The modern French school, following the distinguished Guyon, entertains the peculiar view that enlargement of the prostate is not a local condition and the effect of local causes, but that all the urinary organs, and particularly the bladder, undergo changes of analogous character, the origin of which should be looked for in structures bearing absolutely no anatomical relation to the urinary system; implying, in short, that enlargement of the prostate is dependent upon general atheroma. Thus this school claims that the walls of the bladder fail in their power with a resulting accumulation of resid ual urine followed by cystitis, prior to the enlargement of the pros tate. Reginald Harrison has also asserted that the habit of partial retention frequently precedes the vesical signs of prostatic enlarge ment, the depression of the posterior wall of the bladder being a primary change. In this the author heartily concurs. Harrison further holds that the depression of the posterior wall of the bladder results in a compensatory hypertrophy which determines the develop ment of a strong muscular band or buttress at the base of the trigone, and finally enlargement of the prostate itself.
It is obvious that even though we admit that, in certain cases, de pression of the floor of the bladder and alteration in the walls of the viscus precede perceptible pathological change in the prostate, this condition may in no way be causative of the prostatic disease. I con tend that such cases are no argument against what appears to me to be the correct view, viz., that serious pouching of the bladder is gen erally a secondary condition. General atheroma, for example, with a resulting alteration of the structure and power of the bladder, might occur and subsequently become associated with hypertrophy of the prostate, which condition is clue to the same causes as in other cases in which prostatic hypertrophy is unassociated—primarily at least— with disease of the bladder.
Much of the obscurity of origin of prostatic hypertrophy is probably due to the clinical fact that the primary condition which precedes true hypertrophy is rather exceptionally brought to the attention of the surgeon. A certain amount of diffuse hyperplasia from prolonged hypereemia incidental to various causes of irritation in all probability exists in many men under middle age. It is not, however, until distinct hypertrophy or hyperplasia has occurred that definite symptoms are complained of. In fatal cases the process is so far advanced as to bear very little resemblance to the chronic en gorgement and simple hyperplasia which constituted the initial stage in the so-called hypertrophic process. Concerning Thompson's views in regard to inflammation or circulatory disturbance as factors in the etiology of prostatic hypertrophy, this much may be said, viz., Chronic
congestion and inflammation do not produce true hypertrophy it is true, but they do produce hyperplasia, especially where the circu lation is impeded by the relatively dependent position of the part. The hyperactivity of the part induced by the resulting irritation will explain the true hypertrophic element of the disease, which as a mat ter of fact is subordinate to the hyperplasia. This argument is especially true as applied to the prostate, which is a glandulo-muscu lar organ.
Racial peculiarities seem to have a marked influence in the etiology of hypertrophy of the prostate. It is met with in the negro but rarely. Dr. Hunter McGuire, states that he has never found an ex ample of it in the pure-blooded negro, but has seen several in stances of it in mulattoes. Other surgeons in the Southern States have met with the disease in pure bloods.
The causes of the disease, according to the views of the author, may be classified as follows : It is obvious that the local and general etiological factors are most effective when associated. It is true that these causes are not recog nized by most modern authorities, yet in my opinion such etiological deductions are based upon sound physiological reasoning, taking into consideration the structure and function of the organ. The prostate is one of the most important organs associated with the sexual function. It is particularly important from the fact that it is the seat of sexual sensibility and is intimately involved with the venereal orgasm. One of the most important elements in the sexual act is active hyperemia of the prostate, and it seems plausible from this fact alone that excessive sexual indulgence may produce permanent injury to the organ. Should sexual excesses be alter nated with prolonged and ungratified sexual desire, a permanent im pression will be still more likely to result. Constant over-stimula tion of the glandular tissues of the prostate is a very important element for consideration.
The enlargement of the prostate produced by chronic hyperEemia is usually of no particular importance, from a mechanical standpoint, during the youth or early adult life of the individual. This is prob ably explicable by the relief afforded by free secretions, by the elas ticity of the tissues themselves, and by the fact that the bladder retains its normal tonus for some time. When, however, the indi vidual passes the prime of life and his tissues become less resilient and secretion in general less active, if the hyperaemia continues, there is less secretion and a diminished activity of the return circulation, with consequently less relief of the condition of relative hyperaemia.