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sistance of the narrowed and tortuous prostatic urethra, and more or less constant dribbling of urine now makes its ap- pearance, especially at night, when voluntary control is sus- pended by sleep, while the urine habitually retained in the bladder increases from ounces to pints or even quarts, and the viscus is only partially emptied, even when to its own contractility the weight of accumulated fluid, the pressure of the abdominal muscles, and the advantages of position are all added. This constant dribbling of urine is frequently mistaken by the patient and his physician for incontinence due to paralysis of the neck of the bladder until, from exposure to cold, dietary excess, or some slight additional irritation to the bladder, complete retention is produced, and the sur- geon is enabled to make a correct diagnosis. These are the cases which, undetected or unrelieved, frequently end in death from ursemic poisoning. Where the enlargement of the prostate has been chiefly backward toward the rectum or laterally, so that compression has been moderate upon the urethra, complete retention, unpreceded by overflow or untoward symptoms other than frequent micturition, is sometimes the first symptom which leads the patient to seek medical aid, Levitra 20mg Vs. Viagra and commonly follows some irregularity in diet or mode of life. In all such cases a partial reten- tion may have existed for a long time previously, and too much care can not be exercised in making a clear and cor- rect diagnosis of the exciting cause. On the other hand, a fair proportion of the cases which follow the usual course of gradual impediment to micturition, partial retention, overflow, etc., show, on examination, noth- ing abnormal in size or density of the prostate, nor is the urethra! curve lengthened, nor the vesical Levitra 20mg Vs. Viagra neck Levitra 20mg Vs. Viagra lifted up. Such cases show, on examination, one of two conditions : either a hypertrophy of the median portion of the gland (described by Home as the third lobe) protruding up against or into the vesical outlet, or a fibrous tumor of the variety described in Levitra 20mg Vs. Viagra the beginning of the paper, which has gradually grown out of its bed in the gland and become polypoid in its character, just as similar stages mark the growth of submucous fibroids of the uterus. Having reached such a stage in its history, a prostatic fibroid acts as a ball-valve, and produces many Levitra 20mg Vs. Viagra of the symp- toms of ordinary prostatic disease, so that in any given case the absence of enlargement of the prostate, as predicated upon urethral and rectal examinations, is bi/ no means a sufficient rfiison for a diagnosis of vesical paralysis or incontinence j and in such a case a more thorough examination will, as a mil', reveal the condition described. As a matter of fact, paralysis of the bladder (unless caused by spinal or cerebral disease) and incontinence of urine are among the rarest fonus of disease in the adult male, and the latter is, as a rule, a certain indication of prostatic disease, the infrequent exceptions to this rule being found in cases of organic stricture of the urethra. Of the advanced stages of Levitra 20mg Vs. Viagra prostatic hypertrophy it would, I think, be hardly profitable to speak, except in the way of treatment, since they consist essentially of aggravated forms of conditions already described, or complications in the shape of renal and constitutional distui'bances, stone in the bladder, gradual or sudden failure of the vital powers, etc., with all of which you are familiar. A few words as to the diagnosis of some of the more obscure or uncommon forms of prostatic trouble may not be inappropriate. Digital examination may be most conveniently Levitra 20mg Vs. Viagra made by the method first suggested, I believe, by Dr. Otis, which consists in having the patient stand with his back toward the surgeon, who, seated on a chair, directs him to bend forward as far as possible. The finger, well oiled, is then introduced its full length into the bowel, and the base of the bladder, seminal vesicles, and prostate are examined with care. If familiar with the feel and size of a normal prostate, the physician can have but little difficulty in recognizing any considerable departure therefrom ; and, in most cases,, the portion of the gland affected, with the character and size of the enlargement, may all be satisfactorily determined by this method of examination. If, however, nothing ab- normal is discovered in this manner, a full-sized silver catheter should, if possible, be passed into the bladder. If urine is discharged through this when onl}^ six or seven inches of its shaft have penetrated the urethra, and espe- cially if its handle is not much depressed, no great enlarge- ment exists. If, however, it is necessary to bury it to the depth of eight or nine inches or more before urine flows, and especially if, as it passes, the handle has to be depressed to a horizontal line, an instrument known as a prostatic catheter should be introduced and used, not only to meas- ure the distance of the vesical neck from the meatus, but, by conjoined manipulation from the rectum, to estimate the thickness of the intervening tissues. If, in its introduction, the handle is deflected to either side as the beak passes the prostatic urethra (assuming no false passage to exist), there is a strong probability of Levitra 20mg Vs. Viagra unequal lateral enlargement, the greater hypertrophy existing on the side toward which the handle turns. If, however, hypertrophy does not exist to a sufficient degree to account for all the symptoms present, or if a suspicion of tumor or calculus is entertained, the catheter is wholly unfit for purposes of examination, and Thompson's searcher should be passed well into the bladder and rotated by means of its cylindrical handle until its beak occupies the bas-fond of the organ, when, without changing the position of its beak, it is partly withdrawn from the urethra. This movement causes its concave beak to hug the posterior surface of the enlarged gland, or to touch any outgrowth or tumor which may be present, thus enabling the operator to form a Levitra 20mg Vs. Viagra correct idea as to its size and shape. By repeating the Levitra 20mg Vs. Viagra movement and lateralizing the beak, em- 32 ROCKWELL: PATHOLOGY Levitra 20mg Vs. Viagra AND TREATMENT OF ENLARGED PROSTATE. [N. Y. Med. Jook., ptjing or Levitra 20mg Vs. Viagra injecting the bladder Levitra 20mg Vs. Viagra through its hollow handle, etc., a very thorough examination may be made, even of obscure cases, and their diftieult points cleared up. By one or all of the methods just mentioned, a sufficiently clear idea may be obtained of any ordinary case of prostatic overgrowth to guide the surgeon in his selection of the treatment. In the earlier stages of the Levitra 20mg Vs. Viagra disease, as in those of ure- thral stricture, much may be done to prevent the develop- ment of any, or at least of any serious, results in the way of obstruction, retention, etc., and hence the great impor- tance of an early recognition of its threatened approach. F'or the method Levitra 20mg Vs. Viagra of treatment about to be described the profession is indebted to Mr. Reginald Harrison, of Liver-