ATROPHY FROM LOCAL DISEASE, ETC.

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pearance of elementary constituents, which is observed in all the tissues of the body under the influence of continued mechanical pressure. Thus the prostate is sometimes observed to be very considerably diminished in weight and volume from the action of pressure exerted by adjacent tumours, which may have fluid contents, as abscess and hydatid; or by bony and other solid tumours; by calculi in the bladder or embedded in the prostate itself. Not unfrequently, also, from long-continued and extreme distension of the bladder with urine, and of the prostatic urethra itself, when very confirmed structure exists, a considerable pressure is sometimes exerted, which in like manner seems to result in marked atrophy of the prostate. In these cases the structures are sometimes thinned to a very considerable degree, the natural ducts and cavities are dilated, and nearly one-half of the organ, estimating it by weight, may disappear in the course of long-standing and unrelieved stricture of the urethra.

The fourth form of Atrophy is that produced by some local diseases of the prostate itself. Abscess in the prostate will produce disintegration of a considerable portion of the prostatic tissue by impairing the local nutritious supply of the adjacent structures through the agency both of ulceration and pressure; and thus atrophy may be said to occur. A deposit of tubercle will produce similar consequences, and sometimes to a considerable extent. In like manner, malignant disease will cause the proper structure of the prostate to disappear, superseding it by its own morbid growth; and in this sense also the prostate has been said to be atrophied.

Fifthly. Congenital Atrophy.-The prostate is sometimes found in a condition at birth, in which it may be said never to have been naturally developed. This condition is usually associated with congenital malformation of other portions of the genitourinary apparatus,-in extroversion of the bladder for example. It is in conformity with custom alone, a custom scarcely warranted by philosophical precision in the employment of terms, that the condition referred to is named under this head, since

atrophy supposes, strictly speaking, a pre-existing normal condition; no further notice of it therefore will appear here.

SYMPTOMS AND TREATMENT.-It is not known that simple uncomplicated atrophy of the prostate declares itself by any signs or symptoms. Neither is it conceivable that it should do so, except by the diminution in size ascertainable by rectal examination and by diminished secretion. As regards the latter, we know so little of its specific amount in health, that no conclusions can be adopted respecting the change which atrophy produces. No doubt it is associated with a decline of the sexual powers in age. Neither does the condition demand any notice in relation to treatment. There is no reason to believe that we possess any means of restoring an organ affected with senile atrophy. When atrophy results from other causes, such as stricture, abscess, &c., their alleviation or removal will doubtless be a means, and the only means, of beneficially affecting the prostatic affection.

CHAPTER XIV.

CANCER OF THE PROSTATE.

A Rare Affection; but probably less so than generally supposed.-Why it is so.Analysis of Tanchou's Tables. -Malignant Disease of Prostate almost invariably Encephaloid. — Examination of reported Cases of Schirrus.—Melanotic Deposit.— -Ages at which Disease appears.- Duration.-Course.--Morbid Anatomy.— Symptoms. Hæmorrhage. -The Urine.-Treatment.-Eighteen Cases.-Tabular View.

THE prostate may be the subject of cancer either as its primary seat, or when secondarily implicated after the primary appearance of the disease in some other part of the body. In either case prostatic cancer is a rare affection. It is a question, however, whether its rarity has not been in some respects exaggerated, judging from the general impression which appears to prevail respecting it. I am inclined to believe that a certain small proportion of instances is lost sight of among the very large number of cases assigned to senile hypertrophy. The course of malignant disease, when well marked, it is impossible, with ordinary care, not to diagnose from the last-named affection; but in more chronic forms, perhaps sometimes occurring, but most especially in those cases in which a malignant growth arises in a prostate previously the subject of senile enlargement, the cancerous character is sometimes, I believe, overlooked. For a good example of the co-existence of these two affections, which occurred under my own care, I beg to refer to a case at the close of this chapter. The morbid parts illustrating the course of disease referred to, I exhibited at the Pathological Society of London, in 1854.

In reference to this question of frequency, the statistical researches of M. Tanchou are commonly quoted by writers on this subject, and in the form comprised in the following brief state

ment. Among 8,289 fatal cases of cancer, he met with only five affecting the prostate. It will be desirable, however, to pursue our inquiries a little further with these figures, for the simple statement is calculated at first sight to produce an incorrect impression respecting the fact. The manner in which the data in question and the statistical summary were arrived at is as follows: M. Tanchou made an abstract from the registers of deaths for Paris and its suburbs, of every case in which the fatal result was attributed to cancer, during the years 1830 to 1840 inclusive; reporting what was believed to be the primary seat of disease in each case, naming one organ only, and classifying the whole accordingly, with a view, among other objects, to form a numerical estimate of the primary seats of malignant disease throughout the body. The total number comprised 6,957 females and 2,161 males-9,118. In 829 cases, the seat of disease was not originally reported, leaving 8,289 cases. Of these 1,904 were males, and among these the disease was recognized as a primary lesion, five times in the prostate, and all in adults.* But 72 cases are given of cancer of the bladder without distinction of sex. As a primary lesion, this is, I believe, more frequent in the male than in the female. In the latter sex vesical cancer is almost invariably due to extention from a uterine growth. Supposing, then, that fully, or more than, one-half of these may be claimed for the male sex, it is not unreasonable to suppose that some of them may have been prostatic in their origin. The fully developed prostatic encephaloma soon becomes vesical, and may often not be distinguishable except by careful examination. Thus in two of our own cases, viz., Ños. IX. and XXIV., the bladder was almost filled by a tumour which, nevertheless, had its origin in the prostate.

Regarding the source from which these figures were derived, viz., from an ordinary register of deaths, for the purposes of which no special examination is required, it appears to me ex

*Recherches sur le Traitement Médical des Tumeurs Cancéreuses du Sein. Par S. Tanchou. Paris, 1844, pp. 256–261.

THE EXTREME RARITY OF SCHIRRUS.

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ceedingly probable that a source of error, so difficult to guard against, must have vitiated the result in relation to this question. And we are entitled, I think, to believe that the proportion of five cases of primary disease in the prostate, out of 1,904 male cases of cancer, is very much smaller than the true number.

The occurrence of secondary is much more rare than that of primary cancer in the prostate. It has most commonly been observed that the invasion has then taken place by extension from the bladder. I have, once only, seen it succeed encephaloid cancer of the penis, itself a very rare affection.

As to the form of cancerous disease which most commonly affects the prostate, no doubt exists that it is encephaloid. In children it appears to be always so. In adults, an exception, to say the least, is extremely rare. Indeed the occurrence of schirrus there has been denied. After a close examination of all the cases reported, I believe the opinion expressed by Dr. Walshe in 1846, resulting at that time from an examination of necessarily fewer data than we now possess, was correct, viz., that "the evidence of the occurrence of true schirrus of the prostate is defective."* I have tabulated 18 carefully reported cases at the end of this chapter, having rejected those respecting which the evidence is insufficient, and among them at least two well-known cases commonly accepted by contemporary authors as examples of schirrus. Granting its existence, the extreme rarity of this form renders minute details absolutely necessary to establish an example. Wanting these, we must not hesitate to deny the admission to a category so designated, of any case not accurately observed. Moreover, it is necessary to bear in mind that, among the older authors, the term schirrus has been used with the intention of implying merely the presence of an indurated structure. The precision of meaning which modern pathology has assigned to it must not, therefore, be understood when referring to their records.

The Nature and Treatment of Cancer. By W. H. Walshe, Professor of Medicine in University College. London, 1846, p. 414.