Ice has been advocated, some surgeons even advising that sup positories of ice be inserted into the rectum. Hot water containing laudanum is often serviceable as an enema. Simple hot enemata, several quarts of water being used at each sitting, may be given several times daily with great advantage.
Interference with the urethra should be avoided, the usual treat ment for gonorrhoea—if the disease exists—being suspended during the course of the prostatic inflammation. The use of injections may de termine the formation of an abscess in an otherwise slight prostatitis.
Hot sitz-baths, twice or thrice daily, are of marked benefit in prostatitis ; in order to be beneficial, however, they must be very hot and continued for at least an hour. Should retention occur and opium and the hot sitz-baths fail to relieve, then, and then only, is catheterism permissible. A small soft catheter should be carefully introduced and the urine drawn off. Failing in this, aspiration may be required. Throughout the course of the case, rectal examinations should be made as infrequently as possible. This precaution is by no means gratuitous, for the average surgeon is usually over-anxious to observe the progress of the case, and in his misplaced enthusiasm is apt to do injury. As the acuteness of the inflammation becomes less manifest, counter-irritation by means of iodine or blisters to the perineum may prove of great service. Systematic and repeated blis tering may perhaps prevent the supervention of chronic inflammation.
Under careful treatment the inflamed organ will begin to subside and the symptoms will improve in a few days, but it will be several months before the prostate will assume anything like its normal size. The slightest excess is apt to cause a relapse, and the patient will ever after be susceptible to fresh attacks of inflammation—reinfec tion from apparently trivial causes. Very insignificant indiscre tions are liable to prevent resolution and cause the inflammatory process to become chronic. Prostatitis may consequently be a very unsatisfactory affection to treat, in the most tractable and conscien tious patients. Recurrent infection of the urethra simulating a fresh gonorrhcea is one of the most annoying features of the disease.
a general way the liability to prostatic abscess in the course of acute prostatitis depends upon the assiduity with which the foregoing measures of treatment of acute inflammation are carried out. In cases in which the prostatic inflammation is due to the absorption of pus microbes and their products through an abrasion, or via the lymphatics without abrasion, with resulting infection of the inter stitial tissue of the prostate, suppuration is almost inevitable. In
the ordinary diffuse form of inflammation, however, and in the follicular form which precedes it, energetic and conscientious treatment may avert the development of an abscess. The treatment of acute abscess of the prostate is obviously that of acute prostatitis. When pus has formed or when there exists a strong suspicion of its presence, surgical intervention is absolutely indicated. While conser vative treatment by means of poultices to the perineum and the injec tion of hot water into the rectum may be justifiable in cases in which the presence of, pus is extremely doubtful, the practitioner should beware of carrying conservatism too far. SeriOus results may accrue from a large accumulation of pus in and about the prostate long before fluc tuation is manifest. Fluctuation should be carefully sought for, it is true, but in by far the majority of cases operation is demanded long before a sense of fluctuation can be detected in the perineum. In cases in which the abscess involves the periprostatic tissue or openA toward the rectum, digital examination of the gut is likely to detect either well-marked fluctuation or that peculiar oedematous con dition which is characteristic of the presence of pus.
As soon as the diagnosis of abscess is justified by the develop ment of a brawny induration and swelling of the perineum, the char acteristic oedematous condition, or distinct fluctuation on rectal examination, a free incision in the direction of the prostate should be made in the perineal raphe. This locality should always be selected even where well-marked fluctuation on rectal examination indicates the presence of pus in the periprostatic.tissue. Tempted by the close proximity of the pus and the ease with which it was to be reached by the rectum, the author has on several occasions operated through the rectal wall with results which were by no means as pleas ant as could be wished, and by no means to be compared with those obtained by the perineal operation. In case pus should not be found by the perineal incision, the surgeon can console himself with the reflection that he has adopted the best possible means to prevent the formation of an abscess, and in case suppuration should eventually occur he has afforded an outlet in the most favorable direction. If several foci of suppuration be found they should be freely opened and drained. Iodoform gauze drainage should be adopted after evac .uation of the purulent accumulation. Infiltration of urine may pos sibly occur after the opening of an abscess, but it is certainly very rare.