URINARY AND PROSTATIC TROUBLES (ENLARGEMENT OF THE PROSTATE) BY WILHELM KARO, M.D.
URINARY AND PROSTATIC ORGANS:
BLADDER troubles of elderly man are of such frequent occurrence that not only the physician, but also the layman becomes familiar with them. It also is a fact generally accepted, that these troubles are due to an enlargement of the prostate. Whoever has to deal with such conditions, whether a general allopathic practitioner or a homoeopathic doctor, or the sufferer himself, each should have an exact knowledge of the anatomy of the prostate, of its functions and of the pathological conditions which frequently cause obstruction to the urinary flow.
Treating these patients, no practitioner ought to rely on the homoeopathic principles: “Similia similibus curentur,” without a thorough examination of the patient; since a reliance on the patient’s symptoms alone may very easily prove to be fatal.
Considering these facts, I review at first the anatomy and physiology of the prostate. Though it may be difficult to a layman to understand it, I hope he may get some idea of it, enabling him to judge the bladder troubles due to the pathological condition of the prostate, the urethra and the bladder.
The prostate is a glandular organ lying between the pubic bone and the rectum and between two lines going from the pointed end of the coccyx bone at the back to the upper and to the lower margin of the pubic bone in front. The longer line, a line joining the two, roughly defines the prostate. The base of it lying above, the apex below. The urethra passes through the prostate in such a way that the grater part of the prostate lies under the urethra, the smaller part above. The prostate embraces the urethra rather like a signet ring.
In the adult the prostate has the size and shape of a walnut, being about 12 inches broad, I inch long and 3/4 inch thick. Its average weight is about 42 drachms. This, however, represents the average weight of the prostate when removed from the dead body, covered by its “sheath,” which, as we shall state later on, is not really a part of the prostate, but only the envelope in which it lies. The real weight is less-probably about 3 drachms. The base is directed backwards and upwards towards the bladder, the neck of which it embraces, while the apex looks forwards and downwards. The posterior surface, which is smooth and slightly grooved in the middle line, rests on the rectum, from which it is separated by dense fibrous tissue, which forms part of the “sheath” of the prostate.
The prostate consists of two lateral lobes, between which the ejaculatory ducts enter from behind, before opening into the prostatic part of the urethra. A third, or “median” lobe was described by Sir Everard Home in the early part of the last century as existing in the normal prostate, and Sir Henry Thompson refused to agree. His contention has been almost universally accepted. Practical experience derived from numerous dissections of the healthy prostate and 1,625 operations for removal of the enlarged organ in its capsule, convinced Sir Peter Freyer that Sir Henry Thompson was correct in his view and that the so-called “middle” lobe is merely a pathological product, derived from one or both lobes, and that it is non-existent in the normal prostate. There is, it is true, a median portion or bridge of tissue, sometimes forming a rounded prominence above the ejaculatory ducts in the normal prostate, but this is derived from both lateral lobes, which are in this position more intimately blended than in the rest of their course on either side of the prostatic urethra.
Structurally the prostate is composed of glandular substance and stroma made up of muscular and fibrous tissues. The glandular substance consists of follicular pouches with ducts lined with columnar epithelium. The excretory ducts, from twelve to twenty in number, open into the urethra beside the veru montanum. The muscular tissue forms the bulk of the prostate, its supposed function being to eject the glandular secretion or prostatic fluid to mix with that form the ejaculatory ducts of the testicles.
The function of the prostatic fluid consists in mobilizing the spermatozoids. It the semen does not contain the prostatic fluid, the spermatozoids are devoid of motion, consequently such an individual is sterile.
The prostate has a general tendency to increase in size after the age of fifty, but not all these men suffer form any subjective symptom through it. From statistics, collected by the late Sir Henry Thompson and others, about 33 per cent. of men beyond 55 years of age are subject to enlargement of the prostate, but no more than 5 per cent. ever suffer from symptoms. This percentage is rather too low. Anyway, as already mentioned in my first statement, the number suffering from troubles due to the enlargement of the prostate is very large. Every practitioner has to deal with them and is aware of the serious symptoms frequently met with in these cases.
What is the anatomical condition of the enlargement?
The enlargement may be uniform in character, the hypertrophy extending equally to both lobes, the gland thus preserving its symmetry. But in the fully hypertrophied prostate, as will subsequently appear, the pyramidal contour of the organ becomes reversed-that is to say, whereas in the normal prostate the apex of the pyramid lies towards the perineum and the towards the bladder, in the hypertrophied prostate the base of the pyramid lies towards the perineum, the apex being placed in the bladder. The manner in which this alteration in shape is gradually brought about during the process of enlargement of the organ will be explained later on.
The two lobes may be unequally enlarged; indeed, one lobe may be enormously hypertrophied, the other remaining almost unaltered, except as to the shape impressed on it by the bulk and pressure of the other lobe. The surfaces of the lobes may remain smooth and uniform, but frequently nodular outgrowths project therefrom. These outgrowths are always confined within the true capsule of the prostate, they may form polypoid-like outgrowths projecting into the cavity of the bladder and connected with the main body of the organ merely by narrow pedicles.
In size, the enlarged prostate may reach from anything beyond the normal walnut to the size of an orange or even a coconut.
The urethra and the bladder will be altered in shape in accordance with the size and from of this overgrowth. The prostatic urethra is invariably lengthened and may attain to several inches, so that 15 or 16 inches of catheter may be introduced before the urine begins to flow. When the lateral lobes of the prostate are symmetrically enlarged, the urethra is compressed from side to side, and one section resembles a vertical slit. When one lobe only is enlarged, the urethra being diverted to the opposite side, will be curved laterally. If there be a median outgrowth in the bladder, the urethra will be curved upwards towards the inner opening of the bladder; and if this be very large, piriform and projecting into the bladder, there will be a channel on either side, the urethra being Y-shaped. When the overgrowth assumes the form of a collar round the neck of the bladder, as it sometimes does, the urethra will necessarily be contracted at this situation.
The prostate being debarred from expansion below by the perineal ligament, it gradually advances upwards in the direction of least resistance. The urethra is carried with it and the inner opening placed on a higher level than the base of the bladder, which remains stationary. A post-prostatic pouch is thus formed in the bladder, which is never emptied of urine during the acts of micturition. This remaining quantity of urine, which is termed “residual,” gradually increases, as the hypertrophy progresses and the muscular power of the bladder diminishes owing to the persistent overstrain to which the organ is subjected in order to overcome the obstruction to the flow of urine. In the early stages of the disease there is a compensatory hypertrophy of the bladder walls to overcome this obstruction but in times, owing to the constant straining dilation ensues, so that the bladder often contains several pints of urine. The walls may become very thin or muscular trabeculae may develop, between which the mucous membrane bulges outwards, forming saccules of various sizes. In course of time changes occur in the ureters and kidneys from backward pressure due to the obstruction of the urinary flow; due to the disorders of the kidneys, the whole vascular systems gets seriously damaged, resulting in high blood-pressure, heart troubles, haemorrhoids and other disorders of the rectum.
We do not know the cause of the enlargement of the prostate. Many theories have from time to time been put forward to account for the enlargement of the prostate peculiar do declining life, none of which can be said to fit in completely with all the phenomena attending the disorder. Quoted from Sir Peter Freyer’s Lectures on Prostatic Hypertrophy.
