The preceding cases, eighteen in number, have been condensed into a tabular form. They constitute the greater portion of the data on which our knowledge of this disease is founded. The age of the patient, the condition of the prostate itself, and that of other organs of the body also tuberculous, are presented. The sources from which they are obtained are also added in a note.

CHAPTER XVIII.

CYSTS, OR CAVITIES IN THE PROSTATE.

True Cysts unknown-Cavities are of three kinds-Dilated Follicles; Purulent Depôts; and containing Concretions-Hydatid Cysts between the Prostate and the Rectum.

SMALL cavities, which have received from many authors the name of cysts, are frequently to be seen in the prostate, especially in those of aged subjects.

If by the term cyst' it is designed to describe a thin-walled, celllike body or closed sac, spheroidal, or nearly so, in form, containing fluid, a structure of new formation apparently, not a mere dilatation of some already existing cavity, then I know of no such affection of the prostate, either from personal examination or on the report of others. Such cysts are found in many parts of the body, containing hydatids, jelly-like material, serous fluid, &c. But in the prostate we find no such isolated cysts as, for example, in the kidney, nor any formation indeed which can be regarded as analogous to that, which may be considered as the type of simple fluid cysts. Although I have, in conformity with the practice of other authors, referred to 'cystic disease' of the prostate, it does not appear that the use of the term is warranted by the phenomena presented; and if retained, it must be held to signify a formation of a wholly different kind from that which is indicated by it in the breast or kidney; neither is any species of proliferous cyst ever met with.

Cavities are frequently found in the prostate, but these manifestly belong to one of the three following orders :—

(a) Mere dilatation of gland-follicles.

(b) Cavities containing pus; abscess.

(c) Cavities containing concretions or calculi, the walls of which become denser and firmer in proportion to their magnitude, which corresponds with that of the contained body.

Of the first kind, viz., dilated gland follicles, examples may be found in most prostates from elderly subjects; as has been before seen. some of the gland-follicles generally exhibit a tendency to enlarge or

dilate as age increases. The cavity is often filled with yellowish, semifluid material, or with yellow, semi-transparent concretions, of so small a size as only to be discernible with the microscope. And it appears that the increase in size of the contained and of the containing parts takes place pari passu.

The second kind, viz., cavities containing pus, offers no subject for remark here. These have been fully examined and described in Chapter IV., on the results of inflammation, under the heads of Acute and Chronic Abscess.

The third kind of cavities consists of those which contain solid formations, whether concretions or calculi. It is common, when making sections of the prostate from an elderly subject, whether it is hypertrophied or not, to find cavities, of a somewhat irregular form, in its substance, having all the appearance of being dilated follicles of the glandular structure, which contain numerous little dark-coloured concretions. I have seen from thirty to fifty of these bodies occupying a cavity about the size of a grain of wheat or of a small pea.

But larger concretions, that is, of the size of pearl barley, may occupy each a separate recess of its own; and on removing the foreign body, a spherical, thin, and smooth-walled cavity is displayed. Sometimes hundreds of such small cavities may be found in one prostate,but this is a very rare circumstance. A good example may be found in the Museum of the College of Surgeons, Prep. No. 2519.

The cavities referred to do not attain a sufficient size, nor, as far as I know, do they give rise to any symptom whatever, to render a knowledge of their presence possible during life. Generally speaking, they are capable of holding not more than a few minims of fluid. The late Mr. Coulson describes one case in which such a cavity was capable of containing as much as half an ounce; and he regarded this as a dilated duct.1 In one instance, I removed a number of these small calculi during life, from a sac just at the neck of the bladder, not without difficulty, by means of a very small scoop lithotrite at several sittings; the case was seen in consultation with Mr. Savory of St. Bartholomew's. Such an opportunity of meeting with these bodies is, however, exceedingly rare.

Hydatids of the Prostate.-It is doubtful whether hydatid cysts have been met with in the prostate. The only case on record which may have been an example is one which occurred in the Sussex County Hospital, and is recorded by Mr. Lowdell in the 29th vol. of the Med.Chir. Trans.' The author expresses a doubtful opinion on the subject, but appears to incline to a belief that the prostate was the seat of the hydatid formation. Six other cases may be referred to in which retention of urine and distension of the bladder occurred as a result of a hydatid cyst between the bladder and rectum, near to the neck of the 1 Op. cit. 5th ed. p. 587.

former; but in which the prostate was not affected except by pressure. Prostatic enlargement was very closely simulated, certainly in three of them, and in two the prostatic catheter was employed under the belief of its existence.

The first was reported by John Hunter, in the Transactions of a Society for the Improvement of Medical and Surgical Knowledge, vol. i. p. 34. Here the retention caused death, and between four and five pints of urine were found in the bladder at the post-mortem examination. The viscus was pushed up into the abdomen by the pressure of the cyst below.

The second, by Mr. Curling, appears as an appendix to Mr. Lowdell's paper in the volume referred to above, page 356. Here the same appearances were observed, but in a less marked degree, relief having been given to the retention during life.

The third case occurred to the late Mr. Callaway, at Guy's Hospital, and is referred to in the Medical Times' of February 17, 1855. Hydatids were removed when the catheter was passed. After death a large hydatid tumour was found between the bladder and rectum, pressing on the neck of the former.

The fourth, a man aged 40, was admitted into Guy's Hospital with retention of urine; no catheter could be passed, and he died. At the post-mortem, a large tumour occupied the pelvis and hypogastric region, the anterior and upper part of which was formed by the bladder, pushed out of its proper place. The tumour was a cyst containing three pints of hydatids, and forms preparation No. 210452 in the Guy's Museum; near to which is another very similar.

The fifth occurred in a man, aged 59, admitted to the Westminster Hospital with retention of urine, under the care of Mr. White. A catheter could not be made to reach the bladder, which was therefore punctured through the perineum, a pint of urine escaping. He died next day, and a large hydatid tumour was found just above the prostate, pressing against the back of the bladder so as to divide it into two portions, of which the upper still contained two pints of urine; the lower, which held one, having been evacuated by the puncture.

I have recently become acquainted with a sixth case, that of a lad, nine years old, and suffering from retention of urine, in whom a large and fluctuating tumour, occupying the position of the bladder, was felt within the rectum. No instrument could be passed, and the rectal puncture was performed, the result being, not the removal of urine, but of the contents of a hydatid cyst. This relieved the retention, and the boy recovered.

In the Museum of St. Bartholomew's there is a good example of a large hydatid cyst occupying a position between the bladder and rectum. In this case the prostate does not appear to have been affected. It is preparation No. 15, series xxix.

It does not appear unlikely that Mr. Lowdell's case may have belonged to the same category, the prostate being more or less absorbed by pressure from an external cyst, so that the latter came at length to occupy the situation proper of that organ. The case is, however, given here in an abridged form.

HYDATID DISEASE OF PROSTATE. (?)

J. I., aged 64. In Sussex County Hospital, in July 1844, under the care of Mr. John Lawrence, jun. During three or four years had experienced difficulty in making water and frequent micturition; and of late, almost complete retention. The bladder was now emptied by catheter, after great difficulty, and three pints withdrawn. Much pus and mucus passed afterwards. He died in a few days.

P.M.-Bladder very much thickened, and in the situation of the prostate was a tumour larger than a fœtal head, which, when cut open, proved to be a hydatid cyst, closely packed, the true substance of the prostate being lost in it. Hydatid tumours were also found in the omentum.

Whether the hydatid cyst was formed in the prostate itself, or external to the organ, destroying it by pressure alone, is stated to have been a matter of doubt. Appearances led Mr. Lowdell, who reports the case, to the former view. The facts of hydatid disease of the prostate being unrecorded, together with the existence of other tumours in the omentum, inclined him to believe that he should be scarcely warranted in maintaining that opinion without question.'-Trans. Med.-Chir. Soc., vol. xxix. p. 253. 1846. By George Lowdell, Esq.

CHAPTER XIX.

THE BAR AT THE NECK OF THE BLADDER.

Relation of this subject to Prostatic Enlargement-Most Organic Obstacles at the Neck of the Bladder are Prostatic-A few Cases which are exceptional-Mr. Guthrie's Recognition of them-His Views defined-Views of Civiale, Mercier, Gross, Leroy-A Bar may be due to repeated Contractions of the Bladder from any cause whatever, if long continued-Shown to consist, in such cases, of Muscular Hypertrophy-Examples-CONCLUSIONS on the whole subject—Rarity of any affection meriting the appellation of Bar in absence of Enlarged Prostate -DIAGNOSIS-TREATMENT-When due to Muscular Hypertrophy, as in Stone or Stricture, will disappear on removal of the cause-Mr. Guthrie's Proposal to divide Obstructions at the Neck of the Bladder-Mercier's Modes and Instruments-Bottini's Method by Electric Cautery.

A CONDITION of the neck of the bladder is often observed, mostly coexisting with hypertrophy of the prostate, to which the term, 'Bar at the Neck of the Bladder,' has been applied. And such a description not inaptly conveys an idea of the morbid change which is present. It will, therefore, be considered under the title referred to, although constituting rather a variety of disease already studied than a specific affection of another kind.

We have already seen in Chapter V., that a bar at the neck of the bladder is frequently due solely to enlargement of some part of the prostate; but a somewhat similar obstruction is sometimes, though rarely, present when that organ is not the subject of disease. It is to this latter condition that the term, as designating a distinct affection, has usually been applied in this country.

Although numerous forms of obstruction at the neck of the bladder have been frequently described, at some length, by the well-known French writers of the present century on urinary diseases, under the names of bourrelets,' ' barrières urétro-vésicales,' 'brides,' and 'valvules,' no specific distinction was recognised between the form of obstacle about to be described, and that which consists in senile enlargement of the prostate, until the late Mr. Guthrie called attention to the subject in his lectures at the Royal College of Surgeons in 1880. He examined it with care, and arrived at more precise views respecting it than any previous writer had done, pointing out the distinctive characters of the two affections, the prostatic and non-prostatic; and the term which he employed to designate the latter is retained here, in the sense which he originally intended it to convey. The views which he entertained respecting the distinct character of the two affections are summed up briefly by himself, and may be given here in his own words. He concludes :

1. That an elastic structure exists at the neck of the bladder, and may be diseased without any necessary connection with the prostate gland.

2. That the prostate may be diseased without any necessary connection with the elastic structure.'

་

He quotes two cases, one in which, without any affection of the prostate, and particularly of the third lobe, the patient passed his water with great difficulty, in consequence of the barrier formed by this unyielding structure, and died ultimately of the disease, after much suffering.' Another, in which, as a consequence of unequally enlarged lateral lobes of the prostate, the right being most so, the mucous membrane of the neck of the bladder had been drawn up 'so as to form a bar across its under part. This bar,' he adds, 'is quite membranous, and does not include the elastic structure which is not diseased, neither is that part called the third lobe, nor is there any projection into the bladder, save the bar or valve formed by its mucous membrane at the very meatus.'1

Of these two cases, as the author observes, one was exactly the reverse of the other. Each is, indeed, typical of two perfectly distinct classes of abnormal conditions affecting the neck of the bladder.

On the Anatomy and Diseases of the Urinary and Sexual Organs, being the first part of the Lectures delivered in the Theatre of the Royal College of Surgeons in 1830, pp. 23 and 25. By J. G. Guthrie. London, 1836.