9

fitted with a sort of truss which, by exercising pressure on the urethra below the arch of the pubes, enabled him to prevent the involuntary escape of urine, and to go about his work.

Before proceeding to point out the steps by which prostatic enlargement, as it seems to me, is brought about, I would mention one or two points which are generally admitted in connection with the natural history of this growth. In the first place, there can be no doubt though a considerable proportion of elderly males develop it, only a minority suffer from any effects on the urinary apparatus it may produce. If such a growth serves no useful purpose it is difficult to understand how this can be, and why we should draw our conclusions as to the process being a morbid one from the lesser number of instances of it, than the greater. It is a matter of common observation to find persons with largely hypertrophied prostates and yet showing no other structural defect either in the capacity of the bladder to contain or to fully expel the urine for which it acts as a reservoir. Nor with proper safeguards is it necessary that persons so situated should develop any trouble arising out of an enlarged prostate, calculated either to shorten or to render their lives otherwise than normal.

Another point is also worthy of notice in this place. The process of hypertrophy involves no structural substitution or the importation of tissue foreign to the part, other than those degenerations, such as the fibrous, to which the human body is liable. Hence we are narrowed down to offering an explanation as to the purpose for which this excess of normal structure is called in existence.

I will pass on to notice somewhat in detail, the processes connected with prostatic hypertrophy when from the symptoms it produces and leads to, it cannot be regarded as either compensatory or innocuous.

I would here observe that in studying pathological lesions more particularly in relation to function, that instances can be found in the human body where defects may call into existence such compensatory changes as eventually themselves constitute disease. A very small lesion, for instance, in the mechanism of the heart, if it happens at the right spot, is capable of producing an hypertrophy which, though first compensatory, by and bye, proves to be a source of disorder. This prostate, in the course of its growth, so as to form a buttress or support for the most dependent portion of the bladder, tends to project in directions where the resistance is least, and to form, by the fibrous degeneration these portions undergo, those obstructing masses with which we are familiar. Nor, though the whole gland is eventually more or less involved in the hypertrophy, can we fail to observe that in these changes the posterior segment, where it exists, is usually primarily and principally involved...

10

I have already laid stress on the importance of not regarding the normal prostate merely in the light of an individual organ, but as forming a part of the genito-urinary system, and thus relatively to the whole. And this holds good with its pathology. In the study of instances of enlarged prostate in the post-mortem room, it is impossible not to be struck with the coincident changes that are taking place in the adjacent parts. In looking at such specimens the fact cannot escape notice, whatever the explanation may be, that for some reason or other there is a concentration of hypertrophied tissue in the form of buttresses or supports about the perpendicular axis of urine pressure at the base of the viscus. This is seen in the development of the inter-urethral bar, the growth of the prostate, the gradual approximation and consolidation of these two structures, and the restriction of the natural trigonal area.

The trigone or floor of the bladder, in addition to being a highly sensitive part, is peculiar in that it contains the minimum amount of muscular fibre as compared with the rest of the viscus; muscle in abundance may be found as low as a transverse line drawn between the openings of the ureters marking the superior boundary of the trigone, and below in the prostate, but between these two points the power of muscular contraction can hardly be said to exist. Assuming, as I have stated, that from any cause such as the long retention of urine habit, position of the body or the debility connected with advancing years, the floor of the bladder sinks lower within the pelvis relatively to the prostate, so as to offer some difficulty in expelling the last portion of urine the effect will be frequently repeated efforts in all the muscles immediately adjacent to a part of the bladder which, by reason of its connections and structure, has but little power of contraction. It is suggested in this way quantity is substituted for quality, and that as age advances structural deterioration and incapacity is, in a measure, provided against by superabundant tissue.

I have said that although hypertrophy usually includes the entire gland, the posterior segment or that in relation with the rectum is principally involved. When the part which was originally described by Sir Everard Home as the third lobe, but subsequently shown by Sir Henry Thompsont to have no independent or isolated existence, is imperfectly or not developed at all, as is sometimes the case, it is interesting to notice that hypertrophy of the inter-urethral bar may often be observed taking place independently, and thus provision is made by a buttress of this kind for the support of the posterior wall of the bladder. This is well shown in a drawing by Mr. Joseph Griffith's in one of his papers on this subject.‡ Philosophical Trans. 1806.

+Diseases of the Prostate. 1886.

Journal of Anatomy and Physiology. Vol XXIV.

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An inability to empty the bladder and the discomfort or rather the consciousness of an incompleteness of the act of micturition, is a common symptom in connection with the early form of prostatic enlargement. This is due, I believe, not to atony or paresis of the bladder in the ordinary acceptation of the term, but to a sinking or tendency to prolapse of the posterior wall.

Though it is difficult to demonstrate these changes after death by measurements or castings accurately representing the previous shape and relations of the part, there are signs existing during life which tend to corroborate this view. By the catheter and by examination through the rectum we are usually able to convince ourselves of this. That the bladder alters its position relative to the pelvic outlet during life there can, I think, be no doubt. In early adult existence it may be regarded as an abdominal rather than as a pelvic organ; as years advance it gradually sinks within the pelvis, whilst still later on it will be found to have become further depressed within the pelvic area. In this way a prominence is sometimes given to the floor of the prostate, which is due not in the first instance to the development of more prostatic tissue, but to the subsidence of the posterior wall of the bladder. This mode of forming a prostatic bar may readily be imitated and is, I believe, the initial lesion in the hypertrophic changes which subsequently follow.

The most important objections urged against my views as to the muscular origin of the hypertrophied prostate are based on the statement that this organ is essentially a genital gland, and that the muscular fibre it includes, both in the form of intrinsic and extrinsic, is for the most part. occupied in this function. This view has been supported by Mr. Joseph Griffiths, of Cambridge, and is based upon a series of observations* both in human and comparative anatomy, which are deserving of careful consideration. Though in no way taking exception to the histology of the parts investigated, I cannot accept all the conclusions arrived at by this author, relative to the disposition and function of the prostate.

As I have already pointed out, I believe we have formed a wrong. conception of the arrangement of the prostate during life, and that to this is due, in a large measure, the difficulty we have hitherto experienced in recognizing the extent and limitations of its true functions. My views are much more in accordance with those of Professor Viner Ellist who speaks of the prostate as "essentially a muscular body."

The fact, however, that the hypertrophied organ contains a considerable amount of gland tissue of an inferior quality yielding a secretion which *Journal of Anatomy and Physiology, Vols. XXIII, XXIV.

Royal Med.-Chir. Trans., Vol. XXII.

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Mr. Griffiths refers to as "scanty, thin and watery" as compared with the normal exudation is in no way opposed to the views I have advanced in reference to the circumstances under which the conglomerate growth is called into existence. The degenerated character of the gland tissue is in keeping with a function which at this period of life is on the wane, and not in that state of activity which, in some of the lower animals at certain periods is attended with a large and more than usually developed gland (Vide Griffith's paper). Surely there can be no analogy between the large prostate of a rutting animal and that of a septuagenarian male.

Still more recently it has been put forward in consonance, I presume, with the genital view of the function of the prostate that the operation of complete castration is likely to prove of service in connection particularly, with the treatment of the more advanced forms of prostatic obstruction. In a paper of considerable interest. Dr. J. W. White, of Philadelphia, summarises the somewhat slender and scattered evidence that exists in favor of the view that in man removal of the testes is followed by atrophy of the normal prostate, and thus remarks on the suggestion as to its practical value as a means of treatment; "As to the possibility of employing castration as a therapeutic method in prostatic hypertrophy, I imagine that the final answer must be left to our patients. Of one thing I am convinced, however, that if we even reach a point in certainty of knowledge in this direction comparable to that already attained in regard to öophorectomy in relation to utdrine fibroids, and can promise equivalent results, there will be no lack of cases willing to submit to an operation almost painless, with a low mortality, and followed by no such unpleasant conditions as accompany persistent fistulous tracts, either supra-pubic or perineal, even although the operation earries with it the certainty of sacrificing whatever sexual power has survived the sufferings of such patients."

As a contribution to the discussion which this paper elicited on this subject, I narrated the particulars of a case which incidentally came under my notice some years ago where, with the same object in view, and under considerable pressure, I had divided the vasa deferentia of a man with a large and troublesome prostate. The proceedings and its effects were summed up in the following words:

"This operation was readily done,

first on one side and then on the other with a tenotome at a few days interval, and my patient left me in the course of a short time, alleging that he had already derived benefit from it. Six or seven years afterwards, when I was in America, I ascertained that he was alive and well, but as I had no

British Medical Journal, September 9, 1893. *British Medical Journal, September 23, 1893.

13

opportunity of testing the case, I thought nothing further of it until reading Dr. White's interesting lecture."

In a subsequent communication† Dr. White reviews some evidence that has still more recently been adduced, tending to show that shrinkage of the enlarged prostate has followed these proceedings, and for illustrating this point I will select the following case recorded by Dr. White. This gentleman writes: "On January 31, 1894, I operated on a medical man who had a very prostate, about half the size of an orange, who had passed no urine except by catheter for years, whose urine was loaded with mucus, was offensive, and at short intervals was filled with blood. At this time— fourteen weeks later—while he has not urinated secondarily, rectal examination shows a reduction of the size of the prostate to about its normal dimensions. The catheter which was formerly introduced for 91⁄2 inches before reaching urine now goes in only 8 inches, when urine begins to flow. Its introduction is easy and painless, instead of difficult and very painful. No blood has appeared in the urine for two months. The urine itself is entirely normal in appearance, odor, and in all other respects."

So far as it goes, the evidence seems to favor the conclusion that some shrinking of the prostate follows castration and, I think, as pathologists more particularly, we are indebted to Dr. White for giving prominence to this fact, whatever it may be worth from a surgical standpoint.

I would here remind you that shrinkage of the prostate has undoubtedly followed other measures than castration. It may be remembered that some years ago I published; the particulars of a case where, for this condition in its most advanced and distressing form, I punctured the bladder from the perineum through the enlarged prostate and retained the canula in this. position for six weeks. This process has since been described as tunneling the prostate. In the instance just referred to the patient not only entirely recovered his power of normal micturition, but on the removal of the canula we discovered that the prostate had undergone a marked diminution in size, in fact it had almost returned to its natural shape. This patient died at the age of ninety, eight years after the operation, without any recurrence of his ailment or the necessity for again using a catheter.

By assuming that some shrinkage of the prostate follows upon castration, I do not see that such a conclusion is either at variance with the views I have advanced relative to its pathology when enlarged, or proves that it is essentially, that is to say exclusively, a genital gland. That it secretes in association with the genital act no one, I think, will deny. That some

+Ibid. June 23, 1894.

+Surgical Disorders of the Urinary Organs, Fourth Edition, 1893.