THE HEMATURIA OF THE SENILE ENLARGED PROSTATE.
The sponge-like tissue of the enlarged prostate is often very erec tile and is, therefore, singularly capable of sudden and rapid enlarge ment from congestion. Its capability of bleeding is enormous.
Surgeons who have removed enlarged median lobes are often struck with the disparity in size between the lobe felt and seen in situ through the suprapubic opening and the same lobe shortly after it has been removed. This diminution in size is due to drainage. The rapid erection of the prostate causes excessive stretching of the super jacent mucous membrane. As this is pegged down posteriorly by the unyielding trigone and anteriorly by the dense orificial attach ment, its veins become thinned and dilated; finally an ulceration opens into their channels. It used to be the custom to ascribe all spontaneous bleeding from enlarged prostate to the bursting of varices or piles of the bladder. This I am sure is a mistake. It is true that certain large and tortuous veins are often seen with the cystoscope coursing beneath the mucous membrane covering the in travesical enlargement of the prostate, but it is doubtful if definite congeries of tortuous veins meriting the name of varices or piles often . exist. The only instances I have been able to find in European museums are in Upsala, Sweden (Nos. 1229, 1388). They are in jected with blue, which shows their character well.
Slight spontaneous hemorrhage from a senile enlarged prostate which does not obstruct so greatly as to necessitate catheterism is not uncommon. Any slight mechanical cause may suffice to repro duce it when once it has occurred. Jolting in a conveyance, venereal indulgence, or a slight chill may produce a hemorrhage without reten tion. The bleeding is supposed to be a relief to the prostate, and it may be so. I believe in some instances at least that this symptom is a local expression of a general arterial change, for some patients who have suffered thus have subsequently died of apoplexy. This observation, however, needs the correction of wider experience.
Prostatic blood may escape pure in the intervals between urina tion and stain the shirt or bedclothes, leading the medical man to believe that it originated in the anterior urethra. It may appear either at the commencement or at the end of the stream, or it may pass into the bladder and find exit with the contents of that viscus. I have known the urine black for days from this source.
Case. —Enlarged Median Lobe of the Prostate—Sndden Attacks of Profuse hemorrhage with massive Clots.—B., aged 70, consulted me in August, 1894. His history was as follows : In 1886 he was seized with retention from holding his urine too long. A silver catheter was used, and he bled freely. For several years after this he used a soft rubber catheter once daily. Several times in the summers of 1887, 1888, and 1889 he had profuse hemorrhages from the bladder. They occurred without warning and were accompanied by massive clots which had to be removed by suction through a large-eyed silver catheter. Toward the end of 1892, cystitis appeared. He had been repeatedly examined with the sound but no stone had been discovered. He was, however, not satisfied, and in July, 1893, ran down a steep hill, leaping high as possible all the while to ascertain if he could feel a stone. He suffered no pain from this unusual exercise at the time, but intense pain came on next clay, and being at AViirzburg he was sounded by Professor Schonborn and a large calculus was detected. It was completely removed by litholapaxy in three hours. It was then supposed that the cause of the hemorrhage had been dis covered and removed, but the attacks did not cease and the profuse ness of the loss was not at all diminished. They still occurred every few mouths. I examined with the cystoscope and found a small upraised median lobe; no stone existed, the bladder was capacious. There was not the slightest difficulty in introducing the shortest cystoscope. A month after this I was suddenly summoned to see him. The bladder was distended with blood clot, and it was with much difficulty that I passed a very long and largely curved pros tatic catheter and evacuated by suction and washing some eighteen ounces of black clot. The prostate was swollen to a remarkable size and the median lobe, which previously had been inconsiderable, was now most prominent. The patient now mentioned that he had suf fered for years from piles which bled profusely, the blood running down his trousers on to the floor, and that when they bled freely the bladder was better. He recovered completely from the attack. Add ing to this other and similar cases in which I have seen the blood issue from the surface of the median lobe, I have but little doubt that the origin of the hemorrhage was prostatic.