grees of enlargement. The situation he assigns to it is precisely the same. The "protuberantia subrotunda, mediocris uvæ acini magnitudine, intimâ tunicâ vesicæ obducta,”* answers well to the "nipple-like projection, pushing before it the membrane of the bladder."

Another appearance also, that of a fold or bridle, extending from the nipple-formed process to the veru montanum, which Mr. Home supposes to have been unnoticed, is described by Morgagni. This is not the place to multiply quotations from a book so well known, and in almost every one's hands, or it would be easy to prove that Morgagni was acquainted with the figure of the tumour, and the part of the gland from which it proceeded: that he well knew that the tumour was formed by the enlargement of the substance of the gland, and not by any excrescence of a different nature from its surface; and that he was aware of many of the phenomena of the disease during life, and of its being a disease of persons advanced in age.

We should not have noticed this part of the work so much at length, nor perhaps entered at all on the discussion of a point of so little consequence, but that Mr. Home evidently attaches much importance to his discovery, and takes exclusive merit to himself for having made it. It is more than probable that Mr. Home was unacquainted with the passage quoted above, from Morgagni's Adversaria. But at least it was incumbent on him to have examined the writings of this most accurate anatomist with a little more care than he appears to have done, before he asserted that Morgagni had no idea of there being any conformation of the prostate gland which could account for this tumour; and that no anatomist had anticipated himself, either with respect to the natural form of

Epist. Anat. Medica, xli. 18. See also Epist. xli. 6, 17, 19. xlii. 24. xlvi. 5 to 13, where many older authors are quoted as having described this disease: Lieutaud Memoires de l'Academie des Sciences, for the year 1753, and Deschamps traité de la Taille, Tom. i.

Epist. Anat. Medica, xxxvii. 30:

the lobe, or the regularly rounded shape it preserves in the different stages of its enlargement.

The enlargement of the middle lobe being the impediment to the passage of urine, Mr. Home's observations are principally directed to it in the present inquiry. Enlargements of other parts of the gland often form an obstacle to the passage of instruments into the bladder, from the alteration they produce in the course of the urethra, but they are not regarded as immediately obstructing the passage of the urine.

In the inflammatory enlargement of the prostate in earlier life, in consequence of strictures, the middle lobe is said to be but little, if at all, affected. And as the strictures are removed, the swelling gradually subsides. In persons advanced in years, the middle lobe participates in that general enlargement of the gland which so very frequently occurs. In Mr. Home's opinion, few arrive at the age of eighty without, in some degree, experiencing it.

As the middle lobe enlarges and presses on the bladder, it brings on much irritation, and an inflammation, which contributes to the farther swelling of the gland.

"The middle lobe projects into the cavity of the bladder, in the form of a nipple, pushing the membrane before it, so as to put it still more on the stretch, in the direction from the urethra to the veru montanum. In its further increase it loses the nipple-like appearance, becoming broader from side to side, and forms a transverse fold by pushing forward the membrane, connecting it to the lateral lobes, which also become proportionally extended. As the tumour and transverse fold are situated immediately behind the orifice of the urethra, they are pushed forwards before the urine, in every attempt that is made to void it, acting like a valve, and closing up the opening, till the cavity of the bladder is very much distended; when the anterior part of the bladder being pushed forward, and the tumour being drawn back in consequence of the membrane of the posterior part of the bladder being put on the stretch, the valve is opened, so that a certain quantity of

water is allowed to escape, but the bladder is not completely emptied."

The history of the symptoms of this disease is very faithfully given, and will be at once recognized by such as have witnessed the calls to make water becoming daily more frequent and distressing, and the efforts at relief more violent, until a complete retention takes place. The symptoms, in truth, are well known; and Mr. Hunter in describing this disease, supposes them to be so, when he says, " it will be unnecessary to relate the particular symptoms which this disease occasions; they are such as arise from any stoppage of urine, producing an irritable bladder."

The quantity of urine retained gradually increases, but as the patient still continues to pass a little at every attempt, surgeons have committed the mistake of supposing the bladder to be incapable of containing more than an ounce or two of urine, and to be emptied at each effort. This is a mistake of much importance, and one which diverts the attention of the surgeon from the only effectual means of relieving the disease. It is briefly noticed by the author.

In addition to the projection of the middle lobe, the lateral portions of the gland, in the latter stages of the disease, frequently project into the bladder to a great degree, presenting a convex surface to the canal of the urethra, the course of which is materially altered. Mr. Home has in no instance observed this projection in the right lobe. The surfaces of the

tumours become in some cases excoriated, and put on the appearance of being ulcerated.

The irritation of the gland in many cases produces a copious secretion of a very tenacious mucus. It is sometimes so abundant as nearly to equal in quantity the urine that is voided, and of so irritating a nature as to cause much pain in the urethra, from its passage.

As the disease continues, the internal membrane of the bladder becomes generally inflamed, and we find in the urine shreds of lymph, a white powdery sediment, and in some

cases pus, secreted by the mucous membrane of the bladder. The muscular fibres do not relax to their full extent, and when the bladder contains but a moderate quantity of urine, the most violent involuntary action is often induced. Where the obstruction is such as to allow the greater part of the urine to pass, the symptoms continue nearly the same for months; in some cases they even abate from the decreased sensibility of the bladder; and a larger quantity can be retained, without bringing on symptoms of distress.

Among the consequences of this enlargement of the prostate is the formation of a stone in the bladder, and an impediment to the exit of any which may have passed down from the kidneys. The projection of the prostate raises the sound over a small stone, so as to prevent its being felt. Such cases are, we believe, in old persons, not uncommon. Mr. Hunter mentions the case of a gentleman that had been often sounded for a stone, and yet no stone could be found: but it afterwards appeared that there was a stone, which, together with the swelling of the prostate gland, had been the cause of his death. Such cases are noticed also by others.

It appears in another part of this volume, that Mr. Home has succeeded in discovering a stone which could not be felt by the common staff, by means of an elastic gum catheter, and that he always employs it for this purpose. As it empties the bladder, it brings the stone gradually towards the instrument; and Mr. Home says, he has felt it grating against the eyes of the catheter. On the strength of this evidence he has performed the operation in a case in which two other surgeons were unable to detect the stone. The operation was successful, and the patient restored to health. Mr. Home does not say that he has ever succeeded in detecting a stone, in the complicated cases above noticed, by means of the elastic gum catheter, but we certainly consider it, when of considerable length, to be an instrument excellently adapted to this purpose, and one by means of which we may hope to succeed when others fail. Where the stone is the first formed disease,

patients have been for a time" relieved from all the symp toms, by an enlargement of this part of the prostate gland preventing the stones from falling down upon the neck of the bladder, and irritating those parts." These are the words of Mr. Hunter. The same fact is adverted to by Mr. Home.

In patients labouring under the diseased enlargement of the middle lobe, there is generally a less quantity of urine secreted than during health; and as the bladder is relieved, the secretion increases. The diminished secretion, Mr. Home supposes to proceed from the continual pressure on the mammilla of the kidney, by the urine which is prevented from readily entering the bladder. In more violent cases, in which the patient dies from retention of urine, Mr. Home thinks it probable that the secretion is stopped altogether from the same cause. The symptoms observed in persons who die from retention of urine, certainly very much resemble those observed in persons who die from a suppression of urine, in whom no urine is found in the bladder, during the illness or after death. This makes it reasonable to conclude, that in cases of death "from complete retention in the bladder, the pressure of the urine against the mammæ stops the secretion in them; were that not the case, the bladder would be ruptured or greatly distended, which does not commonly happen. Of this fact I have had abundant experience."

We are next led to consider the mode of treatment of cases of enlargement of the middle lobe of the prostate gland. On this point Mr. Home's observations are very valuable. They are made by a person familiar with the symptoms of the disease, and accurately acquainted with its nature. And the very rational mode of treatment which he recommends, and the success which appears to have attended it, are at once proofs of his judgment and of his skill. Although other surgeons may have been acquainted with the disease, and the means of relieving it, Mr. Home is the first who has well explained and insisted on the plan of regularly emptying the bladder in order to remove it. It is true that Desault, in similar cases, strongly