MORBID ANATOMY - OF THE HYPERTROPHIED PROSTATE.
On dissection the hypertrophied prostate is usually found to be hard and indurated as compared with the normal consistency of the organ. Sometimes, on the other hand, although considerably en larged, its texture is comparatively soft and loose. This is usually, however, in the early cases. The more indurated variety is often associated with atheroma. The varying forms of hypertrophy have already been noted. The most frequent variety of enlargement, from an anatomical standpoint, is that in which the structure is uniformly involved. Clinically, however, median hypertrophy is the most fre quently met with because of its invariably disagreeable results. In dividuals with a moderate amount of general enlargement of the prostate may live to an advanced age, without ever experiencing sufficient discomfort to compel them to seek the aid of the surgeon. As a corollary, it is obvious that in the majority of cases which pre sent themselves to our observation, we are justified in assuming that median hypertrophy exists. The three pathological divisions of the prostate, i.e., the median and two lateral lobes, may be so greatly enlarged as to form three tolerably distinct tumors jutting out from the main body of the prostate; this condition of affairs is very apt to be associated with bar at the neck of the bladder. As a consequence of the enlargement of the organ the prostatic urethra is increased in length, and its curve is exaggerated. If the enlargement is at all irregular or asymmetrical the canal is tortuous. The elasticity of the prostatic urethra is necessarily impaired in all cases. The increased length of the urethra is a most important consideration in the sur gery of the part, inasmuch as it becomes necessary to adapt the curve and the method of introduction of the instruments necessary for treatment to the abnormal form of the canal. On section the organ is usually found to be quite hard, pale, and comparatively bloodless. There is in most cases an evident increase of all of the elements of the organ, more especially of the muscular and fibrous stroma. This hyperplasia, is, in the opinion of the author, the most
important factor of the disease. As already stated, isolated tumors, simulating myomata (?) or fibro-adenomata, may be found, in some cases surrounded by a distinct capsule, and in others not so readily outlined. Prostatic concretions may be found in some instances, and if numerous they may be contained in a sort of sac produced by ab sorption of the tissue of the prostate, incidental to the pressure of the calculi. These calculi may be found outside the prostate proper, in the glandular tissue about the vesical neck.
The floor of the bladder behind the prostate is dilated, often thinned, sometimes thickened by atheroma forming the depression already alluded to as the bas fond or lower bottom. This is found in advanced cases to contain more or less fetid and ammoniacal urine mixed with mucus, pus, and triple phosphate. In many instances a definite calculus is found. The occurrence of phosphatic calculi in cases of prostatic disease is very readily explained : As a conse quence of decomposition of the residual urine, more or less phosphatic material is formed; this deposits upon a mass of muco-pus secreted by the inflamed bladder or upon a blood clot, and solidifies, the pro cess being precisely similar to the crystallization of sugar. When once a small calculus has formed it grows with considerable rapidity ; it enhances the inflammation, increases the secretion of muco-pus and deposition of phosphates, and enlarges very much after the fashion of a rolling snowball, layer after layer of phosphatic mate rial being deposited upon its surface until finally in some instances an almost incredible size is attained. The nucleus may be formed by insoluble drugs or foreign bodies introduced into the bladder, or may consist of uric acid or nrates. The typical calculus of the prosta tique, however, is phosphatic. The bladder, as a consequence of obstruction to the urinary outflow, undergoes compensatory hyper trophy, and eventually its mucous membrane becomes inflamed and presents the ordinary appearances of chronic cystitis.