trary, there is a projection of one of the lateral lobes, the beak, in passing the spot, inclines to the opposite side: the handle indicates this movement and the direction in which it is made."*

This portion of the subject may be appropriately closed with a few remarks on the diagnosis of prostatic enlargement from stricture of the urethra, vesical calculus, tumor of the bladder, simple atony or inertia of the coats of the bladder, and paralysis.

In stricture of the urethra, the stream of urine is invariably small, in a confirmed case extremely so; in the prostatic affection, though diminished in force, it is much less so in volume than in the previous case. The use of a fullsized sound, however, marks the distinction clearly. In stricture, obstruction is encountered almost invariably before six inches of the instrument have disappeared, always before it arrives at the prostatic urethra. In enlarged prostate, obstruction is not encountered until eight or nine inches. have passed, and not necessarily then, for, provided that the instrument be sufficiently long, it may pass into the bladder; but the handle has to be depressed between the patient's legs in a manner not required in the normal state. Lastly, stricture almost invariably makes its appearance before middle life, prostatic hypertrophy not until that period is passed.

In regard of calculus, while many of the symptoms are common to both complaints, the occurrence of sudden cessation of the stream of urine, of severe pain at the close of micturition, the exacerbation of symptoms, especially of pain, and the appearance of a little blood after exercise, may be looked upon as strongly indicating the presence of stone in the bladder. But it may exist in the absence of most of these, the two first-named especially, from the cir

* Recherches Anat. &c., pp. 364, 265.

cumstance that the calculus is usually situated behind the

approach the more sensitive The fact of small quantities

enlarged prostate, and does not region of the internal meatus. of florid and unmixed blood being occasionally passed after exercise, more closely approaches in value to a pathognomonic sign than any other. A persistent discharge of mucus, or ropy pus, in the urine should also arouse suspicion.. The use of the sound, however, can alone clear up this case also satisfactorily.

The existence of tumor of the bladder is less easily affirmed. Compared with prostatic enlargement there is much more pain, and exquisite tenderness on the introduction of instruments, the urine is frequently or generally mingled with sanious discharge and flocculi, to which sabulous matter is often seen adhering. Examination of these under the microscope may reveal the peculiar structure of villous growth, or which is almost equally significant, may demonstrate that they consist of organized structures, not of inorganic materials.

Simple uncomplicated chronic cystitis, with catarrh, is by no means a common affection. The series of symptoms thus denoted is almost invariably due to the presence of a foreign body, to some form of obstruction, or to paralysis, depriving the patient of the power of expelling the contents of his bladder, a condition which is tantamount to obstruction. We may rely upon it that in most of the obscurer cases, there is a material cause, most frequently calculus; the presence of which needs a more than ordinarilysearching examination to verify. It may be encysted, or otherwise rendered difficult of detection by the sound. The absence of all the physical signs of enlarged prostate, by rectal and vesical exploration, will, of course, prove the non-existence of that complaint as a cause.

Single or repeated acts of voluntary over-retention of urine

are sometimes followed by atony or inertia of the muscular parietes of the bladder, and a state of chronic retention follows from their consequent inability to expel the vesical contents. The condition resulting resembles much the retention produced by enlarged prostate, and requires frequent relief by the catheter in the same way, at least for a time. Here the absence of positive signs, the suddenness of the attack, its connection with a cause generally recognized by the patient, and the diminished power of discharging the urine after a catheter has been placed in the bladder, are quite sufficient to distinguish this affection. Particular attention should be paid to this last-named point. In enlarged prostate, the urine often flows with considerable force when the influence of the obstruction is removed by the introduction of a catheter, and the current can be accelerated materially by the will of the patient, unless there be atony also, as there may be from undue distension; however, it is not generally considerable, except in longneglected cases. But when the cause of engorgement and retention is not obstruction, but complete atony of the bladder, the urine runs out of the catheter, and is not propelled, neither can the flow be much influenced by any efforts of the patient.

Lastly, there is paralysis of the bladder, a condition in which its nervous supply is either impaired or destroyed. It is almost always associated with a similar condition of the lower extremities, and this may result either from disease or injury of the encephalon or spinal cord. There is no evidence of the existence of true paralysis, that is, a removal or impairment of nervous influence, limited to the bladder; nevertheless, the term paralysis is constantly applied, but most inappropriately, to denote inability of the viscus to expel its contents, whether the cause be obstruction at the neck, or over-stretching (atony) of its muscular walls. The blad

der is not deprived of nervous force, and thus rendered paralytic, except when there is lesion of some nervous centre involving numerous other parts in the same predicament, any more than is the stomach, the intestines, or any other single viscus (see preceding chapter). There can be no doubt respecting its presence; therefore, when it does exist, the indication which catheterism presents is also singularly characteristic. An instrument being introduced, the urine is propelled by the weight of the parts around, the will of the patient exerting no influence upon its flow unless the abdominal muscles should be in a normal condition, as in cases of injury (rare) occurring to the spinal cord between the sources of nervous supply to the muscles and to the bladder, in which case a slight influence is perceptible. Otherwise no impulse is noticeable, except through the agency of acts unassociated with micturition; such as deep inspiration, coughing, sneezing, and the like, by which a momentary pressure is communicated to the paralyzed bladder, and the stream is momentarily accelerated.

CHAPTER VII.

THE TREATMENT OF SENILE ENLARGEMENT OF THE

PROSTATE.

The subject one of considerable importance.-May be treated under Three Heads.-1. TREATMENT for the purpose of obviating the results of obstruction caused by enlarged Prostate. Necessity for removing retained UrineQuestion of patient relieving himself-Instruments to be used-Of permitting a Catheter to remain in the Bladder-Evil results of not relieving the Bladder. Treatment of CHRONIC CYSTITIS - Injections - Counter-Irritation-Baths-Buchu-Pareira brava-Uva ursi-Matico-Lythrum Salicaria-Alchimella Arvensis-Epiga repens-Chimaphila-Wild CarrotCopaiba-Cubebs-Benzoin-The Demulcents. Indications for use of the foregoing. The Mineral Acids-Alkalies-Benzoic Acid.-A Case.IRRITABILITY OF BLADDER-Value of Opiates-Injections.-HEMORRHAGE-Its Treatment.-INCONTINENCE of Urine-Treatment.-Recurring attacks of Congestion.-2. THE GENERAL TREATMENT and Management of patients with Enlarged Prostate-Dietetic, Regiminal, and Moral.-3. SPECIAL TREATMENT against Enlargement itself-Hemlock-Mercury-HydroChlorate of Ammonia-Iodine-Mr. Stafford's Method-Bromine-Kreuznach Waters.-Compression, History of New Method of Applying.-Division and Excision-Crushing, &c.

THE topic presented for consideration in this chapter is one of great interest and importance; and is well worthy to be the subject of prolonged and careful study. Its interest for the practical surgeon consists in the fact that, notwithstanding the generally-admitted intractability of the complaint, much may be done to palliate its most distressing symptoms, and to retard its progress; while, associated with this, is the knowledge that the attainment of any means capable of arresting that progress, or of curing the disease, would be one of the greatest boons ever bestowed by the science of medicine upon suffering humanity. The importance, therefore, of the subject is equally manifest. No wonder, then, that the search for remedial treatment should constitute