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CASES OF PROSTATIC TUMOUR.

121

ENLARGEMENT

ILLUSTRATIVE CASES.

CASE No. III.

OF THE PROSTATE DUE TO ISOLATED FIBROUS TUMOURS; DISEASED AND SACCULATED BLadder.

J. P., aged 74, admitted to the Marylebone Infirmary, October 27, 1855, under the care of Mr. Henry Thompson. Two or three years past he has suffered with the ordinary symptoms of chronic cystitis. Now, there is much irritability of bladder; no retention or incontinence. No. 10 catheter passes with perfect ease. The bladder slowly empties itself of pus and mucus after urine is drawn off. No calculus. Urine thick, opaque, mixed with much pus, slightly acid on several occasions, albumen considerable, no renal casts or crystals.

Only a slight degree of enlargement of the prostate is recognizable from the rectum. Patient suffers very little pain, but is extremely weak, and appears to be gradually sinking. Death occurred on the 7th of November.

Post-mortem, six hours after death.-Bladder and part of urethra removed entire. The former is elongated, and projects upwards behind the pubic symphysis; the walls are thicker than natural. Projecting into the cavity, at its neck, is a lobulated tumour about the size of a small walnut, of yellowish colour and smooth aspect, contrasting strongly with the crimson hue and corrugated surface of the lining membrane of the bladder (Plate VIII., fig. 1). The cavity was contracted, and corresponded with about two-thirds only of the organ removed. The upper third proves to be a sac, opening by a very small orifice into the bladder proper, and an opening made into it gave exit to about an ounce of pus and mucus. The tumour springs from the prostate, which, though not enlarged towards the rectum, bulges into the urethra considerably, and also into the vesical cavity.

Both kidneys are diseased, and contain several small collections of pus, besides some ordinary cysts.

On cutting into the left side of the prostate (marked “left” in the drawing), the section of a rounded body embedded in the gland is seen. This body is four-tenths of an inch in diameter, is isolated

from the surrounding tissues, separable from them in places with a blunt probe, but in others closely adherent, or united by prolongations of tissue common to both. It is lighter in colour, and apparently denser in structure than the adjacent parts.

Several other bodies of a similar character are found corresponding with the protuberances seen in the prostate before making sections of it. Three of the largest of them are dissected out (Plate VIII., fig. 2). The mucous membrane was first divided over them and turned aside; then a few longitudinally disposed fibres, which in places peeled off from the rounded bodies like a capsule, but which at other times appeared to run into their substance, and to be continuous with it. One of these bodies, corresponding with a protuberance on the right side of the gland marked (a) in both drawings, is isolated in the preparation, and bands of fibres appear to unite it with the fibrous constituents of the gland behind. Small portions of tissue detached from any part of the bodies of which section has been made, exhibit under the microscope the elements of the organic muscular and connective tissues, closely packed in bands. Acetic acid developes a number of the rod-shaped nuclei lying longitudinally among the fibres.

An isolated mass of the true glandular elements of the prostate may be seen in one of the sections-that on the right side. It is obvious to the naked eye by exhibiting a yellower tint than the surrounding parts. Under the microscope it presents the ordinary glandular elements as well as some of the minute "concretions" so called, often seen in the prostates of elderly people. None of these structures are found in the rounded bodies before described.

A large proportion of the bulk of the organ is made up of a whitish, fibrous-looking tissue, which intervenes between masses of the gland-structure, almost surrounding and isolating them. This tissue, under the microscope, is seen to consist chiefly of the connective filaments, intermixed with organic muscular fibre. The rounded bodies are made up of the same elements, and are more distinctly connected with this tissue than with the glandular parts, and may be, therefore, considered good examples of the ordinary fibrous tumours of the prostate. In this specimen some are embedded in the mass of the organ; others protrude beyond its periphery into or towards the cavity of the bladder. They do not partake of the characters of the proper glandular structure, nor do they appear to have any close relations with it.

CASES OF PROSTATIC TUMOUR.

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CASE No. IV.

ENLARGEMENT OF THE PROSTATE: NUMEROUS TUMOURS: SEVERAL CALCULI IN THE BLADDER.

A gentleman, aged 65, who had experienced some difficulty in micturition about twenty years. Marked symptoms, amounting sometimes to retention, had existed about six years.

In the commencement of the year 1857 he came under the care of my friend Mr. Sampson, of Ipswich, who suspected the existence of calculus in addition to organic obstruction of some kind. In May I had an opportunity of examining the patient in consultation with that gentleman, and we were satisfied of the existence of very considerable prostatic enlargement; but the condition of the bladder was at that time too irritable to admit of any sounding or operative proceedings for stone. There was more or less retention of urine requiring daily instrumental relief, and there was a depressed condition of the vital powers. It is unnecessary for the present purpose to enter upon the details of the case.

Death from exhaustion took place at the end of June. At the post-mortem examination the prostate was found enormously enlarged, the anterior or pubic portion being that which exhibited by far the greatest increase in size; this portion formed an irregularly shaped nodular mass, about the size of a hen's egg, and contained numerous embedded tumours, each about the size of a kidney-bean. On examination I found these to be made up of fibrous material containing a considerable proportion of the glandular elements of the prostate. Nine small calculi were also found in the bladder, lying in a deep depression behind the enlarged prostate.

CHAPTER VII.

THE CAUSES OF HYPERTROPHY OF THE PROSTATE.

The Subject of Causes obscure.-Its Investigation extremely important.-Most Circumstances alleged to be Causes must be rejected as such.-Present Views Stated. Inflammation not a Cause-nor Stricture nor Calculus-nor Venous Stasis.-Gout, Rheumatism, and Syphilis not Causes.-Sexual Excess.-Prostatic Enlargement not Analogous to Glandular Hypertrophy, nor to Hypertrophy of other Muscular Organs depending on Increased Function.-Enlargement of Prostate and Uterus shown to be Identical in Nature and probably in Causation. Perhaps a Necessity of their Common Structure.-Ascertainable Conditions under which Enlargement occurs.-Analysis of Results arrived at in relation to Age.

NEXT in importance to the discovery of some unquestionably successful means for the cure of enlarged prostate, perhaps, indeed, equal to it, would be a recognition of those circumstances which stand in the relation of causes, remote and proximate, to this remarkable affection. While some authors acknowledge that a considerable degree of obscurity attaches to the subject, others do not hesitate to express decided opinions in reference to it, confidently enumerating many things which they conceive to be undoubted causes; and all appear to agree in reference to some few of these, or, at all events, as to the existence of a strong probability in favour of so regarding them. It appears to me, however, that in order to accept the etiological views of this affection which are at present current, a good deal must be taken for granted; and that if we require a fair amount of evidence before we admit into the category of causes the circumstances and conditions usually recognized, we shall probably reject them all, or very nearly so. However discouraging to the practitioner such a result may at first sight appear-however unsatisfactory such a confession of ignorance may be deemed by the student

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we may rely upon it, that, if it be a true one, it is the necessary and important preliminary step to a better state of knowledge on this subject. The admission of a single circumstance into the list of causes which cannot be sustained there by something better than a fanciful belief, conventional custom, or by, it may be, the "impression" or the " conviction" of an author, unsupported by testimony, must assuredly become a stumbling-block in our progress towards truth. Better were it to sacrifice the apparent completeness which often seems to be thought essential to a pathological treatise, if it can only be obtained by collecting all the suggestions and speculations that have ever been associated with the subject in the literature of the past; and rather to exercise-however much the literary character of the work may appear to suffer-a vigilance, lest we admit too much, than an anxiety to press into our service every line resembling a contribution, under the semblance of information on the subject. Nothing would be easier, on such a principle, than to swell this chapter into a volume, and for the simple reason that so little is known of its subject, so much conjectured. But that the reader may possess a sketch of the opinions of some of the most experienced authors in reference to it up to the present time, I will state them as briefly as possible by way of quotation, and then attempt to enter upon an independent examination for

ourselves.

John Hunter says nothing directly in relation to causes, but states that he has "seen hemlock of service in several cases. It was given upon a supposition of a scrofulous habit. On the same principle I have recommended sea-bathing," &c.* It should be remarked, however, that the distinction between the enlargement of the prostate in earlier years, usually consequent upon inflammation, especially gonorrhea, and the senile affection at present under consideration, was not then made. In the chapter quoted, these two widely differing conditions are spoken

A Treatise on the Venereal Disease. 2nd edit. London, 1788.

P. 174.

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