organs, and generally in other regions of
deposition and aggregation continue until the body also. It is no part of the design
the mass may reach the size of a chest of this work to embrace a consideration
nut ; commonly, not larger than that of a of the symptoms and diagnosis of tuber
full -sized marble. It is then generally culous kidney ; a subject, nevertheless, of
surrounded by a thin limiting fibrous great interest to the surgeon, to whom
membrane, being isolated by it from the the disease is perhaps quite as often pre
surrounding prostatic tissue. Among this sented as to the physician, on account of
mass may be found portions of thin cellu- the increased frequency of passing water,
lar tissue intermingling, the remains, and other symptoms resembling those of
probably, of prostatic structures, which stone or of stricture. The presence of
have given way before the accumulating pus in the urine, of occasional hæmaturia ,
tubercle. Central softening takes placeat of pains in the loins, perineum, and penis,
an earlier or later period ; and if the gives rise to a suspicion of calculus, to be
patient survives, discharge of the detritus resclved sometimes only by careful sound
TUBERCULAR DISEASE OF THE PROSTATE. 129
ing. The state of nutrition of the patient, cases, provokes irritation , and aggravates
his history,and the condition of the lungs, the disease, without conferring upon him
are among the main points to be con- any benefit whatever.
sidered in connection with the urinary de- Tubercle of the prostate is a very rare
rangements, which have probably more affection . It is extremely uncommon to
especially attracted his attention. meet with it in the deadhouse. The pre
Treatment. - Nothing need be said of served examples are few. There is no
the constitutional treatment of tubercular preparation of it in the Royal College of
disease, and little in relation to the local Surgeons, London, although there areone
manifestation in the prostate . Mechanical or two specimens of abscesses in the pro
interference is to be avoided ,and every state, which are supposed to be of a scro
kind of irritating application. It suppura- fulous character or origin . There are two
tion takes the form of external abscess, it examples in the Museum of St. Bartholo.
must be treated as other perineal or ischio mew's Hospital, one in Guy's, one in St.
rectal abscesses. But more commonly George's, one in that of the College of
the discharge of purulent and tubercular Surgeons, Edinburgh , and one in a small
matter takes place into the urethra. The collection at the Royal Naval Hospital,
improvement of the health , by all those Greenwich .
numerous means which regulation of the The following cases, eighteen in num
diet, regimen, exercise, climate, and medi- ber, have been condensed into a tabular
cine enable us commonly to achieve in form . They constitute the greater portion
tubercular patients, constitutes almost the of the data on which our knowledge of
whole of the treatment to be employed in this disease is founded. The age of the
the affection , when involving the urinary patient, the condition of the prostate itself,
or genital organs. The diagnosis once and that of other organs of the body also
established , it is of great importance that tuberculous, are presented. The sources
the patient should be kept free from all from which they are obtained are also
instrumental treatment, which , in such / added in a note.
CASES OF TUBERCLE IN THE PROSTATE.

Patient's
Case
Reported by Age Condition of Prostate Condition of other Organs
1 Mr. Lloyd 23 Enlarged cavity containing • The bladder and kidneys were
an ounce of scrofulous tolerably healthy ;' tuberculous
matter cavities in the lungs
2 Mr. Adams 26 Disappeared by suppuration Tubercle in left kidney, ureter,
and testicle
3 Mr. Hudson .
Several small points of Kidney largely tuberculous ;
softened tubercle, and ureter, lungs, bones, lymphatic
superficial ulceration glands
4 Dr. Basham 29 Granular deposits Right kidney and bladder chiefly
affected
5 Dr. Gross 27 Eight small masses, cach One kidney, ureter, and vesicula
about the size of a pea semin .; spine and lymphatic
glands (not in lungs)
6 Vidal de Cassis 19 Tuberculous cavity . Testicles and resicula semin.;
brain and lungs
7 Ditto 50 Large tuberculous masses Kidneys, lungs, &c.
8 Lallemand 55 Thirty small abscesses and Both kidneys
tubercles
9 Ricord 58 Large al scess in prostate Miliary tubercles throughout
ureter; testicle previously re
moved for tubercular disease
10 Guy's Hospital 23 Tubercular deposits , ' size of Ulceration of bladder ; much con
Museum pin's head to that of a nut gestion of kidneys; tubercle
in both lungs, and in lumbar
vertebræ
11 Bartholomew's Young Small circumscribed masses Tuberclo in kidneys, lungs, and
Museum man otherorgans ; bladder ulcerated
12 Ditto Ditto Large mass of tubercles in Tubercle in left kidney, left testi
left lobe of prostate cle ; in lungs and other organs
K
Patient's
Case
Reported by Age Condition of Prostate Condition of other Organs
13 St. George's 35
Large tubercular carity in Kidneys extensively diseased ;
Hospital Mu prostate, capable of hold- scrofulous abscesses in testicle,
seum ing two ounces secondary to the prostate
symptoms
14 College of Sur- 11 Prostate destroyed by ulcera- Abscess in perineum ; ulceration
geons , Edin tion of right ureter ; both kidneys
burgh full of tuberculous matter
15 Royal Naval 76 Large masses of tubercle de- Tubercle deposited in mucous
Hospital, posited in outer portions membrane of bladder ; in vesic.
Greenwich of the organ sem . , in right kidney, and in
lungs
16 32 Large deposits of tubercle Tubercular meningitis; tubercle
in the prostate of lungs and mesenteric glands;
in the testicle
17 Dr. Guerlain . 43 Large mass of tubercle in Tubercle of the lungs ; and in
left lobe ; smaller ones in bone
right
18 Mr.Simon mentions a case in which the entire genito -urinary tract was more or less
affected with tubercular deposit, from the testicle to the prostate, and from the kidney
to the same point.
1. Lloyd on Scrofula, p. 110, 1821. 11. & 12. Barth . Museum . Series xxix . : 19
2. Adams on the Prostate, 2nd ed . p. 127 . and 20 .
3. Trans. Path. Soc. vol. i . p . 120 , 13. St. George's Hosp. Museum . Series x.
4. Lancet, 1855, vol. ii. p . 542. 14. Catalogue, p. 260.
5. Urinary Organs, 2nd ed . p. 721 . 15. Med .-Chir. Trans. vol . xliii . p. 157.
6. Annales de Chirurgie, 1845 . 16. Rccueil de Mém . de Méd . de Chir. &c.
7. L'Union Médicale, 1850. 1860.
8. Des Pertes Séminales, 1836 , vol . i . 17. Bull. de la Soc . Anat . 1860 , p. 133 ,
9. L'Union Médicale, 1849 . 18. Lancet, vol. i . 1850, p . 290 .
10. Guy's Hospital Museum , No. 2393, 75 .
CHAPTER XVII.
CYSTS, OR CAVITIES IN THE PROSTATE .
True Cysts unknown - Cavities are of three kinds — Dilated Follicles ; Purulent Depôts ; and containing
Concretions - Hydatid Cysts between the Prostate and the Rectum .
SMALL cavities,which have received from such isolated cysts as, for example, in the
many authors the name of cysts, are fre- kidney, nor any formation indeed which
quently to be seen in the prostate, espe- can be regarded as analogous to that,
cially in those of aged subjects. which may be considered as the type of
If by the term " cyst ' it is designed to simple fluid cysts. Although I have, in
describe a thin -walled, cell-like body or conformity with the practice of other
closed sac, spheroidal, or nearly so, in authors, referred to cystic disease' of
form, containing fluid, a structure of new the prostate, it does not appear that the
formation apparently, not a mere dilata- use of the term is warranted by the phe
tion of some already existing cavity, then noniena presented ; and ifretained, itmust
I know of no such affection of the probe held to signify a formation of a wholly
state, either from personal examination or different kind from that which is indi
on the report of others. Such cysts are cated by it in the breast or kidney ;
found in many parts of the body, con- neither is any species of proliferous cyst
taining hydatids, jelly -like material, serous ever met with .
fluid, &c. But in the prostate we find no Cavities are frequently found in the
CYSTS, OR CAVITIES IN THE PROSTATE . 131
prostate, but these manifestly belong to aasonfewdescribes

one of the three following orders :-
minimsofone
Auid. The late Mr. Coul
case in which such a
(a) Mere dilatation of gland -follicles. cavity was capable of containing as much
(6 ) Cavities containing pus ; abscess. as half an ounce ; and he regarded this as
(c ) Cavities containing concretions or a dilated duct. In one instance, I removed
calculi, the walls of which become denser a number of these small calculi during
and firmer in proportion to their magni- life, from a sac just at the neck of the
tude, which corresponds with that of the bladder, not without difficulty, by means
contained body. ofa very small scoop lithotrite at several
Of the first kind, viz., dilated gland- sittings ; the case was seen in consultation
follicles, examples may be found in most with Mr. Savory of St. Bartholomew's.
prostates from elderly subjects; as has Such an opportunity of meeting with these
been before seen, some of the gland- bodies is, however, exceedingly rare.
follicles generally exhibit a tendencyto HYDATIDS OF THE PROSTATE . - It is
enlarge or dilate as age increases. The doubtful if hydatid cysts have ever been
cavity is often filled with yellowish, semi- met with in the prostate. The only case
Auid material, or with yellow, semi-trans- on record which may have been an ex
parent concretions, of so small a size as ample is one which occurred intheSussex
only to be discernible with the microscope. County Hospital, and is recorded by Mr.
And it appears that the increase in size of Lowdell in the 29th vol. ofthe · Med .-Chir.
the contained and of the containing parts Trans.' The author expresses a doubtful
takes place pari passu . opinion on the subject, but appears to
The second kind, viz., cavities con- incline to a belief that the prostate was
taining pus, offers no subject for remark the seat of the hydatid formation. Six
here. These have been fully examined other cases may be referred to in which
and described in Chapter IV. on the re- retention of urine and distension of the
sults of inflammation , under the heads of bladder occurred asa result of a hydatid
Acute and Chronic Abscess. cyst between the bladder and rectum , near
The third kind of cavities consists of to the neck of the former; but in which
those which contain solid formations, the prostate was not affected except by
whether concretions or calculi. It is com- pressure. Prostatic enlargement was very
mon, when making sections of the pro- closely simulated, certainly in three of
state from an elderly subject, whether it them , and in two the prostatic catheter
is hypertrophied or not, to find cavities, was employed under the belief of its
of a somewhat irregular form , in its sub- existence.
stance, having all the appearance of being The first was reported by John Hunter,
dilated follicles of the glandular struc- in the Transactions of a Society for the
ture, which contain numerous little dark- Improvement of Medical and Surgical
Here the re
coloured concretions. I have seen from Knowledge, vol. i. p. 34.
thirty to fifty of these bodies occupying a tention caused death, and between four
cavity about the size of a grain of wheat and five pints of urine were found in the
or of a small pea . bladder at the post-mortem examination.
But larger concretions, that is, of the The viscus was pushed up into the abdo
size of pearl barley, may occupy each a men by the pressure of the cyst below.
separate recess of its own ; and on re- The second, by Mr. Curling, appears
moving the foreign body, a spherical, thin, as an appendix to Mr. Lowdell's paper in
and smooth -walled cavity is displayed. the volume referred to above, page 356.
Sometimes hundreds of such small cavi- Here the same appearances were observed,
ties may be found in one prostate,—but but in a less marked degree,relief having
this isvery rare circumstance. A good been given to the retention during life.
example may be found in the museum The third case occurred to the late
of the College of Surgeons, Prep. No. Mr. Callaway , at Guy's Hospital, and is re
2519. ferred to in the Medical Times ' of February
The cavities referred to do not attain 17, 1855. Hydatids were removed when
a sufficient size, nor, as far as I know, do the catheter was passed. After death a
they give rise to any symptom whatever, large hydatid tumour was found between
to render a knowledge of their presence the bladder and rectum, pressing on the
possible during life. Generally speaking, neck of the former.
they are capable of holding not more than 1 Op. cit. 5th ed. p. 587.
X 2
The fourth, a man aged 40, was ad- cyst occupying a position between the
mitted into Guy's Hospital with retention bladder and rectum . In this case the
of urine ; no catheter could be passed, and prostate does not appear to have been
he died . At the post-mortem , a large affected. It is preparation No. 15, series
tumour occupied the pelvis and hypo- xxix.
gastric region , the anterior and upper part It does not appear unlikely that Mr.
of which was formed by the bladder. Lowdell's case may have belonged to the
pushed out of its proper place. The same category, the prostate being more or
tumour consisted of a cyst containing less absorbed by pressure from an external
three pints of hydatids. The preparation cyst, so that the latter came at length to
is No. 210452. Another preparation is occupy the siiuation proper of that organ.
preserved there very similar to the pre- The case is, however, given here in an
ceding. abridged form .
The fifth occurred in a man , aged 59 ,
admitted to the Westminster Hospital with Case No. XXIII.
retention of urine, under the care of Mr. HydatID DISEASE OF Prostate . (?)
White. A catheter could not be made to
J. I. Aged 64, in Sussex County Hospital,
reach the bladder, which was therefore in July 1844, under the care of Mr. John
punctured through the perineum , a pint Lawrence, jun.During three or four years had
of urine escaping. He died next day, and experienced difficulty in making water and fre
a large hydatid tumour was found just quent mieturition; and of late, almost complete
above the prostate, pressing against the retention . The bladder was now emptied by
back of the bladder so as to divide it into catheter, aftergreat difficulty, and three pints
withdrawn. Much pus and mucus passed after
two portions, of which the upper still con- wards. He died in aa few days.
tained two pints of urine, the lower, which!! P. M. Bladder very much thickened , and in
held one, having been evacuated by the thesituation of theprostate was a tumour
larger than a fætal head, which, when cut open,
puncture.
I have recently become acquainted provedsubstanceto be a hydatid cyst,closely packed,the
with a sixth case, that of a lad, nine years true of the prostate being lost in
it. Hydatid tumours were also found in the
old, and suffering from retention of urine, omentum.
in whom a large and fluctuating tumour, Whether the hydatid cyst was formed in the
occupying the position of the bladder, was prostateitself, or external tothe organ , destroy
felt within the rectum. No instrument ing it by pressure alone, is stated to have been
a matter of doubt. Appearances led Mr. Low
could be passed, and the rectal puncture dell, who reports the case, to the former view.
was performed, the result being , not the The facts of hydatid disease of the prostate
removal of urine, but of the contents of a being unrecorded , together with the existence
hydatid cyst. This relieved the retention, of other tumoursin the omentum, inclinedhim
to believe that he should be scarcely warranted
and the boy recovered. inTrans.
maintainingthat opinion
In the museum of St. Bartholomew's Med .-Chir. Soc., vol. without
xxix. p. question .'
253. 1846.
there is a good example of a large hydatid | By George Lowdell, Esq .
CHAPTER XVIII.
THE BAR AT THE NECK OF THE BLADDER .
Relation of this subject to Prostatic Enlargement- Most organic Obstacles at the Neck of the Bladder are
Prostatic- A few Cases which are exceptional - Mr. Guthrie's Recognition of them - His Views defined
-Views of Civiale, Mercier, Gross, Leroy - A Bar may be due to repeated Contractions of the Bladder
from any cause whatever, if long continued - Shown to consist, in such cases, of Muscular Hyper
trophy - Examples — CONCLUSIONS on the whole subject- Rarity of any affection meriting the appel
lation of Bar in absence of Enlarged Prostate — DIAGNOSIS — TREATMENT — When due to Muscular
Hypertrophy, as in Stone or Stricture, will disappear on removal of the cause - Mr. Guthrie's Pro
posal to divide Obstructionsat the Neck of the Bladder — Mercier’s Modes and Instruments - Bottini's
Method by Electric Cautery.
6
A CONDITION of the neck of the bladder |term , ‘ Bar at the Neck of the Bladder,'
is often observed, mostly coexisting with has been applied. And such a description
hypertrophy of the prostate, to which the | not inaptlyconveys an idea of the mor
THE BAR AT THE NECK OF THE BLADDER. 133
bid change which is present. It will / mucous membrane of the neck of the
6
therefore, be considered under the title bladder had been drawn up ' so asto form
referred to, although constituting rather a a bar across its under part. This bar,'
6
variety of disease already studied than a he adds, ' is quite membranous, and does
specific affection of another kind. not include the elastic structure which is
We have already seen in Chapter V., not diseased, neither is that part called the
that a bar at the neck of the bladder is third lobe, nor is there any projection into
frequently due solely to enlargement of the bladder, save the bar or valve formed
some part of the prostate; but a someby its mucous membrane at the very
what similar vbstruction is sometimes, meatus.'
though rarely, present when that organ is Of these two cases, as the author ob
not the subject of disease. It is to this
serves, one was exactly the reverse of the
latter condition that the term , as designa-
other. Each is, indeed, typical of two
ting a distinct affection, has usually been
perfectly distinct classes of abnormal con
applied in this country . ditions affecting the neck of the bladder.
Although numerous forms of obstruc- In the latter example there is presented
tion at the neck of the bladder have been merely a natural result of certain forms of
frequently described, at some length, by prostatic enlargement which are occasion
the well-known French writers of the ally met with, and some examples of
present century on urinary diseases, under
6
which exist in our museums, in which the
the names of bourrelets,' barrières uré- growth upwards of the lateral lobes alone
tro -vésicales,' brides,' and ' valvules,' no has the effect of drawing up the mucous
specific distinction wasrecognised between membrane from parts below, and some
the form of obstacle about to be described, times with it some subjacent fibrous and
and that which consists in an hypertrophy muscular structures, but in which there
of the prostate, until the late Mr. Guthrie is little or no enlargement of the median
called attention to the subject in his portion. In the former case, there is an
lectures at the Royal College of Surgeous unnatural elevation of certain structures
in 1830. He examined it with care, and which underlie the niucous membrane at
arrived at more precise views respecting the posterior or vesical limit of the
it than any previous writer had done, urethra , but which is unaccompanied by,
pointing out the distinctive characters of and totally unconnected with, any enlarge
the two affections, the prostatic and non- ment of the prostate whatever.
prostatic ; and the term which he em- It is particularly necessary to draw che
ployed to designate the latter is retained distinction clearly between the affection, to
here, in the sense which he originally which Mr. Guthrie thus applied the name
6
intended it to convey. The views which of ‘ Bar at the Neck of the Bladder,' and
he entertained respecting the distinct that obstruction which is constituted solely
character of the two affections are by an enlarged median portion of the pro
summed up briefly by himself, and may state itself. Views, differing very much
be given here in his own words. He con- from those which Mr. Guthrie held , have
cludes : been frequently promulgated as his re
' 1. That an elastic structure exists at specting it. Thus the bar has been de
the neck of the bladder, and may be dis- scribed by more than one author as an
eased without any necessary connection eminence situated just behinıl an enlarged
with the prostate gland . middle lobe of the prostate. Now this is
“ 2. That the prostate may he diseased clearly not what was intended by Mr.
without any necessary connection with the Guthrie ; nor can such an 6 eminence be
elastic structure .' said to have for its locality the neck of
>
He quotes two cases, one in which, the bladder ' at all, inasmuch as it must
6
without any affection of the prostate, and necessarily lie considerably posterior to it.
particularly of the third lobe, the patient As we shall see hereafter, the eminence
passed his water with great difficulty , in so indicated is formed by an hypertrophied
consequence of the barrier formed by this condition of those muscular bands which
unyielding structure, and died ultimately intervene between the two orifices of the
>
of the disease, after much suffering.' 1 On the Anatomy and Diseases of the Urinary
Another, in which, as a consequence of and Sexual Organs, being the first part of theLec
unequally enlarged lateral lobes of the tures deliveredin the Theatre of the Royal College of
Surgeons in 1850. By J. G. Guthrie. London ,
prostate, the right being most so, the | 1838, pp.23 and 25.
ureters, and which are generally known occur in men much younger than those
6
as the muscles of the ureters.' who are the subjects of the prostatic bar,
Civiale devotes a chapter to the con- and this will aid the diagnosis. But the
sideration of this subject. He describes angular sound will generally determine
6
the vesico -urethral barrier '‫ ܕ‬as formed in the difference, since in the muscular bar
some cases by ' a simple fold ofmembrane, the beak on being introduced can be
smooth and thin, and almost transparent, rotated freely, but in the prostatic bar the
extending from one lobe of the prostate to rounded eminence which it forms prevents
>
the opposite ; ' and in others by a fold, this act of rotation .'
thicker, in the form of a rounded cord, Dr. Gross, of Louisville, recognises
which contains some fibrous or muscular the two forms described by Mr. Guthrie,
tissue. In others it partakesmoreor less and gives his adhesion to the view, that
of prostatic substance. And he adds that the non -prostatic bar has its origin in the
a considerable barrier may be found after presence of hypertrophy of the bladder ,
death, when no symptoms have existed which may arise, therefore, from any of
during life ; while in other cases a train of the ordinary modes of obstruction which
very painful disorders of the urinary lead to that condition of the vesical coats.2
apparatus may result from an inconsider- M. Leroy d'Etiolles recognised only
able membranous fold, giving rise, how- the occurrence of valvular obstruction at
produced by pro
ever, to very decided obstruction at the the vesical neck, when To
vesical neck . static enlargement. this common
He also reviews the alleged causes of form of disease he gave considerable at
these valvular obstructions, thatis, when tention , having treated of it in various
not due to enlarged prostate, viz., spas- papers in the French journals, and in his
modic muscular contractions, rheumatism , own published works, during nearly
&c., and expresses his opinion that we thirty years past.
have no certain knowledge of the etiology The form of bar described by Mr.
of the affection . Guthrie, as illustrated by the second of
Mercier, who is familiar with Mr. the two cases cited by him , viz., that
Guthrie's views on this subject, but does which is formed by the drawing up of
not altogether coincide with them, de- the mucousand submucous tissues,through
scribes, as the usual form of urethro- upward development of the lateral lobes
vesical barrier, aa semi-annular eminence, of the prostate, can , of course , only be
very like the pyloric valve of the stomach, seen in those cases where enlargement
if it existed only on the lower half of the affects these, but not the median portion,
orifice.' He recognises two distinct kinds : or, at all events, not to a considerable
one produced by spasm of the muscular extent. Examples of this kind are by no
fibres which close the neck of the bladder, means common, for a tendency to the for
these fibres having become permanently mation of outgrowth is usually manifested
contracted in some individuals after long- in the median portion , when any hyper
continued and repeated attacks of the trophy of the prostate exists; conse
spasmodic affection, so that a permanent quently, it cannot be regarded as a com
bar is the consequence ; the other kind mon, but, on the contrary, only as an
being simply the result of hypertrophy of unfrequent affection . A few specimens
the median portion of the prostate. Re- exist in the Museum of the Royal College
garding the first, or muscular bar, he of Surgeons, in which such a barrier
states that the seat of the affection is the exists ; those, for example, numbered
tissue at the apex of the trigone, between 2488, 2489, and 2490.3 Besides these ,
the mucous membrane and the prostate. there is a very similar specimen from the
The occasion of it he believes may be the Museum of University College. But that
presence of stricture, calculus, or any
other excitant of continued spasmodic 1 Recherches sur le Traitement des Maladies des
action in the muscular fibres referred to. Organes Urinaires, g'c. Paris, 1856. Mémoire ime,
p. 209 et seq.
It may take its rise also in an attack of 2 The Diseases, Injuries, and Malformationsof
inflammation of the neck of the bladder, the Urinary. Bladder, & c. By S. D. Gross, M.D.,
and following generally gonorrhoea,al- 3rd3 ed. Philadelphia, 1876,p. 59.
No. 2489 is represented by Sir E. Home, in his
though sometimes due to other causes. work on the Prostate, vol. i. plate v. He describes
transverse middle the membrane
lateral lobes,of and
the
Consequently, examples of it, he says, may itbladder
as abetween the fold of and
1 Traité Pratique, vol. ii. p. 244. speaks of it as ' a part which merits particular at
THE BAR AT THE NECK OF THE BLADDER . 135
condition in which a fold of mucous and unduly elevated and developed into a trans
submucous tissues obstructs the posterior verse ridge of varied size; there is a con
border of the neck of the bladder, no pro- siderable decrease in the antero-posterior
static enlargement, stricture, or vesical |diameter of the floor of the bladder, or
disease being present, is still more rare.' trigone, and the muscular bands which
Nevertheless, although I have occasionally define that space are hypertrophied, as is
seen an example ofthe kind here described, also the structure of the bladder generally.
it has been so unfrequently , that I cannot Further examination shows an absence
do otherwise than regard it as extremely of enlargement of the prostate, but there
exceptional, notwithstanding that Mr. is usually either stricture of the urethra,
Guthrie has expressed himself to the con- or the patient was the subject of calculus
trary . I am persuaded, after careful and or of some other cause of long-continued
repeated examinations, that unnatural irritation of the bladder. Thus, in many
elevations at the neck of the bladder are preparations of the urinary organs in
more frequently caused by sonie enlarge- which urethral obstruction has long ex
ment or outgrowth, however small (and isted, the floor of the bladder presents the
they may be seen in alldegrees of develop- appearance of having been shortened or
ment), springingfrom the posterior partof compressed from before backwards; the
the prostate ; and that such are not mere orifices of the ureters have approached
elevations of the mucous and submucous much nearer to the internal meatus than is
structures only, but are commonly formed natural , and the muscular eininence, which
by genuine prostatic enlargements, united unites them , is unduly developed ; while
with the main body of the organ by the uvula, or the structures occupying its
proper ducts, not difficult to be traced . situation , have become more salient, and
In such case the smail prominence form a marked prominence across the pos
rising in the centre of the floor of the terior part of the neck of the bladder, very
vesico - urethal orifice elevates a little different from the thin ormembranous bar.
crescentic fold of membrane and under- On making a vertical section of the neck
lying tissues on each side, and often, of the bladder and prostate, this elevation
whatever magnitude the glandular growth is seen to be due to an augmentation of
subsequently attains, these folds still rise the natural constituents composing the
with it. It is through such a fold that uvula, that is, of fibrous and muscular
the point of the catheter is not unfre- elements, while the prostate, as before said,
quently forced in relieving retention of is in no way increased in size. Now this
urine, in which case, of course, the mini- condition of parts was examined by Sir
mum of injury is inflicted on the parts. Charles Bell, and formed the subject of a
Such lesion is usually followed by con paper published in the Transactions of the
siderable hæmorrhage, and happily, as a Medical and Chirurgical Society, vol. iii.
rule, by no other formidable symptom .? 1812 ,entitled ' An Account'of the Muscles
But while such is the character of the of the Ureters, and their Effects in Irri
commoner formswhich obstruction at this table States of the Biadder. '
spot assumes, there is, undoubtedly, an- He there demonstrated his views of
other, not unfrequently met with, distinct the arrangement of those large bundles of
from it, and which is probably that de- muscular fibre which appear to be con
scribed by Mercier in the paragraph above nected with the occluding of the orifices of
quoted, as due to muscular spasm . In a the ureters, and with the opening of the
specimen of it, the uvula vesice is seen to be neck of the bladder. These are greatly
hypertrophied when increased action of the
tention, since it increases theobstruction to the bladder has been long kept up by some
passing of the urine, by preventing it from getting
round the sides of the protuberance,' p. 251. source of irritation , and the result is that
1 There is only oneexample of this in the Col- an approximation of the vesical neck to
lege of Surgeons Museum ). It bears Mr. Gathrie's the orifices of the ureters takes place. But
name, but is not numbered in the catalogue. It is
one on which he set great value as demonstrating Sir Charles Bell stated that it was the
the existence of this affectior . See op. cit. p. 23 . • middle lobe of the prostate,' to which this
? Preparation No. 2513, in the Museum of the muscular apparatus was attached, and he
Royal College of Surgeons, shows well a case in
which the perforation was done with precisely the suggested that the undue development of
result
wards.described. The patient
TheMuseum six five
containslived years
other examples their lobe
after- that was, in all
mechanical cases,
action mainly upon
, drawing to
due it,
ofthe operation of perforation of the median por- bringingitinto its unnatural position , as
tion, in order to relieve retention.
it were, by repeated efforts; and by the the urethra, and constitute the uvula ,
irritation in it thus produced causing its results from frequent and long - continued
hypertrophy. This theory gave too much expulsive efforts of the bladder ; they
prominence to the mere mechanical action appear to be very closely identified with
described, which is obviously inadequate the action of the outlet, and their enlarge
to give rise to the phenomena it was pre- ment, thickening, and undue prominence
sumed to account for. At the same time, are the natural consequence of hyper
it made no advance towards the discovery activity. At the same timeit is probable
of a primary cause for the prostatic en- that repeated spasmodic actions of these
largement, inasmuch as no explanation muscular fibres , situated at the neck of
was offered of that which determined the the bladder, produce not only hypertrophy
muscles to act in this abnormal manner but inflammation ; so that they lose ( like
upon some prostates, and not upon others. the fibres of the iris in similar circum
But further, an examination of the pre- stances) the power of relaxing ,and become
parations in our museums demonstrates permanently contracted, as Mercier has
that the development of the muscles of suggested. Such I believe to be the true
the ureters ' does not by any means neces- pathology of an obstruction at the neck
sarily coexist with enlargement of the of the bladder, when it is not formed by
median portion of the prostate; butshows development of the median portion of the
that it occurs when extraordinary con- prostate itself; nor by a simple fold of
tractions of the bladder have been long mucous and submucous tissue drawn up
habitually exerted, whatever may have by enlarged lateral lobes ; and when the
been the nature of the obstruction which median portion is not at all or only slightly
has called them into play; and that the hypertrophied.
appearance of the prostatic enlargement It should be added that this appear
itself, rising, as it often does, into the ance may be the only thing found some
bladder in a polypoid form , with a pe- times afier death, when no cause for
dicle at its base, does not indicate that it urinary symptoms, which may have been
has been drawn into its position, or in any severe during liſe, yhas been disc overed.
way produced by niuscular action . Further- It is not necessar to suppose, as Mr.
more, the best examples of the hypertro- Guthrie suggested, that the bar had, even
phied muscular apparatus in question, and in such a case, been the source of those
of the elevation at the neck of the bladder symptoms. Its existence simply proves
associated with it, are found in connection that there has long been an undue amount
with long-standing stricture of the urethra of expulsive effort on the part of the
and not in cases of prostatic enlargement. bladder. It is itself but the result of
But the muscular bundles in question, that activity expressed in the form of
it is now well understood, are not in- hypertrophy; and the cause of the undue
serted , in the manner described , into any action which produced the bar has still to
portion of the prostate ; but are disposed be sought. That there are cases of irri
in the following manner, Having united table bladder,' as it is termed , in which
with the submucous layer of the bladder, neither stricture, enlarged prostate, cal
they continue onwards to the vesical culus, disease of the kidney , nor of the
oritice, those of each side crossing each rectum , or other satisfactorily ascertained
other there, and forming the “ uvula ; ' cause are present, is a matter of rare but
they then become continuous with the occasional experience to most surgeons.
longitudinal muscular coat of the urethra. In such, if the symptoms have been severe
This is clearly shown by Professor Ellis, and long continued, we shall undoubtedly
formerly of University College, who find , as their result, a state of the muscular
elaborately dissected and described the coats of the bladder, which , in a degree
arrangement of muscular fibres through- more or less marked, presents the pro
out the genito -urinary apparatus. ' An jecting bar at its neck , but we must
hypertrophied condition of these muscular search more deeply for the cause which
bands, which associate the ureters with produced the irritable bladder, and look
L'An Account of the Arrangementofthe Mus- upon the anatomical change as its conse
cular Substance in the Urinary and certain of the quence. Doubtless long existing idio
Generative Organs of the Human Body ' By G. V. pathic chronic cystitis, which is not oc
Ellis, Professor of Anatomy in University College, casioned by any of the causes above
London . — Medico - Chirurgical Transactions, vol.
xxxix . p. 327. named , or other such local sources of
irritation, will likewise produce it, of a ridge or barrier, situated at the pos
through the extreme irritability of the terior border of the neck of the bladder,
bladder so occasioned . this unnatural elevation is constituted by
It is the presence of this bar in old an outgrowth arising from the median
cases of stricture which , besides the en. portion of the prostate.
larged lacunæ in the dilated urethra Secondly, that an organic obstruction
behind it, appears to be sometimes the may exist at the neck of the bladder
cause of obstruction at the neck of the when there is no enlargement of the
bladder, long after the instrument has median portion of theprostate.
passed the stricture, and which inay oc- Thirdly, that in this case it is most
casionally cause some difficulty in drawing commonly due to hypertrophy of the
off the urine by the catheter. ' It appears muscular fibres at the neck of the bladder,
also to explain the statement, often made, produced by long- continued irritability of
that a patient with strictured urethra has the viscus, and generally occasioned by
enlarged prostate also, a concurrence of stricture of the urethra, inflammation, or
circumstances less common than might calculus of the bladder, and occasionally
otherwise be supposed. And, lastly, it appearing without any of these con
accounts for some, although not for all, ditions.
of the cases in which difficulty of mic- Fourthly, that sometimes the ob
turition and other symptoms of obstruction struction consists of a fold of mucous
persist in those who are the subjects of membrane and submucous tissue drawn
urethral stricture, even after the urethra upwards by enlarged lateral lobes of the
has been satisfactorily and fully dilated. prostate, the median portion being slightly,
The bar remains at the neck of the blad- sometimes not at all, affected .
der, and is the cause of existing symptoms. The two distinct conditions described
As this subject has been regarded in in the last two paragraphs are those to
a manner which differs in some respects which Mr. Guthrie applied the term “ bar
from that which has been followed by at the neck of the bladder,' and which he
other writers, some examples of this form employed in order to distinguish them
of bar willbe referred to below, consisting from the well-known elevation there
6
in hypertrophy of the tissues at the neck caused by enlarged middle lobe,' from
of the bladder, arising from long con- which they are perfectly distinct, and
tinued hyper-activity of the expulsive with which it is obvious they cannot co
function, and generally as the result of exist.
stricture of the urethra.1 The foregoing conclusions show how
In order to conduce to the object of rarely we have to encounter any affection
affording a clear exposition of the facts meriting the appellation of bar at the
brought forward in relation to this subject. neck of thebladder, as distinguished from
and of theviews which have been founded prostatic enlargement affecting that part,
upon them , I shall sum up with a brief or from the condition described as muscu
statement in the form of conclusions, lar hypertrophy and generally resulting
It appears : First, that in the majority from stricture, calculus, or other similar
of cases ir, which there exists an organic cause of constant irritation.
obstruction, baving more or less the form DIAGNOSIS. — The subject of diagnosis
1 Royal COLLEGE OF SURGEONS MUSEUM . — of obstructions at the neck of the bladder
Examples of thickening of the structures at the has been fully considered in Char. X.,
neck of the bladder, forming a bar, apparently due
to hypertrophy of muscles controlling thisorifice, devoted to the subject. ( See page 77
are found in Preparations Nos. 2545, 2550, 2572, for the mode of recognising the difference
and 2567,the last named being the most striking between prostatic tumour and non-pro
one.
UNIVERSITY COLLEGE MUSEUM . ( No. 482.) static bar at the neck of the bladder .) At
A marked example of bar; prostatic urethra di- the same time a knowledge of the age at
lated behind a stricture at the bulb.
In Guy's Hospital MUSEUM a good example which the symptoms appeared will aid
may be seen (No. 2399) of valvular fold of mucous the inquiry, as well as of the fact of ab
nent bar at the neck of thethin,
membraneonly,forminga bladder.
promi- sence
and urethra
sharp,The or presence of prostatic swelling
from rectal examination. We may be
passing through the prostate is dilated
stricture exhibita quite satisfied that prostatic obstruction
at the bulb. Nos.2405 and 2406behind
bars at theneckof the bladder, coexistent with does not exist before fifty - five or fifty -six
stricture.
In none of the foregoing is the bar prostatic in years of age, and rarely at so farly a
its nature. period .
TREATMENT OF THE BAR AT THE Neck in the most simple cases, but without evi
OF THE BLADDER.-It is obvious that dence of any benefit arising therefrom .
when obstruction at the neck of the bladder After discussing the proprietyof fol.
consists only in an hypertrophiedcondition lowing the example of Sir Wm . Blizard.
of the muscular apparatus described, pro- who, in a few instances, practised incisions
duced by the irritation accompanying resembling those made in lateral lithotomy
stone, stricture, or other source of con- for the purpose of affording relief in very
tinued frequent and painful micturition, confirmed and advanced enlargement of
no other treatment is necessary, or will the prostate, Mr. Guthrie suggests that a
be of any service, which does not remove simple bar may easily be divided, and
the exciting cause. In most cases there mentions two instances in which he had
is, indeed, no utility in regarding it sepa- so acted with advantage. In these he
rately from that cause; any more than employed a modification of one of Mr.
exists for separately treating an hypertro- Stafford's stricture instruments, consisting
phied or a dilated bladder, or an enlarged ofa prostatic catheter, containing a blade
ureter, or most other consequences of which was easily projected from the side
urethral obstruction or vesical irritation. of the instrument at its extremity, after
Remove the cause, and all these secondary this had been passed into the bladder, so
evils will generally diminish or disappear. as to make an incision in the act of with
But the case is different when the cause drawing it; or two incisions might be
being removed the symptoms are still made, one during the act of entering, and
present, or are but very slightly amelio- the second as just described. He also
rated. We must then seek the occasion intimates his belief that in some cases
of the continued distress either in chronic much relief would be obtained by making
inflammation of the organs, in atony and an incision in the median line of the peri
inertia of the bladder ( for treatment of neum into the membranous part of the
former see pp . 83-91 ), or in still existing urethra, and thence dividing the prostate,
obstruction , probably at the vesical neck . together with the bar or any other form
If on examination we find that a me- of obstruction which might exist. This,
chanical barrier does exist there, consti- Mr. Guthrie adds, he has not yet put in
tuted either by the very common enlarge- practice. The operations thus initiated
ment of themedian portion of the prostate, seem to have fallen into disuse—or rather
or by thelesscommon one, a non -prostatic perhaps it would be more correct to say
bar ; and that this barrier, whatever its that they never came into general practice
structure, is the cause of grave difficulties in this country ; but similar proceedings
of micturition, the absence of calculus, were adopted in Paris about the same
stricture, vesical tumour, or other such time, M. Leroy d'Etiolles having ad
source being absolutely ascertained ; it dressed the Academy of Sciences ( 1832-3)
becomes a matter of consideration whether for the purpose of advocating scarifications
any relief,and if so what, can be afforded . and incisions of obstructions situated at
The late Mr. Guthrie, to whose espe- the neck of the bladder. The instrument
rience, as the first to call attention to the which he subsequently employed, which
subject, we naturally turn, says,that the was exhibited to the Academy in 1837,
treatment by simple dilatation and by and was figured, I believe, for the first
permitting the catheter to remain perma- time in 1840, resembled very much that
nently in the bladder, although often just described, excepting that the blade
useful, doesnotalways succeed ; in which could be projected from either the con
6
case, he adds, the bar, or dam , at the vexity or the concavity of the curve, this
neck of the bladder must bedivided, and latter being extremely small, like that of
the question is, how is it to be done with the exploring sounds exhibited at page 76 .
the greatest safety ?' 1 Besides this , however, there was another
The same conclusion has been arrived blade, which was intended to act against
at by the French surgeons. Thus, the the original one, like the blades of a pair
tying in a large catheter for a few days in of scissors, and to serve the purpose of ex ?
some cases, and in others attempts to cising a small outgrowth when necessary
depress the salient portion by mechanical M. Civiale states that he has frequently
means, as by sounds of large curve, & c., 1 Traité pratique. Civiale. 1858. T. 2 , p. 157.
have been resorted to with some benefit Also Mercier and others,
i Op.cit. p. 274. 2 Comptes -Rendus des Séances, vol. iv. p. 551.
practised moderate incisions of the ob- or an incomplete incision made from with -
structing bar under certain circumstances. in the bladder, in the manner justdescribed,
After describing his method, he adds, in may be completed by
terms which will commend themselves to placing the beak, directed
the minds of English surgeons :—But I upwards, in front of the
cannot too much insist that we should bar, and making the knife
thus operate only in cases which are per- project from the canula on
fectly understood, after having recognised its convex aspect, as seen
with precision the spot on which the in- in the figure, and indicated
strument is to act, after having placed the by the asterisk . In this
patient in the most favourable condition, and case the screw V' is first
after becoming absolutely certain that all turned in order to regulate
other means of cure have been exhausted . the movement. In this
M. Mercier, who has paid great atten- manner incision is per
tion to this particular subject, has employed formed; the method recom
the practice of incising freely, and also, mended by M. Mercier,
in some cases, of excising portions from the where the bar is narrow ,
obstructing bar. The annexed figure ofan or thin and prominent.
instrument for incision is copied from his If the bar is rounded
work . (Fig. 29. ) It consists of a silver ca-
a
and wide, as most prostatic
nula, naving the form of his exploring in- enlargements in this situa
strument, containing a blade, cutting from tion are, he practises ex
either the convex or concave aspect of the cision by means of an in
curve of the canula, as already described . strument somewhat similar
When the blade is sheathed the instrument to a lithotrite ( fig. 30), by
is employed as a sound, and being intro- which, the beak being
duced into the bladder, previously injected turned downwards, he
with a few ounces of water, the beak is seizes a portion between
turned downwards, as in sounding behind the blades of the instru
the prostate. By means of the screw at v' ment, fixes the yielding tis
an adjustment is made which regulates the sue by means of an arrow
distance to which the blade is permitted to headed needle, seen in the
slide out of the beak and along the shaft; figure, which renders it im V V
in the figure that distance is indicated by movable, then closes the
the letter L. By drawing the circular blades, and in so doing
handle r towards himself, the operator, excises the portion con
therefore, makes an incision of the bar tained. This, being fixed R
against which the beak rests, dividing the by the needle aforesaid, is
tissues more or less perfectly between it removed when the instru
and the point l. To ensure complete ment is drawn out. Fre Fig. 29. - Merci
division , the blade is pushed back again bleeding, er's instrument
quently some bleeding,
into the beak, and this process may be generally a good deal, ap- for dividing a
bar at the neck
repeated if necessary . The instrument pears to follow thisprocess; of the bladder.
may also be used in front of the prostate, sometimes it has occurred
1 Traité pratique. 1858. T. 2 , p. 171. to a dangerous extent. This is treated
Recherches, gc. Par A. Mercier. Paris, 1856, by smallinjections of cold water, by ele
p. 216. M. Mercier has stated, in an extended ana
lysisofmy works,which hehasdonemethehonour vating the pelvis above the level of the
topublish ( Étude surDivers Points, fc. Paris, head,and by internal astringents. After
that ; and Gazette
1860 inthe first edition ., 1860,work
Hebdomofthis the operation,
I didhim, the
severalpapers) surgeon's the
presence , tois desired,
patient empty thein
some injustice in my notice of his views and pro
ceedings, in describing his instrumentand operation bladder of the water injected previously.
as a modification of those of Leroy d'Etiolles. It is important, says the author, that he
After a re-examination ofthe subject, I cometo the should do this wħile lying on his side,
conclusion that the difference is essential, and that,
although there is an obvious resemblance in the and without effort. If it does not flow , a
form of the instruments employed, the proceeding full-sized catheter , with large eyes, should
of M. Mercier is original and distinct as compared
with the scarificationsmade by Leroy . I exceed- be passed . A catheter should not be left
ingly regret that I should have erred in not attri- lying in the canal, as it provokes spasm
butingtheutmost value to thelaboursofonefor andrepeateddesiresto pass water, and so
whose original and sagacious observations I enter- favours bleeding . It is better to pass an
tain the highest respect.
instrument from time to time when the case during four years, in another two
patient feels the desire to urinate. After years. Seven were improved in various
some exterded remarks upon the subject degrees, some very considerably ; these
6
of hæmorrhage, M. Mercier says, “ It is were reported by the author as cases of
at present the only serious accident which cure. In one no alteration was produced
I have observed to by the operation in the power of passing
result. I repeat that water, but he can pass a catheter, which
by the aid of the previously he was unable to do. Such
means indicated I are the results, judging from a perusal of
have never failed to these fifteen histories, and they may be
overcome it, and my taken as a fair example of the practice.
experience rests on a M. Mercier regards them as belonging to
sufficiently extensive the most serious and obstinate class of cases,
base, since my opera- the milder onės being remediable either by
tions have reached mechanical pressure or by incision.
the number of 300, The question of performing this opera
some of my patients tion demands for any case a very cautious
having been operated consideration . So much can the condi
'1
upon several times. tion of almost all patients suffering with
More recently he has obstruction be ameliorated by care and
stated that there is management, and by emptying the bladder
less to be feared on once, twice, or more daily, when neces
Fig. 30. this score from ex- sary, that the cases must be rare in which
cision than from the proposal to employ this treatment can
incision , because the vessels are more be entertained here. And I believe that
crushed by the former process, while in the best mode of proceeding, whether the
the latter they are more cleanly cut. bar is to be divided or excised, would be
About six days after the operation he to open the urethra from the perineum,
passes a flexible catheter with great care, and examine the obstruction with the
lest hæmorrhage be excited , and, accord- finger in the manner which I have adopted
ing to circumstances, but generally about with so much advantage for the worst
the tenth or eleventh day, having intro forms of prostatic disease, and which is
duced the same catheter, he passes into it fully described at pp. 114-15.
an elastic steel stilet, in order to make Professor Bottini, the distinguished
pressure with it upon the seat of the professor of surgery, formerly of Pavia,
wound by way of preventing union, in- now of Milan, endeavours to effect free
creasing the force employed from the division of prostatic obstruction by means
second to the third week following the of a wire heated by the electric current ;
operation . He speaks in very decided and he has devised an ingenious method
terins of the benefits which have followed and an efficient instrument for effecting
the practice in numerous cases, citing the his purpose. He states in his little bro
reports of fifteen in illustration. The chure on the subject, and he has person
names and residences of these patients ally informed me, that he is satisfied with
are appended ; in most instances the the advantage which some of his patients
operation was perfornied in presence of have derived from division thus made .
some one or more of the most distin- Certainly, by this manner of performing
guished surgeons of Paris ; and in five division of the part, one great objection
cases the patients were examined by the to the cutting procedure, viz., the hæmor
Commission of theArgenteuil prize. The rhage, is avoided. And I may say that
reports are therefore open to correction if if I consented to mploy an operation for
any undue partiality for the proceeding dividing internally a prostatic barrier,
has been manifested by the author. Of which , being neither thick nor massive,
these, two died ; one of dysentery, one might offer an inducement to me to
6
of “ fever. In five cases, in which the attempt the section, Bottini's instrument
urinary difficulties, such as habitual re- and method would be those which I
tention and dysury, had been consider should adopt in preference to all others.
able, complete relief was afforded, and 1 Di un nuovo Cauterizzatore ed Incisore Termo
had been verified as continuing in one galrunico contro le Iscurieda Ipertrofia prostatica.
1 Op. cit. p. 240 . Bologna, 187+,
PROSTATIC CONCRETIONS AND CALCULI. 141
CHAPTER XIX.
PROSTATIC CONCRETIONS AND CALCULI.
PROSTATIC Covcretioss - Distinct from Calculi - Physical Characters to naked Eye and Microscope
Chemical Characters ,Analysis-Are they Naturalor Abnormal Formations ? -Mode of Formation,
and History — May become Nuclei for Calculous Matter - Analogy between Prostatic and Biliary
Concretions - and other Concretions — Views of Dr. Jones and Mr. Quekett ; Virchow, Wedl - Pro
STATIC Calculi – Different kinds, sizes, & c. — Analyses — Situation - Numerous Examples — Operative
Measures for Removal .
It is exceedingly common, when the present very beautiful microscopic ob

urethra of an elderly male subject is laid jects, varying in size, for the most part,
open, to observe in the prostatic part, lying from about the one thousandth to the
around the verumontanum , and in the one-hundredth of an inch ; generally oval
orifices of the prostatic ducts especially, in form , sometimes angular, and then
numerous little brownish or blackish apparently from the result ofmutual pres
bodies, the largest of which ordinarily met sure. They have a yellowish hue, vary
with are about the size of poppy-seeds. ing between the faintest tint and a deep
They are not free in the canal, but gene. orange, evidently acquiring intensity of
rally just within some of the orifices colour with age or increase in size. They
named, sometimes beneath the epithelial have a well-defined outline, as if limited
layer of the mucous membrane of the by some kind of cell-wall, and exhibit nu
urethra, barely visible over them . Again , merous concentric rings in their anterior,
when a section of the prostatic substance which , although the object is more or less
is made, especially if the knife be directed translucent, suggests strongly to the ob
hackwards and outwards on either side of server the appearance of a uric acid calcu
the verumontanum , many of the same lus when cut; a resemblance which no
bodies may be frequently seen. Indeed doubt originally suggested a relationship
they may be dispersed through all parts with formations of that class. The central
of the organ, although they rarely attain part, or nucleus, as it has been termed ,
the size named in situations very remote does not usualiy exhibit these rings, but
from the urethra . has aa cellular appearance, as if constituted
These bodies have received the name by a conglomeration of corpuscles partially
of Prostatic Concretions. They have in fused together. This central mass varies
their origin no relation to urinary calculi ; in size, but is usually present ; and around
nor should they be confounded with the this it is that the concentric circles are
hard white porcelain -like masses which placed. Often two, three, or more of
are sometimes met with in the prostate, very small concretions are seen lying
and from which they differ also. It is closely together, each possessing more or
the more necessary to draw the distinc- less angularity, and forming the nucleus
tion, as the concretions have not unfre- of a larger formation : occasionally lines
quently been spoken of as urinary calculi, are seen radiating from the nucleus to
and still oftener are viewed as having a the circumference ; sometimes cleavage of
similar constitution, and as not being the mass takes place in the direction of
generically distinct. They will there- these lines. Sometimes the concretion
fore be considered here separately. appears to consist almost entirely of the
Prostatic CONCRETIONS. — The bodies agglomerated corpuscles; at others these
described above under this term are not exist in very small relative proportion to
generally observed before middle or ad- the concentric rings, in which latter no
vanced age. But although, as a rule, to trace of corpuscular arrangement can be
which there are occasional exceptions, no detected. It is easy, when examining a
examples visible to the naked eye can be considerable number, to trace a series of
detected during the periods of youth and these small semi-transparent bodies, as it
early manhood, the microscope reveals were in different stages, until they gra
them of very small size at all ages, except dually become the dark, almost opaque,
that before puberty. In the first series forms at first described. Even in the
of fifty prostates examined by myself they latter some remains of the concentric
were present in every instance. arrangement may be occasionally ob
In the early stages of formation they served, but, generally speaking, they are
too dark and opaque to transmit light, with a solution of potash, hot or cold,
>
and only appear asdark -brown masses of there is no change, and on adding an acid
spheroidal form , with enough of trans- no precipitate is formed in the alkaline
lucency to enable the eye to detect easily liquid. When the concretion is heated, a
at their edges that they have really a strong ammoniacal odour is evolved.
deep orange or red colour. In consistency From these reactions I conclude that
they have also considerably changed. In the organic constituent of the concretion
the early stages these bodies are soft, and is not a true protein body , but most
readily cleave or divide as a soft body probably belongs to that class of nitro
does under superincumbent pressure, even genised substances, sometimes termed
when as large as the one -hundredth of an protein derivatives, of which fibroin ,
inch , by the application of a very little gelatin, and chitin are examples.
weight to the thin glass which coversthe The following results were obtained
object under the microscope. But when by incineration :
they have arrived at the size and colour Concretions · 0244 gramme
Yielded of Ash 0112 ,
above described , they have acquired also
considerable solidity, are firm and even which equal 45.9 per cent. of residue.
brittle when force is applied to break This consisted chiefly of phosphate of
them . lime, with a small quantity of the car
Their chemical reactions are peculiar. bonate.'
The small soft pale and yellow bodies are Is the presence of these concretions in
not acted on by acetic, nitric, hydro- the prostate to be regarded as a natura .
chloric, or sulphuric acids cold ; nor by or as an abnormal circumstance ? This
sulphuric ether, liquor potassæ, or am- question has been variously answered. I
moniæ . The larger hard and brownish have examined not less than a hundred
concretions I have found to be unaltered prostates, at all ages over twenty years,
by the addition of alkalies, except that and have detected them in every one. I
they occasionally become rather more have found them also in one specimen at
translucent. By hydrochloric and nitric fourteen years of age, and have failed to
acids they are sometimes influenced, find them in childhood. There is much
giving off a few bubbles of gas, and difference, however, as to their number
slightly diminishing in size. Sulphuric in different cases. In some - in most
acid liberates gas more rapidly, and some after fifty years of age — they are obvious
times after they have ceased to be affected enough to the naked eye in the urethra
by the former acids. Occasionally they around the verumontanum as soon as the
become soft, and disintegrate into amor- canal is laid open ; in others it is neces
phous matter, losing very little of their sary to make section of a lateral lobe, to
colour or bulk by immersion in sulphuric scrape the surface, and place the milky
acid. On the other hand, some specimens semi-transparent fluid under the micro
appear to be very little affected by any scope, when they may be seen , sometimes
reagent. in small, sometimes in large numbers.
In order to obtain an exact qualitative At other times it may be necessary to
and quantitative analysis of these bodies, make several such sections before finding
I submitted about 200 of the hard dark- any. They are smaller, paler in colour,
coloured concretions to my friend, Dr. oreven almost destitute of it, in young
Williain S. Squire, who, after a careful subjects, and vice versâ in aged ; but
investigation, has furnished me with the there is not an unvarying relation in
following report : regard of number, size, &c., between their
' Immersed in acetic acid the concre- development and the age of the subject.
tion resists its action, but if brokenbefore In No. 15 of the table, from a man aged
this agent is applied, it becomes slightly sixty -six years, I found more than in any
softened and swollen. Nitric acid , cold , I have ever examined, including subjects
has no effect; when hot it dissolves the at ninety. I estimated the number of
concretion entirely, producing a very dark - coloured concretions visible to the
slight yellow tint. A portion of the con- naked eye in this case as amounting to
cretion treated with a solution of iodine several thousands.
does not change colour. Sulphuric acid Generally speaking, they have been
and sugar do not produce any effect considered abnormal. One of the most
characteristic of protein. When treated | recent writers on the subject, Wedl, re
gards them as the product of enlarged which are represented ( figs. 32-4 ). In the
prostate. From the facts just brought larger masses, obviously occupying crypts,
forward I cannot, however, but conclude
that their existence is a necessary result
of the performance of natural functions
on the part of the prostate, although there
does not appear to be any evidence to
show that they ultimately disintegrate and
yield up some elements to the natural
secretion of the gland ,' as has been sug
gested by an observer who has studied
them closely .
My examination of the preparations
referred to has led me to the following
conclusions respecting these bodies. It 3
may , however, first be stated in what
manner the inquiry has been prosecuted.
The urethral surface of each prostate has
been exposed, and come concretions, if
present, removed for examination. These Fig.taining
31. - Fluid expressed from the prostate, con
epithelium, yellow granules, and con
have been submitted to the chemical tests cretions.
enumerated, of which
been already given. Next, results have
theseveralsections orfollicles, oftheglandular structure, these
have been made with Valentin's knife,and may be seen notonly cohering, butisfused
examined in situ. The best of these I together,and then an appearance pre
have mounted in preservative fluid, of sented identical with that which may be
which I possess not less than a hundred seen occupying the centre of the larger
examples, admirably drawn by Mr. Tuffen concretions. Judging from these appear
ances and the frequency of their occur
West, from
are taken which
. The thealso
fluid following figures rence, I cannot but conclude that the
which exudes
from the prostatic ducts on pressure has coalescence of these yellow bodies or
granules; their partial fusion into a mass
been separately examined .
By such means I have observed that, more or less homogeneous ; the stratifica
in addition to the corpuscles, obviously
epithelial or glandular, which are found
abundantly in the prostatic fluid, however
obtained , there are always present also,
and in considerable numbers, some small
yellowish bodies, in appearance sometimes
granular, sometimes homogeneous, about
the size of red blood corpuscles, but not
so uniform , being from about our to
oo of an inch in diameter; they possess
considerable refractive power, nearly so
much as to give them a resemblance to 2
oil globules. They are not acted upon
by ether, however, nor by the other re
agents mentioned. They are not only
found in the prostatic fluid, but may be
washed from sections of the organ, and FIG . small
32.- Small ducts stuffed with yellow granules;
concretions lying free on the section .
may be found lying in clusters, aggre
gated and adhering in various parts of it. tion, perhaps, in part, of this mass itself,
>
Further, it is common to see small ducts or more probably the deposit upon its
and cæcal pouches stuffed with these surface of fresh layers of fluid matter
bodies, as well as with yellow granules of similar to that which originally constituted
smaller size, several marked examples of the yellow bodies ; and, finally, some ad
ditions of earthy matter to it, either by
1 Rudiments of Pathological Histology. By infiltration or accretion, are the steps by
Carl Wedl. Translated by G. Busk , F.R.S. Lon
dou 1855. p. 269. which the formation of a prostatic con
cretion is very frequently accomplished. At a very early period, however, they

Most, if not all , of the appearances thus seem to be impregnated with the earthy
constituent in some form or proportion
which does not much impair the trans
lucency of the object. Most appear to
remain in this condition, although liable
to considerable increase in size after their
formation, which probably at first depends
on that of the cavity in which the aggre
gation occurs.
When circumstances give rise to an
addition of opaque earthy matters to the
concretion, their size increases not only
by such addition, but by that also of the
organic matters with which such deposits
are associated. It is then that they
acquire density, more or less opacity, and
give proof of the presence in large — that
is, predominating - quantity of mineral
Fig. 53.— An aggregation of numerous small con- constituents to chemical reagents.
cretions forming one large one ; prostatic epi
thelium seen free in the field . The acquisition of this opaque earthy
matter by a concretion may be thus ex
described are very accurately shown in plained. One of these bodies having
the drawings referred to. Those con- formed within a follicle, and the size
cretions which are not found lying at the having greatly increased by fresh layers
orifices of the ducts, as at first described, of secretion , it becomes, sooner or later, a
occupy generally the larger ducts and kind of foreign body, and as such creates
follicles of the secreting portion of the a certain degree of irritation. Now it is
organ . In examining sections under a well known that secreting, membranes
power of 200 or 250 diameters, it is easy throughout every part of the body are
to see the circular arrangement of fibres prone to deposit opaque earthy matter
around the concretion, when it has been under certain forms or degrees of irrita
preserved in situ, and in other places tion , the product in all cases consisting
around the openings from which these chiefly of the phosphate, with a little of
bodies have escaped . the carbonate of lime ; and in this manner
Perhaps all these yellow bodies are the secreting membrane of a prostatic
originally composed — that is, in their follicle appears to produce a fluid from
which earthy salts are precipitated upon
the nucleus, until its size has increased
from that of a microscopic object, under
favourable circumstances, it may be, even
to that of a grain of pearl barley, or of a
pea , or even larger. Together with this
earthy matter, mucus, gland -cells, &c., in
varying proportions, will be also inter
mixed . Thus at various stages of their
formation the chemical analysis of a pro
static concretion will exhibit a different
result, being found to contain a larger
proportion of organic matter in the early
period, when only visible to the eye as
dark points, and more of inorganic, when
as large as those of the extreme sizes just
described . Analyses of the latter have
Fig. 34. - A prostatic duct cut transversely ; CON
cretions seen lying within . frequently been made, and the inorganie
matters have amounted to 85 per cent
earliest stages of formation of purely instead of 46, as found in the smaller
organic matter, and that matter a product kinds examined here. Arrived at this
of the secreting structures of the prostate. stage, the walls of the follicle originally
containing it have become absorbed and by removal of water, enter largely into
have disappeared ; other calculi from their composition at first. Ultimately
neighbouring crypts have come into con- phosphatic salts - generally, as in other7
tact with it by a similar process ; and concretions, the phosphate of lime—are

now, perchance, a number of these bodies added, and form a constituent part of the
will be found occupying together a single biliary calculus. In many respects there
sac, in which the work of deposition appears to be a considerable analogy
ceases, and then they may lose their between this product and the prostatic
spheroidal form, and acquire facets by concretion, not only in manner of forma .
attrition or juxtaposition. There is, tion, as originating from an organic basis,,
therefore, nothing more of a urinary and in the ultimate relative proportion
character about these concretions than of the mineral constituent, but in their
belongs to salivary, biliary, or other frequency of occurrence. Besides these,
glandular concretions. But the case is I shall but allude to the similarity which
somewhat different with some of the cal- obtains in the character and mode of
culi which are found in diseased prostates, formation of calculi in the lacrymal gland,
and which appear to be the products of in the frontal sinuses, in the mouth, in
bladder derangement as wellas of pro- the pancreas, in the vesiculæ seminales,
static secretion ; these will be considered in the mammary ducts, and elsewhere. "
separately hereafter. Meantime, it will The views entertained here differ, it
be desirable very briefly to illustrate the should be said, in some respects from those
history here given of the structure of the which have been held by some who have
prostatic concretion , and of the steps by at a former period paid much attention to
which it becomes approximated in con- the subject. Dr. Handfield Jones pub
stitution to a true calculous body, by an lished in 1847 a very interesting paper
allusion to analogous processes which describing the results of his researches,2
occur in mucous membranes of other which many of the observations here
parts of the system . As stated above, recorded have but fully confirmed. He,
wherever there is a inucous membrane, however, then believed the concretions to
or a simple follicular membrane exercising originate in a simple vesicle containing
a secreting function, there exists the granular matter, and generally a nucleus;
requisite agency for the production of and that they increase mainly by endo
earthy matter when certain kinds of genous growth ; regarding their origin
irritation are applied to it. Thus is and constitution to be entirely organic in
formed the phosphatic calculus of the the earlier stages of existence. Mr.
urinary bladder, resulting from the irri- Quekett, on the other hand, describes
tation of chronic cystitis; so different in them as commencing by a deposit of
origin from the uric acid stone which earthy matter in the secreting cells of the
descends from the kidney ; and thus also gland, increasing either by aggregation or
the coating of phosphates, which the by deposition in the form of concentric
latter so frequently acquires after its layers.'3
arrival, So we find the salivary glands With the first -named observer I am
containing phosphatic calculus, a little disposed to agree as to the organic com
spicula, as from the husk of some grain position of the concretions at first, a fact
taken as food,having originally supplied which must be regarded as proved by
both the irritation and the nucleus. The their behaviour with chemical reagents.
tonsil is the seat, although rarely, of a As to the vesicular origin described,
similar occurrence . Still more rarely do favoured as it seems to be by theappear
the nasal passages, the pharynx, and so- ance of some of the smaller formations, I
phagus furnish like forms, and doubtless feel, nevertheless, some difficulty in ad
through the agency of similar exciting mitting the probability of such a mode of
causes.. Throughout the intestinal canal production, especially as we know of no
phosphatic formations have frequently · For an interesting and very complete account
been observed ; in the north especially of these formations,see an article in the Cyclopædia
the hard husk of the oat, which forms a of Anatomy and Physiology,under the title of Ad
ventitious Products,' by Dr. W. H. Walshe, Pro
staple article of diet, having there usually fessor of Medicine in University College.
furnished the nucleus. With biliary cal- 2 The Medical Gazette, Aug. 20 , 1847, and
culi all are familiar. The histological Reportof Pathological Society,1816-7;p. 129.
5 The Anatomy and Diseases of the Prostate
elements of the liver secretion, inspissated | Gland. By JohnAdams. 2nd ed. 1853, p. 158.
L
process in regard of any other cell- forma- | cord, especially in elderly subjects, and
6
tion, normal or abnormal, seen in the named amyloid bodies' by Kölliker and
human body, which can be said to be at Virchow. He believes all these to be the
all analogous with it. As to the larger result of a pathological exudation fre
formations, I have little doubt, judging quently occurring in various organs in &
from the appearances already described, advanced age, and which he terms . colloid
that they are often, if not always, pro- matter,' on account of its resemblance in
duced by the aggregation in follicles, physical characters to liquid glue, and he
ducts, and in interstices of adjacent tissue, proposes to call the concretions in question
of the small yellow bodies which have concentric colloid corpuscles.' He re
been referred to. gards them as ' principally composed of an
What the - yellow bodies ' are I am organic substance, and consequently the >
not able satisfactorily to explain . Whether names of “ stones ” and “ concretions” to

they are themselves altered secreting cells be inappropriate ; ' although he has
from the gland follicles, or whether only occasionally observed that the colloid
the product of secretion by these struc- matter is deposited upon some of the
tures, does not at present clearly appear. rounded or nodular forms of calcareous
Thus much I have observed, that the salts which are found scattered in the
small fusiform and spheroidal epithelium parenchyma of the prostate, and which
lining the prostatic ducts is often loaded thus form the nuclei of some few of the
with yellowish granular matter, appear concretions. A further study of this
ing in all respects to be identical with subject since the above appeared in the
that seen in a free state elsewhere, which first edition confirms me in my opinion
seems to favour the view that it is a that evidence is wanting at present to show
natural product of gland secretion ( figs. that these bodies are examples of amyloid
31-33). It may be added that I have degeneration ; or indeed that they are the
constantly found similar yellow granules in products of any morbid change at all.
the fluid of the vesiculæ seminales also, in Reviewing, however, all that has been
which, at all events in some elderly persons, ascertained of the mode of formation and
they appear to be more constant than are constitution of these bodies, I see no valid
spermatozoa . In this situation, bodies objection to the use of the term concre
which are evidently the same have been tions, at all events for the small formations
described in a recent article on the which have hitherto been described. Nor,
vesiculæ seminales, by Mr. Pittard,
6
perhaps, at present, is it easy to find a
appearing in the Cyclopædia of Anatomy better, since it is one which involves no
and Physiology,' as ' very numerous in- theory, except the simple one that the
soluble globules, which have a great mode of aggregation of their component
tendency to coalesce, and appear very elements is mechanical rather than organic
much like oil : their refractive power is, in its essential character. When they
however , less, and there are reasons for have arrived at a size sufficient to occasion ,
doubting that they are really globules of as gources of irritation , the deposit of
oil. Besid
6
es these, the same observer dense opaque earthy matter in the manner
finds suspended like conglomerated above referred to, they may be regarded
masses of transparent solid , just visible to as belonging to the category of calculus
the naked eye,' which have, under the rather than of concretion . The inorganic
microscope ,the appearance of a nodulated component now becomes predominant, the
mulberry -like surface, as if composed of
>
body increases in size ; and although
smaller balls ; ' these, he thinks, are made there is no exact period at which it can be
up by a coalescing of the minute globules said to cease to be a concretion and to
before mentioned . ' become a calculus, yet there can be no
Virchow believes the concretions to be hesitation as to which of the two terms
derived from a peculiar insoluble protein could be applied to most examples met
substance mixed with the semen . Wedl , with of either kind.
before referred to, regards them as identi- PROSTATIC CALCULI. — Prostatic calculi
cal with certain bodies found abundantly exist in very various sizes and forms.
in the enlarged thyroid gland, and with The smaller examples which are most
tirose met with in the brain and spinal
1
1 Rudiments of Pathological Histology. By C.
1453.
Cyclopædia of Anatomy and Physiology, p. Wedl. Translated for the Sydenham Society by
G. Busk, F.R.S 1855. pp. 38 and 271 .
frequently met with are rounded or These small prostatic calculi are often
ovoid ; the larger are irregular, often found lying each in a separate space for
elongated, sometimes branched, and com- itself, or hollow in the substance of the
monly consist of several fragments uniting organ , corresponding with the size of the
to form a mass. These fragments fit calculus itself. At other times several
almost accurately one to the other at their occupy a larger space or cavity, in which
adjacent surfaces, but nevertheless appear they are moveable; and thus their sphe
to be separate and distinct calculi which roidal form gives place to a more or less
have become adapted in form one to angular one, from their mutual pressure
another by close proximity. The small or attrition . In this state they may some
isolated formations are about the size of times be felt by the finger introduced into
grains of pearl barley, rarely as large as the rectum, and the grating, from their
peas ; and these form the purest specimens movements one upon another when pres
of prostatic calculus. The masses formed sure is made, plainly perceived. At the
by coalescence are of all sizes, but have same time a similar sensation is com
been seen reaching the length of four or municated to the hand by the catheter
five inches in very rare instances. In the passed along the urethra ,when the instru
latter case they extend into and along the ment traverses the prostatic part. I re
urethra, and even into the bladder. Still cently exhibited at the Pathological
in these circumstances chemical analysis Society some good examples, which fell
shows them to be mainly composed of under my own observation. They were
phosphate of lime, and to have but a taken from a patient who died at the age
small admixture of the ordinary vesical or of 89 years. The prostate was enlarged,
urinary product, the triple phosphate of although not greatly so, but occupying a
ammonia and magnesia. They are in concavity in each lateral lobe; and also im
sistence hard, and so close in texture as to mediately beneath the verumontanum
bear some resemblance to porcelain . They were numerous dark-coloured calculi, very
are white , fawn, or pale brown in colour, hard in texture, with polished surfaces,
the surface being usually of a darker tint each calculus having several irregular
than the interior. facets, varying from the size of a grain of
Analyses of several of the small round pearl barley to that of a large pea. These
variety have been made, and the com- characters distinguished them completely
position has pretty generally corresponded from calculi of renal or of vesical origin.ź
with the result of Dr. Wollaston's ex- The larger masses met with , occupying
amination , who first pointed out their partly the prostate and partly a space in
chemical character, and showed that they the tissues intervening between it and the
were not urinary products. Dr. Wollas- surface of the perineum , cannot be re
ton described them as composed of the garded absolutely as prostatic in their
neutral phosphate of lime, tinged with origin like those heretofore described ;
the secretion of the prostate .? Among nevertheless their situation demands that
modern observations, that of Lassaigne, they should be considered under that
which is generally quoted, may be adduced head in this place. Moreover, while they
as follows : consist largely of the same material as
Phosphate of lime . .
84.5
.
those of the preceding class, that is of the
Carbonate of lime . 3.5
0
phosphate of lime, they usually contain
Animal matters, &c. .
15.0
.
also enough of the triple phosphate in
their composition to relate them more or
100.0 less closely to the class called fusible
We have already seen, however, that calculus, this term being understood to
the proportions of these constituents may embrace many varieties in regard of the
vary considerably. It appears that as we relative proportions of the two phosphatic
approach the earliest stages of their for- salts. These formations often occupy
mation, the mineral constituent is found 1 Good examples of these small calculi, im
in diminished relative proportion to the bedded in the substance of the prostate, may be
animal. Thus the small concretions de- seen as under :
Royal College of Surgeons, Nos. 2519 and 2520.
scribed at pages 141-2, were composed University College Museum , Nos. 1640 and 3844.
of about equal parts of organic and in- state
Some areexamples of encysted Crosse'sofTreatise
well represented in Mr.calculi the pro on
organic matters. Calculus. London, 1835. Pl. xi.
1 Phil. Trans., 1797, p. 397. 2 Trans. of Path. Soc. vol. xii. 1861.
L2
large spaces in the prostatic substance and Numerous cases have been detailed
1
among the adjacent tissues ; irregular varying but little from the foregoing ,
cavities which enlarge with the increasing except in the much smaller size of the
bulk of the calculous formation . It is calculus met with. Many surgeons of
worthy of observation that they are most the last century refer to them , and to
frequently met with in young men. operative measures for their removal.2
.
One of the most complete descriptions The operative proceeding by which
on record of a case in which an extremely large prostatic calculi have been removed
large calculus of this kind existed, was is usually an incision in the perineum
reported by the late Dr. T. H. Barker, of carried into the urethra upon a grooved
Bedford . This gentleman successfully staff, in the manner and situation of lateral
moved a mass formed by 29 portions, i Cases of Calculi formed in the posterior part
weighi ng three ounces and ahalf, from a of urethra (notmerelylodged there ), all being
the
patient 26 years of age. He describes probably of prostatic origin
Mr. Jos. Warner, of Guy's Hospital, removed ,
them as of 'a whitish colour, and porce- froma man aged20, twohard and polished calculi,
lainous lustre and hardness ; indeed the weighing 350 grains, from the perineum, where
er
latter charact is so well marked that it they could be felt by the finger before the opera
tion. - Phil. Trans., vol. li. p . 304, with plate.
is with some difficulty that any impression A second case , in which the calculi were very
can be made upon them with a knife.' 1 much larger, is reported by the same surgeon :
It was found to consist of phosphate of patient aged 22. — Phil. Truns. vol. lii. p. 258,with
6
plate.
lime (like salivary and bronchial calculi), Dr. Livingston , of Aberdeen , two cases.
with a rather larger proportion than usual Edinburgh Essays and Observations, vol. lii. p. 546.
a
of the ammoniaco -magnesian phosphates .' 1771.

. Cheston, of Gloucester, one case . — Medical
Dr.
When the
nt stone was restore
nts d by the
justme of the fragme , it measured 47 ad- Recordsand Researche
Mr. Wickham
s ,p. 163. 1798
, of Winchester .
, a post-mortem
case . — Medical Facts, vol . viii. p. 126. 1800.
inches in length. Dr. Marcet relates a case in which 100 calculi
A case very closely resembling this is were found . — Drawn , Pl. ix. Essay on Calculous
recorded by the late Mr. B. Gooch, of Disorders. 2nd. ed. London. 1819.
Sir Astley Cooper
relates three cases. l -Surgica
Norwich. The calculus consisted of six - Lectures, 1825. Vol.ii. pp. 295, 296.
teen fragments , which when applied to Sir B. Brodie, a case in which the calculi were
each other formed a mass nearly six inches lodged in a sac, from which he removed someby
in length. They are described as being urethral forceps.-Urinary
Mr. Crosse Organs,4th
,of Norwich , several ed .p.362.
cases.— Treatise
like alabast
rather er inpolish.'
a finer colour, and as fineg or
A ofdrawin is
on Calculus. London, 1835. p. 26 , et seq .
Mr. Liston removed one of characteristic appear
appended representing the natural size. ance in several fragments, by a scoop , through the
urethra . - Drawn, Lancet, Oct. 28, 1843 .
Mr. Fergusson, of London, a case of thirty frag
Two
which aresuch casessketche
briefly have fallen to my :-lot,
d as follows ments, forming a mass as large as a walnut, -
Lancet, 1848, vol. i. p . 91. Another large speci
men.- Lancet, 1849, vol . ii . p. 552.
A gentleman, aged 44, came to me from China Mr. Erichsen, of London, a case of prostatic
suffering severely with stricture of theurethra, associatedwithvesicalcalculus in a youth .--- Lan
which admitted cnly No. 2 catheter. This was cet, 1850, vol.ii . p . 575 .
treated by continuous dilatation , and while doing Dr. B. Jones, a post-mortem case, tenfrag
so stone was felt. On February 17, 1878, I ments. — Described and engraved in Path . Trans.
vi. p.254
divided the stricture externally from the peri- vol.Cases .
on record in which calculi of this kind
neum , and found just outside the neck of, the
the have escaped externally through abscess in the
s
bladder a sac filled with numerou calculi
fragments fitting by their polished facets. 'Mr. perine um tren
Dupuy : , after dilating with the knife some
Clover gave ether,and Mr. G. B. Browne i with articulat
held perineal fistulæ ,removed 12 calculed,
the staff. He made an excellent recovery,and ing surfac es, from , as he believ the prostate.
I have recently seen him perfectly well (1882). rd Théna sed
analy , and found 86 percent, of
them
On August 3 of the same year, I operated phosphate of lime, 13 of animal matter, and traces
on
a gentleman aged 63, with Mr. Brewer of of carbonate of lime. -Journal Univ . des Sciences
Huddersfield . I encountered three large calculi MédLenoir
., Aug. and .
1820Nelaton, a case each ; made up of
in a cavity
which I hadclose to the
some neck ofin the
trouble bladder,
removi from.
ng them several fragments ; removed by simple pressure,
Their position was well made out beforehand by lithotrity and by cutting. – Gaz. des Hôpitaur,
184 . 6
by rectal examination . The calculi fitted each Gond examples are preserved in the museum of
other by polished facets, and weighed two the College of Surgeons :the best are those num
ounces .
bered H 13, 15, and 23. The first, which is the
largest, weighs 1 ounce and 95 grains .
Trans. Prov. Med . and Surg. Ass., 1847, with Dionis. Oper. de Chir. par La Faye, p. 221 .
4 drawing of the stone. l Deschamps, Sur la Taille, tom . iv. p. 161, et seq .,
· Cases and Practica Remarks on Surgery. | 1796. Sabatier, Méd . Opératoi re, . p. .
tom . iii 136
Norwich, 1777. Vol ii. p. 174, 1810 .
VESICAL CALCULUS IN HYPERTROPIILED PROSTATE . 149
lithotomy. Occasionally the opening has When by their increased size irritation is
been made in the median line, i.e. in the set up, abscess may be formed or obstruc
raphe of the perineum . Undoubtedly tion to the flow of urine be occasioned ; the
this situation isthe best and safest for the latter may take place also from the escape of
incision , inasmuch as the median opening small calculi into the urethra . The treat
gives a niore complete command of the ment of these consists in their removal if
position occupied by the stone ; and is possible by means of the forceps or long
also a nearer and less hazardous route to cuvette, in the same manner as advised
the neck of the bladder under these cir- for the removal of fragments after the
cumstances. The operation is less dan - operation of lithotrity, in the succeeding
gerous than that of ordinary lithotomy, chapter. But when marked symptoms
as the bladder remains untouched , sup- are present, and a foreign body can be
posing there is no vesical calculus also, ascertained by the sound or catheter to
a point which must be carefully investi- be embedded ' anterior to the neck of the
gated beforehand. bladder, or when it can be recognised
The existence of these bodies, when from the rectum or perineum, an incision
small and embedded in the prostate, is from the latter spot will offer a simple
not revealed by symptoms during life. and efficient means of removing it.
CHAPTER XX.
ON THE RELATION BETWEEN HIPERTROPIJED PROSTATE AND STONE IN THE BLADDER .
Vesical Calculus a frequent Result of Enlarged Prostate-How this may be accounted for — Calculus.
often overlooked — Best means of discovering it, by Sounding, & c. — Difficulties in removing it,
Lithotomy and Lithotrity - Objections to each considered-General Applicability of Lithotrity-
The method by one sitting the best for most cases - Statistics— Injection of Solvents — Their use
Superiority of modern Mechanical Treatment.
So closely connected is enlargement of not invariably, aa vesical product, that is,

the prostate, through the resulting chronic one owing its existence mainly to the
cystitis, with the formation of earthy de- bladder itself. From the altered condi
posits in the bladder, that it is necessary tion of urine depending upon constant or
to give some consideration in these pages long- continued retention within the viscus
to that subject, at all events under one of a certain quantity which cannot be
of its several aspects, and that certainly expelled by the efforts of the patient,
neither the least difficult nor the least owing to the existence of obstruction at
important one. For no one can have the its neck, irritation of the mucous lining
care of many cases of enlarged prostate is set up, and much viscid secretion is
without sometimes meeting also one of often poured out. This action having
calculous formation in the bladder, although long continued, it will frequently be ob
he might, perhaps not improbably, over- served that some whitish soft or gritty
look its presence, so much are the symptoms matter, a phosphatic deposit, is evolved
of the one malady masked by those of the from the same source ; at first, perhaps,
other. Of this oversight I have witnessed only in inconsiderable quantity. This
not a few instances. Nevertheless, it is may pass off entirely with the mucus, in
one which ought not to occur, since the which streaky portions are seen to be
discovery of calculus in these circum- entangled ; and no more than this may
starces is easy ; the removal of it when occur . The formation may take place in
small is a safe and simple proceeding ; small quantities, and may possess no very
while, lastly, it is a matter of vital impor- great cohesive power, in which case the
tance to the patient that he should be bladder can bemaintained tolerably clear
relieved of the foreign body at as early a by occasionally injecting it with warm
period as possible. water, either unmixed or to which a
The calculus which is met with under minute quantity of mineral acid has been
these circumstances is generally, although | added. On the other hand, the calculous
deposit may assume a more solid consis- |magnesia, with some phosphate of lime
tence, a nucleus may be formed, and, and a very small quantity of carbonate of
aggregation taking place, a phosphatic lime. Such are the constituents frequently
stone may not slowly result. This con- met with in the circumstances described,
dition is very much favoured by the state of the deposits which form a proportion
of the urine itself under circumstances of of the calculi produced at all ages, but par
retention, as, instead of being acid, and so ticularly of those which occurat advanced
affording a menstruum favourable to the periods of life.
solution of a phosphatic formation, it Secondly. - There is the unhealthy state
becomes alkaline, and not only tends to of the mucous membrane lining the
produce irritation of the mucous mem- bladder, which results from the altered
brane, but also to augment the earthy condition of the urine, and augments the
formation by accretion. In the same tendency both to alkalinity and to deposit.
manner also, if a solid body be introduced The presence of carbonate of ammonia
into the bladder while the urine remains habitually produced in the manner de
in this unhealthy condition, it is almost scribed, irritatesthe mucous membrane, and
certain rapidly to acquire a coating of an unusualquantityofitssecretion, which is
this same deposit. And so it happens naturally alkaline, is poured out ; this added
that if a small renal calculus which con- | to the urine, even when the latter is in its
sists of uric acid or urates, or of oxalic normally acid condition, is sufficient to
acid, descend at this time through the render it alkaline. But when the urine
ureter, a large phosphatic stone will pro- is already decomposed from retention, this
bably at no very long time be formed action of the mucous membrane renders
upon it as a nucleus. But this descent of the secretion still more morbid in quality.
the renal product is no mere contingency For the mucus, or muco -pus, which is so
under the circumstances, no mere unlikely familiarly known by the tenacious and
coincidence with the vesical state, but the adhesive character which it presents when
contrary. Many individuals in the middle removed from the body and cooled , con
tains earthy phosphates, chiefly the phos
ranks of life pass small uric acid calculi
between fifty -five and sixty -five years of
phate of lime, with a trace of the carbon
age; and in the bladder of a patient who
ate, and often to a large amount ; these
does not empty it by the natural efforts,
being of course insoluble in the alkaline
such a one is almost certain to be de-
secretion, are also precipitated in addition
tainedand to acquire a phosphatic coat-
to those derived from the urinary secre
ing. The process in question is thus tion proper. Thus the inorganic con
effected : stituents of a phosphatic calculus are
First.— There is the altered condition abundantly supplied, and in circumstances
of the urine, sometimes resulting from particularly favourable to its formation,
neglected retention ; namely, its alkalinity, viz., in a surrounding menstruum in
and consequent tendency to deposit the which solution of the earthy precipitate
earthy phosphates in the form of an inso- cannot be effected ; contained in a cavity
luble precipitate. The alkalinity may be from which , both on account of its form
attributed primarily to the production of and impaired vital powers, the contents
carbonate of ammonia from the decompo- are with difficulty expelled, and in which,
sition of urea, favoured by the presence consequently, aggregation and concretion
of some organic matter (probably mucus) ; are promoted; while, lastly, all this takes
a process which takes place in the urine place in presence of an adhesive organic
of a healthy person, if permitted to stand material, well adapted to form a binding
in the air for a day or two after its re- cement for the saline particles of calculous
moval from the body. It now deposits matter. As might be expected under
the phosphate of limeand magnesia , which such circumstances, the resulting forma
in small proportions are normal consti- tion most commonly met with is the fusi
tuents of healthy urine, but which in its ble calculus, composed of the phosphate
normally acid condition remain in a state of ammonia and magnesia, intermixed
of solution. The urine being alkaline, with the phosphate of lime in greater or
these salts tend to precipitate, and doing less abundance ; the proportions doubtless
so in presence of the carbonateofammonia depending on the relative preponderating
just referred to, there results the forma- influence of either of the two sources of
tion of a triple phosphate of ammonia and the deposit pointed out.
VESICAL CALCULUS IN HYPERTROPHIED PROSTATE . 151
The calculous contents of the bladder the position of the body of the patient.
resulting from , and frequently associated The pelvis should be raised above the
with, enlarged prostate, assume two forms level of the shoulders, on a hard cushion,
as regards their physical condition, viz., so that the neck of the bladder is raised,
calculi, of tolerable density and hardness, andthe stone made to roll away from it.
ovoid, or irregular in form ; and deposits The sound to be employed should not
of softer matter, almost like mortar, and only possess the form which has been
taking no defined shape. indicated (see fig. 21, page 77 ), but
Whenever the symptoms accompany- should be hollow , so as to admit of the
ing enlarged prostate, especially pain and passage of a stream of water through it
involuntary straining, are in any case either inwards or outwards as may be re
more severe than those which are ordi- quired. It should be made of steel, so
narily encountered ; whenever the occa- that it may possess weight and solidity ;
sional appearance of blood in the urine and should be plated, that the channel,
has been noted, unassociated with the which , is necessarily small, may not be
use of thecatheter, and occurring especially blocked up by rust,an accident which is
after moderate exercise ; inquiry should otherwise very apt to happen . There
be made for calculus. We have already may be also a plug or stop -cock at the
seen how much the ordinary signs of its handle, the opening in the latter being
presence are frequently masked by the adapted to fit the nozzle of an injecting
enlargement, partly from the fact that the instrument.
foreign body is less liable to come in The sound having been introduced
contact with the neck of the bladder, and into the bladder when it is neither dis
partly because the viscus itself is often un- tended nor empty, but holding only a
able to contract altogether upon its in- small quantity of urine, the search may
tents, and so the pain at the end of the be conducted by passing the beak laterally
act of micturitionis but slight, or may be from the prostate to the upper part of the
absent altogether. Nevertheless, it is not bladder, first on one side, then on the
the less important to verify the fact of its other. The instrument, having been
existence or the contrary, and this occa- directed through the upper fundus and
sionally requires a mode of search more back part, is now conducted to the de
rigorous in some respects than that pression behind the prostate. Withdraw
adopted in ordinary cases, and one which ing it until the heak arrives as near to the
is specially adapted to the circumstances neck of the bladderas the tumour permits,
resulting from this form of complaint. the handle is slowly depressed between
The ordinary silver catheter will generally the patient's thighs, so that it can be
fail to encounter the stone, and thus it is fairly rotated, and its beak turned down
that its presence is often never suspected, wards towards the rectum . It is then
although it may bave existed for years ; moved gently to the right and left, back
the daily use of such an instrument with wards and forwards, during which it will
out finding it being deemed sufficient probably be felt to glide lightly over some
evidence. Generally the foreign body projecting muscular columns, if the
lies in a depression behind the enlarged bladder be fasciculated. At this point, if
prostate, and is rarely detected except by nothing is found , the patient's pelvis may
the use of the short-curved or angular be elevated in order to dislodge the sus
sound or catheter (see fig. 23), the beak pected calculus from behind the prostate,
of which, if sufficiently short, that is, less and move it into the body, or towards the
than one inch in length, can, after intro- upper part of the bladder. Nothing being
duction into the bladder, be turned down- still discovered, the patient may be placed
wards with perfect ease behind the base in the upright posture, or he may be
of the prostate into this depression . In partially seated, while the water is per
some cases even this movement fails to mitted to flow through the sound ; during
reach the stone, and other means must be which it sometimes happens that the stone
adopted . Thus the finger of the left hand is brought down against the sound, or
being introduced into the rectum, some that the relations of parts are in some way
times suffices to elevate the base of the altered, so as to permit a stone to be felt
>
bladder or to displace the stone, and per- which had hitherto escaped detection. In
mit contact between it and the sound to cases of doubt, a lithotrite of moderate
be made. Another mode is by changing size offers some advantages as a sound .
152 THE DISEASES OF THE PROSTATE
The ability to open the blades a little derable to the easy introduction of
presents a fresh mode of searching, and the instrument, and sometimes causes a
enables the operator to sweep a larger little more difficulty in seizing the
field in the distended bladder, adding to stone ; but these are difficulties of small
our chances especially when seeking to importance. Careful management of the
detect small stones or fragments. Civiale lithotrite will overcome any difficulty
sometimes employed a lithotrite, of which met with in traversing the urethra,
the male blade contains a channel , so as even when considerably deviating from
to permit water either to be injected the normaldirection and length ; or in
through it, or to escape, during its employ- dealing with the calculus in the bladder
ment in the bladder, whether for sounding itself. This subject is discussed at length
or for crushing the stone ; but this is a re- in my work on Lithotomy and Lithotrity.
finement which I have never known to be There can be no doubt that the main
necessary . objections to lithotrity in cases of enlarged
The presence of calculus having been prostate do not lie on the ground of any
verified, the mode of removing it comes particular difficulty in performing the
next under consideration . operation . A more formidable obstacle
Enlargement of the prostate is doubt is a contracted irritable bladder, which
less a source of difficulty in the perform- will not easily retain the requisite quan
ance both of lithotomy and lithotrity. tity of fluid ; in which there is neither
In lithotomy it prevents, if very large, space enough to work, nor ability to bear
the finger from reaching the bladder, and the necessary manipulation . Neither of
determining the situation of the stone, these conditions commonly exists in asso
renders the application of the forceps more ciation with enlarged prostate, for, on the
uncertain, and the seizing and extraction
of the stone more difficult. The distance
from the surface of the perineum to the
vesical cavity is increased in proportion
to the degree of enlargement. The pro
static urethra, as we have seen, may be
lengthened from one and a half inch to
three inches, or even a little more, and
beyond this there may be a tumour pro
jecting, over which any instrument must
be carried before the calculus, which lies
deeply behind it, can be reached. In any
case of notable enlargement the finger
can barely reach the bladder or tonch the
stone, so as to verify or influence its posi
tion. Again, the depth of the wound
limits the motions of the forceps consi
derably ; it is not merely necessary to
seize the object without the assistance of
the finger, but the range of movements Fig . 35. — The Author'saspirator, for removing
fragments, small calculi, and concretions frouz
possible to the instrument is circumscribed the bladder.
-indeed , in some rare cases it would
scarcely be practicable to obtain contact contrary , the bladder is generally dilated,
with the calculus, unless the blades were and the urethra often well accustomed to
specially curved to enable the operator to instrumental contact. The objection on
search behind the prostate for it. On the the ground of the difficulty of expelling
same ground, the extraction is more diffi- the fragments was formerly regarded as
cult ; an increased length of passage re- more considerable.
quires a proportionate augmentation of But this no longer exists, since the
diameter, in other words, a more extended method of crushing the store at one
use of the knife, to permit a facility for sitting, and removing all the fragments by
extraction equal to that enjoyed in ordi- the aspirator, has been proved the most
nary cases. successful operation ever practised in deal
In lithotrity, the enlarged prostate ing with very large and hard formationen
affords an obstacle more or less consi. When I last reported my own experience
VESICAL CALCULUS IN HYPERTROPIIIED PROSTATE . 153
of this operation , the cases dealt with , to repeat the process six, eight, or even
were 101 in number, all adults ; the mcan ten times, maintaining him thus in a
age being over sixty -two and a half years. condition of safety and tolerable comfort.
Of these 101 individuals, several were There are some cases, perhaps, in
the subjects of hypertrophied prostate, which it may be possible to obtain assist
and were compelled to depend on cathe- ance from the injection of solvents into
terism for relief of the bladder. Only the bladder.
three deaths occurred , a result which, I It has been already stated that many
may venture to say, had hitherto been of the formations met with in the bladder
unequalled in the history of lithotrity. in connection with enlarged prostate are
The lithotrites employed were in type phosphatic in their character. And these
those which have been adopted by the are also the most susceptible to the in
profession for several years past ; and the fluence of chemicalagents, not only on ac
aspirator is a modification by myself of count of their own chemical constitution,
the original aspirator by Mr. Clover, but on the ground of the state of physi
which has for many years been so service- cal aggregation which they usually affect.
able to me in the same way, but to a So greatly, however, has the me
smaller extent, for these cases. The appa- chanical process of removing calculous
ratus of Clover was that which I advised matter in any form been improved, that
in previous editions, to be employed for there are very few instances in which
this purpose. My own aspirator, which the use of solvents can be necessary as a
I now invariably employ, and which is substitute for an operation. As a means
very serviceable for removing small phos- of preventing the occurrence of concretion,
phatic concretions, and phosphatic gra- of dissolving the earthy deposits in the
nular and mortar-like deposits, is shown earliest stage of formation, solvents play
at fig. 35. It may be also occasionally an important part in the matter of treat
employed for the purpose of removing ment. Sir B. Brodie employed weak
blood clots from the bladder ( see p. 93 ). solutions of nitric acid to dissolve small
In regard of the phosphatic concretion's phosphatic concretions, and was successful
and deposits just referred to, which are in two cases, which he reported at length .
formed in the bladder-and of course After that the effect of weak solutions of
wholly distinct in their nature from the acetate of lead was found to be still more
prostatic concretions of which the history considerable upon these bodies, and
has been given (p. 141 )—this instrument excited at the time ( 1830–40) much in
affords the best method of dealing with terest. I found by much experimentthat
them. They are not to be admitted to the one grain to three ounces of distilled water
rank of vesicalcalculi, to which the largerwas the strongest solution which could be
and more mature examples belong Had employed for the purpose without irri
I so regarded them , the number of my tating the bladder. But the proceeding
stone operations' would be greatly aug- is for myself now wholly obsolete, so far
mented . But after a calculus of some size as removal of an existing calculus is con
has been removed from a patient whose cerned. The solution in question is,
prostate compels him to pass all his urine however, still the most efficient known
by catheter, the formations in question are agent to prevent the appearance of the
very prone to recur, and may be regularly phosphatic deposits in those who are
and periodically removed while quite small, subject to their occurrence. It should be
thus preventing the re-formation of what used by injection bottle once or twice
6
might be correctly termed a ' calculus.' | daily - say four ounces at a time, leaving
Such a patient finds from time' to time his one to two ounces in the bladder on each
symptoms aggravated by the presence of occasion . Although this treatment con
a small phosphatic concretion, weighing trols the tendency to produce phosphatic
perhaps from ten to twenty grains, too large deposit, it cannot be said always to
to wash out by the ordinary bottle, but prevent it, and the re-formation of such
which a single introduction of the litho- concretions will take place in some
trite or aspirator suffices to remove. This patients, whatever local or general treat
proceeding may be repeated sometimes ment is adopted. Indeed, no general
once or twice in a year ; and thus, for a treatment or even regimen and diet have
single individual, the surgeon may have any influence on the bladder in relation
1 Lancet, January 14, 1882. to its abnormal tendency in this matter.
1
INDEX
PAGE PAGE
ABSCESS of the prostate, chronic 34 CALCULI , prostatic 140
morbid anatomy of 31 Calculus, diagnosed from hypertrophy 68
symptoms . 33 >> with enlarged prostate 151
33 causes of 149
treatment
31
Abscess of the prostate, acute . mode of sounding for 151
morbid anatomy of 31 > lithotrity for 152
symptoms and treatment 33 solvents for . 153
chronic cases 34-36 Cancer of the prostate
Acetate of lead injections 91 99 frequency of
Acid injections for bladder 90 morbid anatomy of 121
Acute prostatitis 2 92 symptoms of 122
Acute and chronic abscess 34 2 urine in 123
Adams, on course of urethra in prostate 11 treatment of 123
on use of alkalies 89 > 29 cases of 124
on scirrhus of the prostate 120 Capsule of the prostate 18
Age, the, when hypertrophy appears . 63 Cases 34, 36, 55, 56, 124, 129, 132
Alchemilla arvensis 86 of abscess of prostate 34, 36
Alkalies, value of 89 of prostatic tumour 55, 56
Amyloid origin of concretions 146 9 of cancer of the prostate . 124
Analogy between prostatic and uterine tu
mours .
of tubercle in the prostate 129
53 " of hydatids 131
Analysisof164 prostatic dissections 63 of prostatic calculi 148
Anatomy of theprostate 1,14 Catheterism , when necessary 79
Angular catheter of Mercier 104 by the patient himself 80
Aspiration for vesical hæmorrhage 93 in retention 100
Aspirator, new, for removal of fragments 152 mode of performing 103
Atony or inertia of the bladder . 70 Catheters, gum elastic 80, 101, 103
diagnosis of 78 English and coudée O 81, 102
often mistaken .of tying in the 81, 108
for paralysis 78 Causes of hypertrophy 57
treatment of 83 opinions respecting 58
Atrophy of the prostate 117 exceedingly obscure 57
forms of 117 of prostatitis; 24
symptoms and treat- Changes in urethrafromhypertrophy 41, 44
ment 119 Characters of urine in hypertrophy 67, 150
Children , prostate in 18
BALSAMS, the use of .
87 | Chimaphila umbellata 87
Bar at the neck of the bladder 132 Chios turpentine 87
conclusions re- Chronic prostatitis 28
specting 137 Civiale, on causes of hypertrophy 59
diagnosis of 77, 137 on bar at the neck of the bladder . 134
treatment of 138 on operations for 139
prostatitis
Baths, hot, in cystitis 27 Cock's instrument for puncture . 109
in 84 Compression 97
in retention 101 various modes of 98
Bell on muscles of the ureters 135 Conclusions respecting operations for reten
Benzoic acid , value of 90 tion 116
Bladder to be emptied daily 80 Concretions, prostatic 141
99 when not to be emptied . 82, 106 Congestion of hypertrophied prostate 93
not to be emptied always 106 treatment of . 94
of death from so doing 107 Counter -irritation in cystitis 84
case
the bar at the neck of 132 Course of urethra through prostate 11
Blood in the urine 92 Cruveilbier on prostatictumours 48
Bottini on electric cautery 140 Crypts or vesicles of prostate 16
Brander's, Dr., puncture through symphysis 109 Cystitis, chronic, diagnosed from hyper 78
Brodie, on hypertrophy of prostate 58 trophy .
on catheterism 82 caused by hypertrophy. 83
‫وو‬ on injecting the bladder 90 treatment of 84
on value of solvents for stone .
153 Cysts or cavities in prostate 130
Buchu, properties of . 84 varieties of 131
156 INDEX .
EHB1 $ SM 玩
L'AGE PAGE
DANGER of catheterism in some cases 82, 107 Hypertroply, changes in tlic urethra in 41
Daucus Carota 87 structural changes in 44
Decoctions . 88 different forms of . 38, 45
Demulcents, the use of not, an effect of age 63
modes of making rarely causes incontinence 71
Desault on hypertrophy . 59
almost always causes retention 66
Diagnosis of hypertrophy 73 91 treatment of 79
of tumour at neck of bladder . 77 6
llunter, on the third lobe ' 10
of bar at neck of bladder
Dietetic rules in hypertrophied prostate.
137 on causes of hypertrophy 57
94
Different forms of hypertrophy 45
69
INCONTINENCE, often used erroneously
9%%%%%%%% 四四
.
Dilatation of the bladder 72
Diseases of the prostate 24 of urine, treatment of . 93
Dissections of the prostate is rare 71
19-23
to define prostate 2
Inertia of the bladder 70, 83
Division of obstructions by cutting 139
Inflammation of prostate,acute 24
99 causes 24
by electric cautery 99, 140
morbid anatomy 25
8
9
of the prostate into lobes 99 symptoms . 26
treatment 26
Effects of enlarged prostate on micturition . 69 chronic 28
prostatic obstruction 71 , 72 99 causes 28
Ejaculatory ducts 13 morbid anatomy 28
Electricity . 99 symptoms 29
Ellis on anatomy of prostate and bladder 14 treatment 29
Encephaloid of prostate 120 enlargement result
Engorgement of the bladder 69, 71 ing from 31
Enlargement from hypertrophy . 39 Injections in lithotrity 153
%%%
prostatitis . 31 locline in hypertrophied prostate .
96
Enormous prostatic calculi . 148 Irritability of bladder 71, 90
Epi gwa repens 87 : suppositories for 90
Epitheliam of prostate 16
Examination of prostate by rectum 71
JOXES, HANDFIELD, on tissue of prostate 14
4
by the urethra 75 46
External relations of prostate 6
on hypertrophy
on prostatic concretions 145
FALSE passages
106 | KÖLLIKER , on anatomy of prostate 14
mode of avoiding 106 Kreuznach waters 97
Mercier's instrument for 107
Fotal development of prostate 18
Follicles of the prostate 16 LEROY D'ETIOLLES, on bar at the reck of the
Forms of soundto be employed 76, 77 bladder 134
Frequency of hypertrophy 63 his treatment of 138
of atrophy 118 2 on treatment of prostatic
of prostatic tumours 47 enlargement . 98
Function ofmicturition in hypertrophy 69 Lithoto my; with hypertrophied prostate

Lithotrite scoop, use of
152
152
Lithotrity , with hypertrophied prostate 152
Glaxd lubules of prostate 17 injections in 153
Glandular structures of prostate 15 aid of solvents in 153
Gross, on size andweight of the prostate .5 , 18 Lobes of the prostate 8
on causes of hypertrophy . 58 Lobules of the prostate 16, 17
99 on enlarged prostate 73 Lymphatics of the prostate
on remedies for cystitis 84 , 85, 88, 89 Lythrum Salicaria, Prout on 86
on bar at the neck of the bladder. 134
Gum elastic catheters 80, 101 , 103 MANAGEMENT, general, of patients with hy
Guthrie,' on bar at the neck of the bladder 135
on operations for 138 pertrophy 93
Matico 86
Measurements of prostate . 4 , 5, 20
HÆMATURIA . 91 Melanosis of prostate 121
Hæmorrhage into bladder 139 Mercier,'on course of urethra in prostate 12
aspirator for 93 on causes of prostatic hypertrophy 59
treatment of . 92 * on paralysis of the bladder 70
Healthy prostate, measurements of 4, 5 92 on hypertrophy causing incontinence 71
Hemlock in hypertrophied prostate 95 his angular catheter 104
History of solvents for stone . 153 mode of avoiding false passages 106
Hodgson, Dr., on size of the prostate . 5 instrument 107
‫ܕܕ‬ on course of urethra in 12 on bar at neck of the bladder 134
9
on hypertrophy of urethra . 46 his operations for 139
Home, 6 on the third lobe ' 9 Mercury in hypertrophied prostate 96
on hypertrophy 42, 57 Messer, Dr., on weight of prostate 6
Hydatids near to the prostate . 132 his dissections 21 , 39
Hydrochlorate of ammonia 96 29 on absence of symptoms 44
Hypertrophy of the prostate 37 on tumours in prostate 47
morbid anatomy of 37 Microscopical examination of hypertrophied
physical characters of 37 1 rostate 45 , 51
' parts affected by . 38 history of concretions 144
amount of enlargement from 39 Minute anatomy of prostate 14
INDEX. 157
PAGE PAGE
Minute anatomy of prostate, Kölliker on . 14 SACCULATION of the bladder . 72
>
Ellis on 14 Scirrhus of the prostate 120
17 | Section of prostate in lithotomy 5
Mode ofexamining the minute structures
% W % H 昭uu7 % 们经历。
73 Senega 86
examining the prostate 117
Morbid anatomy 28, 31,32, 37 , 121, 128 Senile atrophy of prostate 103
Morgagni ' on the third lobe '
6
10 Silver catheters, mode of passing
Mucus or muco - pus in the urine 67, 150 Simpson, on analogy between uterus and
3, 14, 15 53
Muscular fibres of prostate prostate .
Sinus prostaticus 12
NUMERICAL prevalence of hypertrophy . .
63 Solvents, use of 153
Sounding for stone when prostate is enlarged 151
OPERATIONS for diminishing hypertrophy 99 Sounds to be employed 76, 77, 113, 151
for relief of advanced cases 111 Spence, on irregular vessel near prostate
by supra-pubic puncture 113 Stafford's treatment of hypertrophied prostate 63
>
96
" by perineal incision 115 Statistics of hypertrophy
77
Opiates 90 Stricture diagnosed from hypertrophy 44
Outgrowths from the prostate 52 Structural changes in hypertrophy
Over -distension of the bladder 70 Structure of prostatic glands . 15
Overflow of urine . 69, 71 Structures of prostate and bladder continuous 3
Styptics 92
PAGET, Mr., of Leicester, his cases 110 Suppositories . 90
on supra -pubic puncture 113 Suppuration of the prostate 31

)
49 Supra- pubic puncture . 113
on prostatic tumours
9
Paralysis of the bladder diagnosed from hy- Symptoms of hypertrophied prostate 64

pertrophy 78
85
Pareira brava, properties of 108 TABLE of diseases of prostate 24 , 127, 129
Perforation of the prostate in retention
Perineal incision for relief of bladder . of 194 prostates 19-23
115
91 Tanchou's cases of cancer 119
Phosphatic urine Treatment of hypertrophy of prostate 79
injections,use of for 91
of its results 80
63 92
Prevalence of hypertrophied prostate general . 94

Prostate, an independent organ
external relations of 6 special 95
form of 4 of vesical hæmorrhage 92
18 of bar at the neck of the bladder 138
in young subjects 4
Triticum repens . 85
measurements of .
3 Tubercle of the prostate . 128
structural anatomy of 5 morbid anatomy of 128
weight of symptoms 128
abscess of 31
ulceration of 36 treatment 129
cases of 129
Prostatic calculi 146
Tumour of the bladder, diagnosis 77
99 > analysis of 147
148 Tumours, simple, of prostate . 48
cases of . 47
9
operations for 148 frequency of
141 Cruveilhier on 48
concretions 50
analysis of . 142 29 Gray on
"
ducts 13, 16 Rokitansky on 49
37 Paget on 49
hypertrophy 2 > Velpeau on 48
ligaments : 3 99 examples of 50
muscles .
52 description of . 51
9 outgrowths 47 cases of 55
tumours, simple of prostate and uterus compared 53
urethra 12
Prostatitis, acute
24 Tying in the catheter 81 , 108
Puncture of the bladder, supra-pubic 108
by rectum 109 ULCERATION of the prostate . 36
through symphysis Urethra, course of 11
pubis 109 relationof, to thegland 11

> appreciation of me- Urethral mucous membrane 13
thods 110 | Urine , alkaline, action of 67, 150
case of 110 the, in hypertrophy of prostate 66, 150
Utricle, the .13
QUAIN , Mr., on an artery supplying the pro- Uva ursi, properties of 85 , 88
state 7 Uvula vesicæ . 12
RARE form of prostatic tumour 55

89
VEINS of the prostate
Rees, Dr., on use of alkalies Velpeau on prostatic tumours 48
Regimen and diet 94
Vesicles of the prostate 16
Retention of urine, treatment of 100
Vessels of the prostate 7
catheterism in . 101
99
exceptional 8
puncture of bladder in 108
Virchow on concretions . 140
produced by prostatic tumours 41 , 71
the common result of hypertrophy 66
"
treatment of . 100 WALSHE on cancer of the prostate 120
Rokitansky on prostatic tumours 49 | Weight of healthy prostate
Spotlisuoode & Co., Prirlers, Neu -strect Square London ,

1
LANE MEDICAL LIBRARY
To avoid fine, this book should be returned on

or before the date last stamped below.
MAR 16 1960
NOV 25 1981
N69 Thompson , Sir H.
146 The diseases of the
1883 prostate ,
NAME
54078
DATE DUE
11
A Lone MAR 10
294. 2976
P.C.3-2 5/ 0
P"

The Diseases of The Prostate

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DISEASES OF THE PROSTATE

PATHOLOGY AND TREATMENT

Jacksonian Prize Essay for the Year 1860

SIR HENRY THOMPSON

Clinical Lectures on Diseases of the Urinary Organs :

Practical Lithotomy and Lithotrity ;

The Preventive Treatment of Calculous Disease , and the Use of

The Pathology and Treatment of Stricture of the Urethra and

THE FIFTH EDITION

The preceding edition having been recently exhausted, I have

Finally, I am glad to be able to follow the course I originated in

35 WIMPOLE STREET, CAVENDISH SQUARE

The effects of enlarged Prostate in relation to the function of

WIMPOLE STREET, CAVENDISH SQUARE :

PART 1 . THE ANATOMY OF THE PROSTATE.

I. THE TOPOGRAPHICAL AND STRUCTURAL ANATOMY OF THE PROSTATE 1

PART II. THE DISEASES OF THE PROSTATE .

III, INFLAMMATION OF THE PROSTATE, ACUTE AND CHRONIC 24

IV. SUPPURATION OF THE PROSTATE ; ABSCESS, ACUTE AND CHRONIC 31

V. HYPERTROPHY OF THE PROSTATE ; ITS ANATOMICAL CHARACTERS 37

XI. THE TREATMENT OF PROSTATIC ENLARGEMENT, FROM HYPERTROPHY AND SIMPLE

XIV. ATROPHY OF THE PROSTATE 117

XV . CANCER OF THE PROSTATE 119

XVII. CYSTS OR CAVITIES IN THE PROSTATE 130

XVIII. THE BAR AT THE NECK OF THE BLADDER 132

XIX , PROSTATIC CONCRETIONS AND CALCULI 141

8. Diagram of typical form of enlargement 41

13. Bladder and prostate ; general hypertrophy 43

14. Small tumour causing total obstruction 43

15. Tumour of verumontanuin .

16. Tumours of prostate, largely developed 56

18. Prostatic tumour ; sacculated bladder .

23. English gum catheter mounted on over-curved stilet 81

25. Olivary catheter 103

28. Instruments for opening bladder above the pubes 113

30. Ditto for excision . 140

31. Prostatic concretions 143

32. Ditto . 143

33. Ditto 144

DISEASES OF THE PROSTATE .

PART 1. — THE ANATOMY OF THE PROSTATE .

THE TOPOGRAPHICAL AND STRUCTURAL ANATOMY OF THE PROSTATE.

to have been originated by anatomists, for which it forms an enveloping sheath,

deal in respect of external physical cha- | forates it at a point a little in advance of

An analysis of the measurements pro - tomy, the prostate as measuring twenty to

interval between them , occupied con- years subsequently, viz., in 1811. Re

It is not, he says, an isolated piece, and

or of the prostate, or to a small tumour THE PROSTATE. — Commencing at the neck

descriptions represent them as spheroidal A question naturally arises, and one

portion of the sinus itself remaining.

FACTS RELATIVE TO WEIGHT, SIZE, AND MORBID CONDITION, OBTAINED BY DISSECTING

At the conclusion of the foregoing portion in researches by dissection which are

A Tabular View of the Facts observed in 194 Dissections of the Prostate.

1st Series.—Nos. 1 TO 30.

No. Age Weight Remarks Length Breadth Thickness

85 4 44 Ditto . 1.25 1:55 .95

63 4 35 Ditto 1.35 1.7 • 75

2ND SERIES . - Nos. 31 to 130.

No. Age Weight Remarks

123 71 9 30 Ditto ditto ditto