DIAGNOSIS OF THE HYPERTROPHIED PROSTATE.
The most accurate information regarding the condition of the prostate body is to be obtained by rectal exploration with the finger. The bowels should be evacuated by means of an enema, and if the patient is very sensitive a small quantity of morphine or cocaine may be introduced by suppository a short time previous to the examina tion. The prostate is discernible to the expert finger even in its nor mal condition, but whenever it is at all prominent some condition of disease may be inferred. In certain cases of enormous enlargement of the organ the rectum is so encroached upon that the tumor can be felt immediately the finger passes the sphincter, rendering it neces sary to depress the finger in order to pass it by the obstruction. By this mean of exploration the size and conformation of the prostate are very readily made out. When the median lobe is enlarged a certain degree of resistant fulness will be detected above the upper border of the body of the organ at a point where, when the prostate is nor mal, nothing can be felt, excepting the elastic fluctuating wall of the bladder. It is desirable to note whether the bladder is accessible beyond the border of the prostate as evidenced by marked fluctua tion, especially if there exists the possible necessity of tapping the bladder through the rectum. If there is much inflammation or acute hyperaemia, the finger elicits great tenderness with rectal and vesical tenesmus. Any irregularities of the prostate which may possibly indicate tumorous outgrowths should be carefully outlined and noted.
Great assistance in exploration is afforded by a metallic catheter introduced into the bladder. The instrument and the exploring fin ger in the rectum are made to engage between them the structures about the neck of the bladder. In this way a very fair approximate idea of the extent of the hypertrophy and the degree of induration may be formed. By urethral exploration we may often derive con siderable information regarding the condition of the prostate. In a suspected case of hypertrophy the first attempt at exploration should be made with an ordinary catheter. If this passes readily without the necessity of marked depression of its handle, and if, more over, urine flows through it when it has penetrated to the depth of seven or eight inches, the prostate is in all probability not apprecia bly enlarged. If, on the other hand, hypertrophy exists it will be found necessary to depress the handle of the catheter well downward toward the feet of the patient before its point will enter the bladder, and even then it may be found impossible to introduce it without the use of undue force, because of the point impinging upon the bar at the vesical neck or the median lobe, as the case may be. If we suc
ceed in entering the bladder the urine often does not flow until the in strument has penetrated to a depth of say ten inches or more. If the ordinary catheter does not readily enter the bladder Thompson's metallic prostatic catheter, which has a longer and greater curve, should be employed. If median hypertrophy or bar exists this in strument will usually pass by the obstruction with comparatively little difficulty. When the lateral lobes are asymmetrically enlarged the point of the catheter and consequently the handle are deflected in a direction corresponding to the existing malformation of the urethra. The depth to which it is necessary to pass an instrument before the urine flows is a fair criterion of the degree of enlargement. Thomp son has devised a "searcher" for exploration of the bladder, which in practised hands gives very valuable information regarding the size and form of prostatic hypertrophy, the presence of tumor or stone, and the depth of the bas fond.
It will be found best in the majority of cases to examine the patient in the dorsal decubitus with the knees and thighs flexed and separated. In rectal examination of the prostate, however, the writer has found a posture similar to the Sims gynecological position most favorable to exploration.
The differential diagnosis of hypertrophy of the prostate requires the exclusion of stricture, vesical calculus, vesical tumors, atony, paralysis, and simple catarrh of the bladder—stricture and vesical calculus being the diseases for which it is most likely to be mistaken. Most of these conditions may usually be excluded by a careful study of the history of the case and physical examination of the size and form of the prostate and the contour and length of the urethra. The age of the patient is in all cases a most important consideration.
It is wise not to be too arbitrary iu the matter of diagnosis based upon subjective symptoms ; as these diseases have many symp toms in common. Very often a calculus will coexist with enlarged prostate and be unsuspected because of the fact that, as already stated, the contractibility of the vesical walls is so impaired that the stone cannot be forced against the tender vesical neck. Rectal ex ploration and the passage of instruments into the bladder are neces sary to complete the diagnosis in any case.