the exercise of all his functions by the patient, and, provided only he attend scrupulously to keeping his bladder clean by warm-water injections, leaving him capable of enjoying a life as long, as comfortable, and as useful as if his bladder were sound. This statement, of course, does not apply if either of the three complications, so common with this form of disease, exists-namely, stone, mild pyelitis, or fatty atrophy of the kidneys. Where stone is present, it must be removed.

The radical treatment of enlarged prostate by medicine is in my opinion a delusion. The cases recorded prove nothing. Many a man has enlarged prostate and retention, and uses a catheter for a longer or shorter period, and then under milk diet or improved health he recovers his expulsive power and abandons his catheter. I have several instances of this among my patients, none of whom took ergot, while I have given ergot in large and small doses to scores of people for months at a time, and I have yet to see the first case that derived any advantage from the drug that I could appreciate. The same is my opinion of the interstitial injection of ergot or of iodine into the prostate (Heine's method). By this method Dittel* once produced acute prostatitis with suppuration.

The surgical means for reducing the size of the prostate are radical and often effective. Harrison's suggestion of puncturing through the substance of the prostate and leaving in a silver tube, to produce atrophy, I have not tried. The method of Mercier-of crushing off a portion of a third lobe, or of a prostatic bar-is not accurate enough, and is too rough to be good surgery. It sometimes yields good results, but the same can be accomplished better, more surgically, and with no greater risk to the patient.

The method of Bottini, of Pavia-namely, incision of third lobe. by a galvanic cautery prostatotome passed through the urethra-is open to the same objections, besides requiring special apparatus and some skill as an electrical expert. Good results, however, have been reported from its use.

But the best radical methods are undoubtedly either (1) suprapubic cystotomy for ablation of the third lobe, which is of easy accomplishment and yields good results, although it is an operation too serious to be lightly undertaken for a malady which itself does not kill, and may be so readily alleviated as to its symptoms; or (2) perineal section with ablation of any interstitial tumor which may project into the incision, or most often cutting or tearing away of third lobe or pro

#

"Centralblatt f. Chirurgie," November 27, 1876.

+ "Lithotomy, Lithotrity," etc., London, 1883, p. 65.

Described at length with many other methods in the excellent article "Prostate," in the "Nouveau Dict. de Méd. et de Chir. Prat."

# Sir William Laurence had such a case. Reported by Ferguson, "Med. Times and Gazette," April 18 and May 23, 1857. Harrison had another, and others have been reported-Keith, Thompson.

jecting portions of prostate through the incision; or, finally, slitting through third lobe or prostatic bar, tying in a large tube, and allowing a new floor to the prostate to form by cicatrization about the tube. Both these latter operations I have done a number of times, always with relief to the patient, although what may be called a positive cure can not generally be effected. In one instance, however, I restored to a patient who had only urinated through a catheter for four years the power of voluntary urination by taking away his third lobe through a perineal incision, and a number of patients with cystitis of high grade have been greatly benefited at my hands by perineal drainage combined with cutting into the floor or taking away an outstanding portion of prostate. These radical measures I can therefore heartily indorse in severe cases when palliative means fail to comfort the patient or to protect his general health.

MODE OF DEATH IN CASES OF HYPERTROPHY.-The not very infrequent complication of a low grade of inflammation of the ureters and pelves of the kidneys is always a serious matter. This becomes easily aggravated by cold or imprudence in diet, developing at once symptoms of mild uræmia, with hot, dry skin, loss of appetite, sleeplessness, great restlessness, dry, red, or pasty tongue, parched mouth, tendency to depression, headache, tendency to wandering of the intellect, constipation-all this attended, as a rule, by polyuria, a little albumen, and a few pale casts in the urine. A fatal termination of these symptoms is a not uncommon mode of death in cases of prostatic disease. The complication is best treated by confining the patient to bed, in a room where the air can be frequently renewed, and the temperature kept high, at 80° Fahr. or thereabouts; exciting the action of the skin and bowels; giving diluents in abundance, and a mild (milk) diet. The combination of potash and hyoscyamus acts well upon these cases, and some mild stimulant is not only admissible, but necessary to keep up the general strength until kidney congestion has subsided. These evils are more easily avoided than cured.

A more uncommon but a possible cause of death is peri- and epicystitis with their complications. A remarkable case of perforation of the bladder after prolonged retention, due to prostatic disease with extensive suppuration burrowing upward into the pleural cavity, is recorded by Duplay."

*"Archiv. Gén.," March, 1877, p. 604.

CHAPTER XI.

DISEASES OF THE PROSTATE.

Congestion. Parenchymatous Prostatitis. - Terminations: in Resolution, Chronic Prostatitis, Abscess.-Treatment.-Gonorrhoeal Prostatitis.-Prostatic and Peri-prostatic Abscess.--Treatment of all Forms of Abscess.-Follicular Prostatitis.-Its Liability to be mistaken for Stone in the Bladder.-Treatment.-Tubercular Prostatitis.-Cancer of the Prostate.-Prostatic Concretions. Prostatic Calculi.-Neuralgia of the Prostatic Urethra.-Syphilis of the Prostate.

CONGESTION of the prostate occurs physiologically during venereal excitement. If such excitement be unduly prolonged without being gratified, even sometimes without erection, if the imagination be given. up to erotic fancies, the mucous follicles of the organ secrete more or less of a peculiar, viscid, bluish mucus, without odor, which, mixed with urethral mucus, finds its way out at the meatus. This phenomenon is perfectly natural. Physiologically it is analogous to the watering of the mouth of a hungry individual at the sight, smell, or even thought of food. Many individuals, however, whose sexual requirements are not met, live in such a state of mental inquietude, particularly in regard to the genito-urinary organs, that this drop of mucus appearing during erection excites in their minds the most lively alarm, and they hasten to their surgeon to demand his aid for spermatorrhoea, stating that they never have an erection without the involuntary emission of seminal fluid.

Of this idea it is often hard to dispossess the patient's mind, but an honest explanation of the whole subject will rarely fail to convince him; while the observance of purity of thought and the avoidance of occasions of sexual excitement, or, better still, marriage, to place him. in natural sexual relations, will prove, infallibly, effective of cure.

If this physiological hyperæmia be kept up for a long time (several hours), the prostate is liable to remain congested, throbbing slightly, feeling full and hot, giving rise, perhaps, to frequent calls to urinate, and attended by a very slight gleety discharge. If the patient urinate frequently, straining to empty the bladder of its last drops, the prostatic congestion is maintained and aggravated. All these uncomfortable feelings, due to prostatic congestion, are relieved by rest; more quickly by a cold sitz-bath, or by a very hot sitz-bath of short duration. The desire to urinate produced by the contact of water should not be yielded to.

Slight congestion of the prostate frequently complicates gonorrhoea, stricture, etc. It is usually ephemeral in character, announcing itself only by a little increased frequency of urination, or it may continue

on to actual inflammation. Congestion may be excited in the prostate by sexual excess, masturbation, etc., and this, being kept up and often repeated, may lead to chronic follicular prostatitis, without passing through any acute stage.

PROSTATITIS.

Inflammation of the prostate is of two kinds :

1. Parenchymatous. 2. Follicular.

PARENCHYMATOUS PROSTATITIS.-Spontaneous (primary) inflammation of the prostate is rare; inflammation, traumatic, or extending to the prostate from contiguous parts, is not uncommon.

CAUSES.-Among the causes of prostatitis may be enumerated gonorrhoea, stricture, extreme and prolonged sexual excitement, concentrated acid urine, cold, violence from instruments, stone fragments, etc.; chemical irritants, strong injections, cantharides internally, etc. Gonorrhoeal inflammation, after the first week, may run rapidly down the urethra and involve the prostate, particularly if the patient indulge in liquor, sexual intercourse, or take violent exercise, or use strong injections, throwing them deep in the canal. Sometimes, during gonorrhoea, without appreciable exciting cause, the prostate inflames. The inflammation behind a stricture may run back and involve the prostate in the same way. Sexual hyperæmia, too much prolonged or too often repeated, may lead to it.

COURSE.-Prostatitis commences as congestion. Passing on to true inflammation, it terminates by resolution, exudation of pus on the free surface, perhaps by croupous exudation; by abscess, or periprostatic formation of pus; or, finally, it may linger indefinitely as a chronic (follicular) inflammation, mild in degree, occasionally becoming aggravated.

SYMPTOMS.-The organ swells rapidly, putting the capsule on the stretch, and often reaching the size of a small orange. It may feel square (Vidal), or be unevenly enlarged. The exploring finger in the rectum strikes at once against this mass, which juts into the cavity of the gut, is very tense and hot, and can be felt distinctly to pulsate. It is exceedingly sensitive to pressure-unlike prostatic hypertrophy, which is not sensitive unless inflammation be present. In prostatitis the lightest touch, even the presence alone of the finger in the rectum, at once excites a desire to urinate. Pressure over the pubes brings on the same desire. The patient is conscious of something protruding into the rectum, and may experience an unnatural desire to go to stool. If he endeavor to do this, he strains ineffectively, causing himself pain, but getting no relief, even if he succeed in forcing out a little fecal substance, after suffering great distress in the effort. The perinæum feels hot, and is sensitive to pressure. The subjective sensations,

locally, are heat, weight, throbbing. There is a sort of dragging feeling over the lower part of the abdomen, as well as in the penis and scrotum. There may be pain in the back and limbs. If gonorrhoea be the cause, or stricture with profuse gleet, the urethral discharge ceases at once, or becomes very scanty and thin. It returns, however, as the prostatic inflammation subsides. The stream of urine is small and is passed with effort. The prostate may swell to such an extent as to obliterate the prostatic urethra entirely for a time, causing retention. Thompson believes this to be the cause of all retentions which occur during acute gonorrhoea-in fact, of all retentions supposed to be produced by so-called inflammatory stricture; but this is certainly wrong, urethral spasm is most often at fault.

With this swelling of the prostate is almost invariably associated congestion of the vesical neck, and a constantly-recurring, never-satisfied desire to urinate. If retention comes on, as it rarely does, this feeling exists as a matter of course; but, even when the bladder is entirely empty, it feels partly filled, there is no sensation of relief after voiding the urine, and, when a few drachms have re-collected, the urgency of the sensation forces the patient to another effort, equally unsatisfactory. The urine causes pain on its passage, but the pain is most severe as the last drops are being expelled, when the circular fibers at the bladder's neck squeeze the tender prostate. It is now that blood is often discharged from the overloaded vessels, coloring the last drops of the stream. A pain like that occurring with stone is experienced, both in the perinæum running down the urethra and, often with greatest intensity, on the under surface of the penis in the urethra, at about three quarters of an inch from the meatus. Coinciding with all these features, which map out the disease so plainly that it is impossible to mistake it, there is general febrile disturbance, with usually the utmost concern, apprehension, disquietude, and depression with excitement of mind, such as is rarely caused by inflammations of much greater magnitude, and attended by far more severe pain elsewhere. The patient is irritable, despondent, and suspicious; often, in fact, wild to an extent amounting to mild acute mania. He can not sleep, he will not eat, and it is with difficulty that he can be kept quiet. Fortunately, his feverish condition induces him to drink abundantly of mild, bland fluids.

The inflammation may subside before the malady has reached this point. Resolution may come on at any time, even after the above extreme has been reached; the throbbing pain and heat disappear, and usually a little discharge appears from the prostatic sinus. This discharge may continue for a considerable period (follicular prostatitis), or may rapidly cease while the calls to urinate grow less frequent, and the sensation after the act approaches the full relief felt normally. If the inflammation has extended into the seminal vesicles, there may be