The associated pathological conditions of that portion of the genito-urinary tract above the prostate naturally call for considera tion under the head of the morbid anatomy of prostatic hypertrophy. It will be understood that these conditions are mainly secondary to the prostatic hypertrophy, varying in degree according to the variety and extent of the obstruction and dependent more particularly upon the presence or absence as well as the duration and severity of infec tion, secondary to the urinary obstruction. The mechanical disturb ance produces in the first instance serious obstruction to the return flow of blood through the veins. Vesical hyperplasia and congestion of the mucous membrane with resultant excessive formation of mucus is a natural result. In some instances the bladder becomes enor mously thickened as a consequence of the frequent and forcible efforts at micturition. Interstitial proliferation of connective tissue occurs, and the bladder finally contracts down into a hard mass little resem bling the normal viscus, the cavity of which may contain but a few drachms of urine. In other instances, as a consequence of attacks of retention from time to time superadded to the continual obstruction to the urinary outflow, the bladder becomes atonic, dilated, and pre sents a trabeculated appearance incidental to the hypertrophy of the fasciculi of muscular fibres composing its walls. The portions of the bladder walls corresponding to the interstices between these bun dles of muscular fibres are relatively thinned, dilated, and perhaps sacculated, the sacculi containing decomposing urine, muco-pus, phosphates, and perhaps one or more calculi, presenting in short the same conditions as does the bas fond in the presence of a .septic cystitis. The mechanical effect of the prostatic hypertrophy extends further than the bladder and involves the ureters and kidneys. These may be dilated and thickened. The kidney presents more or less thinning of its cortex with dilatation of its pelvis. These results occur sooner or later whether or not infection of the bladder is superadded. The disturbance of nutrition incidental to this condi tion of dilatation and thinning from the backward pressure of the urine affords a locus minoris resistentice which is extremely favorable to bacterial infection. The slightest degree of hyperemia super added to this condition may completely suspend the already more or less inhibited function of renal secretion with resulting urmia and speedy death. Necessarily the impairment of function incidental to the chronic conditions produced by the urinary obstruction results in a greater or less degree of urinary empoisonment of the general system. The septic effects of prostatic hypertrophy are attributable
directly or indirectly to bacterial infection. The congested hyper secreting mucous membrane of the bladder affords a favorable soil for bacterial infection; the mucus secreted favors chemical changes in the urine. The collection of residual urine in the bas fond behind the obstruction is more or less stagnant as a consequence of imperfect emptying of the bladder and very readily undergoes decomposition under favorable circumstances of bacterial infection. The condi tions necessary for infection are almost invariably afforded by septic catheterization by either the patient or his physician. Consequent upon the sepsis, cystitis with ammoniacal decomposition of urine results. The infection in extreme cases travels along the ureter to the kidney, setting up septic pyelitis and finally pyelonephritis. The process _develops so gradually that the patient may tolerate it for a prolonged period. In some instances the urine when freed from the products of mucous inflammation appears so nearly normal that serious renal disease is not suspected. The degree of involvement of the kidney compatible with life is, in these cases, something ex traordinary. The patient may tolerate his pyelonephritis for a pro longed period and may appear to be a favorable subject for opera tion. Operative shock and anesthesia, however, precipitate acute of the already damaged kidney, and the patient dies, the post-mortem examination revealing the fact that but a very small pro portion of cortical substance of the kidney remains, and this is so damaged that it is extraordinary that the patient should have been able to endure it for so long a time. The gradual development of the process, with a relatively slow tissue metabolism and a certain degree of acquired tolerance of urinary toxemia is the probable explanation. The practical point which the author desires to emphasize is that seri ous impairment of the kidneys is inevitable in all cases of prostatic hypertrophy which produces even moderately serious obstruction to the urinary outflow, if the obstruction be allowed to continue for any great length of time. In long-standing cases in which operation is proposed, the existence of serious impairment of the structure and function of the kidneys is to be taken for granted, the condition of the urine to the contrary notwithstanding.