Book GqfiyriglrtN?. COKFIGHT DEPOSIT. Aj ENLARGEMENT OF THE PROSTATE DEAVER J v \ ) By the Same A ut hor Surgical Anatomy A Treatise on Human Anatomy in its Application to the Practice of Medicine and Surgery. With 499 Full-page Illus- trations, engraved from original drawings, made by special artists, from dissections prepared for the purpose in the dissecting rooms of the University of Pennsylvania. Three Royal Square Octavo Volumes. Half Morocco or Sheep, $30.00 Half Russia, $33.00 Surgical Anatomy of the Head and Neck With 177 Full-page Plates, nearly all of which have been made from special dissec- tions. Royal Octavo. Half Morocco, $12.00 Appendicitis Its History, Anatomy, Clinical ^Eti- ology, Pathology, Symptomatology, Diagnosis, Prognosis, Treatment, Tech- nique of Operations, Complications and Sequels. Third Edition, Thoroughly Re- vised and Enlarged. With sixty-four full- page plates, eight of which are coloured. Large Octavo. Cloth, $7.00; Half Morocco, $8.00 Surgery of the Upper Abdomen Surgical Diseases of the Stomach ; Duo- denum ; Pancreas ; Liver, its Ducts, in- cluding Gall-Stones. Their Diagnosis, Technique of Operations, and After- Treatment. Fully Illustrated. In Preparation ENLARGEMENT OF THE PROSTATE Its History, Anatomy, ^Etiology, Pathology, Clinical Causes, Symptoms, Diagnosis, Prognosis, Treat- ment, Technique of Operations, and After-treatment BY JOHN B. DEAVER, M.D. Surgeon-in- Chief to the derman Hospital, Philadelphia ASSISTED BY ASTLEY PASTON COOPER ASHHURST, M.D, Surgeon to the Out-Patient Department of the Episcopal Hospital : Assistant Surgeon to the Orthopedic Hospital, and to the Dispensary of the German Hospital ILLUSTRATED WITH 108 FULL-PAGE PLATES AND A COLOURED FRONTISPIECE PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1905 -V V^ fc LIBRARY of OONGRESS Twc Copies rteceiveu MAY 15 iyu5 GLASS «*^ COPY • entry XXC. Not oo 8. Copyright, 1905, by P. Blakiston's Son & Co. PRESS OF WM. F. FELL COMPANY 1220-24 Sansom Street philadelphia. pa. TO JAMES TYSON ?=:-5S5:p :.= 1 -.z::;:--h ;v ?:-: = .'-. = -;;--: :- ?=nnsylvan:a IX EVIDENCE OF MY HIZH APPRECIATION 3? KIM AS AN ACCCMPLISHEE PHYSICIAN OF HIS WELL KNO'A'N WC?H< IN ZISEaSES OF THE J-?z? C-ENITO-VRINaR^: FRACT AXE AS A TRUSTEE FRIEND PREFACE. The surgery of the prostate gland has acquired within the last few years such a conspicuous position in both surgical litera- ture and practice, that the publication of another text-book on the subject can scarcely be a matter of surprise. And as the author has had considerable experience, both operative and otherwise, with prostatics, it was not unwillingly that he com- plied with the request of his publishers to write a monograph on this subject. In preparing this volume, the aim has been to produce a work fully representative of the subject of which it treats. While the results of the author's own experience have been included, he has taken pains not to remain uninformed of the opinions of other surgeons. A conscientious search and study of pros- tatic literature has therefore been made, to the end that no per- sonal bias should infect the principles of diagnosis and treatment which it has been endeavoured to inculcate. The present work, therefore, claims to be more than a mere compilation of the ideas of others; the author has not hesitated to hold his own opinions when these have seemed preferable, and he has tried to present the reasons for these opinions in such a way as to command the attention which he thinks they deserve. The illustrations have been chosen with great care. They are in most cases original, but where it proved impossible to obtain original material, selection has been made of those which most nearly presented the requisite characteristics. Although an attempt has been made — and, the author ventures to think, not without success — to illustrate every important phase of pros- tatic surgery, both pathological and clinical, as well as opera- Vlll Preface. tive, yet in no instance has a plate been introduced which was not considered illustrative of the text. All the illustrations have been drawn by Mr. C. F. Bauer, except the microscopical plates, which were prepared by Mrs. J. D. Z. Chase, under the direction of Dr. A. O. J. Kelly. The treatment, other than operative, has been discussed in greater detail than may seem warranted to some; but realizing that this forms by far the largest part of actual practice, it has seemed wise to the author to consider it at length. In concluding a work which has occupied much of his time for over a year, the author desires to express a hope that the volume will prove of real value to those surgeons and family physicians who have prostatics under their care, and will serve in some little degree to elucidate the principles of surgical treat- ment of one of the most distressing maladies of mankind. 1634 Walnut Street, May, 1905. CONTENTS. PAGE. Description of the Plates, xi Chapter I, i History and Literature. Chapter II, 20 Embryology; Comparative Anatomy; Gross and Microscopical Anatomy; Relational or Applied Anatomy; and Physi- ology. Chapter III, 46 Pathology and Etiology. Chapter IV, 72 Clinical Pathology: Effects on Urethra, Bladder, Kidneys, Urine, and Rectum. Chapter V, 84 Clinical Causes: Race, Age, Occupation, Social Habits, Previous Diseases. Chapter VI, 92 Subjective Symptoms. Chapter VII, 100 Objective Symptoms — Physical Examination. Chapter VIII, 108 Diagnosis and Differential Diagnosis ; Prognosis. Chapter IX, 121 Treatment: Constitutional; Catheterism; Prevention of Com- plications ; and Treatment of Complications. Chapter X, 166 Local Palliative Treatment, Including Urinary Fistula, the Bottini Operation, and Castration. Chapter XI, 200 Indications for Radical Treatment by Suprapubic and by Peri- neal Prostatectomy. Chapter XII, , 215 Technique of Operations, Including the Preparation of the Patient, with the After-treatment. Bibliography, 243 Index of Names, .- 253 General Index, 257 DESCRIPTION OF THE PLATES. Frontispiece. page . Plate I, 2 Tunneling the Prostate in a Case of Urinary Obstruction (Cru- veilhier) . Plate II, 4 Harrison's Olivary Bougies for Systematic Compression of the Enlarging Prostate. Plate III, 6 Mercier's Prostatotome and Prostatectome. Plate IV, 8 Sir Henry Thompson's Instruments for Establishing a Suprapubic Urinary Fistula. Plate V, 10 Tapping the Bladder from the Perineum in the Case of an En- larged Prostate (Ashhurst). Plate VI, 20 Developement of the Genito-urinary Tract. Plate VII, 22 Fcetal Prostate from a Six Months Fcetus in the Museum of the German Hospital. Plate VIII, 24 Developement of the Aponeurosis of Denonvilliers (Cuneo and Veau) . Plate IX, 26 Testes, Prostates and Protometra of the Goat (Owen). Plate X, 27 Accessory Male Glands and Protometra of Hyaena Striata (Owen). Plate XI, 28 Congenital Absence of the Left Vas Deferens and Seminal Vesicle, associated with Imperfect Developement of the Prostate on the Side Affected (Socin after Launois). Plate XII, 29 Median Sagittal Section of the Pelvis and Lower Abdomen, show- ing the General Relations of the Prostate to the Bladder, the Urethra and the Rectum. Plate XIII, 30 Transverse Section of the Pelvis and Prostate. Plate XIV, 36 Urethra and Bladder Laid Open from Above. xi xii Description of the Plates. PAGE Plate XV, 36 Diagram of Sheath of the Prostate in Sagittal Section. Plate XVI, 37 Diagram of Sheath of the Prostate in Transverse Section. Plate XVII, 37 Diagram to show the Dilatability of the Various Parts of the Urethra. Plate XVIII, 37 Coronal Section of the Pelvis through the Prostate (Spalteholz). Plate XIX, 37 View of the Base of the Bladder and the under Surface of the Prostate. Plate XX, 40 Side View of a Dissection of the Pelvis showing the Fasciae around the Bladder and the Prostate (after Proust). Plate XXI, 41 The Same, showing Relations of the Muscles after the Various Layers of Fascia have been Removed. Plate XXII, 42 Side View of the Pelvis showing the Relations of the Peritoneal Reflections when the Bladder is Empty and when it is Dis- tended (Gerrish). Plate XXIII, 42 Surgical Anatomy of the Perineum: the Superficial Muscles. Plate XXIV, 42 Surgical Anatomy of the Perineum: the Superficial Layer of the Triangular Ligament. Plate XXV, 43 Surgical Anatomy of the Perineum: the Deep Vessels and Nerves and the Deep Transverse Perineal Muscles. Plate XXVI , 44 Surgical Anatomy of the Perineum: the Membranous Urethra. Plate XXVII, 44 Surgical Anatomy of the Perineum: the Levator Ani. Plate XXVIII, 44 Surgical Anatomy of the Perineum: the Prostate Exposed. Plate XXIX, 48 Under Surface of an Enlarged Prostate, weighing 145 Grammes (about 5 Ounces). Plate XXX, 49 Upper Surface of an Enlarged Prostate, weighing 145 Grammes (about 5 Ounces). Plate XXXI, 50 Enlarged Prostate weighing 30 Grammes (1 Ounce). Plate XXXII, 52 Enlarged Prostate (No. 1533). Description of the Plates. xiii PAGE. Plate XXXIII, 54 Enlarged Prostate (No. 1469). Plate XXXIV, 55 Enlarged Prostate (No. 1555), weighing if Ounces. Plate XXXV, 56 Enlarged Prostate (No. 1623), weighing 4 Ounces. Plate XXXVI, 57 Cut Surface of Enlarged Prostate (No. 1623). Plate XXXVII, 58 Upper Surface of Enlarged Prostate (No. 1542), weighing 4 Ounces. Plate XXXVIII, 58 Under Surface of Enlarged Prostate (No. 1542). Plate XXXIX, 58 Cut Surface of Enlarged Prostate (No. 1542). Plate XL, 59 Enlarged Prostate weighing 100 Grammes (3 J Ounces). Plate XLI, 60 Enlarged Prostate (No. 2138), weighing 5 J Ounces. Plate XLII, 60 Enlarged Prostate (No. 2138). Plate XLIII, 61 Enlarged Prostate (No. 1826), weighing 56 Grammes. Plate XLIV, 62 Under Surface of Enlarged Prostate (No. 1826). Plate XLV, 65 Microscopical Section from Prostate No. 1502, showing Con- siderable Hyperplasia and some Dilatation of the Glandu- lar Structure. Plate XLVI, 66 Micro photograph from Prostate No. 1258, showing Marked Glan- dular Hyperplasia. Plate XLVII, 67 Microscopical Section from Prostate No. 1623, showing Cystic Dilatation of the Acini. Plate XLVIII, 68 Microscopical Section from Prostate No. 1542, showing both Glandular Hyperplasia and Fibrous Overgrowth in the Same Microscopical Field. Plate XLIX, 69 Microscopical Section from Prostate No. 1542, showing Marked Connective Tissue Hyperplasia. Plate L, 72 Sagittal Section showing Elevation of the Vesical Orifice of the Urethra and the Formation of a Retro-prostatic Pouch. xiv Description of the Plates. PAGE. Plate LI, 73 Urethra Laid Open from Above, showing Lateral Deviation of the Prostatic Portion from Unequal Enlargement of the Lateral Lobes of the Prostate (Anger). Plate LII, 74 The same, showing a Y-shaped Prostatic Urethra due to the Presence of a Pedunculated "Median Lobe" (Cruveilhier). Plate LIII, 75 Sagittal Section through the Prostatic Urethra showing Great Overgrowth of the Parts beneath the Urethra, Obliterating the Subpubic Curve (Anger). Plate LIV, 76 View of an Enlarged Prostate from within the Bladder, showing "Cervix Uteri" Enlargement (Socin and Burckhardt). Plate LV, 77 Bar at the Neck of the Bladder (Watson). Plate LVI, 78 Dilated Atonic Bladder, with Enlargement of the Prostate. (From a specimen in the Mutter Museum of the College of Physicians of Philadelphia.) Plate LVII, 80 Contracted Infected Bladder, with Enlargement of the Prostate. (From a specimen in the Mutter Museum of the College of Physicians of Philadelphia.) Plate LVIII, 82 Dilatation of the Ureters from Enlargement of the Prostate. (From a specimen in the Museum of the Pennsylvania Hos- pital.) Plate LIX, 104 Combined Examination, with a Catheter in the Bladder and a Finger in the Rectum. Plate LX, , 128 Soft-rubber (Nelaton) Catheter. Plate LXI 130 Figs. 1 and 2. — Metallic Catheters with Prostatic Curves. Fig. 3. — Mercier's Elbowed Catheter. Fig. 4. — Mercier's Double Elbowed Catheter. Plate LXII, 131 Diagram of the Subpubic Curve of the Urethra (Van Buren and Keyes) . Plate LXIII, 132 Fig. 1. — Catheter with Caoutchouc bridle attached, to facilitate its Retention in the Bladder. Fig. 2. — English Catheter Moulded on an Over curved Stylet, by which its Curve can be Altered at Will. Plate LXIV, 134 Portable Catheter Case. Description of the Plates. xv PAGE. Plate LXV, 136 Portable Catheter Cases. Plate LXVI, 1 68 McGuire's Suprapubic Fistula and Obturator (Ashhurst). Plate LXVII, 170 Fig. 1. — Stevenson's Suprapubic Drainage Tube. Fig. 2. — Senn's Sigmoid Catheter for Use in a Suprapubic Fistula. Plate LXVIII, 172 Stevenson's Suprapubic Drainage Tube in Use (after DaCosta). Plate LXIX, 174 Senn's Sigmoid Catheter in Use (DaCosta). Plate LXX, 176 Fig. 1. — Owens's Perineal Tube. Fig. 2. — Watson's Perineal Tube. Plate LXXI, 188 The Bottini Apparatus. Plate LXXII, 190 Freudenberg's and Young's Incisors for the Bottini Operation. Plate LXXIII, 192 The Bottini Incisor in Use (after Socin and Burckhardt). Plate LXXIV, 194 Diagram of Incisions used in the Bottini Operation. Plate LXXV, 196 Incisions in the Prostate made in the Bottini Operation, seen from within the Bladder (Socin and Burckhardt). Plate LXXVI, 219 Suprapubic Prostatectomy: the Skin Incision. Plate LXXVII, 220 Suprapubic Prostatectomy: Separating the Fibres of the Rectus Muscle with the Handle of the Scalpel. Plate LXXVIII, 221 ' Suprapubic Prostatectomy: the Bladder is Exposed, and Steadied with a Tenaculum. Plate LXXIX, 222 Suprapubic Prostatectomy: the Bladder has been Opened and an Incision has been made through its Mucous Membrane over the Prostate. Plate LXXX, 224 Suprapubic Prostatectomy: Sagittal Section of the Pelvis show- ing the Finger Enucleating the Prostate, as Counter-pressure is made in the Perineum and Rectum by the Fingers of the Other Hand. Plate LXXXI, 225 Suprapubic Prostatectomy: Appearance of the Parts after the Prostate has been Removed. xvi Description of the Plates. PAGE. Plate LXXXII, 226 Suprapubic Prostatectomy: Method of Checking Haemorrhage by Packing the Cavity from which the Prostate has been Enucleated. Plate LXXXIII, , 228 Suprapubic Prostatectomy: Drainage-tube and Dressing in Place. Plate LXXXIV, 230 Perineal Prostatectomy: Proust's Inverted Perineal Position. Plate LXXXV, 231 Perineal Prostatectomy: Transverse Skin Incision. Plate LXXXVI, 232 Perineal Prostatectomy (Proust) : Division of the Recto-urethral Muscle. Plate LXXXVII, 232 Perineal Prostatectomy (Proust): Aponeurosis of Denonvilliers Opened. Plate LXXXVIII, 233 Perineal Prostatectomy (Proust) : Method of Enlarging the Field of Operation with the Fingers. Plate LXXXIX, 233 Perineal Prostatectomy (Proust) : Separating the Sheath of the Prostate from its Capsule. Plate XC, 234 Perineal Prostatectomy (Proust): Hemisection of the Prostate. Plate XCI, 234 Perineal Prostatectomy (Proust): Dissecting the Prostate off the Urethra. Plate XCII, 235 Perineal Prostatectomy (Proust): Suturing the Floor of the Urethra. Plate XCIII, 236 Perineal Prostatectomy : Skin Incisions — the Inverted Y and the Inverted V Incisions. Plate XCIV, 236 Young's Two-bladed Prostatic Tractor. Plate XCV, .--;-* 2 3 6 Fig. 1. — Young's Prostatic Tractor in Use, seen from within the Bladder. Fig. 2. — Diagram showing the Portions of the Prostate Removed in Young's Operation of "Conservative Perineal Prostatec- tomy." Plate XCVI, 237 Perineal Prostatectomy (Young) : Incisions into the Prostate. Plate XCVII, 238 Perineal Drainage with Continuous Irrigation (after Young). Description of the Plates. xvii PAGE. Plate XCVIII, 238 Fig. 1. — Ferguson's Prostatic Depressor. Fig. 2. — Syms's Rubber Bulb Tractor for Perineal Prostatec- tomy. Fig. 3. — The Same with its Bulbous Extremity Distended. Plate XCIX, '. 238 Syms's Rubber Bulb Tractor in Use. Plate C, 239, Murphy's Hooks for Perineal Prostatectomy. Plate CI, 240 Perineal Prostatectomy: Skin Incisions — the Straight Median Incision, and Dittel's Incision. Plate CII, 240 Perineal Prostatectomy: Straight Median Incision, Exposing Colles's Fascia. Plate CHI, 240 Perineal Prostatectomy: Colles's Fascia has been Opened. Plate CIV, 240 Perineal Prostatectomy: Membranous Urethra Exposed. Plate CV, 240 Perineal Prostatectomy: Membranous Urethra Opened. Plate CVT, 240 Perineal Prostatectomy: the Prostate Exposed. Plate CVH, 240 Perineal Prostatectomy: the Prostate is being Enucleated with the Aid of Murphy's Hooks as Tractors. Plate CVIII, 241 Perineal Prostatectomy: Drainage-tube Introduced and Wound Dressed. ENLARGEMENT OF THE PROSTATE CHAPTER I. HISTORY AND LITERATURE. It is a remarkable thing that any part of the human body liable to such important pathological changes as the prostate gland should have acquired a conspicuous place in surgery within such comparatively recent years. Its very existence was unknown until the beginning of the sixteenth century, and it is only within the short space of a decade that its operative surgery has been deemed of sufficient magnitude to require exposition in mono- graphs of any size. The symptoms of this malady, if we may believe Sir Everard Home [123],* have been recognized from time immemorial. This ingenious author surmised that the enlargement of the prostate gland met with so universally in old age is " alluded to in the beautiful description of the natural decay of the body, in the Bible, in the book of Ecclesiastes, the 12th chapter, the 6th verse, where it is written, 'or the pitcher be broken at the fountain, or the wheel broken at the cistern/ Expressive of the two principal effects of this disease, the involuntary passing of the urine, and the total stoppage." From scattered observations among the works of the classic authors it appears that these writers considered that patients with prostatic hypertrophy suffered from " excrescences " or "carnosities" at the neck of the bladder; and that when these outgrowths offered obstruction to the evacuation of the bladder * The figures throughout the text enclosed in brackets [thus] refer to the correspond- ing numbers in the Bibliography, pages 243 to 252. 2 P 2 History. their destruction was attempted with metallic instruments, intro- duced, of course, through the penile urethra. Certain of the ancient authors recommended incision of the neck of the blad- der through the perineum in patients with retention of urine who were " nearly dying with the pain," when the urethra was much inflamed, and therefore impassable to the catheter, even if no calculus existed to serve as an excuse for lithotomy; but it is not known that they actually performed such an operation. The ignorance of the ancients as to the anatomical existence of the prostate may be explained on the hypothesis that they did not practise dissection of the human body. According to Galen [94], Herophilus first employed the term " prostate," which he, however, appears to have applied to the seminal vesi- cles (adevoetdeu yrpoffTdrat, "prostatas glandulosae"), while the term xtpffoetdeis izporecalled that the genito-urinary tract is developed from three main sources — the Wolffian bodies and ducts, the Mullerian ducts, and the allantois. This last structure, which is the earliest of the three to be formed, juts forth in the second week from the primitive gut near its posterior extremity, devel- opes forwards and protrudes at the umbilicus, forming a reservoir for waste materials. In the third week the Wolffian bodies appear, one on each side of the body cavity, as a series of tubules, caudal to the region of the heart, and lying approximately at right angles to the Wolffian ducts, and in the long axis of the body cavity. The Mullerian ducts, one on each side, appear about the fifth week, and lie parallel to the Wolffian ducts. Both pairs of ducts empty into the portion of the allantois closest to the gut. In the sixth week one can see that the allantois has ex- panded slightly between its point of departure from the body cavity at the umbilicus, and the point at which it receives the two pairs of ducts — Wolffian and Mullerian. This expanded part of the allantoic tube forms the future urinary bladder; and growing out from it, practically parallel with the two pairs PLATE VI Developement of the Genitourinary Tract (Diagrammatic). Ellll Body wall. A. Allantoic stalk at umbilicus. B. Urinary bladder. C. Cloaca. G. Primitive gut. 5. Symphysis pubis. M, M' . Miillerian ducts. W, W. Wolffian bodies and ducts. U, U' . Ureters with kidneys attached. Embryology. 21 of ducts, is now observed a third pair of tubes, these being the ureters. The altered portion of the allantois into which the Mullerian and Wolffian ducts empty is known as the urogenital sinus. That portion of the allantois between the urogenital sinus and the bladder later constitutes the urethra, as seen in the female. In the male this original urethra becomes sub- sequently greatly lengthened by the developement of the penile portion by an infolding of the skin along the lower border of the penis. As is well known, the Wolffian ducts persist in the male and form the vasa deferentia; while in the female the Mullerian ducts persist, coalescing in their lower portions to form the uterus and vagina, but in the upper part remaining distinct, and con- stituting the Fallopian tubes. In the male, although these Mul- lerian ducts in great part disappear, yet their lower coalesced extremity persists, and is found in the adult as a little diverti- culum from the prostatic urethra, known as the uterus mas- culinus. As mentioned above, the prostate gland is first discoverable in the third month of foetal life, and it can then be recognized as a thickening of the posterior wall of the urethra. Thus the analogue of the prostate gland must be sought in the female, not around the uterus, but, as Sir James Y. Simpson [211] says, "in the follicular glands and structures that exist so abundantly in the course, and at the extremity, of the female urethra"; and Hodgson [122] quotes Leuckhart as stating that in women there exists a true rudimentary prostate, consisting principally of mucous follicles and situated between the beginning of the urethra and the reflection of the vagina. He further states that Virchow admitted the existence of this body, and had often found at the neck of the bladder, especially in old women, when the internal orifice is thickened, round grayish-yellow enlargements in which there are gradually formed firm dark-coloured bodies lying em- bedded in the mucous membrane. These bodies Virchow con- 22 Anatomy. sidered identical with or analogous to the concretions found in the prostatic portion of the urethra. Guthrie [107], writing in 1834, had no doubt that females possessed a prostate. Most observers have held that while the glandular portion of the prostate originates thus from the urethra, yet that the stroma of the organ developes from a thickening of the genital chord — which is the name given to the connective tissue containing the Wolffian and Mullerian ducts. But Griffiths [103, 104], who studied the developement of the prostate in considerable detail, taught that no part of the prostate arose from the genital chord. W. G. Richardson [199] from his more recent studies is of the same opinion. Griffiths [104] described the course of events as follows: The normal tubular glands of the ure- thra on its posterior surface, especially on each side of the verumontanum, grow outward, backward, and finally turn and come forward, so as to enclose the sides of the urethra, and at last coalesce again on its anterior (superior) surface. During their growth these glands project into and between the muscular fasciculi of the thickened posterior half of the external circular non-striped muscle coat of the urethra in this situation. This external circular layer of muscle is the continuation of the cir- cular coat of the bladder, the bladder's external muscle-coat, which is longitudinal, ceasing at and being inserted at or near the vesical orifice of the urethra. Naturally, therefore, we find that in the adult the prostate surrounds the uterus masculinus, being anatomically merely a compound tubular developement of the urethral glands on the two sides of this rudimentary structure. (Compare the genitalia of the goat, Plate rx.) As the foetus continues to develope it is found that the Wolf- fian ducts (vasa deferentia) empty into the urethra upon or even within the margins of the coalesced Mullerian ducts (uterus masculinus) ; while the orifices of the prostatic (highly developed urethral) glands retain their original situation on each side of PLATE VII, Fcetal Prostate, with Lower Halt of Bladder Attached. Natural size, and ten times natural size. (From a six months' foetus in the Museum of the German Hospital.) Embryology. 23 the opening of the uterus masculinus. Thus is explained the apparent passage through the prostate of the ejaculatory ducts of the vasa deferentia. The two lobes remain distinct until about the fifth month of intrauterine life, when they coalesce about the urethra. Even at birth the prostate can be recognized as a bilobed organ, lying almost entirely behind the urethra. In rare instances the urethra has been found in the adult to merely groove the anterior surface of the prostate, and not to be completely encircled by it, as is usually the case. In connection with the embryology of the prostate a few words must be said in reference to the so-called " third lobe." From the account of its developement just given it is seen that the prostate is really a paired organ, arising in two distinct places from the urogenital sinus, much as the ureters do from the blad- der; and when the gross anatomy of the organ is studied it will be seen that the bilobed condition persists with more or less dis- tinctness throughout life. From the day of its discovery the prostate was constantly referred to as the "glandulae prostata? " — the " prostate glands," showing that it was considered as a multiple organ, composed of numerous glands; and its bilobed state in fcetal life was well known. It was not until about one hun- dred years ago that Sir Everard Home [123] took credit to him- self for discovering a third lobe, although both John Hunter [128] and Morgagni [166, 167] had recognized a pathological enlarge- ment of this part of the organ a number of years before. Home's observations passed practically unchallenged .among English surgeons, and enlargement of the third lobe became the most popular pathological change to which the prostate gland was subject. In France, however, surgeons were not so ready to acknowledge so important a discovery, as it seemed, by a foreign author; and they rather grudgingly denominated this portion of the prostate the third or median "part," being unwilling to accord it the dignity of a distinct lobe. 24 Anatomy. Sir Henry Thompson [224], writing in 1858, opened the con- troversy anew by pointing out both that Home's observations were not numerous, and that he had not found his third lobe in every case. Sir Henry therefore came to the conclusion that this middle lobe was merely a pathological formation, and did not normally exist at all. Griffiths [103] in his studies, observed in the greater proportion of specimens examined by him, that posterior to the verumontanum, as well as on its two lateral aspects, orifices of gland ducts could be seen,* and that pressure on the corresponding portion of the gland squeezed out prostatic secretion from glandular tissue which he found lay between the urethra and the ejaculatory ducts. His conclusion was that a third or median lobe sometimes existed, but that it was not constant; and that where it was congenitally absent, it could, of course, never become the seat of enlargement. Such a collection of gland tubes might well be called an accessory lobe. Thorel [226] has described such accessory pro- static glands in the human subject, lying between the ureters, in the submucous tissue of the bladder; some such accessory glands are believed to exist in some of the lower animals; and since in the immense majority of cases, if not in all those carefully examined in recent years, a median projection has been found to take its origin by a pedicle from one or the other of the two lateral lobes, it is probably safe to conclude that a median or third lobe does not normally exist. There is, moreover, nothing to prevent us from thinking, in the cases described by Home and by Griffiths, that the glandular structure they found posterior to the urethra and above the ejaculatory ducts was as much separated into two lobes as that beneath the urethra and on both sides of, or anterior to, the ejaculatory ducts. A further embryological fact of importance is the formation of a bursa between the prostate and the rectum, by the oblitera- *This position of the ducts from the third lobe was distinctly described by Home 1 1 23], with whose original paper Dr. Griffiths does not appear to have been familiar. PLATE VIII. *mmamm Comparative Anatomy. 25 tion of the upper end of a serous process extending downward from the peritoneum, much as the tunica vaginalis testis is formed. This closed serous cavity between the prostate and the rectum has been recently studied by Cuneo and Veau [55], and is widely known by the name " aponeurosis of Denonvilliers." In the adult, though separable into two layers, these processes of serous tissue no longer enclose a distinct cavity. Comparative Anatomy. — All mammals possess a prostate, but there is in birds, according to Strieker [218], no analogous organ. In certain of the batrachians he states that the pelvic and anal glands swell up during the procreative season, and discharge their secretion into the cloaca; these glands are sup- posed to represent the prostate and glands of Cowper. In fishes there are aggregations of acini that communicate with the vas deferens through ducts. Owen [184] states that insects have three pairs of prostates. Although all mammals are endowed with a prostate, yet it is by no means identical in form in all. In some mammals the prostate developes around the lower extremity of the Wolffian ducts, and when fully developed retains its close relation to the vasa deferentia, but as two distinct glands, and is not, as in the human adult, applied around the first portion of the urethra embracing the ejaculatory ducts only incidentally. Moullin [176] states that even in man the situation of the prostate was probably originally around the Wolffian ducts, but that its place has become shifted in the course of racial developement. In the bull, the buck, and other of the ruminants, indeed in almost all the forms of mammalian life below the human, including the monkey, the prostate continues throughout life a bifid gland. The close resemblance whichat bears in some of these animals to the seminal vesicles may account both for the ignorance of the ancients respecting the existence of the human prostate gland, and for the habit of the earliest of the modern anatomists of referring to it as the "glandulae prostatas" 26 Anatomy. W. G. Richardson [199, p. 35] has recently called attention to the location of the accessory glands of generation — the pros- tates, the seminal vesicles, and the Cowperian glands — in various animals. He finds that the seminal vesicles are constantly in relation with that part of the genital tract developed from the Wolffian ducts, that the prostates are placed next, in relation with that part developed from the urogenital sinus, while the glands of Cowper are furthest away from the testicles, in rela- tion with the bulbous urethra. This same general arrangement exists in the human being, the glands of Cowper discharging their secretion into the bulbous urethra, the prostate glands into the prostatic urethra, and the seminal vesicles pouring their secretion into the vasa deferentia before these latter have joined the urethra. In the lower animals the accessory genital glands differ much in relative size and importance, all three sets not always being present. In the civet cat, for example, Cowper's glands are exceptionally large, apparently to compensate for the entire absence of the seminal vesicles; while in the guinea-pig the seminal vesicles are of immense size, and the glands of Cow- per very insignificant in comparison. In the squirrel, on the other hand, the Cowperian glands are very large, and the seminal vesicles are small. The genitalia of the goat (Plate ix) approach most nearly to the primitive or indifferent sexual type. Here the Miillerian ducts persist throughout their length, as well as the Wolffian ducts, and we have the unusual sight of the uterus masculinus extending as a bifid organ from the urethra to the epididymis. Nor do the lower ends of these persistent Miillerian ducts pierce the prostate to empty into the urethra; on the contrary, the prostate glands, one on each side of the urinary channel, are far removed from the situation of the uterus masculinus, being much nearer the bulbous urethra. This satisfactorily disproves the theory formerly held by some that the male prostate gland was the homologue of the female womb. PLATE IX, Testes, Prostates and Protometra of the Goat. Below are seen the prostates. Between the vasa deferentia is seen the uterus mas- culinus, which is bifid; its two horns diverge and continue, closely applied to the vasa deferentia, as far as the epididymis of each side.— {After Owen.) PLATE X. Accessory Male Glands and Protometra of Hyaena Striata. Above is seen the bladder. Emptying into the prostatic urethra are the vasa de- ferentia on each side of the minute uterus masculinus (protometra). The prostate glands are large, somewhat kidney-shaped bodies, in no way connected with the uterus mascu- linus. Emptying into the penile urethra below are seen the immense glands of Cowper. Natural size. — (After Owen.) Comparative Anatomy. 27 In the hyena the genitalia (Plate x) approach more nearly the human in type, but conclusively show that there is no neces- sary connection between the uterus masculinus and the prostate. The Cowperian glands of the hyena are of extraordinary size. In mammals who have a rutting season the prostate gland enlarges noticeably at this period, and at its close again diminishes to its former size. John Hunter [128] studied the prostate gland in moles, and found that while it was small and insignificant during winter — the period of quiescence — yet that in the rutting season it became very large and was filled with mucus. His observations have been confirmed by Owen [185] and by Griffiths [104]. The last-named author also studied the pros- tates of hedgehogs, and found them to have the same charac- teristics. Such observations as these, taken together with the facts that castration in animals has long been known to produce a certain amount of prostatic atrophy; that failure of develope- ment of one vas deferens has usually been found associated with a prostate which is small and ill-formed on the affected side (see Plate xi); and the theory of "displacement" in the course of racial developement, adopted by Mr. Mansell Moullin [176] on the authority of Schafer; leave no reasonable doubt that the prostate is physiologically a part of the genital and not of the urinary apparatus. This idea may be further strengthened by a consideration of the ornithorhyncus, or duck-mole. In this animal, a small oviparous mammal of Australia, the urine is discharged through the cloaca, in common with the faecal matters, as is the case in birds; and the penis with its contained urethra serves solely and entirely for the transmission of the semen and the fluids from the accessory generative glands. And although, unfor- tunately for the complete proof of our theory, this interesting animal is not endowed with a prostate, yet it is clear that were a prostate present, its secretion would be discharged along with 28 Anatomy. that coming from Cowper's glands, which, as well as the lower ends of the vasa deferentia, are considerably enlarged. No seminal vesicles are present either, but the enlargement of the lower ends of the vasa deferentia is evidently to compensate for this lack. In connection with the comparative anatomy of the prostate, a few words in relation to its comparative pathology will not be out of place. It is well known that of all animals the dog is most prone to prostatic enlargement. According to Ciechanowski [50], it is also the only domestic animal which suffers from an infec- tious urethritis. From this fact he draws an argument in favour of his theory that all prostatic overgrowth is due to an inflam- matory change. In other animals castration invariably causes prostatic atrophy; whereas in dogs it frequently fails to have any effect, although it was until recently about the only method of treatment applicable for their relief. Perineal prostatectomy has also been employed; and Loumeau [146] states that a veterinary surgeon, a friend of his, had employed ten times successfully an operation precisely similar to Freyer's suprapubic prostatectomy, before learning from Loumeau that the same operation had been prac- tised upon man. Gross Anatomy. — The shape of the prostate is approxi- mately that of a truncated cone, and has often been compared to a Spanish chestnut or a horse-chestnut, having its apex down and forward, and its base beneath the urinary bladder. In size this gland is normally about one and a half inches (four centi- metres) from base to apex, a little longer in transverse diameter, and from three-fourths to one inch (two to two and a half centi- metres) in depth or height. Its weight varies from four to six drachms (fifteen to twenty-four grammes). The prostate consists of glandular acini and ducts embedded in involuntary muscle; the latter, supported by fibrous tissue, PLATE XI. Congenital Absence of the Left Vas Deferens and Seminal Vesicle, Associated with Imperfect Developement of the Prostate on the Side Affected. — (Socin, after Lannois.) PLATE XII. Median Sagittal Section of the Lower Abdomen and Pelvis, showing the Gen- eral Relations of the Prostate to the Bladder, the Urethra, and the Rectum. Gross Anatomy. 29 constituting the stroma of the organ. This stroma forms by a peripheral condensation a capsule for the gland, which is distinct from its sheath, this latter being derived from the pelvic fascia. The stroma constitutes more than half of the bulk of the organ, the remaining portion being composed of glandular tissue. Piercing the prostate from base to apex, a little anterior to its central axis, runs the urethra, whose first part, extending from the vesical orifice behind to the deep layer of the triangular liga- ment in front, is called "the prostatic urethra." Emptying into the floor of the prostatic urethra, and conse- quently coursing through the posterior portion of the prostate gland, are found the ejaculatory ducts of the vasa deferentia and seminal vesicles. One of these ducts empties on each side of a small diverticulum, known as the uterus masculinus, extend- ing backward from the floor of the prostatic urethra into the substance of the prostate gland. At times the ejaculatory ducts empty within the margins of the uterus masculinus. The uterus masculinus has its axis obliquely directed to that of the prostatic urethra, though lying in the middle line, and its cavity looks forward, so that a small catheter or sound passed along the floor of the urethra may catch in its orifice. The upper wall of the uterus masculinus causes, just back of its orifice, a prominence in the floor of the prostatic urethra; and this prominence is termed the caput gallinaginis or verumontanum. A transverse section, therefore, about the middle of the pro- static urethra is crescent-shaped, with the convexity upward. On each side of the caput gallinaginis are found the orifices of the ducts coming from the prostatic acini. Those depressed portions of the urethra on each side of the caput gallinaginis, into which these ducts empty, are known as the prostatic sinuses. The ducts may readily be demonstrated by compressing the gland, when some of the contained fluid will be seen oozing out from these orifices. The number of prostatic ducts probably varies within wide limits, being usually from fifteen to twenty. 30 Anatomy. Any glandular tissue which may exist anterior to the urethra empties through ducts in the lateral walls of the urethra; and where glandular acini exist in that portion of the organ popularly known as the middle lobe (above the ejaculatory ducts, and below the urethra), their ducts discharge their contents into the floor of the prostatic urethra just posterior to the caput gal- linaginis. The prostate gland is formed by the coalescence of two lobes around the urethra. The lobes grow from behind forwards, and accordingly the exact depth in the gland at which the urethra is found depends somewhat upon the extent of the growth. In some instances the urethra has been found merely grooving the anterior or upper surface of the prostate; but in the majority of cases it is situated with one-third of the organ in front and two-thirds back of it. The developement as a paired organ is evidenced in the healthy adult gland by a slight longitudinal furrow along both the inferior and superior surfaces of the gland. On the inferior surface there is also a transverse cleft, serving for the passage forward to the urethra of the ejaculatory ducts. The inferior surface is rather flat, and rests upon the rectum. The superior surface is more convex, and is placed about three-fourths of an inch or less behind the lower part of the symphysis pubis. The base rests against the neck of the bladder, and the apex is in contact with the deep layer of the triangular ligament of the perineum. The axis of the prostate makes an angle of about forty-five degrees with the horizon, when the individual is in the erect posture. Sheath of the Prostate. — Tracing the transversalis or pelvic fascia down along the sides of the pelvis, we come to the white line of origin of the levator ani muscle, which stretches from the neighbourhood of the pubic symphysis in front to the spine of the ischium behind. At this white line the pelvic fascia divides into two sheets, the inferior or external (called the obturator fascia), passing between the obturator internus and the levator PLATE XIII Ejaculatory duct Rectovesical fascia Otturatorint ft/Mcbonc Bladder Prostate /tectum, levatorAni Ischium 1 Gluteus maxima? \ Obturator fascia — * Int. Pud ic vessels & nerve m Analfasaa schio -rectal fossa jEzL Sphincter Ani Int. Sphincter Ani Transverse Section of Pelvis, showing the General Relations of the Prostate to the Pelvic Walls. Looking Forward Towards the Symphysis Pubis. The plane of section is nearlv horizontal with the subject in the erect posture. Compare Plate XVI. Prostatic Sheath. 31 ani, and later giving off two processes — one, on the outer wall of the ischiorectal fossa, encircling the internal pudic vessels and nerve; while the inner layer covers the inferior or external surface of the levator ani, and is called the anal fascia. The second original division of the pelvic fascia, called the recto- vesical fascia, arising at the white line, passes over the superior or internal surface of the levator ani muscle, and subdivides into three layers: (1) The superior layer passes along toward the median line, above the prostatic plexus of veins, and over the upper surface of the prostate, and coalesces with the external coat of the bladder. (2) The middle layer of the recto-vesical fascia passes below the prostatic plexus of veins, beneath the prostate and bladder, and above the rectum, and joins with its fellow of the opposite side. (3) The third and last layer of the recto- vesical fascia hugs the superior or internal surface of the levator ani, and blends with the outer coat of the rectum. The two layers last described form together the aponeurosis of Denon- villiers [62], which lies between the prostate above and the rectum below, and is really a serous sac originally derived from the peri- toneum (see page 25), although more conveniently described here as part of the recto-vesical fascia. These three layers of the recto-vesical fascia are distinguish- able only at the sides of and below the prostate. Toward the median line above they are not separate, but form the pubo- prostatic ligaments, intervening between the most anterior fibres of the levator ani muscle (levator prostatas of Santorini [204]) and the space of Retzius, and blending at the median line, between these muscular fibres (where they contain the dorsal vein of the penis), with the fascia on the outer side of these muscles — the deep layer of the triangular ligament of the perineum, which is itself a pro- longation of the obturator fascia. Between this sheath of the prostate and its capsule various fibrous prolongations pass, surrounding the venous plexus in a mesh, and binding the prostate in place. Above the prostate 3 2 Anatomy. these fibrous prolongations form a more or less firm septum, separating the pericapsular space around one lateral lobe from that about the other, and serving as well as a medium of sup- port. In cases of long-standing prostatitis and periprostatitis the strength of these fibrous partitions extending among the ven- ous plexus becomes much increased, and great force may be necessary to tear the prostate out of its enveloping sheath. Thus it is seen that the prostate is enclosed more or less con- centrically first in its own capsule ; then within its venous plexus at the sides and anteriorly, and by the bladder above; and, finally, outside of the venous plexus again, passes the sheath of the prostate. The Prostatic Plexus. — The dorsal vein of the penis passes beneath the subpubic ligament, being provided just before its passage with valves, sometimes three in number; and then divides into two branches which clothe the sides of the prostate. Here it is joined by veins from the substance of the prostate, and by other minor tributaries, forming the venous plexus of Santorini [205]. No tributaries, however, come from the parietal veins of the pelvis. This plexus lies chiefly on the anterior and lateral aspects of the prostate, and its veins, like others in the pelvis, and in spite of the large number of valves present, are prone to become engorged. In the aged they fre- quently become varicose, and the formation of phleboliths is not at all uncommon. This plexus lies within the meshes of the sheath of the pros- tate, entirely outside of its capsule. Its veins travel backward, receiving veins from the sides and base of the bladder, and from the cellular tissue about the rectum, and finally empty into the internal iliac veins. Fenwick [76] has shown that this important plexus has three distinct sets of valves, which all tend to prevent backward pressure. One set is found at the commencement of the system; one at the end, in the internal iliac veins; and a third set, which is less constant, about the middle of the plexus. Vascular Supply. 33 Practically all the veins which enter this plexus are valved, so that Fenwick compares the condition to that of a series of rooms with many different entrances, but only one exit, the result being that the direction of the current is normally always straight onward. The branches received from the internal pudic veins and from the perirectal veins are powerfully valved, so that normally no regurgitation into the hemorrhoidal circulation can take place. The Arteries. — The arteries of the prostate are numerous but insignificant. They arise from the internal pudic, inferior vesical, and middle hemorrhoidal arteries. The largest is the vesico-prostatic artery, derived from the inferior vesical, passing along on the lower part of the sides of the bladder to the pros- tate. The twigs given off from this artery on the surface of the prostate in part supply its substance, piercing its capsule, and in part anastomose with twigs from the corresponding artery on the opposite side, above the prostate. There are seldom many communicating branches below the gland, while the branches from the internal pudic and middle hemorrhoidal are rarely of sufficient size to be noticed. Sometimes the internal pudic artery is smaller than usual, and its terminal branches are then derived from the vesico-pro- static, or from an accessory pudic artery, rising from the internal pudic artery just before its passage through the great sacro- sciatic foramen. When they are derived from the accessory pudic, they may be wounded in operations on the perineum; but when springing from the vesico-prostatic, they lie above the prostate and urethra, and are not so liable to injury. The Nerves. — The nerves are largely derived from the sym- pathetic system through the pelvic or inferior hypogastric plexus, some medullated fibres being found also. These last are derived chiefly from the third sacral nerve, but also to some extent from the second and fourth. The nerves accompany the arteries, lying between the prostate and the levatores ani in their forward 4P 34 Anatomy. course. The bladder, the urethra, and the cavernous tissue of the penis receive their nerve-supply from the same source; and thus the reflex pains felt at the end of the penis, in certain affec- tions of the bladder, are readily accounted for. The Lymphatics. — The lymphatics are both deep and super- ficial. The former accompany the smaller vessels in the stroma of the gland, while the superficial series lies with the venous plexus between the prostatic capsule and its sheath. These are eventually joined by the deep vessels, and they together empty into the lymphatics along the course of the internal iliac vessels. Microscopical Anatomy. — Histologically the prostate is classed as a compound tubular gland. The acini are embedded in a meshwork of involuntary muscle and fibrous tissue, this latter extending as septa inward from the prostatic capsule, which is formed by a peripheral condensation of the stroma of the organ. Among the muscular and fibrous tissues and around the acini are found the arterial twigs, the venous radicles, and the deep set of lymphatic vessels. The ultimate distribution of the nerves is not definitely known. The glandular tissue is most marked in the two lateral lobes of the prostate beneath the urethra, and is in greater evidence toward the apex than the base of the organ. In the portion of the prostate anterior to the urethra there is little glandular tissue; this part as well as that immediately beneath the urethra representing the areas of coalescence or the commissures of the two lateral lobes, and being almost wholly composed of muscular and fibrous tissue. Sometimes gland tubules are found below the urethra and above the ejaculatory ducts, forming the so-called third lobe of the prostate ; but more usual is it for glandular tissue to be absent in this region. The muscular tissue of the prostate, as shown by Hodgson [122] and by Griffiths [104], is a continuation, more or less direct, of the circular layer of the bladder; the outer vesical layer, which is longitudinal in direction, ceasing at the level of Histology. 35 the urethral orifice. This circular layer has become displaced by the growth into it of the glandular tissue, which arose from the mucous lining of the urethra; accordingly the ducts of the pros- tate are found to be devoid of a special muscular investment, whereas the acini have a layer of involuntary muscle surrounding them throughout their extent. The muscular fibres of the prostate are arranged as a com- pact layer around its periphery, forming with the contiguous fibrous tissue the true capsule of the gland; and also circularly around the urethra, acting here as the muscularis mucosae; while, finally, there is a poorly marked longitudinal layer of involuntary muscle just external to the urethral muscularis mucosae. There are thus in the prostatic urethra three coats of involuntary muscle ; the most internal is circular, and forms the muscularis mucosae; the middle, poorly developed, is longitudinal, and is really a continuation of the muscles of the ureters; while dispersed throughout the gland is found an outer circular layer, which may be recognized as the circular coat of the bladder. This description is that generally given, and most widely received. It is well to note, however, that Pettigrew [192] pro- posed the ingenious theory that all the fibres of the bladder are really in a figure-of-eight form, in seven layers. Of these layers, he asserted that the fibres of the central crossed so very obliquely that they appeared circular; while the fibres composing the three external and the three internal layers are of different degrees of obliquity, so that the most internal and the most external appear longitudinal. The muscle of the prostate, according to this view, is derived from the outer halves of the three external vesical layers, while the internal halves of these layers enclose the prostatic urethra immediately outside of its usually recog- nized muscular coats, which, Pettigrew says, are really the cen- tral and three internal layers of the bladder. Wallace [240] asserts that striped as well as unstriped mus- cular fibres are found among the glandular tissue of the normal prostate. 36 Anatomy. The gland ducts are lined close to their orifices at the urethra with a prolongation of the usual transitional epithelium of this canal; deeper in they are lined by a single layer of columnar epithelium, but possess no distinct basement membrane. They often penetrate the urethral walls obliquely. In infants ducts only are found, no acini having developed. The acini themselves are paved with columnar epithelium, which, though usually in a single layer, is frequently stratified, smaller pear-shaped or polyhedral elements filling up the crevices between the columnar cells. The nuclei of these acinous cells are placed nearer to the basement membrane than to the free end of the cells. The cells are often granular in appearance. Walker [235] has described collections of small round cells in the prostate. These he regards as lymph nodes; but he has not succeeded in demonstrating lymph channels, except at the periphery of the gland. His observations do not appear to have been confirmed by other investigators, who regard Walker's lymph nodes as evidences of inflammation. Elastic tissue also is found in the prostate, lying circularly around the urethra, and sending figure-of-eight processes out around the prostatic ducts, just beneath the mucous membrane. The uterus masculinus is an oval or rounded saccule, about one-fourth or one-third of an inch in length, lined with mucous membrane containing small tubular glands homologous with those of the female womb. It possesses, moreover, a thin layer of involuntary muscle, and is contained within a dense fibrous envelope of its own. Its orifice will admit the tip of a small probe or catheter. The prostatic urethra extends from the bladder above to the deep layer of the triangular ligament below, where it becomes the membranous urethra. Its course is at first downward, but toward the termination of the membranous portion it has com- menced its upward journey, which is continued in the bulbous portion until the penile urethra is reached, when the curve again PLATE XIV. Urethra and Bladder Laid Open from Above, showing in Bulbous Urethra the Orifices of the Ducts of Cowper's Glands, and in the Prostatic Ure- thra the Orifice of the Uterus Masculinus, with the Openings of the Prostatic Ducts on Each Side of the Verumontanum. Note the Orifices of the F.jaculatory Ducts on the Margins of the Orifice of the Uterus Masculinus. PLATE XV. Peritoneum oneurosis °f Denoiwiitiers Prostate Ant. layer °/7ri, angular liyament rost. /ayer °J ' 7?ias?. u w W H f pt| O £ w Size and Direction of Growth. 57 grammes) or over in weight. Freyer [90] has removed one weighing fourteen and a half ounces. He has also removed pros- tates weighing ten and a half, and ten and a quarter ounces, respectively, with perfect functional result. The measurements of this last gland were five and a half inches antero-posteriorly, and three and a half inches transversely. The average weight of prostates removed at operation is probably not over three ounces; and the dimensions rarely exceed two inches trans- versely or three in the antero-posterior diameter. The greater the amount of fibrous tissue present, the less the size of the organ, other things being equal, and the greater the relative weight. The average weight of forty adenomatous prostates I find was 3! ounces; and of ten fibrous prostates the average weight was 2 ounces. Hence it is seen that the greatest enlargement takes place, as a rule, in an antero-posterior direction. The lateral lobes are not usually equally enlarged, but neither one is found to be con- stantly larger than the other. In the majority of instances no marked enlargement of the so-called median lobe exists. That this statement is contradicted by the greater number of museum preparations, is of no weight when we consider the great passion all surgeons may be said to have for preserving curious speci- mens; thus four or five prostates without a median projection may be discarded for the one possessing such an anomaly, which is preserved. It is very probable, moreover, that the number of patients with median projections who are operated upon is greater than the real ratio of occurrence of such lesion ; for where no such obstruction exists, and where residual urine is caused only by transverse obliteration of the urethra, easily overcome by catheterization, the patient is not so liable to be submitted to an operation. When a median projection into the floor of the bladder just posterior to the urethra does occur, it is probably safe to say that its origin may be traced to one or other of the lateral lobes. 58 Pathology. PLATE XXXVII. The patient, S. L. T., aged seventy-three years, was admitted to the Ger- man Hospital July 9, 1903. He states that he has never used alcohol. He had an attack of gonorrhoea when about eighteen years of age. His present illness began two and a half years before admission, with frequency of urina- tion, especially at night; he was obliged to get up every fifteen or twenty minutes to urinate; and often when upon his feet he would pass his urine involuntarily. The flow lacked force, coming in a thin stream. Lately bright blood was present at times. At the beginning of this illness much sediment was passed in the urine. Examination on admission showed an enlarged prostate, very firm, the size of a lemon. Suprapubic prostatectomy was performed July n, 1903. Owing to his advanced age the patient did not react very well, but failed gradually, and died in a uraemic state on July 26, more than two weeks after the operation. The prostate, No. 1542, which is shown in the accompanying Plates, is an excellent example of the mixed type of enlargement, being partly glandular (Plate xl viii, facing page 68), and in places extremely fibrous (Plate xlix, facing page 69). PLATE XXXVII. View of the Upper Surface of an Enlarged Prostate (Xo. 1542), Measuring 7X6x6 cm. (2f X 2\ X 2 h Inches) and Weighing 120 Grammes (4 Ounces). A Catheter has been Introduced through the Urethra. PLATE XXXVIII, View of the Under Surface of an Enlarged Prostate (No. 1542), Measuring 7X6x6 cm. (2§ X 2\ X 2h Inches) and Weighing 120 Grammes (4 Ounces). A Catheter has been Introduced through the Urethra. PLATE XXXIX, A < W W u . £ < i-i « x§ x« vo w xS < W 51 s 5? W O IS PLATE XL. Enlarged Prostate (No. 1502), Measuring 6X6X5 cm. (2$ X 2§ X 2 Inches) and Weighing 100 Grammes (3 J Ounces). Size and Direction of Growth. 59 PLATE XL. The patient, H. M. Y., aged sixty-six years, was admitted to the German Hospital June 8, 1903. The patient's father had died of prostatic disease. The patient had always been a moderate user of alcohol. For the past fifteen years he had suffered from frequency of urination, which was most marked at night. Two years before admission he had developed an acute attack of cystitis. In July, 1902, he had been operated upon for vesical calculus, since which time he had had a suprapubic fistula. He has not passed urine through the urethra for six months. Rectal examination on admission showed a very hard prostate, about the size of a lemon. Suprapubic prostatectomy was done June 15, 1903; a stone the size of a lima bean was extracted from the bladder, and the prostate removed entire along with the prostatic urethra. Recovery was rather tedious, but the pa- tient was discharged August 1, 1903, in good health, and with no urinary trouble. The prostate, No. 1502, which is shown in the accompanying Plate, was the seat of considerable catarrhal and interstitial inflammation, as seen by the microscopical section, Plate xlv (facing p. 65). Its weight was 100 grammes (3 J ounces). 6o Pathology. PLATE XLI. The patient, W. T. D., aged seventy-three years, lawyer by occupation, was admitted to the German Hospital December 3, 1904. He had always used alcohol and tobacco in moderation. He had had the ordinary diseases of childhood, and had had enteric fever twice, in 1862 and 1863. Since that time he has always enjoyed good health. For a little more than three years he has had slightly more frequent desire to urinate, with occasional imperative urination. Three years ago, after slight alcoholism, there developed acute retention of urine, which was relieved by the catheter. For a week subsequently a catheter had to be passed twice daily, and since this time the patient has had to be catheterized on the average of once in a week or ten days, sometimes only every two weeks; never with any degree of regularity. The chief indication for catheterization was pain; a considerable amount of urine would usually be drawn, and the patient would urinate generally about five times during the night following these catheteriza- tions, though there would be times when he would not get up at all. On admission there was found to be residual urine amounting to 60 cc. (2 ounces). Suprapubic prostatectomy was done December 8, 1904. On opening the bladder it was found that the prostate was markedly enlarged, especially upon the right side, which equaled a lemon in size. On attempting to enucleate the whole gland the tip of the much enlarged right lobe broke off from the body of the enlarged organ, and lay free in the bladder. It was removed, and the re- maining portions of the prostate were then enucleated in one piece. Unin- terrupted recovery followed, and the patient is completely relieved of his urinary symptoms. The prostate, No. 2138, which is shown in the accompanying Plates, weighed 162 grammes (5 J ounces). PLATE XLI. View of an Enlarged Prostate (No. 2138) Weighing 162 Grammes (5J Ounces). Very Marked Enlargement of the Right Lobe. PLATE XLII, t wfw^ T ^' ME PROSTATE (X °- 2I - 8) SH ° WN » P ^TE XLI (a) (6) the right lobe, (b) the intravesical portion. (c) The left lobe PLATE XLIII. II View of the Upper Surface of an Enlarged Prostate (No. 1826) Weighing 56 Grammes. A Catheter has been Introduced through the Urethra. Size and Direction of Growth. 61 PLATE XLIII. The patient, A. S., aged sixty-eight years, was admitted to the German Hospital March 25, 1904. He had always enjoyed good health, and had lived a very active life. For fourteen months previous to his admission he had had frequency of urination, and at times had been forced to use a catheter every fifteen minutes. For the last three months he had been confined to bed with a catheter constantly in the bladder. He likewise suffered from diabetes. His general condition, however, improved so much after the institution of con- tinuous drainage, that an operation was deemed justifiable. Suprapubic prostatectomy was accordingly performed on March 26, 1904. The operation proved to be perfectly successful. Urine was volun- tarily passed through the urethra first on April 6, and the patient was soon afterwards discharged with the suprapubic wound firmly healed, and with his urinary functions in normal condition. The prostate, No. 1826, is shown in the accompanying Plate. It weighed 56 grammes (nearly two ounces), and is a good example of irregular enlarge- ment, the projection of the so-called middle lobe making the under surface of the gland nearly clover-leaf in shape. 62 Pathology. In the immense majority of cases carefully examined in recent years, demonstration of such origin has been possible, the pedun- culated growth being attached to a lateral lobe much as a sub- peritoneal fibroid is attached to the uterus. It seems, indeed, not impossible that, in those cases where it has been said that no such attachment existed, the growth had finally torn its pedicle loose, and that it might in time even have migrated, as is not unfrequently the case with the somewhat analogous tumors of the uterus. There is, however, another condition, well described as the formation of a lip at the vesical orifice of the urethra, which is sometimes mistaken for a median outgrowth. This lip in reality is formed by the enlargement of accessory prostatic glands situated beneath the vesical mucous membrane, and within the limits of the internal sphincter of the bladder. Where an adenomatous mass springing from one lateral lobe projects beneath the mucous membrane in this situation, the internal vesical sphincter is not separated from the bladder by the growth, which merely pushes this sphincter before it. But in the process known as the lip formation, which has been especially studied by Ciechanowski [49], the adenomatous mass is found between the vesical mucous membrane and the sphincter, and may in time, by over-stretching this latter structure, keep the prostatic urethra constantly patu- lous, and urinary incontinence may even ensue. Such a process as this may exist without any involvement of the prostate gland itself. Residual urine may form in a pouch behind this posterior urethral lip, and indeed all the subjective symptoms of prostatic enlargement may harass the patient. I am persuaded that this is an unusual condition, and it seems to me that some writers make it unduly prominent. Physical Characters. When we come to a consideration of the physical characters of the enlarged prostate other than its size and weight, we find PLATE XLIV. View of the Under Surface of an Enlarged Prostate (No. 1826) Weighing 56 Grammes. A Catheter has been Introduced through the Urethra. Physical Characters. 63 that the most important from a therapeutic point of view is its density. This varies from that of cartilaginous hardness, such that the knife creaks as it cleaves the tissue, to a glandular soft- ness which may perhaps best be compared to a wet sponge of close texture. The former characteristic, hardness, is found exclusively in prostates which contain much fibrous tissue, and which I have placed in the second class ; while the softer the organ is found to be, the more surely may it be considered to belong to the adenomatous group of cases. Between these two extremes all grades of density exist; but few indeed are the cases where it is impossible to class the gland readily in one or the other category. The rate of growth is variable both of the gland as a whole, and of its individual parts. The soft glandular prostates grow with greatest rapidity, and may furnish evidence of increase in size to the palpating finger within a period of a few months. Extremely rapid growth occurs only in neoplasms. The fibrous prostate grows slowly, and, as already remarked, rarely equals the glandular in size. Some authors have even contended for a progressive decrease in size occurring in this form, constituting true prostatic atrophy; but their views have not met with un- reserved acceptance. In the fibrous variety, moreover, it is un- usual to find pedunculated or sessile growths projecting from the surface of the prostate, these so-called prostatic tumors oc- curring almost without exception where the organ has under- gone a glandular overgrowth. These " prostatic tumors" are quite characteristic. In the prostate have been found at times true tumors, myomata, adeno- mata, and other growths; but what is understood by a prostatic tumor is a localized overgrowth of glandular acini, without in- crease in the number of the corresponding ducts. This acinous overgrowth compresses the surrounding stroma into a capsular envelope, which it has been customary to regard as a myomatous growth, the prostatic tumors being denominated adenomyomata. 64 Pathology. Later investigations, however, have shown that this capsule is in reality composed of new connective-tissue elements, or fibro- blasts, while the muscle tissue probably does not increase in quantity. In time the stroma surrounding these localized glan- dular outgrowths itself begins to grow, and may eventually, accord- ing to Moullin [176], compress the pre-existent acini, so that the prostatic tumor formerly almost wholly glandular in character becomes eventually fibrous and solid. Moullin claims that in- crease in size, though less rapid, still continues during this which he calls the second stage of the pathological process. Whether or not we accept this view, that the fibrous is a subsequent stage of the glandular change, it is certain that the prostatic tumors, no matter what their state, are under considerable pressure from the surrounding stroma, and that they tend to grow in the direc- tion of least resistance. This latter fact frequently causes them to project beneath the mucous membrane of the bladder, pos- terior to the urethral orifice. When seated within the substance of the gland, they are prone to start out of it on section, and may readily be enucleated with the finger, the few ducts from which the numerous new acini spring, unless they are included in the section, serving as their pedicle of attachment to the rest of the organ. In some cases no such prostatic tumors are found, the gland presenting a nearly uniform, general enlargement, either glandular or fibrous in character; or a general glandular enlargement may exist in some areas, and a general fibrous enlargement in others. When this is the case, no nodulation of the surface occurs, and there can be, of course, no " median lobe" present. When a large part of the prostate becomes intravesical, it is usual to observe a constriction between this and the extravesical portion. This constriction is produced by the edges of the pros- tatic sheath, which as Mr. Freyer [90] says, has been shouldered aside by the prostate in its efforts to expand beneath the mucous membrane of the bladder. PLATE XLV. A Section from Prostate No. 1502 (See Plate XL) showing Considerable Hyperplasia and Some Dilatation of the Glandular Structures. For the most part the lining epithelial cells are disposed in a single layer, but here and there there are two or more layers, which, together with the mucoid infiltration of the cells and the periacinar round-cell infiltration, indicate catarrhal and other inflam- matory alterations. ( X 250.) Microscopy. 65 Pathological Histology. Our knowledge of the pathological histology of the enlarged prostate is due almost entirely to the monumental and exhaustive work of Ciechanowski [49,50], supplemented by the researches of Albarran and Halle [3], of Motz [172 a], of Greene and Brooks [102], of Crandon [54], of Daniel [56 a], and of Herring [120a]. Ciechanowski' s original article was published in 1896 in Polish, and hence did not find a very large circle of readers. It was re- published in German in 1900, after being in the editor's hands for nearly two years; but it was only on the appearance of an article from his pen in French in 1901, that his views became widely known and thoroughly appreciated. His studies fall into two groups, in the first of which he dis- cusses the changes occurring in the bladder as the result of old age, of prostatic obstruction, and of chronic cystitis; the second division being devoted to a consideration of the prostate itself. By careful and repeated microscopical measurements he showed that vesical insufficiency occurred from a diminution in the amount of muscular tissue in the bladder walls. He detected no increase in the connective tissue except where chronic cystitis was present. This is in accord w T ith the clinical observation of Guyon [108], who noted that if no cystitis was present the residual urine gradually accumulated without producing many symptoms, until the bladder might be distended to above the umbilicus, before overflow from retention occurred; whereas if infection was present frequent urination arose early in the case, and the bladder did not dilate, but became thickened and con- tracted. Ciechanowski held, and Greene and Brooks as well as Cran- don, who each undertook a separate examination of his conclu- sions, agree with him, that both the glandular and the fibrous overgrowths of the prostate are the long-delayed result of a chronic inflammation, insidious in onset, slow in course, and for many years perhaps entirely latent. The process of overgrowth Cie- 6P 66 Pathology. chanowski thinks may be observed to occur simultaneously in both the glandular and the stromal portions of the prostate. The description given in the following pages is freely borrowed from the authors above mentioned, and to their works I here desire to express my indebtedness. Examination of a microscopical field from an enlarged prostate shows most noticeably, as a rule, increase in glandular structure. Some have thought that new acini were formed, as in the case of the true adenomata observed in the mammary gland, where the chief pathological change evident is the preponderance of glandular tissue over the normally present fibrous reticulum; but in the prostate the process does not appear to be one of true tumor formation, since it seems certain that these extra gland acini are merely dilated gland tubules which, though previously present, were then insignificant in size. Study of the mucous membrane lining these gland spaces shows a variety of changes present. The cells may exist in only the usual single layer, or they may be heaped up into several layers, showing a catarrhal inflammation in which new cell formation has taken the place of secretion. In this way the acini may become closely packed with epithelial cells, simulating on hasty examination cancer nests. Albarran and Halle [3] observed epithelial prolifera- tion such as this in fourteen out of one hundred cases examined, and classed them all as commencing carcinomatous degenera- tion. But as pointed out by Greene and Brooks [102], such a large percentage would be unheard of, and contrary to all clinical evidence. Moreover, these authors found such acini in many of their own cases which were undoubtedly not cancerous; so it seems safe to conclude that a carcinomatous change cannot be diagnosticated unless epithelial cells can be found displaced from the alveoli and proliferating in the stroma. This condition was also observed by Albarran and Halle [3], some of whose cases were undoubtedly instances of carcinoma; and while we must reject their former conclusions as erroneous, we must yet PLATE XLVI. ^:%aM A Section from Prostate No. 1258 showing Marked Glandular Hyperplasia (Photomicrograph, x 280.) PLATE XLVII. Wk e.\\ N '« #3 ^ 1 &J&; *?» MA A Section from Prostate Xo. 1623 (See Plates XXXY, XXXYI) showing Cystic Dilatation of the Acixi with Consequent Flattening and Atrophy of the Lining Epithelium. (X 180.) Microscopy. 67 be grateful to them for calling our attention to the not very re- mote possibility of malignant change. In some cases the acini will not be completely filled with epithelial cells, but there will be such an admixture of lymph- ocytes, and even of polymorphonuclear leukocytes, as to constitute true suppuration; the prostate in these cases being riddled with minute abscesses, although outwardly presenting only the usual evidences of senile enlargement. If secretion takes the place of cell proliferation, the single layer of columnar cells will still surround the acinus, but this will be dilated by a variable amount of mucoid material, very probably containing one or more concretions. In some instances extreme dilatation of a few of the acini is present, and the well- known though rather rare cystic prostate is produced. In some of these cases the epithelial lining is squeezed out of existence entirely, and the cyst is surrounded only by stroma. The cells may at times be seen lying in rows detached from the acinous wall, free in its cavity. Sometimes two neighbouring acini are seen with only a thin partition between them; and it is easy to con- ceive how the coalescence of two or more such acini might occur. Turning our attention now to the ducts, we find that these are, as a rule, compressed in direct proportion to the dilatation of the acini. In some places a duct will be seen with its opposed mucous linings flattened by pressure; and other ducts may be found which have become converted into fibrous bands, with no trace of epithelial structure remaining. It is to be noted that the pros- tatic concretions have never been observed to plug the ducts; these seem to be always compressed by an outside influence. Yet Daniel [56a] was "struck by the frequency with which the ducts are obstructed by lecithin or amyloid bodies, desquamated epithelium, or pus cells." This process of proliferation in the acini, and compression of the ducts, leads in many instances to the formation of the " pros- tatic tumors," or pseudo-adenomata, previously discussed. But 68 Pathology. for an explanation of this process we must advance our obser- vations from the glandular structure and consider the changes found in the stroma. One of the first things to meet the eye as it studies the stroma is the collection here and there of groups of small round cells — true round-celled infiltrations, according to Ciechanowski [49] and others. These aggregations of cells are not regarded by Crandon [54] as at all the same as the lymph nodes described by Walker [235] as occurring in the normal prostate. They are most frequent beneath the mucous membrane of the urethra, then in patches along the excretory ducts ; but are also sometimes observed surrounding the terminal alveoli. These round-celled infiltrations are here, as elsewhere, significant of inflammation, and indicate a rather acute process in their immediate locality. But in the enlarged prostate they are seldom observed in large areas, or very uniformly distributed. They seem rather to be aggregated in a few spots for some recent local inflammation. The stroma surrounding the ducts, and that immediately about the acini, shows the presence of true fibroblasts, the same that are seen in areas formerly inflamed, but becoming cicatricial. And in other spots of the stroma may be seen fully formed fibrous tissue — true cicatrices — where the contracting fibroblasts have perhaps compressed and even obliterated one of the excretory ducts or an acinus. Evidence of this last event is found in the occasional existence of a prostatic concretion in the midst of scar tissue, this concretion having naturally resisted the obliteration which its containing acinus suffered. The muscle cells are not found to be hypertrophied. What were formerly considered muscle cells are now recognized as the fibroblasts. But it is not impossible, when an acinus first begins to dilate, that for a short time its immediately surrounding muscle cells may hyper- trophy, and endeavour to evacuate the contents of the retention cyst forming within their embrace. But any such hypertrophy, if it ever exists, is very soon overcome by the fibrous growth. PLATE XLVIII \» ; vsfe£ , A Section, from Prostate No. 1542 (See Plates XXXVII, XXXVIII and XXXIX), showing Considerable Glandular Hyperplasia Adjacent to Much Con- nective Tissue Overgrowth, and Two Corpora Amylacea. The connective tissue hyperplasia was more marked in other portions of the speci- men (Plate XLIX), and throughout the specimen there was a moderate amount of round- cell infiltration, especially about the blood-vessels. (X 180.) PLATE XLIX. '. St} •'■'.-> \ A Section from Prostate No. 1542 (See Plates XXXVII, XXXVIII, and XXXIX), showing Marked Connective Tissue Hyperplasia with Considerable Atrophy and More or Less Complete Obliteration of the Acini. In another portion (Plate XLVIII) there was considerable glandular hyperplasia, and throughout the specimen there was a moderate amount of round-cell infiltration, especially about the blood-vessels. ( X 100.) Microscopy. 69 The particular form of the enlargement found depends en- tirely for its glandular or fibrous character on the situation of the intraglandular and interglandular changes, and on their relation to each other. If the intraglandular changes occur most markedly in the periphery of the gland, that is to say, away from the ducts, while the interglandular or stromal changes arise chiefly in the interior of the gland, around the prostatic ducts and about the urethra, then the character of the enlargement is adenomatous, since the ducts are obstructed, and the acini undergo cell-proliferation or cyst formation. But if the periglandular changes are most marked in the per- iphery, then the acini are compressed, perhaps obliterated, by the surrounding growth, and the ducts are all that remain of the glan- dular structure of the prostate, which may then be a mere mass of scar tissue. If the scar tissue continues of the embryonic type, consisting largely of fibroblasts, the prostate will enlarge, though very slowly ; but if true fibrous tissue forms, it is probable that a decrease in size will occur. As remarked before, it does not seem to me at all likely that one of these processes succeeds upon the other. It appears to me far more rational to suppose that an enlargement which has commenced by constriction of ducts and dilatation of acini, will continue as such for all time, or until a prostate the size of a cocoanut has been produced; and that a process in which the gland acini are compressed and obliterated by fibrous tissue which is more marked in the periphery than in the centre of the prostate, has been such from the beginning; not that the large adeno- matous structure subsequently became fibrous. The fibrous form is generally admitted to be distinctly rarer than the adenomatous, but Greene and Brooks [102] found it to preponderate in the specimens, fifty-eight in number, examined by them. 7° Pathology. These authors describe the clinical course of the disease in the following terms: Suppose, for instance, that acute inflammation of the prostate arises. "With a cessation of acute inflammation following a removal of its cause and normal reaction on the part of the tissues of the organism, interstitial hyperplasia should cease, and retraction and atrophy follow from sclerosis of the fibers, as the embryonic tissue takes on adult form. Such a result does follow in favorable cases of prostatitis in the young and healthy, and, as the sclerosis of the newly formed tissue continues, the atrophic or small hard prostate follows to a greater or less extent, always provided, however, that this same fibrous sclerosis does not excite secondary changes in the glandular epithelium. But in the middle-aged or old man, particularly where more or less general or arterial disease exists, resolution and healing do not so readily follow, and instead of cessation of connective-tissue hyperplasia the condition becomes chronic. With the increased fibrosis, con- sequent thickening of the walls of the veins and lymphatics fol- lows, and chronic congestion is added to the factors tending to prolong and increase interstitial hyperplasia, edema and inflam- matory exudation. So it happens that in the enlarged prostate of the aged, acute and subacute proliferations are found mingled with the thickened masses of adult sclerosed connective tissue. As an inevitable result of this overgrowth of stroma, atrophy of the smooth muscle cells follows. This may be of greater or less degree, greater if the inflammation partakes more of the acute type where parenchymatous degenerations are most rapid, less if the process be more chronic. ,, Thus by a fibrous overgrowth alone, continuing for months or years, the prostate may be considerably increased in size; but when the glandular changes are concerned as well, quite rapid enlargement may occur. Greene and Brooks [102], who, it will be remembered, found the fibrous type of enlargement more frequent in their specimens, seem to incline to the opinion that /Etiology. 71 it is the primary change, and that epithelial or glandular pro- liferation is produced by it. Their views, however, are not very clearly expressed. Whether these recent views as to the invariably inflammatory origin of prostatic enlargement will be hereafter disproved, re- mains to be seen. It is at present the easiest solution of a vexed question; but I am not sanguine as to its being final. Two things seem to me to need emphasis: the first, that the truly adenomatous origin of the glandular form does not appear to have been disproved ; and, secondly, the very great importance of chronic passive congestion, or call it chronic inflammation if you will, in the production of the fibrous form of prostatic enlargement. CHAPTER IV. CLINICAL PATHOLOGY: EFFECTS ON URETHRA, BLADDER, KIDNEYS, URINE, AND RECTUM. As the prostate gland enlarges, whether from tumor formation or as the result of a general hyperplastic process, various changes are produced in the urethra, the bladder, and the rectum; and less directly on the urine, the kidneys, and the general health. Effects on Urethra. The length of the urethra is probably always increased. Its normal length averages eight inches (20 centimetres), according to the extensive statistics compiled in 1898 by Keyes [132]; but it varies from six to ten inches in health, and thus a length of over eight inches may be no longer than normal for any individual patient ; while, on the other hand, the urethra may be abnormally long by two inches when its length merely reaches the average. In drawing conclusions from such measurements the patient's height, his age, and the length of his penis, should all be borne in mind. The urethra is generally considered to increase slightly in length with advancing years, apart from any pathological change; and, other things being equal, the taller the patient, and the longer his penis, the greater may be expected to be the length of his urethra. The length of the penis, however, and consequently that of the urethra, varies so much in the same individual, according to the local temperature and nervous emo- tions on being examined, that this increase, unless marked, and accompanied by other symptoms, cannot be regarded as of very great importance. One more point in this connection should be borne in mind; that is, that when the bladder is full, and the 72 PLATE L. Elevation of Vesical Orifice of the Urethra and Formation of a Retro- prostatic Pouch. Note the increased curve and length of the subpubic urethra. Compare with Plate _XII. PLATE LI. Lateral Deviation of the Urethra Towards the Patient's Right, Due to Overgrowth of the Left Lobe of the Prostate. — (After Anger.) Effects on Urethra. 73 desire to urinate is present, the prostatic urethra, unless retention occurs, becomes physiologically part of the bladder; and the urine is withheld from the bulbous urethra only by the voluntary muscles surrounding the membranous portion of this canal. Hence it will be found that if a catheter is passed into the blad- der to draw off residual urine, or urine which there is no desire to evacuate, the whole length of the urethra, including the prostatic portion, will be traversed before any urine flows; whereas if desire is present, and the prostatic urethra is in physiological continuity with the bladder, a corresponding length of catheter will be subtracted from the total length formerly required. The length as measured will also be greater in a curved than in a straight instrument. In some of these cases the length of the urethra may be in- creased up to fourteen or sixteen inches; so that where urinary retention is evident the surgeon must not be discouraged on fail- ing to reach the bladder with the ordinary length of catheter. This increase of length occurs chiefly in the prostatic portion, which may measure as much as four inches. The bulbous urethra is also lengthened. The means by which this increase in length is brought to pass may be explained by the fixation of the prostate gland at its apex, and the necessity which therefore exists for any enlargement to take place in a posterior direction. As will be remembered, in speaking of the relational anatomy of the prostate, attention was called to the greater firmness of its attachment to the rectum, as compared with its superior relations; hence its greater enlarge- ment is usually found extending into the floor of the bladder, this being a more compressible viscus than the rectum, which is so often filled with solid faecal matter, while the fluid contents of the bladder offer little resistance to prostatic encroachment. The enlargement upward of the prostate explains how in the en- larged organ the prostatic utricle comes to occupy the lower part of the prostatic urethra instead of its centre. 74 Clinical Pathology. The fact that the neck of the bladder is thus encroached upon brings about a second change in the urethra, and this is in its direction. The vesical orifice of the urethra is thus raised from its normal situation, even where no isolated median enlarge- ment exists; and the vesical half of the prostatic urethra may in extreme cases assume a right angle with its outer portion, so that the curve of the ordinary metal or English catheter will not fit the prostatic urethra, its point impinging upon the posterior wall. Besides a change in direction in the sagittal plane thus produced, there may be a lateral deviation of the urethra, due to unequal enlargement of the two lateral lobes, the channel being deflected towards the less enlarged lobe. Hence in passing a metal catheter in cases of obstruction from enlarged prostate, if the beak of the instrument cannot be made to ride over the ob- struction by depressing its handle, the surgeon should turn it first to one and then to the other side. If a pedunculated enlarge- ment exists just back of the vesical orifice, a Y-shaped channel may be present, and the catheter will pass to either side of the median line. By the same process by which the vesical orifice of the urethra is raised, the posterior or inferior wall of the prostatic urethra is much lengthened; and if no corresponding growth occurs in that portion of the prostate anterior to the urethra, and the an- terior wall of the prostatic urethra remains unchanged, the diam- eter and consequently the capacity of the prostatic urethra may be much increased, so that it may hold an ounce or two of urine. Such extreme enlargement is, of course, rare; indeed, it more often happens that this portion of the canal is more or less com- pressed by the centripetal enlargement of the lateral lobes, so that on transverse section it appears as a vertical chink, instead of the normal crescentic outline. If this lateral compression be marked, and it is more apt to be so in cases of fibrous overgrowth than in adenomatous enlargement, total retention of urine may ensue, even though the vesical orifice of the urethra be not dis- PLATE LII, Formation of a Y-shaped Channel due to Presence of a Pedunculated "Median Lobe." Several orifices of vesical pouches are also seen. A small concretion is attached to the "middle lobe." — (After Cruveilhier.) PLATE LIII. Overgrowth of Suburethral Portion of Prostate, Changing Subpubic Curve of Urethra. — (After Anger.) Effects on Urethra. 75 placed, and the catheter enter with its usual facility; for while a catheter may easily overcome very considerable lateral com- pression, the bladder will be unable to effect a like dilatation of the canal by hydrostatic pressure applied only to its vesical ori- fice. Instead of retention of urine being produced by the de- formities of the urethra caused by enlargement of the prostate, true incontinence of urine — not merely retention with overflow — has occasionally been noted where the eccentric growth of the prostate keeps the urethral orifice constantly patulous. If the parts below the urethra enlarge with greater rapidity towards its floor than towards the vesical trigone, the normal curve of the subpubic urethra may be obliterated, the canal here becoming straight; or its convexity may even be directed for- wards, towards the pubic symphysis. In such cases the catheter must be reversed before it will enter the bladder. (Plate liii.) Vignard [234] has shown that among twenty-eight specimens which he examined, in sixteen obstruction to urine existed through- out the whole prostatic urethra; in nine cases the obstruction was chiefly at the vesical orifice, but also to some extent in the urethra; while in only three out of the whole twenty-eight cases did it exist at the vesical orifice alone. Besides the changes in length, direction, and size, to which the prostatic urethra is thus subject, it may be curiously distorted by submucous adenomata springing into its canal from any direc- tion, most frequently from beneath its floor. Failure to remove such masses, palpable neither from within the bladder nor from the perineum, is the probable explanation of persistence of symp- toms after many a prostatectomy. The large submucous veins of the prostatic urethra become much engorged along with all other neighbouring veins, and by a sudden access of congestion are the chief cause of attacks of acute retention of urine. They may bleed spontaneously at times, and even the most gentle catheterization may provoke consider- able haemorrhage. 76 Clinical Pathology. Effects on the Bladder. Of all the changes produced in the bladder by enlargement of the prostate gland, none is of greater importance than the formation of a post-prostatic pouch, by the combined elevation of the urethral orifice and descent of the vesical floor. This is probably a much more frequent cause of residual urine than is the ball-valve action of a pedunculated submucous adenoma blocking the urethra. The descent of the vesical floor is the result, not the cause, as Mr. Harrison [116] maintained, of the enlarged prostate. Where obstruction exists to the evacuation of a hollow viscus, it is surely always the preceding change, and the dilatation which is found arises from vain efforts to expel the contents. A familiar example of this is seen in pyloric stenosis. If this obstruction be overcome, by gastroenterostomy or otherwise, the atonic stom- ach recovers its normal physiological action in the vast majority of instances. Similarly, if the urinary obstruction be removed, by excision or even by suprapubic drainage, the dilated and feeble bladder will recover, if the condition has been relieved in time. The prostatic obstruction throws increased work on the blad- der, as Mansell Moullin [176] has well said, and when it is no longer able to empty itself, the floor, which is the part last to be emptied as well as the weakest, is the first to dilate. When this stage has been reached, every effort of the bladder for evacuation only serves to press the urine against its floor and to increase the capacity of the post-prostatic pouch. The shape of the urethral outlet of the bladder may be vari- ously altered according to the part of the prostate most overgrown. It is usually crescentic in outline, the concavity of the cres- cent being directed towards the most enlarged part. But if the prostate enlarges nearly equally in both its supra-urethral and infra-urethral portions, a collar-like projection will occur into the bladder all around the urethral orifice. This form of enlargement PLATE LIV, Collar-like or "Cervix Uteri" Enlargement of Prostate, seenjfrom within the Bladder. — {After Socin and Burckhardt.) PLATE LV Enlargement of the Lateral Lobes of the Prostate forming between Them a Bar at the Neck of the Bladder. — (Watson.) Effects on Bladder. 77 has been graphically compared, both in appearance and in feel, to the cervix of the uterus, the urethra being placed in the midst of a hillock, like the cervical canal between its lips. (Plates liv and lvi.) If the lateral lobes enlarge uniformly and tend to spread away from the middle line, they are apt to raise a fold of tissue taut across the vesical orifice of the urethra. This fold may be com- posed of mucous membrane alone, or may have a varying amount of submucous tissue in it as well. It is the most usual form of "bar at the neck of the bladder," and in many instances is a serious obstacle to catheterization. (Plate lv.) As has been already remarked, an isolated adenomatous mass, springing from the prostate beneath the neck of the blad- der just posterior to the urethral orifice, may cause the inner part of the urethra to become Y-shaped. (Plate lii.) Very great impairment of the urinary function may result when there is no apparent mechanical obstruction. In such cases the cause of the trouble is the existence of a hard oedema, or of an arteriosclerosis or fibrosis in the neck of the bladder and the prostate. Such processes, the result of long preceding congestions or chronic inflammations, render the normally soft and pliable vesical outlet firm and rigid, so that the prostatic urethra can no longer open up into practical continuity with the bladder during urination; and as a consequence, obstruction arises from the immobility of the parts. In such cases the pros- tate may be little or not at all enlarged, but extremely hard; thus furnishing a marked example of the fibrous class. While the most prominent changes in the bladder are thus seen to occur in the neighbourhood of its neck and the trigone, certain alterations throughout its walls occur in many cases, and these are of nearly equal importance. They are partly the re- sult of the efforts to overcome the obstruction, and partly the result of the chronic cystitis which almost invariably accompanies prostatic enlargement. 78 Clinical Pathology. The increased work thrown on the bladder causes first an hypertrophy of its muscular walls. If the obstruction is not relieved in time, atony ensues, with dilatation of the bladder, or fibrous degeneration takes the place of the hypertrophy, and the bladder contracts. In cases where the obstruction is unre- lieved, chronic retention occurs, and the amount of residual urine gradually increases. The walls of the bladder may then become much distended and extremely thin; and its fundus may reach to the umbilicus or above, before partial relief occurs from over- flow. Atony of the bladder from actual disappearance of its muscular fibres through fatty degeneration may thus arise; and although atony so extreme as to be irremediable is no longer thought to be very frequent, yet the surgeon should bear this danger in mind, and see that his patients are relieved of their retention before matters have gone too far. But the bladder may not dilate; its walls may become much thickened, corrugated and pouched; its cavity may even con- tract, and contain only a few drachms of urine, necessitating its evacuation every ten or fifteen minutes. As the muscular walls become fibrous they contract on the contained mucous coat, and this may be seen bulging out in pouches in the interstices be- tween the thickened fibrous bands, as efforts to expel the urine are made. These herniated pouches may in time remain perma- nently, not disappearing even when the bladder is relaxed. In such cases not only may residual urine collect in these pouches, but calculi may form in them, and thus much increase the pain and discomfort of the patient. The changes in the bladder walls the result of cystitis differ in no respect from those due to cystitis from other causes. Vesical catarrh is a prominent symptom, and the viscid ropy mucus adds to the urinary obstruction. The mucous membrane is highly congested; it may be ulcerated in places; and calcareous deposits are frequently found on its surface. So turgid are the veins that it is the rule for some degree of hematuria to be developed as soon as the bladder is relieved of the urinary pressure. / PLATE LVI. Atoxic, Dilated Bi.al.deb, from Enlargement of the Prostate without Marked Cystitis. (From a specimen in the Mutter Museum of the College of Physicians of Philadelphia.) Effects on Kidneys. 79 Where infection is present, it is probable that chronic urinary retention so extreme as to produce overflow never occurs; but that the acute pain and frequency of urination claim the sur- geon's services at an earlier stage of the case. It is therefore in the infected cases that the small rugous and thickened bladders above referred to are oftenest encountered; and it may be con- sidered a question whether the infection causes the contraction primarily, or whether this occurs only because the high grade of cystitis present makes relief to obstruction imperative before dilatation of the bladder has taken place. Effects on the Kidneys and Ureters. From the presence of residual urine in any amount, changes may further be observed in the orifices of the ureters. Normally these tubes enter the bladder wall obliquely, passing through the vesical coats for one-quarter or one-third of an inch; and they discharge their contents into the bladder in driblets or in spurts at intervals of some seconds. But as the bladder becomes distended the ureteral openings are compressed, and the dis- charge of their contained urine becomes more difficult. When the bladder is excessively distended, and its wall is overstretched in all its parts, the ureteral orifices may become constantly patu- lous, by the approximation of their course through the bladder walls to a straight line. Dilatation of the ureters may result. (Plate lvtii.) As soon as the pressure in the ureters becomes increased, a damming up of urine occurs into the pelvis and calices of the kidneys; and this change in pressure, apart from any infection, is soon manifested in the behaviour of the kidneys themselves. Circulatory disturbances are produced in the kidneys, the im- mediate effects of which are not accurately known ; but from the observations of Cabot [41] it is evident that in their early stages they are not beyond the hope of cure. Generally speaking, it is pretty sure that this increased pressure alone, even without 80 Clinical Pathology. any infection, will cause the production of fibrous overgrowth in the kidneys, as well as an increase in the quantity and a decrease in the specific gravity of the urine excreted. That the primary change in the kidneys is probably atrophy of secreting structure, while fibrous hyperplasia is a subsequent occurrence, has long been an accepted theory; but as I have already remarked, I do not think this same sequence of events has been proved to occur in the diseased prostate, although here also it is a plausible and a most convenient theory. Where infection exists as well, and especially where the vesical orifices of the ureters are more or less patent, pyelitis and surgical kidneys soon develope. Effects on the Urine. The residual urine almost invariably becomes alkaline, and is a prolific cause of cystitis. Being alkaline, phosphatic or mul- berry (oxalate of lime) calculi are prone to form. It has been estimated that nearly one-quarter of all patients with enlarged prostate have calculi as well. The calculus, however, being usually fixed rather firmly in the post-prostatic pouch, frequently gives no characteristic symptoms, and is difficult of detection with a sound. Especially is this the case where a calculus forms in or becomes subsequently lodged in one of the pouches already alluded to; or when its surface becomes covered with mucus, or it is surrounded by prostatic overgrowths. As already men- tioned, the urine may be deposited in calcareous crusts over the entire vesical walls. When chronic cystitis developes the urine presents the well- known characteristics of this disease. Shreds of mucus, pus, clots of blood, and various crystals may be found. Ammoniacal decomposition is frequent. The colon bacillus, imparting to the urine its characteristic odour, may be the infecting medium; it is not impossible for this germ to gain entrance to the bladder directly from the intestinal tract, though of course its more usual PLATE LVII. Contracted, Infected Bladder, with Thickened Walls and the Formation of Vesical Sacculi, from Enlargement of the Prostate Accompanied by Marked Cystitis. (From a specimen in the Mutter Museum of the College of Physicians of Philadelphia.) Effects on Urination. 81 avenue of approach is through the urethra. Streptococci, staphy- lococci, and other micro-organisms are also found. The pus, the mucus, but especially the blood clots, are fre- quent causes of stammering in micturition; and as they are sucked into the eye of the catheter impart to the hand a readily recognized sensation. The blood may come from spontaneous rupture of engorged veins, or from trauma by a calculus or a catheter. At times the clots are found nearly filling the cavity of the bladder. When the kidneys become affected the urine becomes corre- spondingly altered, as seen in the early stages of interstitial neph- ritis from other causes. The quantity passed in twenty-four hours may reach ninety or a hundred ounces, or even more; the specific gravity will show a proportionate decrease; and albumen and tube casts may be detected. It should not be over- looked, however, that renal disease may have long antedated the prostatic trouble. Effects on Urination. Such widespread and serious changes throughout the urinary apparatus cannot fail to produce marked changes in the manner and the power of micturition. These will be more fully discussed under the heading of symptomatology, but it is well to recall briefly in this place the modus operandi: residual urine causes cystitis; cystitis causes frequent desire for urination; frequent urination increases the existing congestion; this in turn may bring on retention of urine; catheterization is resorted to, once or oftener; infection is very liable to occur in a bladder already so inflamed ; the retention and the infection of the urine produce circulatory disturbances in the kidney; the quantity of the urine is increased, and a vicious circle is established, which, unless the primordial cause, urinary obstruction, be removed, will quickly affect the patient's general health. The dilatation of the bladder, and consequent weakness of 7? 82 Clinical Pathology. its walls, causes two well-known symptoms — feeble power of expulsion, and slowness in completing the urinary act; while finally the inability of the vesical neck to act properly, and the interference with the muscles around the membranous urethra, cause the last portions of urine to be voided in dribbles, no power remaining of evacuating it in spurts. Effects on the Rectum. Enlargement of the prostate, as is well known, is very apt to be accompanied by haemorrhoids and prolapsus ani. These affections may be produced by the prostatic hypertrophy, or they may be due to an independent though concurrent cause. Venous engorgement of the prostate and the vesical neck is one of the main causes of sudden urinary retention, as mentioned above; and such venous engorgement, when prolonged or when recurring frequently, leads soon to a varicose condition of the prostatic plexus. Under these conditions incompetency of the valves in this plexus developes, and the blood regurgitates through communicating branches, and becomes dammed up in the in- ternal pudic and the middle and inferior haemorrhoidal veins. Since these all, as well as the prostatic plexus itself, empty into the internal iliac vein, no real relief to the venous obstruction ensues; but haemorrhoids develop?, and by their pain add to the misery of the patient. Some slight relief might occur from vas- cular overflow into the superior haemorrhoidal veins; but as these are radicles of the portal system, which has no valves, and which is very apt to be already congested or obstructed in persons who have reached the prostatic age, the superior haemorrhoidal veins are only too often varicose even before the middle and inferior become so. Phleboliths are common in the prostatic plexus. Not only does prostatic enlargement affect the rectum in this manner by producing haemorrhoids, but it may seriously obstruct the rectal canal when the gland is much enlarged in this direction. The act of defalcation is rendered difficult and painful by this PLATE LVII1. Dilatation of the Ureters and Hydronephrosis from Long-standing Prostatic Obstruction. (From a specimen in the Museum of the Pennsylvania Hospital.) Effects on Rectum. 83 enlargement; obstipation is favoured, and this again reacts for evil by increasing the tendency to piles. Prolapsus is liable to follow in the wake of these other troubles, both from the straining in the efforts to empty the bladder, and from the haemorrhoidal condition of the rectum itself. Pelvic congestion is favoured by nearly every circumstance — especially by the condition of the patient's heart, kidneys, and liver, which have all of them, as a rule, begun to show the fibrosis of age; as well as by the prostatic changes produced by what- ever cause. CHAPTER V. CLINICAL CAUSES: RACE, AGE, OCCUPATION, SOCIAL HABITS, PREVIOUS DISEASES. Since there is very little accurately known of the causes of enlargement of the prostate, it is impossible to altogether avoid theorizing in their discussion. Not until large numbers of cases have been collected, in which the patient's previous history has been studied in considerable detail, can we hope to reach any definite conclusions as to the influences exerted by occupation, personal habits, previous diseases of the generative organs, and similar possible causes. Race. — It does not appear probable that race per se — that is, apart from the personal habits characteristic of any particular race — exerts special influence in predisposing to the disease in question. The negro race has been held to be rather less predisposed to this affection than is the white. Conner [52] expressed this opinion; Schultz I believe has made a similar statement; but the opinions of both surgeons appear to have been based on general impressions rather than on accurate records, and must hence be accepted somewhat guardedly. My own impression agrees entirely with theirs, and is based on no more substantial grounds. The well-known salaciousness of the negro, however, should, if all theories be correct, render him rather more liable to pros- tatic enlargement than the white man; since it is held, and with apparent reason, that prostatic overstrain and former in- flammations of the gland are among the most probable of causes for its overgrowth. In natives of India there is probably little doubt that pros- 84 Race and Age. 85 tatic enlargement is abnormally frequent. Wanless [241] has given considerable attention to this matter, and his experience shows that enlargement of the prostate with complete retention of urine is quite common in that country. He is of the opinion that the chief cause lies in the excessive sexual excitement, "for the reason that sexual intercourse is begun earlier and continued later in life than ... in western coun tries.' ' Among other possible causes, he mentions the excessive use of curry and hot spices, so common to Indians. These condiments produce, by their habitual use, constipation and engorgement of the por- tal circulation; and thus a chronic congestion of the haemor- rhoidal vessels arises, which, as already pointed out in these pages, tends to impede the circulation in the varicose prostatic plexus. The complete urinary retention which he observed so often in India occurred chiefly at the time of the monsoon rains, when exposure and chilling were almost unavoidable; and in practically every case of urinary retention the cause was prostatic obstruction. Still another cause, and one which favoured the formation of phosphatic calculus, was the concen- tration of the urine due to prolonged work under the hot tropical sun; so much of the bodily fluids being thrown off by the sweat glands that the urine excreted was abnormally concentrated. In Turkey, also, prostatic troubles are comparatively fre- quent, chiefly due, according to Wishard [252], to the excessive sexual activity. In China and Japan, however, they are con- sidered to be extremely rare; but not probably on account alone of the absence of the same exciting cause. Age. — Age appears to exert a marked influence, although it is not any longer regarded as a cause sine qua non. More and more it is becoming recognized that it is not the prostatic enlarge- ment which developes first in old age, but that it is the symptoms of this disease which begin to manifest themselves only in the decline of life. Some fifty years ago or more prostatic troubles in men under sixty years of age were next to unknown. Sir 86 Clinical Causes. Henry Thompson [224] stated that enlargement of the prostate never occurred under fifty-three years of age; but McGill [152] operated on two men, aged fifty- three and fifty-four years re- spectively, in whom enlargement must have existed for some time before the patients were seen by him. McGill [153] later reported another patient in whom enlargement existed at thirty- five years. Moullin [176] mentions the age of one of his patients as forty-nine years, and refers to one of Henderson's patients aged forty-eight years, and to other patients of forty-one and thirty-six years; while Dr. Mudd [179, 180] reported cases occur- ring in a young negro of twenty-seven, in a child of five years, and in an infant of thirteen months. But in spite of these unique examples, the fact remains that symptoms due to enlargement of the prostate under fifty years of age are very seldom observed. The researches of Thompson [224], Dittel [68], and others have shown that appreciable enlargement exists in about one-third of persons over sixty years of age, but that it produces manifest symptoms in only one out of every twenty. When the seven- tieth year has passed without enlargement of the prostate, sub- sequent trouble from it is very unusual. Prof. Humphrey [127] stated that only seventeen out of seventy-two patients between the ages of eighty and ninety years, and only one out of thirty patients over ninety years, presented symptoms of prostatic enlargement. Hunter McGuire [156] held that while enlargement of the prostate might exist in younger men, yet that symptoms were not manifested until the urinary tract, in company with the rest of the body, showed the results of senile changes. Such an explanation as this is in accord with the fact that natives of India and other tropical countries, as a rule, show symptoms of prostatic enlargement some fifteen or twenty years earlier than do the inhabitants of more temperate climes, their span of life being that much shorter than ours. Occupation. — It is not probable that occupation exerts very Social Habits. 87 much influence over the develop ement of prostatic troubles. Some of the earlier writers thought that excessive horseback- riding caused enlargement of the prostate; and in more recent times bicycle-riding, especially with the seat high and the handle- bar low, has been held responsible for the production of this condition in certain patients. Probably of more real aetiological value in this respect than such direct causes are factors which exert their influence indirectly, such as a sedentary life, or other habits which predispose to pelvic congestion. Social Habits. — Under the title of "high living" may be grouped a certain number of influences which undoubtedly make the patient prone to prostatic troubles. The gouty, the rheu- matic, the lithaemic ; the man with hepatic and portal congestion, with a tendency to haemorrhoids, or to varicose veins of the legs, is a not unfrequent victim of enlarged prostate; and thus, as Wanless [241] has pointed out, in the case of the Indian noted above, dietetic habits or errors may become potent though in- direct causes of enlargement of the prostate gland. In many respects the causes of this malady and those predisposing to the formation of vesical calculus are the same, and the concurrence of the two affections is frequent. Over-indulgence in sexual intercourse has long been con- sidered a possible factor. From the enlarged and tender pros- tate of the young masturbator, to the similar organ of the old man who marries a young wife, — it has been common to blame the sexual excitement as the efficient cause; but, as remarked by J. William White [247] it is probably quite as logical, if not more so, to blame the enlarged prostate with exciting unnatural desires. In accord with this view is the recommendation of Tobin [229], who regards persistence of sexual desires in old men as an indication for double castration. Lydston [149] teaches that enlargement of the prostate is in great part due to its " overstrain," which he defines as hyperfunctional activity of the organ; this overstrain, he thinks, may have occurred in SS Clinical Causes. early or middle life (from prostatitis, urethritis, congestions from masturbation or ungratified sexual desires, etc.), and yet may not show itself until past middle life, when a general sclerotic tendency arises — as an old injury to the knee, for example, will only begin to give permanent symptoms when gout, rheumatism, arthritis deformans, or some similar disease makes its appear- ance. Harrison [116], arguing along lines somewhat opposed to the overstrain theory of Lydston, said: "That the withdrawal of a portion of that function of the prostate in which it has been the most actively engaged, should be followed by a continued activity in which growth is substituted for secretion, is not, I consider, pathologically illogical." But Hodgson [122], on the other hand, thought the enlargement might well be due to the necessity which the prostate was under of supplying a fluid for sexual intercourse after the secretion of the testicles had become insufficient for that purpose. The whole subject of the relations of the testicles to the pros- tate is quite obscure, and many very contradictory and appar- ently irreconcilable facts are at hand. The testicles undoubtedly furnish to the ceconomy an internal secretion, the action of which at the advent of puberty produces the sexual characteristics of the individual. If the testicles are removed before puberty, the boy remains of neutral sexual characteristics, and the prostate and seminal vesicles fail to develope. If the testicles are removed after puberty, the sexual characteristics which were then acquired do not disappear, but in some instances atrophy of the prostate and seminal vesicles occurs. Cryptorchism in no way prevents the developement of the sexual characteristics, showing that these depend upon the internal secretion of the testicles for their manifestation, and not upon the power of procreation possessed by the individual. From certain observations it seems probable that the prostate is more closely connected with the epididymis and the vas deferens than with the testicle, since some persons have been observed with two normal testicles, but with an Influence of Testicles. 89 undeveloped vas deferens on one side, the corresponding half of the prostate being rudimentary. Likewise a unilateral develope- ment of the prostate has been noticed where the kidney and ureter on the same side were absent. Remete [198] is of the opinion that only normal prostates are caused to atrophy by cas- tration; and that the more hypertrophied a prostate is, the less likely is castration to produce any beneficial effect upon it. It is certainly true that removal of one testicle does not usually cause atrophy of the corresponding half of the prostate, even when this latter organ is normal. Moreover, Moses [172] has observed a case in which prostatic enlargement developed for the first time some years after double castration. MacEwen [151], similarly, advocated the theory that the testicles furnished an internal secretion which regulated the growth of the prostate, and that enlargement occurred when the testicular atrophy of age caused this influence to be in abeyance. Under such teach- ings castration as a remedial measure would be preposterous in the extreme. It is interesting to note the observations of Ciechanowski [50] in this connection. He showed that dogs are the only domestic animals which have an infectious urethritis. It is well known that of all animals dogs are most prone to enlarge- ment of the prostate. Moreover, in other animals castration invariably causes prostatic atnphy, but in dogs it often fails to produce any beneficial influe.ice. If the influential internal secretion comes from the testicles, it is difficult to see how ligation or excision of a part of the sper- matic cords or vasa deferentia could cause atrophy of the pro- state, unless it were by first producing a change in the testicles themselves; indeed, it seems not impossible that the atrophy is due entirely to the physiological rest which is obtained for the prostate through the absence of sexual desire. But, on the other hand, it must be remembered that castration does not always cause a loss of sexual desire. Mere subsidence of con- gestion is a much more usual result of castration than is actual 90 Clinical Causes. atrophy; and the return of voluntary micturition within a few hours after orchidectomy only shows, in my opinion, that other manners of relieving the prostatic congestion would have had a similar effect. A further fact in favour of physiological rest being the cause of prostatic atrophy, however its action is obtained, is the observation of Hodgson [122] of a patient, aged thirty- five years, whose penis had been amputated some years before his death: in this case the autopsy showed the prostate, the seminal vesicles, and the testicles all much reduced in size. All these considerations really bring us back to the proposition with which we started, that excessive sexual intercourse is a fre- quent cause of enlargement of the prostate gland. It is not, however, the only cause, nor in all probability the most impor- tant one. This affection, as is well known, has at times afflicted the most moral and continent of men. Previous Diseases. — Probably the most prevalent of all causes is a preceding inflammation of some kind. The views of Ciechanowski [49, 50], of Greene and Brooks [102], and of Cran- don [54] on this subject have already been discussed, and a mere reference to the question is here required. Naturally the most frequent of these inflammations is the gonorrhoeal; and although many patients of over sixty years may have forgotten it, or may be unwilling to acknowledge it, yet a negative history in this respect cannot carry too much weight. Even if the in- flammation of the deep urethra and the prostate have not been of gonorrhoeal origin, the repeated attacks of congestion and the catarrhal exudation, from whatever cause, which frequently occur in this part of the human frame, are a quite sufficient cause in the majority of instances. Stricture of the urethra has been thought by some authors to rather militate against prostatic obstruction, from the increased fluid pressure which exists behind the seat of stricture tending to dilate the prostatic urethra. Yet a stricture of some size is present in many cases of enlarged prostate. I have obtained Previous Diseases. 91 a history of gonorrhoeal infection or have noted the presence of strictures in four out of eighteen cases; and in only three of the remaining fourteen cases was it noted that venereal history was positively denied. Other diseases may act as predisposing causes. Among these, arterio-sclerosis is prominent in the nosological tables of the French school. Other affections, such as cardiac insufficiency, hepatic cirrhosis, or other diseases which cause congestion of the pelvic organs, should also be considered; but their action is very indirect, and may be a mere coincidence, not an actual cause. CHAPTER VI. SUBJECTIVE SYMPTOMS. Not every patient with enlargement of the prostate presents symptoms of his malady. Only about one person among every seven who has an enlarged prostate suffers from it; and even among the number who do develope symptoms there are many in whom these begin so insidiously that the patients will per- haps be unaware of any deviation from the normal until acute retention of urine occurs from some access of obstruction, or until overflow relieves the unperceived chronic retention. The affec- tion, on the other hand, while gradual in onset, may yet make its presence felt by symptoms which arrest the patient's atten- tion from the first. Some change in the urinary function is almost invariably that which is earliest observed, and usually consists in an increased frequency of micturition. This, if it occurred only during the day, might easily escape notice; but since it is present at night as well, and compels the patient to arise once or oftener from his sleep, is a change which is very soon observed, and for which an explanation is usually promptly sought. Especially with younger patients is this true; among the old a not unnatural idea exists that frequency of urination is one of the signs of age, and is therefore rather to be anticipated. Frequency of urination is due mainly to two causes: first and foremost, because the congestion or inflammation of the vesical neck and the parts around the prostate renders the bladder more sensitive to the presence of urine, and hence less able to support a large volume of fluid; and, second, because residual urine lessens the capacity of the bladder, which as a consequence 92 Frequency of Urination. 93 reaches its usual grade of distention at shorter intervals. Be- sides these factors, the quality of the urine is often exceedingly irritating, and so its expulsion is demanded more frequently. Many authors have taught that the frequency of urination was greater at night than during the day; but, apart from the lack of reason for this phenomenon, I doubt its being a fact. Greater stress is laid upon nocturnal frequency by the patient, and consequently in many cases by the surgeon, merely because it arrests the attention sooner than increased frequency of urina- tion by day. A man may wash his hands eight or ten times during the day, and think nothing of it; but if he was to wake during the night with an irresistible desire to get up and wash his hands, he would be very sure to remember the fact in the morning, and to seek for an explanation. This is an extreme comparison, but serves to show how much more importance is attached by some to nocturnal frequency, than to that occurring during the day. These patients are not inclined to urinate oftener while recumbent in day-time, so the horizontal position cannot be given as a cause for greater frequency by night. Sleep may possibly be the factor of greatest importance, by lessening the power of inhibition over the involuntary sphincter, and by unconsciously increasing the resistance of the voluntary sphincter : thus when the patient finally wakes, his bladder is fuller, because a longer interval has elapsed since it was last emptied, than is the case during the day; and after this first sound sleep of a few hours, the bladder has been rendered so irritable by overdisten- tion that calls to urinate occur with greater frequency during the remainder of the night. This is given as a possible explana- tion by Moullin [176]; and it appears to be a fact that the first interval at night is the longest. Other explanations of nocturnal frequency have been given, such as sexual emotions during sleep ; but it is probable that these are as much a consequence as a cause. Of course, when cystitis developes this in itself causes the 94 Symptoms. desire for urination to be more frequent; and where ulceration or fissure of the bladder exists, the vesical tenesmus may be con- stant and uncontrollable. The patient is likewise unable to expel the urine with his accustomed force. Starting the stream is difficult, much strain- ing being required, because there is both increased obstruction and decreased expulsive power. When started, the stream does not spurt forth in the normal parabolic curve, but tends to drop vertically from the meatus. A longer time than usual is required to pass the urine, although a smaller quantity than normal is passed, since the intervals are less and some residual urine remains. The stream is not smaller than in health, unless stric- ture causes it to be so. As the act of urination draws to a close, the urine dribbles involuntarily. It will thus often wet the patient's shoes; so that if there be much sediment present, these spots on drying will be incrusted with salt; from this fact alone a tentative diagnosis may be made. The cause of the dribbling, without the power being present of evacuating the last drops in spurts, probably lies in the impaired contractility of the bladder, which fails to send forward into the membranous and bulbous urethra a suffi- cient quantity of urine for the voluntary muscles to contract upon. The prostatic urethra, moreover, is unable to put itself into physiological continuity with the bladder, and acting as a more or less rigid tube, interferes with the normal flow. Intermittent urination has been described as present in some cases, but is very rare. It may be due to the ball-valve action of a prostatic outgrowth, which is more tightly forced against the vesical outlet the more forcefully the bladder contracts, and which permits urination only when it is floated back from the orifice of the urethra, during intervals of straining. If not due to such a cause as this, the ordinary " stammering with the urinary organs," as Sir James Paget [188, p. 57] termed it, affords a sufficient explanation. The presence of a calculus might also act in this way. Retention of Urine. 95 Retention of urine is observed by the patient only when acute, or when the chronic form is accompanied by overflow. By far the most frequent cause of acute retention in these cases is an access of congestion in the vesical neck. A man who very likely had thought himself previously perfectly healthy will attend some party of pleasure, eat and perhaps drink more than he is in the habit of doing, be exposed to draughts, become overheated, or in some way commit an indiscretion ; and on his return home will rind himself unable to pass his urine. When relieved by catheterization, a similar event may not occur for months or years, perhaps never again. Overflow from retention is in some instances the symptom which first attracts the patient's attention. When the bladder has reached its limit of distensibility, as soon as any urine is received from the ureters, an equal amount must be discharged by the urethra. This involuntary leakage may be noticeable first only at night, when the influence of the will is withdrawn, or by day only during the effort of lifting some heavy object, in stooping to pick something from the floor, or during defalcation — all these acts necessitating contraction of the abdominal muscles, and hence diminution in bladder capacity. At later stages this overflow becomes a constant symptom, and unless relieved the patient must wear a urinal, or have his clothing constantly wet. The odour attendant upon this condition will frequently, in the poorer class of patients, at once direct attention to the true state of affairs. As previously pointed out, this symptom is much more fre- quent where there is no cystitis. The probable explanation is that no catheter has ever been passed to relieve the bladder of its residual urine, and to prevent its walls from losing their muscular tone through overdistention ; and that since no catheter has been passed, no cystitis has developed. Incontinence oj urine is extremely unusual. It has often been supposed to be present when the true condition was that just 96 Symptoms. described — overflow from retention. Prof. Ashhurst [9] in his Surgery states that he "once saw a patient who, supposed to have paralysis of the bladder, had been taking strychnia for one year; the introduction of a catheter effected the evacuation of nearly a quart of urine, and showed the real condition to be one of prostatic retention with overflow." If true incontinence of urine does exist, it may readily be determined by catheterization, when the bladder will be found empty. It is probably due, when present, to a form of prostatic overgrowth which keeps the vesical orifice of the urethra constantly patent, and to inability of the voluntary sphincter to properly contract. In the normal condition as soon as urine enters the prostatic urethra, desire for micturi- tion is present; and where urine is constantly in this portion of the urethra, a constant effort of the will is required to avoid its passage. Hence, even if the voluntary sphincter can act normally during the day-time, incontinence will be present in these cases during sleep, except where the elastic resistance of the urethra is stronger than the contraction of the bladder walls. But, as a rule, when true incontinence occurs at all, it is present through- out the twenty-four hours. The symptoms of cystitis arising in a patient with enlarged prostate are the same as those in other cases of cystitis, and do not require extended mention in a work of this kind. Cystitis in these cases is practically never caused in any other way than by catheterization. It is theoretically possible for bacteria to gain entrance to the bladder in other ways, as through the kid- neys, directly from the rectum, and by extension along the ure- thra. When gonorrhoea is the cause, this last route is not un- frequent, but even then the gonococci are more apt to be carried back to the bladder by a catheter than to travel there of their own accord. Urination which was frequent before, becomes doubly so when cystitis developes; tenesmus is more pronounced, and the relief obtained by the partial evacuation is slight. A heaviness and Cystitis and Hematuria. 97 burning may be felt in the perineum; suprapubic pain may be marked ; or the most infernal of all tortures, the burning, boring, uncontrollable pain in the neck of the bladder, may render the patient nearly insane. Pus, mucus, and blood may all be ob- served by the patient in his urine. Hematuria, though not one of the most prominent symptoms, is met with sufficiently often to command the surgeon's parti- cular attention. It may be due to the spontaneous rupture of varicose urethral or vesical veins, may be produced in certain instances by the most gentle catheterization, or may come from ulceration due to the prolonged cystitis or to calculus. In cases of marked obstruction the patient after persistent straining may relieve himself of only a few drops of blood. In such cases the blood probably comes from congested veins. If the blood is mixed with the urine as it flows, it probably comes from the pros- tate or the neck of the bladder, and may flow from an ulcer or a ruptured blood vessel. If it flows only at the close of urination, and particularly if it is clotted, it is apt to come from the post- prostatic pouch of the bladder. Symptoms of renal failure may arise at various stages of the disease. Nephritis may, of course, be an independent affection; but if not already present, is usually manifest very soon after the quantity of residual urine becomes great, or when infection of the bladder causes retrograde pyelitis. The patient may notice that he not only passes urine more frequently, but that the total quan- tity passed is greater, and that he is unaccountably thirsty. This increase in quantity is one of the earliest evidences of impair- ment of the kidneys, and should be carefully noted. If complete retention occurs in such cases, uraemia may rapidly supervene, from the inability of the kidneys in their diseased state to excrete under increased pressure the toxic matters whose retention in the blood gives rise to the well-known symptoms: confusion and anxiety of mind, dyspnoea, dry burning skin, feverish eye, parched tongue, urinous odour to the breath, hiccough and vomiting, 8P 98 Symptoms. somnolence and coma, convulsions, and death. If pyelitis be present from infection, irregularly recurring chills, with fever and sweats, may be added to the above train of symptoms. Closely following upon the heels of renal involvement, certain cardiac symptoms may appear — slight dropsy in the ankles or the hands, shortness of breath on exertion; palpitations; loss of appetite from gastric congestion; and other symptoms too generally recognized to need repetition here. Sexual power is usually lost if the prostatic disease be far advanced; in earlier stages intercourse may be painful, pain being marked especially after completion of the act. Not un- frequently the sexual appetite is abnormally active, and distres- sing priapism may occur. If the prostate enlarges much towards the rectum, certain additional symptoms may be noted by the patient. Both con- stipation and obstipation may arise; and the constant straining to urinate or defalcate may produce haemorrhoids, and even pro- lapsus ani, as in the case of children straining on account of vesical calculus. It is in this form of enlargement, too, that the fullness and uncomfortable feeling in the perineum, so often complained of, are chiefly found. If calculi form in the bladder, some special symptoms of this malady may be noted; but, as a rule, they are subordinated to the peculiar prostatic symptoms, since the stone is held fairly firmly in the post-prostatic pouch, or in one of the mucous pouches of the bladder. To attempt clinical pictures of patients suffering from en- largement of the prostate, by dividing the disease into certain stages, is a rather arduous task, since the duration of any one symptom or set of symptoms varies exceedingly in different in- dividuals. Perhaps as just an appreciation as any of this view of prostatic enlargement may be reached by grouping the patients into three classes, in the first of which, the earliest stage, may Stages of the Disease. 99 be placed those patients whose chief complaint is nocturnal fre- quency of urination; in the second stage those patients who suffer occasionally from complete retention, but whose cystitis is insignificant, and whose general health is fairly good; and in the third class those wretched individuals whose retention is nearly absolute or quite so, who depend entirely on catheteriza- tion, whose kidneys are markedly diseased, and whose general health is on the verge of collapse. Some patients will remain in the first stage all their lives; some will within a few months pass into the second stage; and others will seemingly jump at once from the first to the third stage with scarcely an appreciable sojourn in the second. Some patients, on the other hand, will never be conscious of having passed through the first stage, but will first be impelled to seek medical aid for sudden retention of urine; and may then, if fortunate, return to the first stage and remain there all their lives. In many instances patients who reach the second stage without having been aware of the first will remain in the second stage throughout their lives; but in very rare instances only do patients pass at once from a life of seemingly perfect health to one of absolute and complete catheter ism. The surgeon should, above all things, bear in mind that a positive diagnosis of enlargement of the prostate can never be made from the symptoms alone: a physical examination is absolutely essential. t.rfC. CHAPTER VII. OBJECTIVE SYMPTOMS— PHYSICAL EXAMINATION. When a patient, suspected from the symptoms he describes to be suffering from enlargement of the prostate gland, presents himself to the surgeon, the first and most important physical sign to be looked for is the presence of a hypogastric tumor, with the characteristics of a distended bladder. Important as it is in all cases, it is above all in those patients who have been afflicted with chronic urinary retention and overflow that this precaution is indispensable. In patients such as these the hasty introduction of a catheter may cause immediate syncope, from the decrease of intra-abdominal pressure, and may lead, in a few days, to the patient's death from renal congestion and uraemia. I am well aware that Dr. Cabot's [41] recently reported experi- ences are at seeming variance with this time-honoured doctrine ; but in the cases he reported continuous bladder drainage was instituted in patients such as those now under discussion with chronic retention and overflow; and the happy results in his hands may have been due to the facts that the drainage was constant, not intermittent, and that the patients were kept under careful constitutional regimen. But to regardlessly plunge a catheter into such bladders in our office, or at a hospital dis- pensary, where the patients are not provided with the requisite facilities for proper after-treatment, will, I venture to think, ever remain a most dangerous and unsurgical procedure. Having detected such a hypogastric tumor, or having as- certained its absence, the patient should next be requested to urinate. We may then observe the facility, or the difficulty, with which he starts the stream; the force with which it is ex- Urination. 101 pelled from the bladder ; its size, as indicative of stricture or not ; whether it is suddenly interrupted at any time, showing the pos- sible ball- valve action of a pedunculated " middle lobe," or of a calculus; and whether he concludes the urinary act in the normal manner, or if the last portions dribble out of his urethra without voluntary control. From a strict attention to these details — and no details are too insignificant in urinary affections — much may be learned that will prove of subsequent interest. The quantity of the urine just passed is then to be measured, and a portion of it preserved for chemical and microscopical examination. Its colour, odour, and the presence or absence of sediment, as roughly gauged by the eye, will be of immediate use to us in approximating the condition of the bladder and the kidneys. By learning the interval since the last urination, and knowing the quantity just passed, we may form an estimate of the total quantity passed in twenty-four hours; and if the amount of residual urine be fairly constant, this quantity serves as an index to the action of the kidneys. A patient who passes four ounces of urine, more or less, every two hours has probably no serious renal lesions. If he passes four ounces only every three or four hours, either the normal amount is not excreted by the kidneys, or else the quantity of residual urine is rapidly increasing. If, on the other hand, from a half ounce to an ounce is passed every ten or fifteen minutes, the patient's kidneys will be excreting from fifty to one hundred and fifty ounces of urine daily, and retention with overflow probably exists. If it appears that the bladder is not distended, it will then be proper and convenient to insert a catheter to determine the amount of the residual urine, and to aid in palpation of the pros- tate. For these manipulations the patient should be in the hori- zontal position. In many cases the surgeon will be forced to try several cath- eters before he will succeed in reaching the bladder. Where possible, for diagnostic purposes only, I prefer a metal instru- 102 Physical Examination. ment, about number twenty of the French scale. I say for diag- nostic purposes only. For habitual use in these cases I do not think metallic catheters are advisable ; but for the first examina- tion they present many obvious advantages, such as the ease with which they are sterilized by being passed through the flame of an alcohol lamp, or by igniting alcohol which has been poured over them; the fact that the surgeon need touch them only at the extremity which does not enter the bladder; and finally, what is of great importance, that they serve as an exploratory sound both in the urethra and within the bladder. I have little doubt that many a soft-rubber catheter which is as pure as the new-fallen snow when taken into the hands, becomes oftentimes foully contaminated by the manipulations that are necessary for its insertion into and passage through the urethra. As this metallic catheter passes, the surgeon should note the presence or absence of strictures, any deviation from the normal line of the subpubic urethra, the height to which its vesical orifice is raised, and lastly the distance from the urinary meatus at which urine first begins to flow. In passing the catheter the following facts favour the diag- nosis of enlarged prostate: if it is found that the shaft has to be unduly depressed between the patient's legs before any urine flows, showing that the vesical orifice of the urethra is raised; if the urinary distance (that from the meatus to the point at which urine commences to flow through the catheter) is increased above eight inches; if the catheter deviates towards one or the other side as it passes through the prostatic urethra, showing an in- equality in size of the two lateral lobes; or, finally, if an obstruc- tion to the passage of the catheter is encountered at a distance of more than seven inches from the meatus, showing that the obstruction is not due to strictures, which are never present in the prostatic urethra. The surgeon should not be deceived into thinking the bladder has been reached when a small quantity of urine is evacuated Catherization. 103 from an enlarged prostatic urethra. It will be remembered that this portion of the urethra may at times hold as much as an ounce or two of urine. The bladder having been reached with the catheter, the resi- dual urine will flow. If it flows through the catheter without effort on the patient's part, it indicates a fairly good vesical tone; but if even with the aid of his abdominal muscles the patient cannot expel the residual urine, and only by suprapubic pressure with the surgeon's hand can this be made to flow, it is evident that atony of the bladder is far advanced. The amount and the character of the residual urine will then be noted. From it much more accurately than from that passed voluntarily can the state of the bladder be inferred. Some sedi- ment will almost invariably be evacuated. If much is present, it is probable that catheterization has often been resorted to before, and that a more or less marked cystitis exists. Clots of blood are frequently found. Possibly some calcareous sediment will exist. The odour of the residual urine is usually ammoniacal. But apart from the fact of there being residual urine, its quality does not aid the diagnosis of enlarged prostate, merely showing the grade of cystitis present. It is next well to inject a few ounces of warm boric acid or saline solution, to hold the walls of the bladder away from the beak of the catheter. By the resistance encountered during the injection an idea of the condition of the bladder walls — whether dilated or contracted — can be obtained. Using the metallic catheter with all gentleness, then, as a sound, we can detect the approximate amount of intravesical enlargement of the prostate; the quality of the bladder walls, whether flabby and dilated, or thick, rugous, and pouched; the existence of calcareous crusts on the surface of the bladder, and of a calculus in the post-prostatic pouch, or in one of the vesical sacculi. The surgeon should next, without removing the catheter, io4 Physical Examination. introduce a finger of the left hand into the patient's rectum. In doing this it is usually more convenient to stand on the patient's left side, and to manipulate the catheter or the sound with the right hand. By this method of combined examination it will be possible in every case to detect positively any enlargement of the prostate. The intravesical instrument is to be regarded merely as a very long finger, and the amount of information that can be gained through it by an experienced surgeon will be a matter of astonishment to the tyro. The examining finger is not to be thrust blindly and suddenly into the rectum — such a procedure is both painful and danger- ous, since haemorrhoids with considerable proctitis may be pres- ent; but by a very gradual and gentle boring motion the finger may be insinuated so as to cause the patient very little discom- fort. As the finger passes the sphincter we can feel the catheter in the bulbous urethra, then can trace it back into the membran- ous urethra, but in case the prostate is enlarged it will be im- possible to trace it further. The finger next encounters the pros- tate in the anterior rectal wall, and, passing to either side, to- wards the ischial tuberosities, the outline of the enlarged lateral lobes can be detected. In most cases it will require a long finger to reach well beyond the enlarged prostate, and to feel the tip of the catheter in the retro-prostatic pouch; but this should always be attempted, as we thus obtain a very much more ac- curate idea of the size and shape of the prostate; and where the beak of the catheter is not long enough to reach the floor of the pouch, it may be possible to elevate this by the finger in the rectum, and thus to detect a calculus which might otherwise have escaped notice. By directing the patient to close his mouth and "bear down," the prostate may be forced into reach of the finger even when very much enlarged. Before withdrawing the finger the state of the seminal vesicles should be examined if they are within reach. The existence of high internal hemorrhoids can also be determined. PLATE LIX, Combined Method. 105 If it has been impossible to satisfactorily examine the rectal relations of the prostate on account of its size or its high posi- tion in the pelvis, an assistant may be able, by well regulated but firm suprapubic pressure, to bring it within reach of the pal- pating finger; or it may be gently drawn down by the aid of the catheter within the bladder. Such an examination as this will enable us to say positively in every case whether there is or is not an enlarged prostate. The surgeon should remember, however, that many symptoms of enlargement of the prostate may exist without there being any enlargement present; and that enlargement of the prostate may exist and yet give rise to no symptoms; and, furthermore, that even where characteristic symptoms and prostatic enlargement are both found, one is not necessarily caused by the other. Hence no surgeon should undertake any plan of treatment hastily, or without due consideration in cases of this kind. Indeed, it is often best to temporize for awhile, until by making repeated and careful examinations all possible sources of error have been eliminated, and the condition of the parts involved has become familiar to the surgeon. In the local examination such as has been described, it has been assumed that the urethra was freely open to instrumentation ; but in very many patients this is not the case: strictures, false passages, and obstruction by the prostate itself may any or all of them render such an examination impossible; and hence oftentimes the best that can be done is to improve the condition of the urethra, and so persist until a satisfactory examination finally becomes possible. Enlargement of the prostate is not a disease in which haste is advisable. Besides the condition of the urinary tract, the surgeon should always make a thorough general physical examination. The signs of age, whether premature or not, should be sought for: the condition of the arteries, the arcus senilis, the cardiac action, and the general circulation all require attention. The general 106 Physical Examination. health should be determined — the appetite, the habits as to smoking and drinking, the digestion, the amount of sleep usually obtained, and the ability to pursue the usual occupation — none of these should be neglected. The state of the heart and kidneys is of the utmost importance: increased renal pressure and the consequent toxaemia so soon make their presence known by cardiac hypertrophy, with increase in size of the left ventricle, evidenced by displacement of the apex-beat downwards and to the left, and by the stronger and longer first cardiac sound in the same situation, with the well-known accentuated second aortic sound; that any surgeon who pretends to accuracy in diagnosis would be guilty of great oversight if he neglected a careful examination of the heart. Of even greater importance than the detection of cardiac hypertrophy, is it to discover the early signs of dilatation of the heart. It is probable that the accentuation of the second aortic sound above referred to is not an early sign of hypertrophy, so that where it has existed for some time, the evidences of dilatation may be shortly expected; here the weakening of the first apical sound, with the production of a mitral systolic murmur, and increase of cardiac area to the right of the sternum, with perhaps occasional murmurs of incom- petency over the aortic valves, I regard as the most valuable local signs. But as further evidences of cardiac dilatation I would call special attention to the various results of venous con- gestion, such as dyspnoea, oedema of the extremities, varicose veins, haemorrhoids, hepatic and gastric congestion, loss of ap- petite, and flatulency with indigestion. The chief means we have for determining the condition of the kidneys is, of course, by means of urinalysis. Without pretend- ing to deny the value of microscopical examination of the urine, I am free to confess that I place much more reliance on the total quantity excreted in twenty-four hours, on the specific gravity, and on the percentage of uraea present, than I do on the presence of tube casts or albumen. These latter, unless in excessive Urine. 107 amount, I have come to regard as nearly normal in persons past middle life; but where the excretion of solids, as shown by the uraea content, is diminished, and where the total amount of urine excreted is constantly much above the normal, I am far more chary of undertaking serious operative measures than in the former case. The normal amount of urine excreted in twenty-four hours is from forty to fifty ounces (1200 to 1500 cc); the normal amount of uraea in the same period is five hundred grains or over (35 grammes); and the normal specific gravity is 1017. Naturally, where the total quantity of urine is increased, unless an increase in the amount of uraea excreted occurs, the specific gravity will be decreased; hence it is not sufficient to calculate the amount of the uraea present from a single specimen of urine: the whole quantity passed in twenty-four hours must be considered. The normal percentage (2.8 per cent.) of uraea may be much de- creased, with the increased quantity of urine excreted, yet the kidneys cannot be seriously impaired if the total amount of uraea eliminated remains nearly normal. An examination of the blood will be of interest; though it cannot be expected to aid in the diagnosis. The percentage of haemoglobin is the most important point to be determined, since by it we gain a fairly accurate index of the patient's ability to withstand operative treatment. CHAPTER VIII. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS ; PROGNOSIS. The diagnosis of prostatic enlargement is not usually difficult. In the first place, the clinical history, or the sequence of symp- toms, is almost invariably characteristic. The increased fre- quency of urination, in a patient past the prime of life, will at once direct our attention to the prostate. Retention may have necessitated the passage of a catheter once or oftener. If the retention has been due to strictures, the patient will usually be quite well aware of the fact, and will be more inclined to confess their presence than perhaps a younger man who may have the memory of their onset and early stages more vividly in his mind, and may regard them as more of a reproach. Many of these patients will have been under treatment by another practitioner, and will know their own malady well, so that frequently the surgeon has only to confirm a diagnosis already made. But it is well not to forget that the previous physician, no matter how high his reputation, may have erred in his diag- nosis, and that therefore in enlarged prostate as in other affec- tions it is safe not to take a ready-made diagnosis. As a rule, the age of the patient and his nocturnal frequency of urination are sufficient to arouse our suspicions. As has been already mentioned, the general aspect of the patient, together with a urinous odour, due to overflow from retention permitting his clothing to be more or less constantly wet, will in some in- stances enable the acute observer to anticipate the diagnosis even before the patient states his troubles. Even in cases seem- ingly obscure at first, a detailed history of the case and a com- 108 Diagnosis. 109 plete and strictly systematic physical examination will invariably enable a correct diagnosis to be made. It is only where small or impassable strictures prevent instrumental examination of the vesical surface of the prostate that a diagnosis becomes at times impossible, unless sufficient enlargement can be felt by the rec- tum to render an intravesical examination superfluous. The stage of the disease is usually more easily determined from the symptoms than from the physical examination. The most important change in the life-history of these patients is that produced by cystitis, which unfortunately is nearly certain to make its appearance sooner or later. Naturally, the earlier the stage at which prostatics are first seen, the greater is the hope of cure. When the urine is constantly of a specific gravity below 1010, the action of the kidneys is manifestly im- paired, and the disease may be considered quite far advanced. The longer infection is absent, the longer is the disease apt to endure in a quiescent state, the patient being troubled mainly with frequency of urination until the accumulation of residual urine produces overflow. The cardinal principle by which we determine the size of any body is by learning the distance between its surfaces, or its diam- eter ; to accomplish this in the case of an organ situated as is the prostate, it is absolutely essential to gain entrance to the bladder superiorly and to the rectum below. It is not sufficient merely to insert a finger into the rectum and to palpate the prostate thence; nor is it enough to learn by catheterization that the urinary distance is increased, that the subpubic urethra deviates from the normal curve, and that there is residual urine. By the rectal touch frequently no enlargement can be detected while decided urinary obstruction exists from overgrowth into the blad- der or urethra; and the information gained from the passage of a catheter alone is manifestly incomplete. Hence before mak- ing a positive diagnosis the surgeon should resort to the com- bined examination with a sound or catheter within the bladder, and a finger in the rectum, as already so often insisted upon. no Diagnosis. But merely to ascertain that the bulk of the prostate gland is increased is not to make sure the diagnosis of " enlargement of the prostate." Enlargement may exist from various morbid processes, such as chronic prostatitis, prostatic abscess, calculus, or tumors of the prostate; and it is chiefly by attention to the clinical history of the case that a distinction between these dif- ferent forms of enlargement is reached, although, as will be mentioned under the head of differential diagnosis, the sense of touch will aid us here as well. I have not heretofore mentioned the cystoscope as an aid to diagnosis, and this omission has been intentional, since I con- sider this instrument of very little use in the average case, and feel that in some patients its injudicious employment may be productive of harm. Where a satisfactory diagnosis cannot be made without the employment of the cystoscope, the surgeon need not hope to make one by its aid; and under such circum- stances it is, in my opinion, quite as well for the experienced sur- geon to do either a suprapubic cystotomy or a perineal urethro- tomy, and thus to explore the bladder and prostate with the eye which nature has placed at the end of his index ringer. In these cases drainage is the all-important indication, and while evil results from over-instrumentation may be few and far between, and while the cystoscope is only slightly more dangerous than an ordinary catheter, yet since so little of value can be gained by its use, it is best to avoid it as a rule. Surgeons there maybe, and probably are, who are more expert with complicated machin- ery than with their hands, and who will always prefer the use of a machine to work performed by their ringers; such operators employ an elabourately complicated needle-holder, a dental en- gine, a Bottini incisor, or a cystoscope, largely because of their admiration of the mechanical perfections of the instrument in question; and what excuse there is for the habitual use of the cystoscope in the diagnosis of prostatic hypertrophy, is when it is in the hands of those surgeons who employ it daily for other Cystoscopy. in purposes. To advise the general practitioner, who may have need of a cystoscope only once in five years, to insert it into the distorted, inflamed, and susceptible urethra of prostatics, is to be guilty of great indiscretion, to say the least. It is quite unfortunate enough that an instrument of some kind must be passed to enable us to complete our examination; and it is to avoid repeated instrumentation that I have recommended a metal catheter in the first instance ; but we should shun the error of making the remedy worse than the disease. In my own experience I have rarely learned more from a cystoscopic examination, in any patient, than I knew already, or could accurately infer. The form and shape of the intravesical growth I have been invariably more able to determine from pal- pation by the aid of a sound or catheter than through the medium of vision by a cystoscope. The employment of the cystoscope, indeed, is only too often like that of the skiagraph at the present day — much abused, and of value chiefly as confirming diagnoses already made. It is an important thing to be able to distinguish between the two main classes of prostatic overgrowth — the glandular and the fibrous — since the same operation, if one is indicated, is not usually advisable for both varieties. The prostate which has undergone a change which is chiefly adenomatous in character is larger and less dense than the nor- mal organ, and is usually not firmly fixed, unless its great size make it so; the rectal mucous membrane glides easily over its surface; the general outline of the two lobes and the intervening commissure can often be distinguished; and well-defiend adeno- matous masses (prostatic tumors) of greater than the normal density may at times be palpable in the substance of the gland; while the surface may present similar protuberances, sessile or pedunculated. The bladder in such cases is more apt to be dilated than con- tracted; cystitis is either slight or absent; and the patient may ii2 Differential Diagnosis. reach the stage of retention with overflow before he has observed any marked deviation from his usual health. The duration of the malady and of the frequent urination will usually have been several years at the least. Where the fibrous prostate has developed, the organ will be but slightly enlarged, or may in rare instances even become smaller than the normal. Its density is increased; periprostatitis as a rule has occurred, causing the formation of fibrous tissue about the prostate, so that it is less movable than normal; the rectal mucous membrane will be less able to glide over the surface of the altered gland; and the outlines of the prostate will be more difficult to determine. No protuberances are, as a rule, to be felt on its surface, and so dense is its whole substance that em- bedded tumors, if any be present, cannot be detected. The bladder, in the case of the fibrous prostate, has probably early been exposed to infection: it is found contracted, its walls thickened, and its surface perhaps pouched. As a consequence of this, distressing symptoms have made themselves prominent early in the case; and the patient may give a history of only a few months' or a year's duration; while he next to never reaches the stage of overflow, as the constantly recurring desire for urina- tion has impelled him to keep his bladder nearly empty, by catheterization or otherwise. It is the contemplation of these two clinical pictures — the one a dilated and passive bladder, the other a contracted, infected, irritable bladder — that makes it seem improbable that the two forms of prostatic disease are due to the same causes: inflam- matory action seems so pronounced in the latter class, and so latent in the former. Differential Diagnosis. Very many of the symptoms and of the physical signs, as well, presented by prostatics, are known to occur in other affections. Hence it frequently becomes necessary for the surgeon to con- Atony of the Bladder. 113 sider the differential diagnosis of these cases, and at times to form his ideas by the method of exclusion. Atony of the bladder, being itself often caused by prostatic obstruction, may first claim our attention. The symptoms of this malady, even when produced by another cause, may very closely simulate those attendant upon enlargement of the prostate: thus the patient will find himself required to strain immoderately to start the flow of urine, will be long in emptying his bladder, and may be aware that some portion of his urine constantly remains unevacuated. As a consequence of these changes the frequency of urination may be increased, and it may become impossible to differentiate the two affections from a recital of the symptoms alone. But the surgeon will very easily distinguish mere vesical atony from the train of symptoms and their complications due to prostatic enlargement as soon as he seeks a cause for the symptoms. The history of the patients may be the same, but by simply passing a catheter, and palpating the prostate at the same time from the rectum, enlargement of this organ can be readily excluded. Of course, if the vesical atony be due to stric- ture, it will not always be possible to make this combined exami- nation, and therefore in those cases we cannot be absolutely sure that prostatic enlargement does not coexist. Hence where strictures of the urethra are present, the ex- clusion of prostatic hypertrophy is more difficult. Although the age of the patient may render the presence of the latter affection extremely improbable, yet many of the symptoms are the same — slow, difficult urination, with atony of the bladder, as well as, possibly, haemorrhoids and prolapsus ani. But the passage of an instrument of full size into the urethra will show obstruction more or less complete to exist within seven inches of the meatus ; and if entrance to the bladder can be gained, the absence of enlargement of the prostate is readily determined by the com- bined rectal and vesical examination already described. In case, however, of an impermeable stricture with chronic retention, it 9P ii4 Differential Diagnosis. will not be possible to satisfactorily examine the prostate until these conditions are relieved. Cystitis, when unaccompanied by stricture or prostatic en- largement, is unattended by residual urine, and although the crebruria may simulate that of overflow from retention, this affection is readily proved not to exist by the passage of a catheter; while combined intravesical and rectal examination will reveal a prostate of normal size. The same remarks apply to the very rare condition, paral- ysis of the bladder. A more common mistake is to suppose that patients suffering from retention with overflow have paral- ysis of the bladder; it being a sad fact that too many physicians are in the habit of diagnosing the rarest complaint possible, and of overlooking very common causes for the malady of the patient, no matter what it is. Where a vesical calculus exists, it is not liable to be mis- taken for an enlarged prostate unless it is both firmly fixed in the neighbourhood of this organ and so thickly coated with mucus that no grating sensation is imparted to the sound. But even under such circumstances there may be no residual urine, which is, as already insisted upon, a nearly invariable accom- paniment of every enlarged prostate producing symptoms; and there will probably not be the characteristic change in curve of the subpubic urethra. If the calculus is prostatic, or even if it merely coexists with an enlarged prostate, a positive diag- nosis is more difficult. In about one out of four patients, it is to be remembered, a calculus complicates the enlarged prostate. Bleeding is more common in cases of calculus than in those of enlarged prostate alone, and the pain is less constant, and more confined to times when the bladder contracts upon the concre- tion, or when the patient is actively moving about. The pain frequently radiates to the end of the penis. In uncomplicated prostatic enlargement pain is usually an insignificant symptom. In calculus, moreover, the greatest frequency of micturition is Prostatitis. 115 during the day, and the patients are not apt to be disturbed much at night. A skiagraphic examination will at times detect the presence of a calculus when other means have failed. Probably the most difficult diagnosis of all is that from poly- poid growths in the bladder, which when springing from the region of the prostate may very closely simulate a pedunculated " middle lobe" of this organ. But in nearly all forms of vesical tumor other than prostatic, spontaneous haemorrhage is an early and conspicuous symptom, and is usually not attended by much pain. In most cases, moreover, fragments of the tumor are passed in the urine, so that a microscopical examination may render the true condition of affairs manifest. Tubercle of the bladder may occasionally simulate enlarge- ment of the prostate by the symptoms it produces. But it prob- ably always coexists with similar disease elsewhere in the body, most often in the epididymis. Hence in doubtful cases this should be recollected, and the spermatic cords and seminal vesicles examined as well. The cystoscope here may be of considerable aid, enabling the surgeon to localize a tuberculous ulcer in the bladder, and thus render it accessible for topical treatment. But it is in precisely such cases as these, where there is haemor- rhage from the ulcer sufficient to cloud the medium, that the cystoscope is most disappointing. If the tuberculous disease affects the prostate, there can usually be detected areas of soften- ing, in the irregularly enlarged organ; and although it might at times seem difficult to distinguish between areas of softening in a prostate somewhat denser than normal (tuberculous disease), and areas of hardening in a rather less dense organ (adenomatous enlargement with prostatic "tumors"), yet other features in the case will usually enable the diagnosis to be made. Chronic prostatitis usually succeeds upon the acute form of the disease, which is sufficiently manifested by its abrupt onset, positive inflammatory character, excessive tenderness on rectal exploration, and by its occurrence, generally as a sequel to gonor- n6 Differential Diagnosis. rhoea, in a younger patient. The chronic inflammation is chiefly characterized by prostatorrhcea, which is very unusual in simple enlargement. Abscess of the prostate likewise usually follows acute in- flammation, but may be traumatic in origin. Besides the history of the case, the course of this affection is so acute compared to that of enlargement of the prostate, that confusion is not likely to arise. Moreover, the abscess may point in the urethra, the rectum, or the perineum; and palpation may enable a diag- nosis to be made before rupture renders it certain. There is another affection of the region of the prostate, de- scribed as sclerosis of the neck of the bladder, and which has been especially studied by Chetwood [44]. Its symptomatology and morbid anatomy do not appear to differ materially from those accompanying post-inflammatory atrophy of the prostate as described by French writers. The symptoms of this affection and of those of senile enlargement of the prostate are almost precisely alike; but by means of the combined examination the absence of any enlargement of the prostate is readily determined. Malignant disease of the prostate is chiefly of the adeno- carcinomatous character. Sarcoma is very rare. Carcinoma of the prostate is distinguished by the great local and referred pain, which latter shoots down the inner sides of the thighs, and may simulate that due to stone in the bladder by being felt at the end of the penis. The prostate is found to be densely hard, enlarged, and firmly fixed ; the rectal mucous membrane becomes adherent, and infiltration of the surrounding tissues finally becomes mani- fest. Haemorrhage into the bladder or urethra may occur spon- taneously. This is rarely the case in benign enlargement. In this connection it should not be forgotten that malignant changes in formerly benign overgrowths are not at all unheard of, and if we may believe the researches of Albarran and Halle [3], may even be expected in more than one-tenth of all patients. Sarcoma, when found in the prostate, may be distinguished Prognosis. 117 by the tendency which it possesses in common with other malig- nant tumors towards production of cachexia; this cachexia is developed more rapidly than is the case with carcinoma, and the rate of growth of sarcomata is, as a rule, more rapid. Prognosis. A question of considerable importance and much interest in connection with enlargement of the prostate is that of prog- nosis. In few other diseases is it so necessary for the surgeon to know what may be accomplished by the various methods of treat- ment possible, and in probably no other class of cases is he more severely blamed for errors in judgement. It is not sufficient, indeed it is neither ethical nor humane, to hope that the patient will die of some intercurrent affection before any necessity arises for instituting active treatment on behalf of his enlarged pros- tate; and hence every physician or surgeon who has such cases under his charge must give careful thought and attention to each individual patient, and must know whether the expectation of life will be lengthened or decreased by the treatment he pro- poses undertaking, or whether the certainty of a life of consider- able discomfort for a rather prolonged period is not less to the patient's ultimate advantage than the immediate risk to life incurred by a somewhat severe and shocking operation, which, if successful, will enable the patient to live out his natural term of life in ease and comfort. There are, then, two main questions to be solved in this con- nection: first, whether the patient's life can be saved, prolonged, or at least not sacrificed by the treatment to be pursued — that is to say, the question of mortality; and, second, whether the patient's sufferings will be relieved wholly or in part, or whether no change at all can be obtained — that is, the question of final functional results. Under medical treatment and catheterism there is practically no possibility of directly terminating the patient's life; with n8 Prognosis. the understanding that every antiseptic precaution be taken in catheterization, his life may even be prolonged, and in certain cases made very comfortable. Many a patient who has to pass a catheter only once or twice in the twenty-four hours will live a life of perfect ease, and will round out his days without inter- ruption. But where the catheter has to be passed frequently — that is to say, as often as four to six times in the twenty-four hours — or where its passage at even longer intervals is attended with pain or difficulty, catheterism must be considered at the present day an insufficient remedy, except in those who are already on the threshold of the grave. The expectation of life, moreover, in patients treated by catheterization, has been shown by Harrison [114] and by Lydston [148] to be, in the average, no more than four or five years; so that it is clear that the life of the average patient is shortened by such treatment. The next mildest form of treatment is drainage of the bladder. By this means may be obtained relief of the cystitis, and conse- quently of the tenesmus, pain, and general unrest, in a certain number of cases. In my opinion, it is applicable chiefly to those in a very debilitated condition, or to the very old. Drainage by a permanent catheter introduced through the urethra can seldom long be endured, and is usually only to be employed in preparing the bladder for a radical operation. The successes of Thompson [225], McGuire [155], and others in treating these patients many years ago by means of suprapubic permanent drainage, and of Harrison [in] by means of a perineal tube, should not be forgotten at the present day; and while we recog- nize the inadequacy of such methods to restore the patient to his normal condition, yet in a limited number of cases they are still useful. Especially is this so in patients with very bad cystitis, and where some immediate relief is imperative. In such cases so radical an operation as prostatectomy will almost surely kill, unless time can be obtained to relieve the cystitis, to get the kidneys into fair condition, and to improve the general health of Mortality. 119 the patient. In patients such as these, the formation of a per- manent suprapubic fistula by McGuire's method, or, if the pro- state be not too large, simple perineal prostatotomy with the introduction of a tube, will afford almost certain relief to the urgent symptoms, and in many instances will enable the con- stitution to withstand prostatectomy at a later date. Neither castration, vasectomy, nor ligation of the internal iliacs will act sufficiently quickly in such cases; indeed, in my opinion, these operations are no longer to be considered desirable under any circumstances. The mortality attendant upon the various operative pro- cedures will be discussed in greater detail in a future chapter; it is sufficient here to consider their relative danger. In the first place, it is quite evident that of those deaths, and they are few in number, that do follow the institution of drain- age by suprapubic cystotomy or perineal prostatotomy, only a very small proportion, if, indeed, any at all, can be blamed upon the operation itself. Practically every patient who submits to such an operation is already in an extremely critical condition, and without such intervention would die at least as soon as, prob- ably sooner than, if he had not been operated upon. The Bottini operation stands midway between the palliative and the radical methods of treatment; and while its mortality is slightly less than that of prostatectomy by either the supra- pubic or the perineal route, yet its results are so extremely un- certain, both as to immediate relief of symptoms and as to per- manency, that it is not, in my opinion, an operation to be advised except in a very limited group of cases. The radical operations have a distinct mortality per se y even when all mitigating circumstances have been considered, and all doubtful cases have been excluded. A few patients die from the operation itself, and we cannot escape the conviction that in such cases they would not have died at that time if no operation had been performed. Hence the conscientious surgeon will make 120 Prognosis. it a matter of the utmost importance to so select his cases that he will not be forced to say to himself, "Had my treatment been different, my patient would have recovered, or at any rate he would not have died as a result of my treatment." The proper treatment, therefore, of prostatics — a convenient term adapted by Belfield [18] from the German Prostatiker and the French prostatique — resolves itself into a choice of remedies, not into any hard and fast rules which may not be transgressed. It has been well said that he is either a fool, or at best a surgeon of very limited experience, who knows of only one method of treatment for a certain class of cases; and while I myself may maintain that a certain treatment is the best, I do so with the distinct reservation that it is not immediately applicable to every case. CHAPTER IX. TREATMENT: CONSTITUTIONAL; CATHETERISM ; PREVEN- TION OF COMPLICATIONS ; AND TREATMENT OF COMPLICATIONS. Patients afflicted with enlargement of the prostate should to preserve their health make everything in their life subservient to regularity and temperance. By regularity I mean the avoid- ance of everything which is not habitual; there should be no exceptions to the amount of sleep, to the hours of meals, to the daily constitutional walk, to the hour of retirement, to the dis- tance travelled, to the quantity of food and drink, to the amount of intellectual labour, or to anything which arises in a man's life. And temperance is epexegetical of regularity: not only should everything conjoin to allow the patient to pursue the even tenor of his way, but there should be moderation in all things; his habits should embrace the happy medium in which alone the path of safety lies. Such habits as these are possible only for the man who is in easy circumstances. The day-labourer, the overworked artisan, who knows not in the evening whence will come the money to buy the morrow's bread, cannot, if he would, lead a life of such orderly quiet as is enjoined on his more fortunate neighbour. And it is only where this life can be led that the purely palliative treatment can be expected to render the patient comfortable. Where it cannot be pursued, radical treatment is urgently de- manded to restore the individual to his. former condition of in- dependence. i. Constitutional Treatment. (a) Hygienic Treatment. — Regularity and temperance being our watchwords, they are to be applied to every aspect of the 122 Constitutional Treatment. individual's life. If possible, suitable climatic conditions should be obtained, the cold winters of the north being avoided by so- journs in lower latitudes. The patient's clothing should be warm enough to avoid chilling at all seasons of the year. Flannel in cold weather, and silk in hot weather, should be worn next the skin. Especially important is the avoidance of wet feet. Waterproof shoes should be worn, or sandals of rubber should be constantly carried in the overcoat pocket, ready for use in any emergency. Of more value even than these precautions, oftentimes, is the invariable rule to change the shoes and stock- ings immediately upon the return from being caught in any dampness, no matter how trivial it may appear. Even if the feet do not feel wet, it is a safe precaution to change the shoes and stockings as a matter of habit. A very slight ischsemia of the cutaneous circulation may bring on alarming prostatic, vesical, and renal congestion, with retention of urine and even uraemic symptoms in a very short space of time; and of no conditions than these is it more true that an ounce of prevention is worth pounds of cure. It is less dangerous to become overheated than to be chilled, provided chilling is not the consequence of becom- ing overheated. To perspire freely is good for these patients; and for the purpose of aiding the excretory action of the skin regular bathing should be enjoined, provided it can be done in a well heated and ventilated bath-room. It will be found safer with patients of advanced age to depend on moderate sweating, followed by a carefully administered sponge bath, or even on merely rubbing the skin dry, where an attendant cannot be pro- vided for bathing, than to risk exposure in a poorly appointed bath-room. The water should be warm; if kidney disease is present hot baths are a valuable adjuvant in securing proper excretion of the waste products. Cold baths are to be condemned. Hot sitz baths immediately before retiring are very grateful in some cases. The bowels should be regularly opened at least once each day; Hygiene. 123 and even if they act normally, the use of a brisk saline cathartic is to be enjoined at least once a month. Straining in defalcation causes general pelvic congestion, and this reacts unfavourably on the prostate. The urine is never to be retained beyond the accustomed period of three or four hours during the day. Holding it longer will be very apt to render the patient unable to evacuate it when he finally makes the attempt. The bladder is to be scrupulously evacuated as the last thing just before getting into bed. If the patient is forced to urinate during the night, it is better for him to use a urinal without leaving his bed, and thus avoid exposure and unnecessary exertion. Of course, where the patient is unable to make his water in the supine position, he will usually have to leave his bed entirely for this purpose. Socin and Burck- hardt [212] condemn the practice of urinating in the supine position, stating that the extra straining thus necessitated pre- disposes to atony of the bladder. The patient may try, at all times of the day, urinating in the knee-chest position, so as, if possible, to overcome the retroprostatic pouch by the aid of gravity. The patient should, on the other hand, be discouraged from passing his urine unnecessarily often. With a bladder not markedly diseased it should seldom be imperative to evacuate less than six or eight ounces of urine at a time. Six to eight hours is enough for a patient to spend in bed at night. If more sleep is required, a nap may be taken in the day- time. He should not sleep long in the same position, changing after an hour or so from the back to one side, and again to the other, so as to avoid congestion of the vesical neck and prostate. Where exercise cannot be taken, massage is an invaluable sub- stitute. His daily occupation should be such as does not require exer- tion either constantly in mild degree or occasionally to excess. It should not interfere with his meal hours, nor by causing mental 124 Constitutional Treatment. worry or fatigue interfere with his repose at night. He should "go softly all his days." (b) Dietetic Treatment. — Certain articles of diet are notori- ously unwholesome even for the healthy man, but in addition to eschewing these, the prostatic should likewise avoid certain edibles usually regarded as harmless. Vegetables of all kinds are per- missible, and meats in moderation. The frequent association of kidney disease makes poultry a more suitable animal food than butcher's meat. Of this latter food, especially to be avoided are pork, ham, sausage, veal, and to a less degree beef. Stewed sweetbreads, boiled fish, stewed or raw oysters, are wholesome articles, and may largely replace meat. Clams and crabs are very unsuitable. Eggs and cheese are to be partaken of with caution. Potatoes should be taken sparingly; green vegetables, pro- vided they do not upset the stomach, are to be allowed liberally, as they tend to keep the bowels soluble. Spinach, cauliflower, asparagus, stewed celery, squash (marrow vegetable), and similar vegetables are the best. Tomatoes, peas, and beans are to be allowed only occasionally, and in great moderation. Corn is not to be taken at all. For solid eating none is so suitable as well- boiled rice. Cereals of all kinds may be given, especially barley ; also wheaten and rye bread, but never hot, nor in any amount when fresh. Salads and highly seasoned gravies and sauces are to be avoided, although lettuce or even fresh celery, with French dressing, may be occasionally indulged in. Of fruits, the most suitable are prunes, especially when stewed without much sugar; stewed rhubarb is another suitable dish; grapes, particularly those of California; oranges, lemons, pears, and apples, in moderate quantities may serve occasionally to vary the monotony. Figs, bananas, peaches, blackberries, straw- berries and raspberries are harmful in the order named. Almost any kind of milk dessert is permissible, including tapioca, sago, rice and bread puddings, as well as ice-cream. Diet. 125 Great abundance of fluid should be taken, except, of course, where, from renal complications, polyuria is the most distressing symptom. Water is, of course, the most valuable beverage, and the most constantly palatable; and is probably of quite as much value uncarbonated and in its natural state. But the various alkaline waters may do good where the urine is acid and the diathesis gouty. The drinking of milk is to be especially en- couraged. Alcoholic beverages are best avoided altogether; but here, as elsewhere, I think that long-continued habits should not be rudely disturbed, and prefer to allow my elderly patients to continue in the very moderate use of whiskey with their meals, as in such quantities, and for such patients, it acts as an un- deniable aid to digestion. .Whiskey is probably, when good, the least harmful form in which these patients can take alcohol; the light Rhine wines also, Hock, Moselle, and others, may be taken, but Port and Madeira are to be studiously avoided. Claret may be allowed in moderation. An excess of sugar throws hard work on the kidneys and bladder, and predisposes to urinary fermentation. Tea is better than coffee, and coffee than choco- late; but none of these beverages should be taken more than once a day, and then in the morning, and with a liberal dilution of milk or cream. Food should not be partaken of late at night; if possible, dinner should be the midday meal. No fluid should be taken during the evening nor on retiring for the night. Patients often find themselves able to sleep the night through without urinating if this rule is observed. Yet in some gouty patients where the urine is much concentrated, a glass of water drunk just at bed- time will, as remarked by Moullin [176], by diluting the urine and rendering it less irritating, have the same effect. (c) Drugs. — Very few drugs are of any permanent service in enlargement of the prostate. Tonics are usually indicated for the general health; and of these I would recommend the time-honoured combination of the tincture of nux vomica, with 126 Constitutional Treatment. dilute hydrochloric acid and some simple bitter, such as the compound infusion of gentian, as being as suitable as any other prescription. Strychnine itself does not seem always to have the same happy effect on the stomach that the tincture of nux has, and unless the heart demands training I usually prefer the tincture. As already mentioned, an occasional cathartic is useful in every case; but many patients are habitually constipated, and must, even in addition to a diet carefully selected for this purpose, take a laxative almost constantly. For this purpose I am in the habit of employing either pills of aloin, belladonna and strych- nine, or, which is preferable if the patient will take it, the fluid extract of cascara sagrada (Rhamnus Purshiana, U. S. P.). These remedies should be commenced in active doses, and the amount taken reduced, as soon as may be, to the least possible required to produce the desired effect. Some patients will keep their bowels happily regulated by chewing senna leaves or rhubarb root, of which they become almost fond in time. Compound licorice powder is another favourite remedy with some. Enemata of cold water may be useful in stimulating the lower bowel, and in decreasing the pelvic congestion. Iodoform or glycerine sup- positories may be employed in preference to injections; or ichthyol, locally, or by mouth ten drops in a capsule three times daily. The patient will usually learn what form of medication suits him best, and will after experiencing a few times the dis- comforts of constipation and haemorrhoids, be very eager to avoid their recurrence, by properly regulating his diet and medicines. The tone of the bladder is best maintained by preventing overdistention. Atropine should never be given long at a time; hence the preference expressed above for cascara sagrada over the use of A. B. & S. pills. Strychnine in one form or another is about the only drug which seems to have any influence on the contractility of the bladder; and as in the form of the tincture of nux vomica it acts favourably on the stomach, the intestines, Drugs. 127 the bladder, and also the heart, is probably the most useful single drug we have. Its prolonged use, however, is injurious, patients becoming nervous and fidgety when it is persisted in. The dose should not, as a tonic, exceed one-fortieth of a grain three times a day; usually one-sixtieth is sufficient, except, of course, where stimulation is required. For the heart, besides strychnine, as recommended above, an occasional course of digitalis will be found beneficial. This drug also increases the amount of urine excreted by increasing the forward pressure in the kidneys, and to flush these organs out it is at times an invaluable remedy. It should never be continued long, both on account of its cumulative action and the danger which always exists of exciting an intractable gastritis. The kidneys are best controlled by diet, no drug being of any lasting benefit. For the prostate itself there is no specific. I am, however, a firm believer in the occasional value of ergot. During an accession of prostatic and vesical congestion, often accompanied by a fit of the piles, and with retention of urine, there are few prescriptions which afford the patient such comfort after the urine has been evacuated by catheter, as the following: I^. Ext. Rhamni Purshian. Fl f *ss Ext. Ergotse Fl f § j Ext. Hamamelis Fl f §iss. M. S. — Teaspoonful three or four times daily, in water. For the urine there are many drugs. It is readily diluted by increasing the amount of fluid, especially water and milk, ingested; and may be concentrated by withholding fluid and promoting perspiration. Boric or benzoic acid will be found useful for alkaline urines, and may be given separately or com- bined, about five grains of benzoic acid being prescribed with double the quantity of sodium borate, to ensure solution. Salol is an excellent urinary antiseptic, and with boric acid, may be employed for considerable periods — several weeks at a time — 128 Catheterism. without producing injurious effects. Sodium benzoate is another good drug; urotropin, however, I prefer. With piperazine I have little experience, and seldom employ it or the more irritat- ing drugs, such as uva ursi, cubebs, buchu, and copaiba. For excessively acid urine the best remedies are a change in diet, especially a reduction in the amount of sugar, and dilution by an increase in the ingested fluid. The neutral or alkaline salts of potassium and sodium will usually be found to aid the change in reaction. The officinal solution of potassium citrate may be freely taken; and the alkaline mineral waters and purges may be advised. 2. Catheterism. It is my opinion that every patient should have a trial of catheter life, or catheterism, as it is called. I am well aware that many patients commence to fail as soon as this course of treatment is entered upon, and such should certainly be cared for by other means; but it is usually impossible to say who will and who will not be benefitted by regular catheterization, and the only sure way to determine this question is to try and see. Catheterism will cure no patients. Some individuals may have their symptoms relieved, and be able to dispense with the catheter in the course of a few weeks; but such cases are prob- ably those where the onset of the symptoms was due largely, if not entirely, to congestion of the prostate and its surrounding structures, and not to permanent obstruction from enlargement. But before entering upon the subject of catheterism in detail it will be convenient to discuss first the different varieties of catheters to be employed, and then their sterilization and pre- servation. (a) Catheters. — Catheters are divided by systematic writers into the flexible, the semi-flexible, and the inflexible, of which three types, the Nelaton or soft-rubber catheter, the English PLATE LX. Catheters. 129 or webbed catheter, and the metallic catheter, are good represen- tatives. The soft-rubber catheter, known by Nekton's name, should for the purposes of prostatic surgery be fourteen or sixteen inches long at the least. Its tip should be solid beyond the eye, and the eye should be moulded in the manufacture of the instrument, and not cut afterwards. By having the tip solid there is no space for the collection of filth, to act as a ready culture-medium for germs, and by having the eye moulded, not cut, there is the assurance that its edges will be smooth and well turned, so that by no possibility can the urethra be damaged. The catheter employed should be new ; and as soon as one commences to grow old it should be discarded. There is great danger of old rubber breaking and of leaving a portion of the catheter in the urethra or bladder, if it becomes brittle; and when it has become flimsy and collapsed it is exceedingly difficult to introduce. The English catheter is made of webbing, covered with shel- lac, which renders its surface smooth, and gives a certain degree of rigidity to the instrument. These catheters are provided with stylets. Cheap English catheters are not worth buying: they are thin walled, break easily, or at least become creased, even when in the urethra, and are sometimes perforated by the stylet when in use. The tip of an English catheter is hollow like the rest of the shaft, and contains the end of the stylet. If the tip were solid, there would be constant danger of the stylet protrud- ing at the eye, and thus lacerating the urethra. These catheters are of such consistency that when placed in hot or even moderately warm water they become limp, and can be readily moulded to any desired curve; and by the action of cold water they again become quite rigid, and will retain their form long enough for use. When not in use, they are kept on the stylet, which should be of the curve desired. As a rule, they are used without the stylet, but this may be allowed to remain in place if more firm- ness be required. When the curve requires to be altered during 130 Catheterism. use, this is readily accomplished by partially withdrawing the stylet, as will be more fully described on a subsequent page. The elbowed (coude) catheter of Mercier is a very valuable instrument made of much the same material as the English cath- eter. Unlike the English catheter, however, the instrument of Mercier should have its tip solid ; the beak is about three-quarters of an inch in length, and is set at an angle of no degrees with the shaft, which is straight, the eye being in the flexure between the two; or there may be one eye on each side of the beak. It is important to purchase only catheters of this variety where the angle is produced in the process of weaving, and to avoid those catheters, of which there are many in the shops, which have been woven straight, and which have had the end subsequently turned up. This latter variety is cheaper, but the elbow seldom is sufficiently pronounced when new, and very soon disappears altogether by the catheter resuming its original linear form. The catheter employed by Leroy d'Etiolles had a longer elbow, which was set at an angle of 130 degrees with the shaft. The double-elbowed (bi-coude) catheter is, as its name implies, one where the terminal portion has a second angle about one inch and a half back of the first. It is made of the same material as that with the single elbow, but the second angle is not so abrupt as the first. Where the tip of the single-elbowed catheter is hollow it may be passed with a stylet of similar form, when by partially withdrawing the stylet a second elbow will be produced at any desired situation (Guyon). There is little risk of the stylet protruding at the eye in its passage, as will be seen by practising these manoeuvres before introducing the catheter. All catheters made of webbing should have the eye woven in the making ; to have it cut subsequently leaves a sharp and often- times ragged or ravelling edge. It is convenient in these, as well as in curved metallic ure- thral instruments, to have some indicator on the handle to show which way the beak is pointing. So far as I know, there is at Plate LX1, c 5 tj §J «S £ >>«? ,5 CQ pi w w ^ a O !< < 2^ u £^ o S? 1 u 1 H < H in O P4 Ph re o, W C W T3 O H O 'O ^ o ° ^ < o o >< t - « 3 >, < U^3 g r '-O 2 ^ Q w o g 3 oJ y cu O .St Ph HH-rS Cfi <^ RJ W w <-> > -rH CJ 05 ^. «rt P sts U £ o pi « t w ■~ Dh^-s o Pn Ph a o .n w ^ t; ™ H .b. • c O 'o ft, c £ g GO PLATE LXXVIII. tnj. in -J O C -Q CO CI "ti S Q w ?; — eu l-Ll ri C "c 3 u X! u 3 «3 * J < r. « "35 ^ C- (U £> > c/: X D c „ o « Suprapubic Prostatectomy. 221 limits of the wound. If it is seen, it is, as a rule, easily recog- nized, both by the typical appearance of peritoneum seen any- where, and by the fact of its being a transverse fold; and it is easily detached from the bladder by blunt dissection. Should it unfortunately be opened, it should at once be sutured, and the perineum should be drained at the close of the operation. The bladder is recognized by its blue appearance and its consistency. If any doubt exists as to its identity, it will be sufficiently manifested by injecting more fluid through the catheter. There are often large and turgid veins on its surface. When the bladder is thus exposed, two retention sutures may be passed through its outer coats, about a half or three-quarters of an inch apart, equidistant from the proposed line of incision, and in its upper third. I formerly passed these sutures through the whole thickness of the abdominal walls as well, and let them remain at the conclusion of the operation, thinking thus to lessen the dangers of extravasation into the space of Retzius; but I think the likelihood of this danger is overestimated, and I have had more fear of causing an injurious anteflexion of the bladder; so that I no longer intend these for permanent sutures, but merely to act as guys during the enucleation of the prostate. If it is difficult to pass these sutures, on account of the depth of the wound, one may be made to suffice by placing it in the line of the incision, at the upper angle of the wound. Indeed, in my later operations I have found it quite sufficient to steady the bladder with a tenaculum until the finger reaches the prostate (Plate lxxviii), and then to remove the tenaculum and let the bladder fall back into the pelvis during the enucleation. The bladder, being thus securely fixed in the wound, is to be opened by an incision made towards the pubic symphysis, and extending below it. This incision in the bladder walls should never be made upwards, as not only might the peritoneum be opened, but a coil of intestine wounded as well. It is inadvisable to make an incision of more than an inch or an inch and a half 222 ^ Operative Technique. in length in the bladder wall, and the left index finger of the surgeon should follow the knife in, so as to palpate the inner sur- face of the bladder, the prostate, and the urethra, before all the fluid has escaped. A much more accurate idea of the relations of the various parts is attained when the bladder is distended. The table may now be replaced in the horizontal position. The finger should first seek to recognize the position of the urethra with its contained catheter. The outlines of the prostate can next be determined, the presence of calculi detected, and plans made for the further continuance of the operation. Any calculi present should first be removed, with forceps or scoop. If no guy sutures have been retained in the bladder it is best not to remove the finger from its interior until the completion of the operation, as its reintroduction may be difficult if the abdominal wound is deep. If a large calculus is found, the in- cision in the vesical wall may need to be enlarged before the stone can be safely removed; but with skill even large stones may be removed through an incision of little more than an inch. In very many cases retractors must be employed to draw apart the sides of the abdominal wound and the bladder wall before the pros- tate can be satisfactorily exposed. At times two other retractors may be used to advantage, increasing the field of operation in its longitudinal diameter (Plate lxxix). If a pedunculated prostatic outgrowth acting as a ball-valve against the vesical orifice of the urethra is found, it should be twisted off with the fingers, or its pedicle should be cut through with scissors or bladder forceps. If no other urethral obstruc- tion exists, — a fact which can readily be determined by partially withdrawing and reinserting the catheter, — the operation may now be terminated, and the bulk of the prostate be left untouched. Often, however, there will be found similar prostatic tumors pro- jecting into and obstructing the urethra, which are not evident from the cavity of the bladder; hence the great importance of making sure of the patulous condition of the urethra before de- PLATE LXXIX. fe - x • — £ .5 >. d 1< 6 p .- - w ■— '- z_ w "S c3 CJ o £ ,-) o gl a ° r 3 -5 'tb 5 w 0) — c x 2 ~ c3 1_ u u r U £ J> Co - - Suprapubic Prostatectomy. 223 riding to conclude the operation by a partial prostatectomy. This is a point which has been much insisted upon by Belfield [18], and is probably the explanation of the failure of so many of the early suprapubic prostatectomies to effect a permanent cure. If no such pedunculated outgrowth exists, or if a complete prostatectomy is indicated even after its removal, an incision, long enough to admit the end of the index finger, should be made over the more prominent of the two lateral lobes. This incision should run parallel with the urethra, and is usually most con- veniently made with a pair of scissors; I have, however, on numerous occasions, simply scratched through the vesical mucous membrane with my finger-nail. The surgeon then introduces the middle and index fingers of his right hand, gloved, into the patient's rectum, passing his arm beneath the flexed thigh; and placing his thumb against the perineum, makes counterpressure on the prostate, and raises it up towards the enucleating finger. The larger and more adenomatous the prostate, the easier it is for the surgeon to find the natural line of cleavage which exists between the prostatic capsule and its sheath. It is not safe to go too wide of the prostate in the endeavour to remove it all. All of it will be removed, except perhaps here and there a flake off the outer surface of its capsule, by clinging close to the adeno- matous organ rather than by going off on voyages of discovery into the sheath. In other words, the prostate is to be removed from its sheath, not the sheath from the prostate (Plate lxxx). The finger should first pass to the outer side of the lateral lobe first attacked. In this situation the attachment of the pros- tate to its sheath is least dense. Then the finger should cau- tiously but not timidly work down and under the lateral lobe, towards the neighbourhood of the posterior commissure and the ejaculatory ducts. Next the posterior and inferior surfaces are separated from the sheath; and, finally, when the lobe is pretty well outlined, the finger may pass along the lateral and inferior surfaces to the apex, and free it from the triangular ligament. 224 Operative Technique. At times the lateral lobe first attacked may come away alone, leaving the urethra still attached to the other lateral lobe. More often in my experience the original incision through the vesical mucous membrane has torn larger during this enucleation, and the vesical orifice of the urethra has become entirely detached by the extension of the tear across the trigone of the bladder. Then the enucleating finger will pass across to the second lobe, almost invariably as it does so tearing loose the ejaculatory ducts from their union with the urethra; and finally, having completed the enucleation of this second lobe, will find the prostate fully detached from all its surrounding structures except where the urethra annexes it to the triangular ligament. At this stage of the operation either one of two things happens — the urethra slips out from the centre of the prostate, remain- ing still attached to the triangular ligament, and hanging loose like the empty finger of a glove (with its end cut off) in the cavity from which the prostate has been enucleated; or, which I think is more frequently the case, the urethra tears off at the triangular ligament, and its prostatic portion is removed entire in the centre of the prostate. I do not see how it is possible, and know it has never been so for me, to leave the prostatic urethra, with the attached ejaculatory ducts in place, annexed at both ends — anteriorly to the triangular ligament, posteriorly to the bladder wall. I have several times been able to remove the entire pros- tate, including of course its urethra, through the one original incision made through the vesical mucous membrane ; but where the organ is very large this cannot be satisfactorily done, and a second incision, comparable to the first, must be made over the other lateral lobe. If the anterior commissure of the gland gives way during these manipulations it is theoretically possible to swing the whole prostate (which is then merely an organ with the urethra lying in a groove on its upper surface) across beneath the urethra, and to deliver it entire through one or other of the incisions in the mucous membrane of the bladder; but even thus PLATE LXXX Cfl 3 P X J£ "" X c s PLATH LXXXI. Appearance of Parts After the Completion of Freyer's Operation, Showing the Remnants of the Prostatic Urethra, Attached Below to the Triangular Ligament and Above to the Bladder. Between the Divided Ends of the Urethra are seen the Remains of the Ejaculatory Ducts. — (Walker.) Suprapubic Prostatectomy. 225 I cannot see how the attachment of the ejaculatory ducts can be preserved, though it is theoretically possible for the prostatic urethra to remain intact, traversing the cavity from which the prostate has been removed much as a resistant artery traverses a phthisical cavity. The condition of the parts which is probably the most usual is shown in Plate lxxxi taken by Mr. J. W. T. Walker from one of Freyer's patients who died two hours after the operation. Here two tongue-like processes can be seen, representing the remains of the urethra, extending downwards from the vesical mucous membrane, and upward from the triangular ligament; while be- tween and below these can be seen the ejaculatory ducts, torn loose from all connection with the urethral floor. When the prostate has thus been delivered into the interior of the bladder, the tissues left between the rectal and vesical hands are felt to be very thin, and no trace of remaining pro- static substance can be detected. The hand is then withdrawn from the rectum, the glove removed, and the prostate extracted from the bladder with the ringers or suitable forceps. The more adenomatous the prostate, the more compressible it will be, and the vesical incision should not be enlarged until attempts to re- move the prostate have failed. The cavity from which the prostate was enucleated will now be found to have become amazingly reduced in size, both by active contraction, and by pressure from the surrounding struc- tures. Bleeding may be free, but is usually only moderate in amount, and readily controlled by the hot douche, which is to be freely applied through the suprapubic wound. Should this fail to control the haemorrhage another plan must be tried. Often by gauze pressure well directed against the oozing area the bleeding may be checked. But if the haemor- rhage persists, or in case of secondary haemorrhage, continuous pressure must be applied. It has been advised to apply this in the following way: a number of layers of gauze, of suitable 16 p 226 Suprapubic Prostatectomy. size, are stitched together at their centre; the end of the suture is left long, and is attached to the intravesical end of the catheter which has been lying in the urethra throughout the operation, or which is to be introduced if not already in place. By with- drawing this catheter, the thread will follow, and will press the attached gauze firmly against the vesical orifice of the urethra. Care should be taken that this gauze does not occlude the ure- teral orifices. This method of haemostasis has always seemed to me to be objectionable. When the gauze becomes soaked through with urine there is risk of its acting merely as a sponge, and thus allow- ing the blood to ooze through its meshes. A safer plan, I think, is to pack with gauze the cavity from which the prostate has been enucleated, and then to suture over the packing the mucous membrane forming the roof of the cavity from which the prostate has been removed, of course leaving an end of the gauze long, to come out through the suprapubic wound, and facilitate its removal. The suture material should be catgut, and the packing could remain in place until it became loosened by the absorption of the catgut — usually in from four to five days. I have recently adopted this plan with the most gratifying results in a case where furious bleeding followed the removal of an ad- herent prostate by Freyer's method. Of course, if this method were adopted for the control of secondary haemorrhage, the patient would have to be anaesthetized and the suprapubic wound en- larged. For secondary oozing which is not marked irrigation with hot water will usually be found an efficient haemostatic; or a solution of adrenalin chloride (i : 10,000) may be used. It is certainly well to try the effect of milder measures first, and not resort to packing injudiciously. As soon as the prostate is extracted from the interior of the bladder, the urethral catheter, if not previously withdrawn, is to be removed; and a long rubber tube of large calibre — one- quarter or three-eighths of an inch — passed into the bladder Plate LXXXII. — U 3 Rj bo 7i to II < — -J O w o Jj; rf o r C o '5b Dressing of the Wound. 227 through the suprapubic wound. This tube should be about two feet long, and I am careful to have it open not only at the end, but also to have large eyes on its sides near the vesical end, since should the bladder wall come in contact with the end opening, all drainage would be effectually prevented. To further obviate the likelihood of any such obstruction I do not pass the tube far into the bladder, merely making sure that it fulfils its purpose as a drain; and under no circumstances dismissing the patient from the table until it is evident that the tube is clear of all clots and other obstructions, and the urine or intravesical fluid can be seen distilling from its further end drop by drop. The anaesthetic may be stopped as soon as the irrigation of the bladder is commenced; and by the time the patient is in his bed he should be fairly conscious of his surroundings. The suprapubic tube is held in place by a stitch through the skin; and the angles of the wound, when this is large, may be sutured, but if the urine is foul no sutures at all should be employed; but as the parietal peritoneum has a tendency at times to prolapse into the upper angle of the wound, one suture in this situation may be necessary. Separate catgut sutures should be used for the sheath of the rectus muscle and for the skin. The dressing, of sterile gauze, cut so as to fit around the tube, and each piece overlying that beneath in an imbricated manner, should be copious, and may be reinforced with absor- bent cotton. Thus whatever urine is not carried off by the tube, but leaks out along its sides, will be quickly absorbed in the dressings, and will not trickle over the patient's buttocks and clothing. The further end of the tube must be connected with a suit- able receptacle below the level of the patient's bladder, so that the syphonage may be continuous. If this detail is attended to there will be no necessity for the employment of a vacuum pump, as described by W. G. Richardson [199] in his recent essay. The urinal into which this suprapubic tube drains should be partly 228 Suprapubic Prostatectomy. filled with some antiseptic or deodorant solution, sufficient in depth to cover the end of the tube ; and in calculating the amount of urine excreted the quantity of fluid already in the urinal must be subtracted. The suprapubic dressing may be renewed as often as it be- comes saturated. As a rule, twice daily is quite frequently enough. Should there be much shock after the operation, suitable stimulation must be administered; but it is of more importance to prevent shock, and for this purpose nothing is so efficacious as external heat. The patient may be surrounded with hot- water bags throughout the operation in many cases with the greatest advantage, or, better still, be placed on a hot- water bed. On the day following the operation, and once each subse- quent day, the bladder is douched through the suprapubic wound. I do not retain a catheter in the urethra, nor do I pass one to irrigate the bladder, after the operation, until this can no longer be accomplished through the suprapubic wound. But if an ammoniacal state of the urine developes I think great ad- vantage is to be derived from douching the bladder through the urethra, the fluid draining off by the suprapubic wound. For the purpose of intravesical douching in these cases it is usually quite sufficient to introduce the nozzle of the syringe into the urinary meatus, there being no necessity to pass a catheter into the bladder, since the passive resistance of the urethra can readily be overcome by fluid pressure. The suprapubic tube may usually be removed on the second day after the operation, and the patient encouraged to pass his urine in the natural way; but there is no objection to leaving the tube in place for five or six days if such a course should seem desirable. Voluntary micturition com- monly returns earlier after this operation than after that by the perineal route; and, as there is no fear of a sinus persisting below, the patient may be propped up in bed on the fourth or fifth day, and be allowed to sit in a chair at the end of a week or ten days if PLATE LXXXIII. Suprapubic Operation. Drainage-tube and dressing in place. After-treatment. 229 his general health permits. Indeed, as soon as the patient feels able to be out of bed, no matter how few days have elapsed since the operation, I think he should be allowed to be up. Unless something should indicate the existence of urethral obstruction, I am not in the habit of passing instruments by this route as long as the suprapubic wound remains available for the daily irrigation of the bladder. Should, however, this fail to show any signs of closing in the second week, I think it proper to sound the urethra, so as to ensure against the for- mation of strictures. I do not regard it as at all impossible for strictures to form as a result of the removal of the prostatic urethra; but I think the injudicious resort to instrumentation might very well render their formation more probable. When, however, the suprapubic wound has closed, which it commonly does in the third or fourth week, I consider it safe to irrigate the bladder through the urethra ; and this, I think, should be done at least once a week for some months after the operation, unless the urine sooner becomes normal. In any case, the regular passage of a full-sized sound once a week for some months after the opera- tion can be productive of no harm, and should, I think, be ad- vocated in most cases, especially where a tampon has been em- ployed for the control of haemorrhage. Some surgeons have found that the suprapubic wound is apt to reopen once or twice before finally healing; but this has not been my experience. Secondary haemorrhage and the means of controlling it have already been referred to; but I think it important to call atten- tion]^ looseness of the bowels as a cause of this complication. Every time the bowels are opened the granulating wound is dis- turbed, and the liability to bleeding increased. Hence diarrhoea should be avoided, and where slight oozing persists it may be well to try the effect of opium or paregoric before more strenuous measures are resorted to. The patient's usual diet and mode of life may be resumed as 230 Perineal Prostatectomy. rapidly as his convalescence will permit; but he should pay particular attention to the state of his kidneys and urine for many months after the operation. He should be encouraged to drink all the water possible from the instant his stomach becomes retentive after recovery from the anaesthetic; this is the surest method of preventing uraemic conditions. The ap- pearance of hiccough and nausea following the recovery from anaesthesia, particularly if a small amount of urine is being ex- creted, is indicative of a mild degree of uraemia, and should be promptly met by medical measures. It is not my practice to resort at once to agents such as calomel, sparteine, caffeine, etc., after operation, but to immediately wash out the stomach with the stomach-tube, this being a far more effective remedy for hic- cough than any antispasmodic drug; I then introduce into the stomach one and a half or two ounces of Glauber's salt in con- centrated solution. Where the stomach is empty the solution soon finds its way into the small intestine, and in a short time bowel action is obtained. I have found this of more service than any other agent. Should further treatment be required, however, rectal, subcutaneous, or intravenous infusions of deci- normal saline solution should be employed, and other appropriate, treatment should be instituted, as already indicated at page 162. Perineal Prostatectomy. — So many variations and modifica- tions of this operation are now in use, that a minute descrip- tion of each in a work of this kind would be impracticable. All the methods employed, however, may be classed in either one of two categories — those operations where an elaborate dissec- tion is required, as seen in the technique of the French school developed by Proust [196], and as modified in this country by Young [261]; and those operations where only a partial pros- tatectomy is performed, the manipulations being conducted through a comparatively small perineal wound. The latter is the form of operation which I have employed myself, and which is, I believe, that most generally adopted by operators in this PLATE LXXXIV. Proust's Inverted Perineal Position for Perineal Prostatectomy. PLATE LXXXV. Perineal Prostatectomy. — {Proust.) The transverse perineal incision. Goodfellow's Technique. 231 country. The technique employed by Dr. Goodfellow, as al- ready remarked, appears to me to differ in no essential parti- culars from that of Mr. Freyer, except that the prostate is re- moved through a perineal instead of a suprapubic wound. Dr. Goodfellow's [98] own description of his operation is as follows: "The usual pre-operative procedures are carried out. . . . With the patient in the ordinary lithotomy position, the legs held by assistants, the bladder being empty or full as the case may be, a lithotomy staff is introduced, the legs then elevated somewhat, a median incision from the base of the scrotum to the margin of the anus is made, and carried to the membranous urethra, which is entered with a straight lithotomy knife and the opening extended into the bladder. The finger is then intro- duced into the bladder, the staff removed, and the moderate flexion of the legs and thighs on the abdomen and the thorax increased to as great an extent as possible; then with the op- posing hand over the hypogastrium the bladder is depressed, and the enucleation, beginning at the beak of the prostate below and working upward next to the bladder, or from above on either side downward, is carried on, the time consumed for complete enucleation rarely being over five or ten minutes, the resulting hemorrhage being virtually nothing. The gland may be removed entire or lobe by lobe. . . . What becomes of the prostatic urethra? has been asked. The answer is that part or all is re- moved with the gland, an incident that in no manner seems to affect the restoration or the continuity of the urethra, nor the power of the bladder to regain and control its functions; nor is stricture or occlusion caused. The seminal ducts are not iigated, for this seems to me an irrational refinement, especially as many of my patients have (so they say) to a greater or less extent regained sexual vigor." Dr. Goodfellow continues: "The points to be expressly emphasized are the position and the incision into the bladder. . . . . I do not find it necessary now to use the knife to 232 Perineal Prostatectomy. enter the urethra and bladder. After cutting to the urethra I am able with the finger to open it and get into the bladder by a boring movement. Then not having a cut through the commissure, I enucleate from above instead of from below as formerly.' ' 1. Perineal Prostatectomy. Technique 0} Proust. — Perineal prostatectomy as practised by Proust requires a special operat- ing table, and special retractors. The patient is placed in the " inverse lithotomy position/' so that the perineum is in the horizontal plane, its surface looking upward. (Plate lxxxtv.) To secure this the patient's lumbar spine and sacrum are placed upon an inclined plane of forty-five degrees, and his legs are held by special stirrups high in the air, with the thighs fully flexed and horizontal. By means of this position it is claimed that a very much larger operative field in the perineum is ex- posed, since, after division of the recto-urethral muscle, and opening of the aponeurosis of Denonvilliers, as will be presently described, the rectum and anus can be drawn upward against the coccyx and lower bones of the sacrum, making a yawning wound. For this purpose a self -retaining retractor is employed, and the aid of an assistant may be dispensed with. The patient being fixed in the position above described, his bladder being empty, and a metal guide or catheter in the urethra being held close beneath the pubic arch, so as to draw the bulb of the urethra well up out of the operative field, a transverse incision is made in front of the anus, with its convexity forwards, from one ischiac tuberosity to the other. The attachment of the external sphincter ani to the perineal centre is then divided, and the dissection continued posterior to the transverse perineal muscles. By drawing the anus backwards, that is, towards the operator, the recto-urethral muscle is put upon the stretch (Plate lxxxvi). This is a somewhat indefinite structure which consists of muscular and fibrous tissue passing from between the layers of the triangular ligament backwards to the rectum, by PLATE LXXXVI, Perineal Prostatectomy. — (Proust.) After dividing the skin, and separating the insertion. of the sphincter ani from the perineal centre (which is raised by forceps in the right hand of an assistant), the recto- urethral muscle is exposed, and is now being divided with scissors, close to the mem- branous urethra. PLATE LXXXVII. Perineal Prostatectomy.— (P>w/s/.) The recto-urethral muscle has been dhided, allowing the rectum to fall away from the anterior structures, and opening the "espace decollable relro-prostalique." PLATE LXXXVIII Perineal Prostatectomy. — (Proust.) The two index finders of the operator are introduced between the two layers of the apo neurosis of Denonvilliers, and enlarge the "espace decollable relroprostatique." PLATE LXXXIX. Perineal Prostatectomy. — {Proust.) The sheath of the prostate (the anterior layer of the aponeurosis of Denonvilliers) has been opened, and the surgeon's finger now detaches the sheath from the prostate by blunt dissection The prostatic tractor sometimes employed by Proust is not shown in this illustration. Technique of Proust. 233 their insertion into which is produced the acute flexure of this canal just within the anus. The recto-urethral muscle must next be divided. This is to be done with a pair of scissors, snipping through these fibres close to the membranous urethra. If great care is not exercised to keep close to the membranous urethra, but without opening it, the dissection will be made below the posterior layer of the aponeurosis of Denonvilliers, between it and the rectum, instead of ^between the two layers of this structure (Plates xv, lxxxvh), where is found the "espace decollable retro- prostatique." As soon as the recto-urethral muscle has been divided in the required place, the rectum will fall away from the anterior struc- tures, and the two layers of the aponeurosis of Denonvilliers may be readily separated with the two index fingers (Plate Lxxxvin). The rectum will now appear like a loop of intestine floating free in the peritoneal cavity, being covered by the posterior layer of this aponeurosis, while the anterior layer still conceals the prostate and seminal vesicles from view. It is to be recalled that the aponeurosis of Denonvilliers is really an obliterated sac of peri- toneum. (See pages 24 and 31.) When the "espace decollable retro-prostatique" is thus widely opened, the special retractor is inserted, and screwed up so as to hold the rectum and anus against the sacrum and coccyx. Beyond the anterior layer of the aponeurosis of Denonvilliers the prostate can now be indistinctly felt, floating away as soon as it is touched. Proust now opens the urethra, at the apex of the prostate, posterior to the triangular ligament, not between its layers; and after withdrawing the guide, inserts into the bladder through the urethral incision a special tractor — DePezzer's — which is very similar to that employed by Young, and represented in Plate xciv. The prostate being thus steadied by spreading the blades of this tractor over its vesical surface (Plate xcv, Fig. 1), the sheath of the prostate (the anterior layer of the aponeurosis of Denonvilliers) 234 Perineal Prostatectomy. is to be opened with scissors, parallel to the urethra. The finger of the surgeon is then inserted between this layer of fascia and the capsule of the prostate, which is thus exposed on its rectal aspect; and the surgeon proceeds to detach the prostate from its sheath by the finger (Plate lxxxix) . He detaches it first along the side of one lateral lobe, then below, and from the vesical aspect, and finally in front, above, and close to the pubis. This enucleation should be done deliberately, and with the most painstaking thoroughness. Proust says that time apparently lost at this stage of the operation will at a later stage be found to accelerate matters considerably. When the prostate is thus freed of all its attachments, except those to the urethra, and to the ejacu- latory ducts, the operation may proceed, but not before. The prostatic tractor is then removed. The wound in the urethra is now to be enlarged. This is accomplished by splitting its floor from the apex of the prostate to but not into the neck of the bladder (Plate xc). This cut hemisects the prostate as well; and each lobe in turn is then dissected off the lateral and upper aspects of the prostatic urethra by means of scissors, the index finger of the left hand being placed on the mucous surface of the prostatic urethra if neces- sary as a guide (Plate xci). Proust ligates the ejaculatory ducts, thinking that by this means orchitis is less apt to occur. He removes each lateral lobe entire, advising against morcelle- ment, which he considers necessary only when the gland is extremely friable and comes away in pieces of its own accord. He follows Albarran in the practice of resecting the floor of the prostatic urethra when this part of the canal is unduly dilated. When an intravesical projection, more or less pedunculated, is present, he delivers this through the prostatic urethra, and accomplishes its removal just as if he was working through a suprapubic wound; or if the pedicle is too short or too broad to allow of its delivery in this manner, he works up from the Plate XC. Perineal Prostatectomy.— (Proust.) Hemisection of the prostate along the floor of the urethra. PLATE XCI, Perineal Prostatectomy.— (Pxoust.) Each lobe ot the prostate in turn is dissected free from the sides of th e prostatic urethra. PLATE XCI1. s> Perineal Prostatectomy. — (Proust.) The ejaculatory ducts have been ligated, and the urethra is now being sutured. Technique of Proust. 235 lower surface of the bladder, and enucleates the mass without opening the vesical mucous membrane. The operation is completed by passing a rubber tube or catheter through the penis into the bladder, and another catheter to the bladder through the perineal wound. Ordinarily the calibre of the prostatic urethra is such that it will easily accom- modate both these tubes; should such, however, not be the case, that through the penile urethra is to be omitted. The prostatic urethra is sutured around the perineal tube with interrupted stitches of catgut, except where the tube emerges, at the triangular ligament (Plate xcn). Three wicks of gauze are required to drain the perineal wound, which is par- tially closed by a few buried sutures, and by two deep (not buried) sutures at each of its angles. A firm gauze pad is placed be- tween the coccyx and the anus, so as to hold the rectum forward, its normal anterior support having been destroyed by the division of the recto-urethral muscle. The usual superficial dressings are applied ; and the patient when returned to bed is so arranged that the bladder shall be higher than the outer end of the peri- neal tube. This is best accomplished by using a perforated mattress, and having the tube drain into a urinal beneath the bed. If this plan cannot be carried out, Proust advises placing a board across the bed beneath the mattress, where the patient's buttocks will rest upon it, and thus be effectually prevented from making a depression in the bed lower than the outer end of the tube, which would then have to drain up-hill. As a substitute for this plan, the patient's buttocks may be made to rest upon a firm pad or pillow, placed above the mattress. Some such device Proust insists is essential to ensure the proper drainage of the bladder. The penile catheter is plugged, and all urine passes by the perineal tube. In the after-treatment, the bowels are kept locked for eight days; for the first week the bladder is irrigated twice daily by injecting small quantities of fluid through the penile catheter, 236 Perineal Prostatectomy. and allowing it to escape by the perineal tube. The dressing is first removed at the end of forty-eight hours, and subsequently renewed once every day. He removes the perineal tube on the eighth day, and lets the urine then drain by the penile catheter. This should be changed frequently to prevent concretions form- ing on it; and in doing so the upper wall of the urethra should be sedulously followed. Proust employs catheters of the general form of Merrier' s, but having an extra eyelet on the convexity of the angle; before withdrawing one he passes a straight flexi- ble guide along its interior until the guide projects through this extra eyelet into the bladder; the catheter is then withdrawn over the guide, which remains in the urethra, and serves as a conductor for the insertion of the new catheter. He prefers to keep the penile catheter in place, changing it frequently, for from three to five weeks, that is, until the peri- neal wound has closed. Complete healing of the perineal wound is generally assured in from five to seven weeks. 2. Perineal Prostatectomy. Technique of Young. — Young [261] calls his method " conservative" perineal prostatectomy, its special feature being the preservation of the connection be- tween the ejaculatory ducts and the urethra. The incision he employs is shaped like an inverted V (Plate xciii). At first he used an incision like an inverted Y, but he has found that the prolongation of the incision forwards on to the bulb of the urethra is not necessary, inasmuch as the entire dissection, just as in Proust's technique, is carried on posterior to the perineal centre and the transverse perineal muscles. Each limb of his A-shaped incision is five centi- metres or less in length. The position he advises may be characterized as the "exag- gerated lithotomy position,' ' the patient's thighs being fully flexed on the abdomen, so as to bring the perineum more nearly parallel with the floor. With a guide in the urethra, the attachments of the anus PLATE XCIIi. Skin Incisions for Perineal Prostatecto: Plate xci-v. Young's Prostatic Tractor. PLATE XCV Fig. i. Fig. Perineal Prostatectomy. — ( Young.) Fig. i. Young's prostatic tractor in place, seen from within the bladder. Fig. 2. Dia- gram to show parts removed in operating according to Young's technique : in the centre a catheter is seen in the prostatic urethra; below are shown the ejaculatory ducts and uterus masculinus in the posterior commissure of the prostate. PLATE XCVI. Perineal Prostatectomy. — ( Young) Incisions on each side of posterior commissure down to the prostatic urethra. The prostatic tractor has been introduced through the opening in the membranous urethra, and draws the prostate well down into the perineum. Technique of Young. 237 to the perineal centre, and of the rectum to the triangular liga- ment, are divided as in the French operation; the "espace decol- lable retro prostatique" being thus opened, an incision is made into the membranous urethra. The edges of the urethral in- cision are caught with silk traction sutures, or suitable clamps, and the urethral guide withdrawn. The prostatic tractor (Plate xciv) is then inserted into the bladder through the perineal wound ; by spreading its blades the prostate can be drawn securely down into the perineal wound. An incision is now made with a scalpel on each side of the median line, through each lateral lobe of the prostate, parallel to and extending as deep as the urethra; leav- ing between these two incisions a bridge of prostatic tissue, in- cluding the posterior commissure, in which the ejaculatory ducts are supposed to lie (Plate xcvi). Each lateral lobe of the pros- tate, lying external to the corresponding incision, is then detached from its sheath with a blunt dissector and the ringer. When one lobe has been freed from its sheath, its connections to the urethra and the anterior commissure are severed, and it is removed. The second lobe is treated in a similar manner. Thus prac- tically all that remains of the prostate is the anterior and pos- terior commissures (Plate xcv, Fig. 2). A median lobe frequently, when present, is removed at the same time as the lateral lobe to which it is attached. If it does not come away in this manner, Young says it is easily enucleated through the upper end of one of the cavities left by removal of a lateral lobe. This is aided by placing one blade of the tractor over the vesical aspect of the median lobe. At the conclusion of the operation the lateral prostatic cavities are to be packed firmly with gauze, additional packing being also placed in the retroprostatic space. One limb of the incision is closed completely, and through the other, which may be partly closed posteriorly, the gauze and rubber drains emerge. He employs two perineal tubes, so as to maintain continuous irriga- 238 Perineal Prostatectomy. tion, which he finds necessary to prevent the plugging of the tube by clots. The continuous irrigation of the bladder through the peri- neal wound (Plate xcvii) he continues for a week, the reservoir requiring to be filled every half hour with saline solution at a temperature of from no° to 120 Fahrenheit. As soon as the patient is returned to bed, a subcutaneous infusion of salt solution is given. The perineal gauze is loosened on the second day, but is not completely removed until the sixth day after the operation. The tubes are removed at the end of a week, and the patient is allowed out of bed. The perineal wound is still kept lightly packed with gauze, and on the ninth day, after passing a sound by the urethra, a catheter is inserted and fixed in place, constant drainage by the penile urethra being maintained for five days more. The bladder is irrigated twice daily through this catheter. The perineal fistula may be expected to close in five or six weeks. Sounds are passed by the urethra only at intervals, not systematic- ally. 3. Partial Perineal Prostatectomy. — The technique about to be described is, I think, that still most widely employed in this country, and that which is usually intended by the term " peri- neal prostatectomy." An ordinary staff, or Ferguson's prostatic depressor, being in the urethra, the patient is brought into the lithotomy position, his legs being supported by assistants. It is undeniable that by flexion of the thighs on the abdomen the perineal distance is decreased, and this manoeuvre may aid in the removal of the offending organ. But I have known femoral thrombosis and gangrene of the leg to result from overflexion of the thigh in one patient where vaginal hysterectomy was the operation, and have since been averse to this exaggerated position for any opera- tion upon the perineum. A straight median incision is then made from the base of the PLATE XCVII. Diagram showing the Use of Continuous Irrigation of the Bladder, after Young's Operation of Perineal Prostatectomy. PLATE XCVII1 i£ — -3 •-' - - w ~ c_ _ - — = a o u - o M Cfl ^ 5 _ be - bb'S PLATE XCIX. Syms's Prostatic Tractor en Use. Its bulbous extremity has been expanded within the bladder, and by traction on the stem the prostate is drawn down into the perineum PLATE C. Murphy's Hooks, for Use in Perineal Prostatectomy. Perineal Prostatectomy. 239 scrotum to the margin of the anus. This incision lays bare the bulb of the urethra anteriorly, and the outer fibres of the anal sphincter posteriorly. This incision is deepened by light touches of the knife, dividing the perineal centre, and exposing the mem- branous urethra. On each side of the wound the fibres of the levator ani will be seen descending, those most anterior passing in front of the rectum and blending with fibres of the deep trans- verse perinei and internal sphincter ani muscles, near the perineal centre. The membranous urethra should now be opened, and, the staff being withdrawn, an ordinary metal sound, or the finger, passed through the prostatic urethra into the bladder; by hook- ing this over the raised vesical orifice of the urethra the prostate may now be drawn down into the wound. If Ferguson's prostatic depressor is employed it should not be removed from the urethra, but an assistant should, by bearing down on it, push the prostate down into the wound. I have no doubt that Young's or Syms's tractors are very useful during this part of the operation, but I have not found them necessary. The anterior fibres of the levator ani are then divided, and drawn to each side by hooked retractors, while the rectum and its overlying tissues are pressed backwards with a blunt retrac- tor. By this means a fairly large operative field is opened up in the recto-urethral triangle. It is not the gaping wound of Proust, nor even the free exposure of Young, but it is quite sufficient for the purpose (partial removal of small fibrous pros- tates), and amply large when the time for healing has arrived. By now drawing the prostate down into the wound its sheath is put upon the stretch, and is readily opened, by two lateral incisions, parallel to the urethra. When this has been done, the separation of the prostate from its surrounding structures should be begun at its posterior part, which is readily reached by going along the lateral surfaces of each lobe. One lobe at a time is attacked, by drawing it down into the perineum by 240 Perineal Prostatectomy. means of Murphy's hooks (Plates c, evil). This dissection is by no means so easy as the shelling out of the gland in the supra- pubic operation, for these fibrous prostates are both hard, and usually closely attached to the surrounding tissues, so that re- moval by morcellement is at times imperative. Especially is this the case when the gland is of cartilaginous hardness. Here the most that can usually be done is to gnaw away the obstruct- ing parts, along with the floor of the prostatic urethra, irrespec- tive of lobes, which are often indefinable. The floor of the prostatic urethra may well be removed in every case, sacrificing thus, of course, the ejaculatory ducts. It is generally best to leave behind the upper wall of the ure- thra, as well as the anterior commissure of the gland, since their removal prolongs the operation and makes it more dangerous, and since there is little likelihood of subsequent trouble being caused by their presence. In these fibrous prostates it is very unusual to find a pedunculated vesical outgrowth, but should one be present, it is best removed through the prostatic urethra, after dividing its pedicle. When as much of the gland as seems advisable has been removed, and it is evident that the vesical orifice of the urethra is as low as the lowest part of the bladder, a good-sized rubber tube is passed into the bladder through the perineal wound, being stitched to the skin, and is gently packed around with iodoform gauze. If the oozing of blood is persistent, and cannot be con- trolled by douching with hot lotions, this packing may be quite firmly applied. It should be removed, as a rule, on the third or fourth day. A light gauze dressing, held in place by absorbent cotton and a T-bandage, completes the operation. On being returned to bed the perineal drain is attached by glass and rubber tubing to a bottle hanging beside the bed. It is well to pay attention to the point so much insisted upon by Proust [196],. and to see that the urine has a down-hill course from the bladder. i PLATE CI. Skin Incisions for Perineal Prostatectomy. The dotted line shows Dittel's incision. The unbroken line shows the incision employed in the technique illustrated in Plates Oil to CVIII. PLATE CII. Perineal Prostatectomy. Straight median incision exposing Colles's fascia Plate cil f Perineal Prostatectomy. Colles's fascia has been incised, exposing the bulb of the urethra PLATE CIV. 1- Perineal Prostatectomy. By retracting the margins of the wound the membranous urethra, the transverse perineal muscles, and the anterior fibres of the levator ani are exposed, in addition to the bulb of the urethra (bulbo-cavernosus muscle) shown in Plate OIL PLATE CV. Perineal Prostatectomy. The membranous urethra is opened on a grooved staff, being more fully exposed by re- tracting the rectal tissues downwards. PLATE CVI, Perineal Prostatectomy. By means of Ferguson's prostatic depressor the prostate is pushed well down into the perineum, displacing the bulb of the urethra forwards, and the levatores ani muscles to either side. The sheath of the prostate has been incised over each lateral lobe, parallel to the urethra. Plate evil. Perineal Prostatectomy. „f ^ Ey blU . nt d ! ssection > and with the aid of Murphy's hooks as tractors each lateral lobe pt the prostate is removed in turn. The finger or an ordinary sou dm introduced enucleation 3 ^ ^^ **"** "* ^^^ de P^ or withdrawn to a[d in the PLATE CVIII. Perineal Prostatectomy. Drainage-tube in place, the wound packed lightly with gauze, and its angles sutured. After-treatment. 241 The outer dressings may be changed once daily, or oftener, if required; the packing should be removed about the fourth day, and the perineal tube at the end of a week. The bladder should be irrigated once daily through the perineal tube. Commencing in the second week, a full-sized catheter or sound should be passed through the urethra every third or fourth day. It will commonly be found that by the end of the second week the patient will pass more urine by the urethra than through the perineal wound. He should be kept quietly in bed until the urine ceases to pass by the perineum, unless his general health suffers from the confinement. To encourage the volun- tary passage of urine he may turn on his side or even into the prone position, early in the second week. The perineal fistula may be expected to close in the third or fourth week, and the wound to be completely healed at the end of five weeks. 17 p BIBLIOGRAPHY. The figures in the text placed within square brackets [thus] refer to the same number in the bibliography. i. Adams, John: The Anatomy and Diseases of the Prostate Gland, Lon- don, 1 85 1, quoted by Hodgson, loc. cit,, p. 6. 2. Albarran: Presse Medicale, 1902, No. 42, 17-24 mai. 3. Albarran and Hall£: Annales des Malad. des Org. Gen.-Urin., 1900, xviii, 113. 4. Alexander: N. Y. Med. Jour., 1896, lxiii, 171. 5. " Trans. N. Y. Acad. Med., Dec. 15, 1898. 6. Amussat: Lecons sur les Retentions d'Urine et sur les maladies de la prostate. Paris, 1832, p. 218. 7. Annandale: Trans. Amer. Surg. Assoc, 1888, vi, 373. 8. Armstrong: Phila. Med. Jour., Dec. 27, 1902. 9. Ashhurst: Principles and Practice of Surgery, Phila., 1893, 6th ed., p. 1026, footnote. 10. " Phila. Med. Times, Dec. 2, 1882. 11. Atkinson: Brit. Med. Jour., 1888, i, 908. 12. 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Physick: see Dorsey's Surgery, loc. cit. 194. Poncet and Delore: Traite de la Cystostomie Sus-Pubienne chez les Prostatiques. Paris, 1899. 195. Pousson: Bull, et Mem. de la Soc. de Chir. de Paris, 1904, xxx, 621. 196. Proust: Manuel de la Prostatectomie Perineale pour Hypertrophic Paris, 1903. 197. Ramm: Centralbl. f. Chir., 1893, No. 35, S. 759. 198. Remete: Wiener klin. Rundschau, 1903, xxviii, 3. 199. Richardson, W. G.: Development and Anatomy of the Prostate Gland. London, 1904. 200. Riolanus, Joannes, filius: Opera Anatomica, Lutetiae Parisiorum, 1649, f- I 5 I et 1 ^7- 201. Roberts: Brit. Med. Jour., 1902, i, 769. 2oi#.Rosenstein: Deutsch. med. Woch., 1904, xxx, No. 36, S. 1309. 202. Rossetus, Franciscus: 'TZTEPOTO MOTOR IA1 (id est) Csesarei Partus Assertio Historologica, Parisiis 1590, Tertia Tractatiuncula, f. 263. 203. Rydygier: Centralbl. f. Chir., 1902, xxix, No. 41, S. 1057. 204. Santorini, Jo. Domini cus: Observationes Anatomical, Venetiis 1724. Cap. x, Sect, v, f. 181. 205. " " Ibid., loc. cit., Sect, xix, f. 199, seq. 206. Schlagintweit : Centralbl. f. d. Krankh. d. Harn-u. Sexualorg., 1901, xh, 73- 207. Schmidt, Benno: quoted by Moullin, Brit. Med. Jour., 1892, i, 1294. 208. " " Munch, med. Woch., Feb., 1889. 209. Senn: Jour. Amer. Med. Assoc, 1903, ii, 414. 210. " Practical Surgery, Philadelphia, 1902. 211. Simpson, Sir J. Y.: Anaesthesia, Hospitalism, etc. N. Y., 1872, p. 509. 212. Socin and Burckhardt: Die Verletzungen und Krankheiten der Pro- stata, Stuttgart, 1902. 213. Spanton: Lancet, 1882, i, 1032. 214. Ssnitzin: Lyon Med., 1894, Tom. 76, p. 132; also Deriuschinski: Cen- tralbl. f. Chirurg., 1896, xxiii, 898; cf. Centralbl. f. d. Krankh. d. Bibliography. 251 Harn-u. Sexualorg., 1897, viii, 693; see also Derujinsky: Annales des Malad. des Org. Genito-urin., 1897, xv, 848. 215. Steinach: see American Textbook of Physiology, 1896, p. 885. 216. Stern: Amer. Jour. Med. Sciences, 1903, cxxvi, 277. 217. Stoker: Brit. Med. Jour., 1904, i, 229. 218. Stricker: Human and Comparative Histology. Translation of New Sydenham Soc, London, 1872, vol. ii, p. 300. 219. Syms: N. Y. Med. Record, 1901, ii, 35. 220. " Annals of Surgery, 1902, i, 468. 221. " Jour. American Med. Assoc, 1904, ii, 1378. 222. Taylor: Brit. Med Jour., 1902, i, 774. 223. Tenney: quoted by Watson, Annals of Surgery, 1904, i, 834. 224. Thompson, Sir Henry: Diseases of the Prostate. London, 1858. 225. " " Lancet, 1875, h 3- 226. Thorel: Beitrage z. klin. Chirurg., 1902, xxxvi, 630. 227. Thorndike: Bost. Med. and Surg. Jour., 1902, vol. 147, p. 233. 228. Tobin: Med. Press and Circular, London, 1890, ii, 571. 229. " Brit. Med. Jour., 1902, i, 774. 230. Trendelenburg: quoted by Moullin, Brit. Med. Jour., 1894, ii, 976. 231. Tupper: see Walker, N. Y. Med. Jour., April, 1895. 232. Velpeau: Treatise on the Diseases of the Breast. Translation of the Sydenham Soc, London, 1856, p. 287. 233. Yerhoogen: Centralbl. f. Chir., 1902, No. 50, S. 1296. 234. Vignard: see Guyon, loc cit., vol. i, p. 198. 235. Walker, George: Johns Hopkins Hosp. Bulletin, 1900, xi, 242. 236. Walker, J. W. T.: Practitioner, London, 1904, vol. 73, p. 239. 237. " " Brit. Med. Jour., 1904, i, 728. 238. " " Ibid., loc. cit., ii, 62. 239. Wallace: Brit. Med. Jour., 1902, i, 764. 240. " Ibid., Jan. 30 and May 21, 1904, p. 1187. 241. W t anless: Indian Med. Gazette, 1904, xxxix, 45, 82. 242. Watson, F. S.: The Operative Treatment of the Hypertrophied Pros- tate. Boston, 1888. 243. " " Annals of Surgery, 1889, ix, 1. 244. " " Ibid., 1904, i, 833. 252 Bibliography. 245. Watson, F. S.: Bost. Med. and Surg. Jour., 1895, ii, 154. 246. " " Ibid., 1904, i, 453. 247. White, J. Wm.: Trans. Amer. Surg. Assoc, 1893, xi, 167. 248. " " Ibid., 1895, xii, 130. 248a. " Annals of Surgery, Dec, 1904. 249. Whitehead: Brit. Med. Jour., 1889, i, 831. 250. Wiener: Jour. Amer. Med. Assoc, 1904, i, 1278. 251. Wiesinger: quoted by Poncet and Delore, loc cit., p. 203. 252. Wishard: N. Y. Med. Jour., Aug. 17, 1901. 253. " Jour. Cut. and Gen.-Urin. Dis., 1902, xx, 245. 254. Wistar: see Parrish, loc cit. 255. Wolf, Moreau-: see Cheron and Moreau-Wolf. 256. W t olef: Deutsche med. Woch., 1899, quoted by Socin and Burckhardt, loc. cit. 257. Wood, A. C: Annals of Surgery, 1900, xxxii, 309. 258. Woolsey: Jour. Cut. and Gen.-Urin. Dis,, 1895, xiii, 229. 259. Wossidlo: Centralbl. f. d. Krankh. d. Harn-u. Sexualorg., 1900, xi, 113. 260. Young, H. H.: Jour. Amer. Med. Assoc, Jan. 11, 1902, i. 261. " Ibid., 1903, ii, 999. 262. " Ibid., 1905, i, 337. 263. Zuckerkandl: Wien. med. Presse, 1889, xxx, 857, 902. INDEX OF NAMES. Adams, 18, 42 Albarran, 14, 15, 208, 213 Albarran and Halle, 65, 66, 116 Alexander, 15, 49 Annandale, 14 Armstrong, 211 Ashhurst, 14, 96, 205 Astruc, 3 Atkinson, 11 Bangs, 6, 179 Barling, 14, 208 Baudet, 14 Bazy, 153 Belfield, 6, 11, 120, 211 Bier, 17 Billroth, 3, 14, 46 Blizzard, 4, 5 Boeckmann, 16 Bottini, 6, 188 Bouffleur, 6, 182 Braun, 10 Brodie, 2 Brooks, 65, 66, 69, 70, 90 Brown, Buckstone, 11 Bryson, 14, 15 Buckstone Brown (see Brown). Burckhardt, 18, 123, 135, 178, 179, 184, 185, 194, 195, 196, 205, 210 Cabot, 79, 100, 159, 163, 196 Cheron and Moreau-Wolf, 10 Chetwood, 116 Chismore, 161 Chopart, 2, 3, 4 Ciechanowski, 28, 47, 62, 65, 68, 89, 90 Civiale, 5, 13 Conner, 84 Coulson, 18 Covillard, 4 Crandon, 65, 68, 90 Cuneo and Veau, 25 Czerny, 178, 182 Daniel, 65, 67 Deaver, 208 Delore, 9, 18, 169 Demarquay, 14 Denonvilliers, 31 Derjuschinsky, 18, 196 Desault, 4, 47 Dittel, 9, 10, 11, 14, 15, 86, 157 Dodeuil, 49 Dorsey, 7 Edebohls, 163 Edwards, Swinford, 9 Englisch, 196 d'Etiolles, Leroy (see Leroy). Fen wick, 32, 33 Ferguson, 14, 208 Fergusson, Sir Wm., 5 Finney, 179 Freudenberg, 6, 178, 179, 182, 183, 185, 186, 189 Freyer, 11, 13, 14, 18, 41, 57, 64, 135, 144, 201, 203, 205, 208, 211 v. Frisch, 182, 183, 185 Fuller, 11, 16, 211 Furbringer, 42 Galen, 2 Gant, 18 Goldman, 53 Goodfellow, 14, 206, 208, 213, 219, 231 Gouley, 4, 5, 6, 10, 13 Greene and Brooks, 65, 66, 69, 70, 90 Griffiths, 17, 22, 24, 27, 34, 49 Guiteras, 16 Guthrie, 5, 22 Guyon, 17, 18, 46, 53, 130, 142 Halle, 65, 66, 116 Haller, 42 Harrison, R., 4, 10, 13, 14, 18, 45, 47, 53, 76, 88, 118, 140, 163, 205 Heine, 10 Henle, 43 Herophilus, 2 Herring, 65 253 254 Index of Names. Hey, 7 Hodernus, Bjorn, 169 Hodgson, 18, 21, 34, 46, 88, 90 Home, 1, 2, 18, 23, 24, 47 Horwitz, O., 6, 169, 179, 208, 211 Humphrey, 86 Hunter, John, 2, 17, 23, 27, 42 Iversen, 10 Keyes, 11, 72, 161, 178, 180 Keyes, Jr., 6 KSnig, 18, 178, 182 Krynski, 53 Kiichler, 14 Klimmel, 1 1 Laeaye, 3 Lagoutte, 169 Langenbeck, 10, 14 Launois, 17 Leisrink, 14 Leroy d'Etiolles, 3, 5, 13, 18, 130 Leuckhart, 21 Loumeau, 28, 208 Lydston, 87, 88, 118 Macewen, 89 MacGowan, 209, 211 Mansell Moullin (see Moullin). Massa, Nicolo, 2 McGill, 11, 86, 202, 207 McGuire, H., 9, 86, 167, 169, 171, 172, 173 McRae, 208 Mears, 17 Merrier, 3, 5, 6, 13, 47 Meyer, Willy, 6, 17, 161, 170, 179, 182, 183, 185 Moore, J. E., 14, 202 Moreau-Wolf, 10 Morgagni, 23, 42 Morris, H., 14 Morris, R. T., 9 Morton, 209 Moses, 89, 198 Motz, 65 Moullin, 17, 18, 25, 27, 44, 49, 64, 76, 86, 93> . I2 5> !3 2 > 134, i9 6 > J 97> 211, 213 Moynihan, 14, 208 Mudd, 86 Murphy, 14, 16, 209 Nicoll, 15 Owen, 25, 27 Paget, Sir J., 46, 94 Paget, Thomas, 8 Parrish, 8 Perassi, 53 Petit, 14, 18 Pettigrew, 35 Physick, 3, 7 Pisani, 178 Poncet and Delore, 9, 18, 169 Proust, 14, 15, 16, 18, 38, 207, 213, 218, 230, 232, 240 Ramm, 16 Remete, 89 Richardson, W. G., 22, 26, 207, 227 Riolanus, 2, 13 Roberts, 13 Rosenstein, 190 Rossetus, 7 Roth, 178 Rouchaud, 18 Rydygier, 182 Santorini, 31, 39 Schafer, 27 Schlagintweit, 190 Schmidt, Benno, 11 Schultz, 84 Senn, 14, 135, 141, 202 Simpson, Sir J. Y., 21 Socin, 154 Socin and Burckhardt, 18, 123 Spanton, 14 Ssnitzin, 17 Steinach, 42 Stern, 43 Stockmann, 185 Stoker, 208 Strieker, 25 Syms, 14, 16, 209, 213 Taylor, 12 Thompson, Sir H., 4, 8, 9, 18, 24, 46, 86 Thorel, 24 Thorndike, 211 Tobin, 11, 87, 198 Trendelenburg, 11 Tupper, 16 Veau, 25 Velpeau, 46, 53 Verhoogen, 178, 209 Vignard, 18, 75 Virchow, 21 Index of Names. 255 Walker, Geo., 36, 68 Walker, J. W. T., 13, 225 Wallace, 12, 35 Wanless, 85, 87, 208 Watson, 6, 11, 14, 18, 152, 163, 169, 178, 179, 184, 202, 210, 212 White, J. Wm, 16, 87, 196 Whitehead, 10 Wiener, 208, 219 Wiesinger, 169 Wishard, 6, 85 Wistar, 8 Wolf, Moreau-, 10 Wolff, 133, 135 Wood, A. C, 17, 196 Wossidlo, 185, 190 Young, H. H., 6, 14, 15, 16, 42, 161, 179, 181, 182, 183, 190, 194, 207, 209, 213, 230, 236 ZUCKERKANDL, I 4 INDEX. Abscess, prostatic, 67 differential diagnosis of, 116 Accessory lobe, 24 prostates, 24, 62 pudic artery, 33 Acini, prostatic, 34 histology of, 36 Acute complete retention of urine, 142 Etiology, 46 After-treatment, Bottini operation, 194 perineal prostatectomy, 235, 237, 241 suprapubic prostatectomy, 228 Age as a cause, 85 Air-distention of bladder, 170 in Bottini operation, 190 Alexander's operation, 15 Alkaline urine, 80 Allantois, 20 Ammoniacal decomposition of urine, 80 Ampullae of vasa deferentia, 41 Anaesthetic, 218 Anal fascia, 31 Anatomy, 20 applied, 37 comparative, 25 gross, 28 microscopical, 34 surgical, 37 Anorexia as symptom, 98, 106 Anus, prolapse of, causes of, 82 as symptom, 98 Aponeurosis of Denonvilliers, 24, 25, 31, 38 Appetite, loss of, 98, 106 Applied anatomy of prostate, 37 Arteries, ligation of internal iliac, 1 7 of prostate, 33 Arteriosclerosis as cause, 91 Artery, accessory pudic, 33 vesico-prostatic, ^^ Artificial urethra, 9 Aspiration of bladder for acute retention, 157 for retention with overflow, 160 Atony of bladder, 78 differential diagnosis of, 113 prevention of, 143 treatment of, 157, 159 Atrophy of prostate, differential diagnosis of, 116 Axis of prostate, 30 18 Bacillus coli communis in urine, 80 Backward pressure on kidneys, 79 Bacteria in cystitis, 81 Bar at neck of bladder, 5, 77 Batrachians, prostate in, 25 Bibliography, 243 Bi-coude catheters, 130 Bier's operation, 17 Birds, prostate absent in, 25 Bladder, aspiration of, 157, 160 atony of, 78 differential diagnosis of, 113 prevention of, 143 treatment of, 157, 159 bar at neck of, 5, 77 changes in, 76 continuous irrigation of, after prosta- tectomy, 238 contracted, 78 dilatation of, 78 dilation of, for cystitis, 150 distended, as symptom, 100 distention of, with air, 170, 190 drainage of, for cystitis, 151 for surgical kidneys, 163 examination of, with catheter, 103 external sphincter of, 44 gradual distention of for cystitis, 150 haemorrhage into, prevention of, 145 treatment of, 161 in cystitis, 78 infected, 78 irrigation of, 148 continuous, after prostatectomy, 238 ligaments of, 38 macroscopical changes in, 77, 78 microscopical changes in, 65 paralysis of, differential diagnosis of, 114 polypi of, differential diagnosis of, 115 pouches of, 78 puncture of, 7, 157, 160 sclerosis of neck of, 116 stone in, as symptom, 98 differential diagnosis of, 114 urethral orifice, shape of, 76 Bleeding in suprapubic prostatectomy, 225 Blood, examination of, 107 257 2 5 8 Index. Blood in bladder, 81 in urine, as symptom, 97 Bottini apparatus, description of, 188 operation, 176 accidents of, 181, 210 advantages of, 185 after-treatment, 194 causes of death after, 210 dangers in after-treatment, 183 history of, 6 incisions in prostate, 194 indications and contraindications, 186, 187 limitations of, 182 mortality of, 178 objections to, 179 results of, 184, 210 special requirements of, 179 statistics of, 178, 179, 210 technique of, 191 through perineal wound, 6 through suprapubic wound, 6 uncertainties of, 181 Bougies, Harrison's olivary, 4 Bryson's operation, 15 Bursa, recto-prostatic, 24 Calcareous deposits in bladder, 80 Calculus, vesical, differential diagnosis of, 114 frequency of, with enlarged pros- tate, 114 prevention of, 144 symptom of enlarged prostate, 98 treatment of, 161 Capsule of prostate, 29, 35 Caput gallinaginis, 29, 37 Carcinoma of prostate, differential diag- nosis of, 116 Carcinomatous changes in prostate, 66 Cardiac dilatation, 107 hypertrophy, 106 symptoms, 98 Carnosities at neck of bladder, 1 Castration, 195 before puberty, 88 effects of, on prostate, 88, 89 due to physiological rest, 89 for persistent sexual desires, 87 history of, 16 in dogs, 28 mania after, 197 Casts in urine, 106 Catheterism, 128 expectation of life in, 1 18 Catheterization, continuous, 7, 151 forced, 3 frequency of, 139 in overflow from retention, 100 Catheters, 128 bi-coude, 130 care of, 132 by patient, 134 cases for carrying, 135 choice of, 135 coude, 7, 130 double-elbowed, 130 elbowed, 7, 130 English, 129 in-lying, 151 intravesical examination with, 103 Leroy's, 130 lubricant for, 135 Mercier's, 130 metallic, 131 method of passing, 135 Nelaton's, 129 permanent drainage by, 151 prostatic, 131 silver, 131 soft rubber, 129 sterilization of, 132 varieties of, 128 webbed, 129 Causes, 46 adenomyomatous changes, 46, 49 age, 85 arteriosclerosis, general, 46, 49, 91 clinical, 84 compensatory hypertrophy, 46, 49 gonorrhoea, 90 habits, 87 high living, 87 inflammation, 49, 65, 90 nationality, 84 occupation, 86 previous diseases, 90 race, 84 sexual intercourse, 87 strictures of urethra, 90 Cervix uteri enlargement of prostate, 76, 77 China, enlargement of prostate in, 85 Chloroform preferred to ether, 219 Clinical causes, 84 pathology, 72 stages of enlargement of prostate, 98 Cock's operation for retention with over- flow with strictures, 161 Coitus, painful, as symptom, 98 Colon bacillus in urine, 80 Coma as symptom of uraemia, 98 Combined examination by bladder and rectum, 103, 104 operations, 15 Commissures, prostatic, 34 Comparative anatomy, 25 pathology, 28 Index. 259 Compensatory hypertrophy, 45 Complications, prevention of, 140 treatment of, 147 Compression of prostate, systematic, 3, 140 Concretions, prostatic, 43, 68 Conservatism in operating, 204 Conservative perineal prostatectomy, 236 Constipation as symptom, 98 Constitutional treatment, 121 Constrictor urethrae, 40, 44 Contents, table of, ix Continuous catheterization, 7, 151 Convulsions as symptom of uraemia, 98 Cord, genital, 22 Coude catheter, 7, 130 Cryptorchidism, 88 Curve of catheter, 131 increased by partially withdraw- ing stylet, 7, 138 Cystic prostate, 6j clinical history, 56 Plates XXXV, XXXVI, XL VII Cystitis, cystotomy for, 153 differential diagnosis of, 114 drainage of bladder for, 151 pathology of, 78 prevention of, 140 symptom of enlarged prostate, 96 treatment of, 147 urine in, 80 Cystoscope in diagnosis, no Cystotomy for acute retention, 157 for cystitis, 153 for retention with overflow, 160 history of, 7 Death, causes of, after operation, 210 Defalcation in enlarged prostate, 82 Denonvilliers, aponeurosis of, 24, 25, 31, 38 DePezzer's prostatic tractor, 233 Depressor, Ferguson's prostatic, 238 Descent of vesical floor, 76 Diagnosis, 108 catheterization in, 10 1 cystoscopic, no differential, 112 of fibrous prostate, 112 of glandular prostate, in principles of, 108 Dietetic treatment, 124 Differential diagnosis, 112 in presence of urethral strictures, 113 of abscess of prostate, 116 of atony of bladder, 113 of atrophy of prostate, 116 of calculus, vesical, 114 of cystitis, 114 Differential diagnosis of malignant disease of prostate, 116 of paralysis of bladder, 114 of polypi of bladder, 115 of prostatic abscess, 116 of prostatitis, 115 of sclerosis of neck of bladder, 116 of tuberculosis of bladder, 115 Digital divulsion of prostate, 10, 175 Diseases, previous, as cause, 90 Distended bladder as symptom, 100 Distention of bladder in Bottini operation, 190 Dittel's incision, 15 Plate CI operation, 15 Division of bar at neck of bladder, 5 Divulsion of prostate, digital, 10, 175 Dog, castration in, 28 prostatic enlargement in, 28, 198 urethritis in, 28 Dorsal vein of penis, 32, 38 Plate XII Double-elbowed catheters, 130 Drainage after suprapubic prostatectomy, 226 Plate LXXXIII of bladder for cystitis, 151 for surgical kidneys, 163 Dropsy as symptom, 98 Drugs in treatment, 125 Duck -mole, 27 Ducts, prostatic, 29 histology of, 35 _ Dyspnoea from cardiac failure, 106 symptom of uraemia, 97 ECCLESIASTES, Book of, I Edebohls's operation, 163 Effects on bladder, 76 on kidneys, 79 on rectum, 82 on ureters, 79 on urethra, 72 on urination, 81 Ejaculatory ducts, 29, 41 ligation of, 234 preservation of, 214 Elastic compression of prostate, 3 tissue in prostate, 36 Elbowed catheter, 7, 130 Electricity, 10 Embryology, 20 Enemata, 126 Ergotine, subcutaneous use of, 10 Espace decollable retroprostatique, 38 Ether, chloroform preferred to, 218 260 Index. Examination, combined intravesical and rectal, 103 Plate LIX physical, 100 general, 105 Excrescences at neck of bladder, 1 Fascia, anal, 31 obturator, 30 pelvic, 30 rectovesical, 31 Plates XIII. transversalis, 30 Female, prostate in, 21 Ferguson's prostatic depressor, 238 Plate XCVIII Fever, urinary, prevention of, 141 Fibroblasts, 68 Fibrous overgrowth, 49 causes of, 69 prostate, clinical history of, 50, 54, 55 diagnosis of, 112 Plates XXXI, XXXIII, XXXIV Fishes, prostate in, 25 Fistula, urachal, 9 urinary, history of, 8, 9 treatment by, 166 Flatulency, 106 Foetus, prostate in, 22 Plate VII Food in treatment, 124 Forced catheterization, 3 Frequency of enlargement of prostate, 86 Freudenberg's instruments, 6, 190 Plate LXXII Freyer's and McGill's operations com- pared, 212 Freyer's operation, failure of, 201 history of, 11 statistics of, 208 Fuller's operation, 16 Function of prostate, 42 Galvanocaustic prostatotomy, 6, 176 Genital cord, 22 "Glandulae prostatas, " 23 Glandular overgrowth, 49 causes of, 69 prostate, clinical history of, 48 diagnosis of, 11 1 Plates XXIX, XXX tissue of prostate, histology of, 34 Goat, genitalia of, 26 Plate IX Gonorrhoea as cause, 90 Goodfellow's operation, technique of, 231 Gout as cause, 87 Gross anatomy of prostate, 28 Growth, rate of, 63 Guiteras's operation, 16 Habits as cause, 87 Habits, regulation of, in treatment, 121, 122 Hematuria, symptom, 97 Haemoglobin, amount of, 107 Haemorrhage in suprapubic prostatectomy, 225 into bladder, prevention of, 145 treatment of, 161 secondary, 229 after Bottini operation, 183 Haemorrhoids, causes of, 82 Haemostasis after suprapubic prostatec- tomy, 226 Plate LXXXII Harrison's bougies, 4 Plate II operation, 10 Heart, disease of, 107 Heart-failure, symptom, 98 Hedgehogs, prostate in, 27 Henle's muscle, 43, 44 Hiccough, symptom, 97 High living, cause, 87 Histology of prostate, 34 enlarged, 65 History, 1 Hooks, Murphy's, 240 Plates C, CVII Hyena, genitalia of, 27 Plate X Hygienic treatment, 121 Hypertrophy, compensatory, of prostate, 45 Hypogastric tumor, 100 Incision of neck of bladder, 2 for suprapubic prostatectomy, 219 Plate LXXVI Incisions in Bottini operation, 194 Plates LXXIII, LXXIV, LXXV in perineal prostatectomy, 14 Plates LXXXV, XCIII, CI Incisionskystoskop, 190 Incontinence of urine, symptom, 95 India, enlargement of prostate in, 84 Indications for radical treatment, 200 Inflammation, cause, 65 previous, cause, 90 Injections of iodine, 10 Insects, prostate in, 25 Intermittent urination, symptom, 94 Index. 261 Internal iliac arteries, ligation of, 17 pudic artery, abnormality of, 33 Intravesical examination with catheter, 103 Iodine, parenchymatous injections of, 10 Irrigation of bladder, 148 continuous, 238 Plate XCVII Japan, enlargement of prostate in, 85 Kidneys, disease of, as a symptom, 97 effects of enlargement of prostate on, examination for disease of, 106 surgical, 80 prevention of, 146 treatment of, 162 Laxatives, 126 Length of urethra in enlargement of pros- tate, 72 Leroy's catheter, 130 Levator ani, 30, 31, 39 Plates XIII, XVI, XVIII, XXI, XXVII prostatas, 31, 39 Ligaments, puboprostatic, 31, 38 Plate XV Ligation of iliac arteries, 1 7 Lip-formation at vesical orifice of urethra, 62 Literature, 1, 18 Litholapaxy for calculus with enlargement of prostate, 161 Lithotomy and prostatectomy, combined, mortality of, 210 for calculus with enlargement of prostate, 161 Lobe, accessory, 24 ducts of median, 30 "median," 23 enlargement of, 61, 62 removal of, 205 Lobes of prostate, 30 Loss of sexual power, symptom, 98 Lubricant for catheters, 35 Lymphatics of prostate, 34 Lymph-nodes of prostate, 36 Walker's, 68 Malignant changes in prostate, 66 disease of prostate, differential diagno- sis of, 116 Mammals, prostate in, 25 Mania after castration, 197 McGill's operation, 11 statistics of, 211 compared with Freyer's, 212 McGuire's obturator, 173 Plate LXVI operation, 9, 169 statistics of, 169 Meatotomy, 137 Median lobe, 23 ducts of, 30 enlargement of, 57 Plates, I, XLIII, XLIV, LII removal of, 205 Mercier's catheter, 7, 130 Plate LXI operation, 5 prostatectome and prostatotome, 5 Plate III Metallic catheters, 131 Plate LXI Microscopical anatomy, 34 Middle lobe (see Median). Moles, prostate in, 27 Morcellement, prostatectomy by, 202, 240 Mortality of Bottini operation, 178 of McGuire's operation, 169 of prostatectomy, 208 Mullerian ducts, 20 Murphy's hooks, 16, 240 Plates C, CVII Muscular tissue of prostate, 34 Neck of bladder, bar at, 5, 77 Plate LV elevation of, 76 Plate L Negroes, enlargement of prostate in, Nephritis, prevention of, 146 treatment of, 162 urine in, 81 Nerves of prostate, 33 Ni coil's operation, 15 Nocturnal frequency of urination, 93 Objective symptoms, 100 Obstipation as symptom, 98 Obturator fascia, 30 for suprapubic fistula, 173 Plate LXVI Occupation as cause, 86 (Edema of extremities, 106 of prostate, 77 Old age, its influence on enlargement of prostate, 86 Olivary bougies, 4 Plate II Operation, accidents of, 210 262 Index. Operation, Alexander's, 15 Bangs's, 6 Bier's, 17 Bottini's, 6, 176 Bouffleur's, 6 Bryson's, 15 choice of, 200 combined, 15 Edebohls's, 163 Freyer's, 11, 219 Fuller's, 16 Guiteras's, 16 Harrison's, 10 Keyes's, 6 McGilFs, 11 Mercier's, 5 Nicoll's, 15 Thompson's, 8 Watson's, 6 Wishard's, 6 Operations, technique of, 215 Orchidectomy, 196 unilateral, 197 Orchitis, prevention of, 146 treatment of, 161 Ornithorhyncus, 27 Overflow from retention, catheterization in, 100 symptom, 95 treatment of, 159 Overstrain, prostatic, 87 Owens's perineal tube, 176 Plate LXX Paralysis of bladder, differential diag- nosis of, 114 Parenchymatous injections of iodine, 10 Partial perineal prostatectomy, 238 Pathological histology, changes in glandular tissue, 66 in stroma, 68 Pathology, 46 clinical, 72 comparative, 28 density of prostate, 63 duration of symptoms in fibrous and glandular varieties, 49, 50 fibrous enlargement, 49 glandular enlargement, 49 histology, 65 inflammation as cause, 65 microscopy, 65 physical characters of enlarged pros- tate, 62 round-celled infiltration, 68 size and direction of growth, 53 suppuration of prostate, 67 theories as to cause, 53 Pathology, weight, 53, 57 Pelvic fascia, 30 Penis, amputation of, its effect on prostate, 90 dorsal vein of, 32, 38 Perineal fistula, history, 9 treatment by, 174 operations, history, 4 prostatectomy, conservative, 236 history, 14 in dogs, 28 statistics of, 208 prostatotomy, 4, 5, 174 puncture, 7 Plate V section for retention with overflow and impassable strictures, 160 tubes, 176 Plate LXX Perineum, anatomy of, 39, 40 Plates XXIII, XXIV, XXV, XXVI, XXVII, XXVIII Peritoneum, relations of, to bladder, 41 Plate XXII Phleboliths in prostatic plexus, 32, 82 Physical examination, 100 Physiology, 42 Piles in enlargement of prostate, 82 Plates, description of the, xi Polypi of bladder, differential diagnosis of, US Postprostatic pouch, 76 Plate L Pouches of bladder, 78 Preface, vii Preparation of patient for operation, 215 Pressure, backward, on kidneys, 79 Previous diseases as cause, 90 Priapism, symptom, 98 Prognosis, 117 expectation of life in catheterism, 118 mortality of various forms of treat- ment, 118, 119 Prolapsus ani, causes of, 82 symptom, 98 Prostate, abscess of, differential diagnosis of, 116 accessory, 24 acini of, 34 histology of, 36 arteries of, ^^ at birth, 23 at puberty, 43 atrophy of, after castration, 197 differential diagnosis of, 116 axis of, 30 capsule of, 29, 35 cervix uteri enlargement of, 76, 77 commissures of, 34 Index. 263 Prostate, compensatory hypertrophy of, 45 digital divulsion of, 10, 175 ducts of, 29 histology of, 36 elastic tissue in, 36 enlarged, abscesses in, 67 clinical stages in, 98 cystic, 67 clinical history, 56 Plates XXXV, XXXVI, XLVII diagnosis of fibrous and glandular forms, in frequency of, 86 growth, direction of, 57 rate of, 63 in dog, 198 intravesical portion, 64 lip-formation, 62 malignant changes in, 66 "median lobe" of, 57 physical characters, 62 prostatic "tumors," 63 size of, 53 stages of, 51 suppuration of, 67 urethra in, 72, 74 varieties of, 49 weight of, 53 first use of term, 2 function of, 42 in birds, absent, 25 in female, 21 in foetus, 22 in monkey, 2 in old age, 44 in sexual excitement, 43 in urination, 44 lobes of, 30 lymphatics of, 34 lymph-nodes in, ^6, 68 nerves of, ^^ oedema of, 77 plexus of, 32 relation of testicles to, 88 shape of, 28 sheath of, 29, 30 sinuses of, 29 size of, 28 stroma of, 29 structure of, 28 veins of, 32 weight of, 28 Prostatectome, 5 Prostatectomy in dogs, 28 partial, indications for, 204 perineal, accidents of, 210 after-treatment of, 235, 237, 241 causes of death after, 210 Prostatectomy, perineal, history of, 14 partial, 238 results of, 210 statistics of, 208 technique of, 230 suprapubic, accidents of, 210 advantages of, 206 after-treatment of, 228 causes of death after, 210 history of, 11 partial, 204 results of, 210 statistics of, 208, 211 strictures after Freyer's operation of, 229 technique of, 219 Prostatic atrophy, differential diagnosis of, 116 concretions, 43 in pathological histology, 67 depressor, Ferguson's, Plate XCVIII fluid, 42 overstrain, 87 plexus, 32 tractor, DePezzer's, 16, 233 Syms's, 16, 239 Plates, XCVIII, XCIX Young's, 16, 237 Plates XCIV, XCV, XCVI tumors, 63, 67 urethra, anatomy of, 29 histology of, 36 utricle (See Uterus masculinus). Prostatitis, differential diagnosis of, 115 Prostatotome, 5 Prostatotomy, galvanocaustic, 6, 176 perineal, 4, 5 technique of, 174 urethral, 5 Proust's operation, technique of, 232 Puberty, castration, before, 88 prostate at, 43 Pubo-prostatic ligaments, 31, 38 muscles, 39 Puncture of bladder, 7, 157, 160 Purges, 126 Pyelitis, 80 Race as a cause, 84 Radical treatment, indications for, 200 Rectal puncture, 7 Recto-prostatic aponeurosis (See Aponeu- rosis o) Denonvilliers). Recto-urethral muscle, 40, 233 Recto-vesical fascia, 31 Rectum, effects on, 82 Renal complications, prevention of, 146 treatment of, 162 failure, symptom, 97 264 Index. Resection of floor of urethra, 234, 240 Residual urine, 76, 80 amount of, 101, 103 prevention of, 143 treatment of, 158 Results of operation, 210 Retention of urine after Bottini operation, 183 catheterization in, 100 causes of, 81, 82 prevention of, 141 symptom of enlarged prostate, 95 treatment of, 154 varieties of, 141 acute complete, 142 treatment of, 154 chronic complete, 143 treatment of, 157 incomplete, 143 with overflow, prevention of, 143 treatment of, 159 Retzius, space of, 31 urinary extravasation into, 221 Round-celled infiltration of prostate, 68 Santorini, plexus of, 32 Sarcoma of prostate, differential diagnosis of, 116 Sclerosis of neck of bladder, 116 Secondary haemorrhage after Bottini oper- ation, 183 after prostatectomy, 229 Senn's sigmoid catheter, 173 Plates LXVII, LXIX Sexual excitement, prostate during, 43 intercourse, overindulgence in, as cause, 87 power, loss of, as symptom, 98 Shape of normal prostate, 28 Sheath of prostate, 29, 30 Shoes, incrustation of, 94 Silver catheters, 131 Sinus, prostatic, 29 urogenital, 21 Size of normal prostate, 28 Somnolence as symptom of uraemia, 98 Sphincter ani, 39, 40 Stages, clinical, of enlargement of prostate, 98 Stammering in micturition, 81 Statistics of Bottini's operation, 178, 179, 210 of Freyer's operation, 208 of McGilPs operation, 211 of perineal prostatectomy, 208 Stevenson's tube, for suprapubic fistula, 173 Plates LXVI, LXVIII Stone in bladder, prevention of, 144 symptom of enlarged prostate, 98 treatment of, 161 Strictures of urethra after suprapubic prostatectomy, 229 as cause, 90 diagnosis in presence of, 113 Stroma of prostate, 29 Structure of prostate, 28 Subpubic urethra, curve of, 131 Suprapubic cystotomy, history of, 7 drainage-tubes, 173 fistula, history of, 8 treatment by, 166 prostatectomy, advantages of, 206 history of, 11 in dogs, 28 technique of, 219 puncture, 7, 157, 160 Surgical anatomy of prostate, 37 kidneys, 80 prevention of, 146 treatment of, 162 Symptoms, anorexia, 98, 106 bloody urine, 97 calculus, 98 cardiac, 98 coma, 98 constipation, 98 convulsions, 98 cystitis, 96 distended bladder, 100 dribbling of urine, 94 dropsy, 98 dyspnoea, 97 frequency of urination, 92 haematuria, 97 haemorrhoids, 98 heart failure, 98 hiccough, 97 incontinence of urine, 95 kidney breakdown, 97 loss of sexual power, 98 objective, 100 obstipation, 98 overflow from retention, 95 painful coitus, 98 priapism, 98 renal failure, 97 retention of urine, 95 sequence of, 108 somnolence, 98 starting stream, 94 subjective, 92 uraemia, 97 vertical dropping of urine, 94 vomiting, 97 Syms's prostatic tractor, 16, 239 Plates XCVIII, XCIX Index. 265 Tapping the bladder, 7, 153, 156, 160 Technique, operative, 215 Goodfellow's operation, 231 perineal prostatectomy, 231, 238 Proust's operation, 232 suprapubic prostatectomy, 219 Young's operation, 236 Testicles, internal secretion of, 88 relation of, to prostate, 88 Thompson's instruments, Plate IV operation, 8 Tractor, prostatic, DePezzer's, 16, 233 Syms's, 16, 239 Plates XCVIII, XCIX Young's, 16, 237 Plates XCIV, XCV, XCVI Transversalis fascia, 30 Transverse perineal muscles, 39 Treatment, 121 after perineal prostatectomy, 235, 237, 241 after suprapubic prostatectomy, 228 by Bottini operation, 176 castration in, 195 catheterism in, 128 constitutional, 121 dietetic, 124 drugs in, 125 hygienic, 121 local palliative, 166 of complications, 147 of retention of urine, 154 prostatectomy, 200 radical, indications for, 200 ventrosuspension of bladder, 53 Trendelenburg position, 219 Triangular ligament of perineum, 38, 39 Tuberculosis, vesical, differential diagnosis of, 115 Tumors, prostatic, 63 formation of, 67 Tunneling the prostate, 2, 3 Plate I Turkey, enlargement of prostate in natives of, 85 Urachal fistulae, 9 Uraea, quantity of, 106 Uraemia, prevention of, 146 symptom of enlargement of prostate, 97 treatment of, 162 after operation, 230 Ureters, changes in, 79 Plate LVIII embryology of, 2 1 muscles of, 45 surgical relations of, 41 Urethra, artificial, 9, 169 changes in, 72 curve of, in enlargement of prostate, 74 direction of, in enlargement of prostate, 74 grooving anterior surface of prostate, 23> 30 length of, 40 prostatic, 29 histology of, 36 resection of floor of, 234, 240 suture of, after Proust's operation, 23S Y-shaped, 74, 77 Urethral orifice, elevation, of, 74 shape of, 76 Urethral prostatotomy, 5 Urethritis, as cause, 90 in dog, 28 Urinalysis, 106 Urinary extravasation, 221 fever, prevention of, 141 treatment of, 162 fistula, history of, 8 treatment by, 166 retention, causes of, 81, 82 prevention of, 141 symptom of enlargement of pros- tate, 95 treatment of, 154 varieties, 141 Urination, difficulty in starting, 94 effects on, 81 frequency of, 92 in knee-chest position, 123 intermittent, 94 nocturnal, 93 prostate during, 44 Urine, acid, drugs for, 128 alkaline, 80 drugs for, 127 amount of, in prostatic urethra, 102 bloody, 80, 81 casts in, 106 changes in, 80 difficulty in starting stream, 94 dribbling of, 94 examination of, 106 in cystitis, 80 incontinence of, 95 medication for, 127 quantity of, secreted, 106 residual, 76, 80 prevention of, 143 treatment of, 154, 157 retention of (see Urinary retention) . specific gravity of, 106 vertical dropping of, 94 Urogenital sinus, 21 266 Index. Uterus masculinus, 29 embryology of, 21 histology of, 36 Uvula vesicae, 45 Valves in veins of prostatic plexus, 32 Varicose veins in prostatic plexus, 82 Vas deferens, ampulla of, 41 relation of developement of prostate to, 27 Vasectomy, 17, 89 Vein, dorsal, of penis, 32, 38 Veins of prostate, 32 Venous engorgement of pelvic structures, 82 Ventrosuspension of bladder, 53 Verumontanum, 29, 45 Vesical floor, descent of, 76 insufficiency, cause of, 65 Vesico-prostatic artery, ^ Vomiting as symptom, 97 Walker's lymph-nodes, 36 Watson's perineal tube, 176 Plate LXX Weight of normal prostate, 28 White line of pelvic fascia, 30 Wolffian bodies, 20 ducts, 20 Y-shaped urethra, 74, 77 Plate LII Young's instruments for Bottini operation, 6, 190 Plate LXXII operation of perineal prostatectomy, 236 Zuckerkandl's incision, 14 L&% v. ,HS R . ARY 0F CONGRESS Ifllllllill 021 067 587 5