DR. PARSONS: Dr. Foster asked for experience with the thermocautery. He says it was followed by sloughing. Let me tell him that thyroidectomy was thought to be a terrible operation, and they used the thermo-cautery because they are afraid of great hæmorrhage. This fear of hæmorrhage is a bugbear in all these cases, unless you have an aneurismal condition; otherwise it is not a hard tumor to remove. You can do it without the loss of more than two ounces of blood, and the most blood will be from the cut in the cutaneous structure. But if you get hold of a case where there have been injections of iodine and other drugs forming adhesions to the skin, then you may have difficulty, but ordinarily you can remove them without the least difficulty. Go down to the capsule in the median line and peel the tumor out, which can easily be done, from its bed. I expose the capsule with an ordinary incision and separate the capsule on one side from the surrounding structures with my fingers and lift the gland through the wound. The capsule should not be opened. Each lateral half may be ligated en masse, or first transfixed and then tied. Sometimes I do not put on any ligature at all, but cut off what I want to take out of the gland and then close up the incision. Do not remove the whole of the gland, as myxedema is likely to follow in that event. The only danger is where there is a pulsation in the tumor like an aneurism. careful; otherwise not.

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I will say that I have had no experience with the thyroid fluid for injections, but a gentleman who came to me from California was taking four thyroid glands a day and had been for six months, and he said that he was better, but I do not know how much. His cheeks and lips and neck were swollen and hard. There was no pitting on pressure, but rather an elastic condition. It was not like ordinary dropsy; it was hard and elastic. His tissues were all hard. There was another peculiar feature in his case, and that was the condition of sensation. If I turned his face to one side and put a solid body in his hand and told him to close his hand on it, he could not give me the physical properties of that body. That is, he could not tell whether it was large or small, or whether it was square or spheroidal. He could not tell whether it was hot or cold, but if I put something extremely hot in his hand he told me it was cold.

How the thyroid glands which he took were prepared I do not know, but I think they were cooked and put up in capsules. It was the extract of the thyroid gland that he took four times a day. They were sheep glands.

PROSTATIC HYPERTROPHY.

BY T. L. MACDONALD, M.D., WASHINGTON, D. C.

PROMINENT among the many ills that, until recently, were relegated to helplessness and hopelessness was the hypertrophied prostate and its associated genito-urinary lesions. And although, in the last few years, specialistic research and clinical experience have done much to increase our knowledge in this direction, I have no hesitation in saying that, from our medical rank and file, the subject is still far from receiving the attention it merits.

Causes. They are not understood. It is surmised by some that prostatic hypertrophy is one of the footprints of Bacchus or Venus, or of both. This, however, is merely conjectural, and it is not surprising that the etiology should be unknown, when, among some, even the physiology of the gland is a mooted question, some believing it to be an accessory organ of micturition, and others that it is a sexual organ. It might be one or both, inasmuch as it is perforated by the urethra and common seminal ducts.

That its essential function is sexual would seem to be borne out by the fact that it is found to atrophy, in both man and animals, after castration, and that among some animals it is much enlarged during the breeding season.

There has been an attempt made to associate prostatic hypertrophy with the general atheroma of advancing years. So far, however, the relationship has not been established beyond the fact that they occur coincidentally. Nor with the gouty diathesis, save that they are more prone to lesions of the genito-urinary tract.

The prostate is regarded by many as the analogue of the uterus, and that the hypertrophy is of the fibroid or myomatous nature, like that which occurs so frequently in the uterus. There is some ground for this belief. In the latter half of the reproductive period both prostate and uterus are subject to hypertrophic changes, the histology of which is quite similar-fibro-myomatous. these facts throw no light upon the etiology.

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This hypertrophy is thought by some to be a remedial lesionthat as age comes on the base of the bladder sinks and the prostate enlarges, to keep the base of the bladder on a level with the urethral orifice. And, therefore, the residual urine precedes the hypertrophy. This theory has few supporters.

As pathological data we know that the gland may undergo general hypertrophy and maintain its normal shape, but most frequently it is irregular. The hypertrophy sometimes consists of growths apparently identical with the uterine fibro-myomataround, firm growths, easily shelled out, often multiple and formed of concentric fibrous layers.

Such growths may form irregular projections from any portion of the gland into the bladder. The gland may vary in size from that of a horse chestnut to an adult fist. In the latter case the prostatic urethra is lengthened and usually made irregular. The gland may grow mainly in the direction of the rectum or one lateral lobe may be the main seat of hypertrophy, or the "middle lobe" may grow upward and overhang the urethral orifice like a valve. Again, by its more general enlargement upward the orifice of the urethra is raised above the basfond, establishing ante- and post-prostatic pouches. Occasionally the urethra may be kept patulous by irregular projections into it, and enuresis, partial or complete, is the result; oftener, however, obstruction to the outflow results.

It is not known how long such a lesion exists before the patient. begins to suffer, but, sooner or later, the mechanical obstruction, to complete evacuation of the bladder contents, disturbed circulation, nerve perturbations from pressure, residual urine and septic infection, produce most dire manifestations.

The obstruction and more or less retention causes dilatation and consequent atony with degeneration of the bladder walls; or, in cases where vigorous and frequent bladder contractions occur, there is much thickening of the vesicle walls and consequent diminished bladder capacity. Here trabeculæ are hypertrophied and feel like ridges or cords to the palpating finger. The pressure thus exerted upon the slowly-escaping fluid causes sacculations in the weaker portions of the bladder. The ureters and renal pelves are dilated, the interstitial connective tissue is increased while the renal substance is decreased. With impaired circulation in the vesical mucous membrane, it can offer but little resistance to infection from

fœtid or ammoniacal urine. This is often hastened or aided by the introduction of dirty catheters. Or, if they are sterilized, filth may be carried in from a foul meatus, and cystitis is the result.

Intense inflammation, then, is a frequent accompaniment, and with the inflamed and suppurating mucous membrane, the urine becomes intensely irritating, and the mucus and pus collect in the post-prostatic pouch and the viscus is constantly irritated by urine. which it cannot expel. Catarrhal pyelitis and interstitial nephritis are not uncommon from the infection travelling upward through the dilated ureters. From over-distension, sacculation, crippling of the detrusor muscles or degeneration of the bladder walls, loss of evacuative power results.

Symptoms. Their onset is variable as to time and character. As to time, they manifest themselves most frequently about the age of fifty, although it is evident that the hypertrophy exists long before the symptoms appear. In fact, Harrison has demonstrated that not infrequently cases of prostatic hypertrophy exist that never give rise to any vesical or constitutional symptoms. Frequent micturition is one of the earliest and most intractable symptoms. It is worse at night, worse from long walks, rough carriage rides and when rising from a sitting or recumbent position. In two of my patients this symptom appeared during a protracted railroad journey, and in this way called attention to the enlarged prostate. The urinary efforts increase in frequency till the patient has little or no This symptom is generally attributed to residual urine, which the bladder is incapable of voiding. I do not believe this, however at least during the early stage, while the urine is normal. For at this period, if the bladder could expel all but a few drachms, this could not cause any more irritation than a similar quantity reaccumulating after complete evacuation (White). Of course, this will not apply later, when there is cystitis and foetid urine. Moreover, I have noted this symptom in cases where it was impossible to demonstrate the presence of any residual urine. I am, therefore, led to believe that the agonizing, frequent micturition is due to irritation of sensitive nerve fibrils of the sympathetic system.

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Now, I have the profoundest respect for the great sympathetic nervous system; at the same time there are conditions in which it shows that it possesses sensation, but no common sense. For instance, if there is an abdominal lesion that requires perfect visceral

quiescence, the sympathetic system insists upon emesis; if there is a pharyngitis, constant deglutition is a concomitant; if there be a stone in the bladder, there is persistent vesical effort. And so I believe in regard to the frequent urination accompanying the enlarged prostate. I believe it is reflex, and its constancy, frequency and intractibility show the truth of Emerson's statement: "When nature desires us to do a thing, she overloads the tendency."

Of course, we can understand the frequent micturition at a later period, when urethro-cystitis and foetid and ammoniacal urine exist. Difficulty in starting the stream is another early symptom. It may be caused by obstruction, spasm of the external sphincter or relaxing of the detrusor muscles, or the valve-like projection, before alluded to, overhanging the urethral orifice, could likewise produce this symptom. The "stammering bladder" may result from the action of this projection, which is drawn down upon the urethral orifice by the outflowing stream, and then rises to its former position as soon as it has stopped, or the same starting and stopping of the stream results from the alternate tiring of the detrusor muscles and the contraction of the sphincter vesicæ.

Incontinence is likewise an early symptom in some patients, nor can I agree with what is usually written as to the cause of this. Some writers say that is always a sign of atony and a full bladder. I am well aware that such is usually the condition of the bladder when the patient is suffering from enuresis passiva, which represents the overflow; but I have demonstrated that this symptom may exist without atony and a full bladder. Coulson, Moullin and others believe that it is due to irregular projections from the prostate, which keep the urethra more or less patulous, or, at least, prevent its proper contraction. White does not believe that such a condition ever obtains. Coulson says it does, but incautiously adds that it is usually irremediable." I am satisfied that the latter writer is correct as to his pathology, but mistaken as to its amenability to treatment.

That irregularities in the prostatic urethra can result in enuresis activa is not at all strange. As analogy, we all know how frequently patients speak of the temporary inconvenience arising from the involuntary escape of gas from the bowel after resection of the pileinch. It is due to the fact that the newly-placed mucous membrane has not yet become accustomed to being properly infolded