PROSTATE GLAND. 



155 



the patient's existence. It would be out of 

 place here to enter into the signs which cha- 

 racterise the progress of this disease. I must 

 confine my observations to the state of the 

 gland itself, to the effect produced upon the 

 adjacent structures by its enlargement, and to 

 its cause. 



In senile hypertrophy, the gland becomes 

 enlarged in all its dimensions ; it expands 

 laterally, extends downwards towards the rec- 

 tum, so as to be readily felt, forming a consi- 

 derable tumour in this situation, and upwards 

 behind the svmphysis pubis, so that in a thin 

 person, with the hand firmly pressed upon 

 the hypogastric region, the surgeon can, in 

 some cases, feel it distinctly. Its outer sur- 

 face is smooth and round, or occasionally 

 irregular and nodulated : the two lateral lobes 

 expanding universally, are pressed together, 

 so as to become flattened at their opposed 

 surfaces ; if one increases particularly at one 

 part, as is often the case, there is a corre- 

 sponding indentation in the other, and thus 

 the direct course of the urethra is altered, 

 and the canal is twisted in various directions. 

 The disease is not usually confined to its 

 lateral lobes ; for the third lobe frequently 

 participates in the enlargement. This may 

 happen to a great extent, in some measure, 

 independently of the increase in size of the 

 lateral lobes ; but usually, where the middle 

 lobe is affected, the lateral lobes are enlarged, 

 although the converse of this condition is not 

 so invariable. The middle lobe sometimes 

 forms a simple pyramidal elevation at the 

 urethral orifice ; sometimes a large pendulous 

 or valvular tumour, occasionally rising up- 

 wards from the posterior part of the prostate 

 in the mesial line direct, frequently inclining 

 to one side. It has been known to attain the 

 size of a small orange ; and where it has in- 

 creased to such an extent, it must of neces- 

 sity happen that the base of the tumour is the 

 smallest part of it. Whatever form of en- 

 largement the middle lobe assumes, the tumour 

 always projects towards the bladder: it is 

 frequently knotty or tabulated on the surface. 

 In its increase, the third lobe draws up the 

 prostatic portion of the urethra, and elongates 

 the veru montanum. Very great interest has 

 attached to this condition of the middle lobe, 

 in a surgical point of view, since Sir Everurd 

 Home particularly directed the attention of 

 surgeons to Mr. Hunter's observations upon 

 it, who states "that it sometimes increases so 

 much, as to form a tumour projecting into 

 the cavity of the bladder some inches." The 

 disease of this part of the gland had not 

 escaped the observation of Morgagni, although 

 he did not attach much importance to it : it 

 was also known to Valsalva. 



Hypertrophy of the prostate is frequently 

 attended with general induration, so that when 

 cut into, it almost resembles cartilage. This 

 has obviously given rise to the term scirrhous 

 prostate, as applied by the older surgeons to 

 the disease in question. In other instances, 

 it feels softer than natural. The capsule be- 

 comes gradually attenuated by distension, and 



the direction of the tumour is always towards 

 the part where there is least resistance. 



It has been very commonly asserted that 

 the left lobe is more frequently hypertrophied 

 than the right. The observation originated 

 with Sir Everard Home. 1 cannot deny the 

 truth of the assertion; but it is divested of any 

 practical importance, as it is well known that 

 the right lobe is in very many cases the larger 

 of the two. However, the fact that the two 

 are very frequently unequally enlarged, ouht 

 to be impressed upon the mind of the surgeon, 

 as he may expect that the course of the 

 urethra will deviate to either side, and (in the 

 introduction of the catheter) in cases of re- 

 tention, from enlarged prostate, he must direct 

 his instrument accordingly. 



The enormous increase of size which the 

 prostate attains, produces serious incon- 

 venience to the parts adjacent. Thus, inde- 

 pendent of the effect on the nerves of the pel- 

 vis, as indicated by pains in the loins, sacrum, 

 groins, and down the thighs, its influence is 

 most sensibly perceived in the altered state 

 ol'the urethra, in the bladder, and the rectum. 

 By the enlargement of the prostate, the urethra 

 is increased in length a fact well known to 

 practical surgeons. This actual elongation 

 takes place only in the prostatic portion of 

 the canal ; the diameter of the urethra, so far 

 from being diminished, is really increased ; 

 but the part surrounded by the gland is al- 

 tered in shape ; for, whereas in the natural 

 state the prostatic sinus is longer in a trans- 

 verse than in a vertical direction, it is now 

 quite the reverse : its sides are also approxi- 

 mated by the coaptation of the lateral lobes ; 

 and if any unequal projection of either lobe 

 exists, it takes a tortuous course to reach the 

 bladder, or reaches it by two channels, one 

 on each side of the middle lobe ; besides 

 which, the urethral orifice into the bladder is 

 more or less blocked up by the projection of 

 the middle lobe, or is raised higher than na- 

 tural, the prostatic part of the canal forming 

 a sickle-like curve, the convexity of which is 

 downwards. The prostatic sinus is occa- 

 sionally dilated to such an extent, as to be 

 capable of holding two ounces or more of 

 urine. The veru montanum is placed at a 

 greater distance than natural from the bladder. 

 The bladder becomes either preternaturally 

 dilated, or contracted to a very small size; 

 these two opposite conditions probably de- 

 pending on the greater or less irritability of 

 the viscus ; sometimes it is sacculated ; its 

 muscular coat is thickened, and its mucous 

 lining becomes the seat of acute or chronic 

 inflammation, with all its accompanying pa- 

 thological changes. So also the ureterand even 

 the kidneys themselves are frequently diseased 

 in the advanced stages of this affection. 

 When the third lobe is much enlarged, it 

 throws the neck of the bladder forwards, and 

 increases the depth of the inferior fundus to such 

 a degree, as to cause the lodgment of calculi in 

 its cavity. In one respect, this circumstance 

 is attended with some advantage, inasmuch as 

 it lulls the symptoms of stone, by preventing 



