enlargement of so severe a degree may exist that, after urination, several ounces of urine may be retained, without giving rise to clinical symptoms of any importance if the urine does not become infected, and if the patient does not become exhausted as the result of intercurrent disease. If the bladder muscle and the fibers surrounding the neck of the bladder and the prostate are weakened because of some systemic disorder, then prostatic obstruction may cause retention. If acute inflammation attacks the base and neck of the bladder as the result of infection, as from gonorrhea or following the passage of an unclean instrument, an enlargement of the prostate tends to retard recovery from such inflammation. Such cases are frequently encountered, very often presenting no marked clinical symptoms except a slight chronic posterior urethritis that does not yield readily to treatment, and the presence of residual urine varying in amount from one to eight ounces. It is sometimes difficult, in these cases, to determine what form of prostatic enlargement is presentwhether of the lateral lobes, the third lobe, or of both. In most enlargements, however, the two side lobes are involved to a greater or less extent. The form of prostatic enlargement may be determined, or diagnosis aided, by introducing a catheter into the bladder and passing it back to the posterior surface of the viscus. All the urine in the bladder, or the residual urine, if the patient has urinated, should be allowed to run out through the catheter, which should then be withdrawn very slowly. After one or two inches of the catheter have been returned, more urine-from 2 drams to 4 ounces-may flow out of the end of the instrument, tending to show the presence of a pocket in the bladder, often due to a third lobe enlargement. On withdrawing the catheter still farther, only a few drops-a half dram or so of urine that may have remained within the urethra will escape. In examining a patient, with chronic retention, if a large amount-over eight ounces- of residual urine is found, the bladder should not be emptied completely at the first examination, unless some other fluid is injected in place of the urine, as the too sudden emptying of an overdistended bladder may give rise to cystitis, hemorrhage, or shock.

The diagnosis may sometimes be made by passing a Kollmann

dilator into the bladder and screwing it up about No. 30. contraction will be felt, offering a very strong resistance to any further distention of the neck of the bladder by the dilator. It is often possible, in these cases, to dilate to within one number of the point at which the contraction is felt without producing discomfort, and without any marked difference being noticed as regards obstruction to the distention of the instrument up to that point. At that particular point and beyond strong resistance is met. Ordinarily this is evidence either of stricture at the bulbomembranous junction or of the results of inflammatory conditions deeper in toward the neck of the bladder, conditions not infrequently found associated with prostatic hypertrophy. In healthy urethras No. 40 can often be reached on the scale of the dilator without contraction becoming apparent. A searcher may be passed, rotated to one side and withdrawn until it is caught, then rotated to the other side of the bladder, and the same procedure gone through, any difference to the extent it can be withdrawn being noticed on the marker on the searcher, also completely rotated and then brought forward. By this means the approximate size of the prostate may be arrived at. It should also be examined with a searcher or sound in the bladder and a finger in the rectum, and, finally, in a doubtful case, the view obtained through the cystoscope will be of great diagnostic aid to the competent observer.

In making a diagnosis of prostatic hypertrophy care must be taken not to confound the difficulty in micturition due to this condition or to stricture with that due to diseases of the nervous system or of the kidney, or to simple muscular weakness due to age or exhausting disease of the bladder-wall. Ciechanowski has found, by making careful measurements of the bladder muscular tissue, comparing the bladder-walls of the aged and of the young, that there is likely to be a diminution-a very large one, of some 50 per cent. or more- in the amount of muscular tissue of the bladder-wall of the aged, even when no acute inflammatory condition of the bladder-wall exists.

Symptoms. The clinical symptoms of prostatic hypertrophy have been previously mentioned and are generally well understood. The most prominent are increased frequency in micturition,

Hypertrophy of the lateral lobes of the prostate with the tumor presenting inside the bladder and showing an oval calculus lodged in a sacculation posterior to the enlarged prostate. (From a specimen in the Carnegie Laboratory Museum.) (Natural size.) a, Thickened and inflamed folds of the bladder mucosa; b, calculus lodged in sacculation of the bladder wall; c, enlarged lateral lobes of prostate; d, root of the penis showing slight degree of enlargement of prostate outside of bladder.

with apparent loss of muscular power to perform the act, the increase being most noticeable at night or toward early morning; diminution in the size of the stream, and, following attacks of cold or of dissipation, very probably a history of retention.

In those cases presenting the clinical appearance of chronic posterior urethritis, together with a resistance to a Kollmann dilator in the prostatic urethra at about No. 30 French, associated with retention of urine-from 4 to 8 ounces-and proving rebellious to the simple treatment of posterior urethritis-that is, not showing a marked tendency to get well under hygienic treatment, as ordinary cases of posterior urethritis often do we may be quite sure that we are dealing with prostatic hypertrophy. The cases of so-called chronic contraction of the bladder neck, as described by some specialists, are to be found in this class. There is no reason why, anatomically, there should not be chronic contraction of the bladder neck. The old belief that stricture, meaning by that the formation of scar tissue, could not exist in the prostatic urethra was found to have no anatomic foundation. The scar tissue forming in the deep urethra may give rise to the so-called third lobe enlargement or enlargement of the lateral lobes of the prostate in the manner already described. It may also, through infiltrating into the surrounding tissue, cause bands of cicatricial tissue to form in the prostatic urethra. Bands do occasionally exist, but are of comparatively rare occurrence. The writers believe that these cases, which have been considered by some observers under the heads of chronic contraction of the bladder neck, are due chiefly to third lobe prostatic enlargement; but whether due to this or to infiltration of scar tissue in the prostatic urethra, the writers have never seen any uncomplicated case that needed operative treatment for its relief, beyond such as might be furnished by dilatation with the Kollmann dilator and treatment of any accompanying posterior urethritis.

Treatment. Dilatation of the prostatic urethra at intervals of a week or two weeks, carefully performed by means of the Kollmann dilator, together with or alternating with solutions of silver nitrate of varying amount and strength, and proper constitutional treatment, will benefit very markedly those cases of contraction at the neck of the bladder for which no radical operation is re