the puncture through that bowel is an easy and safe mode of giving exit to the urine. 4. That if, on the contrary, fluctuation cannot be distinctly felt by the rectum, the puncture through the bowel is a proceeding of doubtful propriety; and the question of opening the bladder, either above or through the pubic symphysis, must be solved for the case in question. That the former operation may be regarded as somewhat less hazardous, when the patient is not corpulent, and vesical dulness can be clearly defined in or above the hypogastric region. Further, if the circumstances of the case indicate that the artificial opening may be required for a long period of time, the suprapubic puncture must be preferred as more safe and convenient than the rectal. 5. Lastly, that the experience of the operation of puncture through the pubic symphysis is not extended enough at present to permit of a comparison being made in regard to its results with other modes; but that it is sufficient, coupled with the apparent advantages derived from anatomical considerations, to recommend the operation to the test of practice, in order that its merits may be duly ascertained. CHAPTER XIII. ATROPHY OF THE PROSTATE. Pathological signification of Atrophy.-Kinds of.-From exhausting Disease.— Senile Atrophy, degree of.-Frequency of.-Nature. From Mechanical Pressure. From Local Disease in the Prostate.-Congenital Atrophy.-Symptoms and Treatment. By Atrophy of the Prostate is to be understood a diminution in the bulk and weight of the organ resulting from a gradual disappearance of some of its constituent structures. Regarding solely the results of this action, it may be considered as the converse of Hypertrophy. Senile Hypertrophy, however, in its popular signification as applied to the prostate, is not, strictly speaking, the converse of Atrophy, since the enlargement of the organ which occurs in the later periods of life is not the augmentation of structure due to increased function, analogous, for example, to the augmentation of a muscle by increased use, but is a process essentially morbid, having no conservative, or compensating design and action; e. g. hypertrophy of the heart for the purpose of overcoming the increased resistance offered by a calcified valve, &c. Atrophic change cannot, however, be regarded as resulting from any active pathological influences, exerted in the organ itself. It is a passive condition rather, and consists in simple wasting of the organ, in the gradual disappearance of elementary structures. What is the precise physiological action by which Atrophy is determined? Is it some active process of absorption removing the constructive elements of the prostate, in the same manner, but more rapidly, than that ordinary process, which results from the S effete tissues throughout the whole body, in order that they may be, as constantly and gradually, replaced by new material? I think not, but believe it to be rather the result of failing power on the part of the body to replace, by new material, the effete tissues removed by the natural process of absorption. It is not that the process of degradation is much more rapid, but that the powers of supply and re-formation are less vigorous than heretofore. When the resources of the body are inadequate to supply the plastic material and the formative power, in an equal ratio with the expenditure, general Atrophy must result. Nevertheless, there are undoubtedly various forms of Atrophy liable to affect the Prostate, which must be considered separately. I. The Atrophy of exhausting general disease. II. The Atrophy of old age. III. The Atrophy caused by pressure. IV. The Atrophy caused by disease in the prostate itself. The first is the Atrophy which occurs from exhausting constitutional disease, particularly in Phthisis. The extent to which Atrophic change occurs from this cause is sometimes very remarkable, as I have several times had opportunities of noting. I have recently had occasion to dissect a specimen from a man 21 years of age, who died of phthisis, in whom the organ weighs only 54 grains, or less than one drachm. It is not unlikely that from longcontinued disease in this case the sexual organs had not been so fully developed as would have been the case at this age in health. Another example is No. 151, from a man aged 78, who died of phthisis, the prostate weighed only 2 drs. 45 grs. In all cases of this kind there is very considerable wasting of all the structures of the body, and herein this form of atrophy often differs from the second form. But the proportion of diminution affecting the prostate appears to be larger than that suffered by most other organs in the body. There are other diseases in which the prostate becomes atrophied; all wasting diseases produce this condition to a greater or SENILE ATROPHY OF THE PROSTATE. 259 less extent, but in none is it so marked as in tubercular and scrofulous disease. A good example is seen in No. 150 of the table of preparations, the prostate of a man aged 90, who died exhausted by carbuncle; here the organ weighed 2 drs. 50 grs. Now in this form of atrophy all the tissues of the organ seem to be about equally affected: one component tissue does not seem to have been diminished in greater proportion than another, judging from the appearances presented on making sections in different parts of the organ. The second kind of Atrophy is that which occurs during old age. There is frequently a general diminution in weight and bulk of the solids as individuals advance in life beyond a certain age. A mere participation in this condition is not what is intended by Senile Atrophy. A prostate, which is the subject of this affection, is one in which the diminution is relatively greater than that which affects the rest of the body. It has been said, but it appears without sufficient foundation, that when hypertrophy of the prostate is not present in the aged, atrophy will always be found to exist. This, certainly, is not borne out by facts. Thus, by analysis of the table in Chapter II. we find no less than 50 individuals at and above the age of 70 years (70 to 94 years), whose prostates ranged in weight between 3 and 5 drachms, a great majority of them being between 4 and 5 drachms. These must be regarded, almost without exception, as cases in which neither hypertrophy nor atrophy could possibly be present. In none of them was there any sign of urinary derangement during life. The number of prostates in this condition is much larger, viz., upwards of 90, if all the individuals between 60 and 70 years are also reckoned; the latter age was chosen for this calculation to place beyond a doubt the statement that a normal condition of the prostate is common at very advanced ages. Among the 164 examples at and above 60 years, 11 only had prostates weighing less than 34 drachms. Organs weighing upwards of 3 and under 4 drachms cannot be considered the subjects of Senile atrophy from the mere fact of weight; some of them are certainly normal; but a knowledge of their structure and of the size of the individual, are data which it is necessary to possess, since, as in other organs, it is not the absolute weight, but, as just observed, that which is relative to the weight of the body, which must be known in order to decide the existence, or the degree, of atrophy present in a doubtful case. Accepting the number of undoubted examples of atrophy as 11, and deducting two as occurring in individuals who died of exhausting disease (phthisis and carbuncle), there remain nine, which may be classified here. Consequently on this calculation, senile atrophy occurs in rather more than 5 per cent. of individuals at and over 60 years of age; and with the wanting data supplied, it is probable that this percentage might be a little increased. This fact appears to have no practical bearing; nevertheless, possessing the materials, it is desirable to eliminate it, for it is not altogether without a scientific interest. Senile atrophy, that is the atrophy which has its origin, not in exhausting disease, but which occurs independently of it in some elderly subjects, is of a somewhat different character, histologically regarded, from the atrophy of exhausting disease. It has been seen that, in the latter, all the constituent tissues are about equally diminished, so far as dissection and careful comparison enable us to judge. In senile atrophy, on the other hand, the glandular tissue seems more diminished than the fibro-muscular stroma of the organ. This latter is often hard and tough, and may even have some small tumours of the same material existing in it. But the glandular element is in smaller proportion to the fibro-muscular or stromal than in the healthy organ. This form of atrophy is, perhaps, also less extreme in its degree than that of exhausting disease. While in the latter case we have seen an adult who died from phthisis, with a prostate weighing only 54 grains we have never seen a prostate affected by senile atrophy weighing less than two drachms and a few grains. The third form of Atrophy is that produced by mechanical pressure. No peculiarity can be affirmed to characterize this form of atrophy. It is that species of diminution, of disap |