PROSTATIC ENLARGEMENT.
In the early stages of enlargement of the prostate there is no procedure of so much importance as the effectual emptying of the bladder by natural means. The patient should be instructed to carefully expel every drop of urine without making violent expulsive efforts, and often after the urine has ceased to flow, by a further attempt a few minutes later when the amount of residual urine is small he may succeed in completely evacuating the contents of the organ. He must also he taught that under no circum stances in the daytime should he permit a period of four hours to pass without voluntary emptying of the bladder, and at night micturition should be performed at least once between bed-time and getting up.
Though there have been few departments of surgery in which so satis factory advances have been made as in the operative treatment of enlarged prostate, still a note of caution is necessary since a percentage of cases reach a standstill in the progress of the enlargement which is compatible with a prolonged life of tolerable comfort without operative interference.
This satisfactory result, in the writer's opinion, is more likely to occur in those cases of moderately small fibrous prostates which occur at a comparatively early age, say about 5o years, where an inflammatory clement enters into the condition. Such cases may be recognised by rectal exploration with the finger and by cystoscopic examination, which will reveal a trifling intravesical protuberance. By careful attention to the emptying of the bladder and by the patient employment of rest and %esical sedatiN es during matte exacerbations, the secondary changes in the bladder Imlay sometimes be indefinitely postponed, even when catheteri sation has heen demanded at sonic time for temporary retention. The following bladder sedative is often of distinct value in controlling the irritability about the vesical neck and prostatic portion of the canal: Ext. Saw Palmetto Lig. Tinct. voscyami 5iv. Syr. A urantii 51.V. dl isce.
Ft. mist. cpt. 3j. grader in die ear ass. ague& The combination will Santal known as Sanmetto and Woolley's Elixir arc both excellent drugs.
Whilst such palliative measures are recommended by the writer as a mild protest against immediate and indiscriminate resort to prostatec tomy, it should be understood that a septic state of the urine should never be permitted to develop. Ammoniacal urine, severe cystitis, haemorrhage
or retention setting in should he a clear indication for radical operation.
The normal bladder should empty itself when moderately full in about 3o seconds after the flow of urine commences; a period of 45 to 6o seconds should be regarded as pathological.
Catheterisation is permissible in those cases in which the instrument is only necessary before retiring to bed: regular " catheter life " should only be recommended in very old and otherwise diseased patients where an operation is strongly contra-indicated, and it is hardly necessary to emphasise the warning that the catheter should never in a case likely to require operation be put into the hands of a patient who cannot be depended upon for the carrying out the most rigid asepsis.
in inoperable cases where a septic condition of the bladder has already occurred, urinary antiseptics as Urotropine or Creosote by the mouth and washing out the diseased organ by saturated Boric Acid solution must be resorted to Sometimes it may be necessary to drain the bladder by regular catheterisation or he retaining the catheter in situ, and when this annot be boric tyr401.01ny may he necessary for the provision of complete drainage.
In operable cases where the bladder has already become infected the stole measures will be necessary to diminish sepsis as far as possible before resorting to the removal of the enlarged prostate.
In the use of time catheter for retention from enlarged prostate some important points must he remembered. A soft rubber instrument with mode end of size 12 E should always he used when such can be passed into the bladder; failing this a large gum-elastic coude should be gently tried: a small or finely pointed instrument should never he employed: in difficult cases before resorting to suprapubic tapping a large and long silver prostatic catheter may be tried, but this should not be placed in the hands of the patient. A. B. Mitchell has proved that suprapubic removal may be safely carried out in acute retention without waiting for temporary relief by the catheter with two provisos: (r) That the urine is sterile, and (2) that there has been no dilatation of the ureters with back pressure on the kidneys. This is indicated by pain in the inguinal region passing upwards along the ureter and a plentiful urine of low specific gravity.