The time to resort to operative meas ures is just as soon as palliative treat ment, carefully executed by competent hands, has failed to give relief. Com plete prostatectomy is always the opera tion of choice, because it is the only operative procedure which cures or gives uniformly good results, when success fully performed in proper cases. The best time for its performance is just as soon as palliative effects have failed or are manifestly impossible of execution and before secondary changes in the bladder and kidneys, due to long-con tinued obstruction, have taken place. Paul Thorndike (Boston Med. and Surg. Jour., Aug. 28, 1902).
Tuberculosis of the Prostate Symptoms.—Perhaps one-third of the cases arc either entirely free from symp toms or have so little inconvenience that the disease is unsuspected. In the milder forms of the affection there is slight irritation of the bladder, as evi denced by some frequency of urination, which may be attended with burning pain. There is a feeling of fullness or weight in the perineum, there may be a muco-purulent discharge from the ure thra, and a similar sediment in the urine. thematuria is also frequently observed. The disease usually occurs in anaemic persons who have tubercular foci else where. It is met with chiefly between the twentieth and forty-fifth year.
Diagnosis.—A number of writers have referred to the similarity between the symptoms of prostatic tuberculosis and of vesieal calculi. A consideration of the symptoms and careful exploration by the sound will serve to make the distinction. The presence of tubercular deposits in other portions of the body will always be an element to excite the suspicion of the physician and the finding of tubercle bacilli in the urine would be conclusive. Guyon states that the most careful ex amination fails to detect the bacilli in 50 per cent. of the eases. Digital exami nation per rectum might show some local enlargement.
Etiology.—This disease is believed to be invariably secondary to deposits else where in the genitourinary tract. The disease is usually manifested by circum scribed collections of cheesy material or by abscesses.
Treatment. — The disease can be, to some extent, guarded against if those who have a tubercular tendency avoid all influences that would tend to cause con gestion or inflammation of the prostate. The treatment is chiefly constitutional unless the local trouble demands opera tive interference. It is proper to delay the latter as long as possible on account of the part not being very accessible and also because it is apt to be a part of a general process. Hill and others have injected iodoform and other substances into the bladder frequently with bene ficial results. Hill's formula is as fol lows:— Todofo•m, 2 parts.
Mucilage of gum arable, 4 parts. Glycerin, 2 parts.
Water, 20 parts.
After washing out the bladder a drachm of this mixture is introduced. This may be repeated every second or third day, depending upon how well it is borne.
In the treatment of tuberculous cases of the prostate the bladder should never be washed out, as the case progresses much more rapidly if this is done. E. Hurry Fenwiek (Brit. Med. Jour., Feb. IS, '99).
The question of operation will fre quently come up in cases of tubercular deposits in the prostate. In a general way it may be stated that, if the general health of the individual is good and if the tubercular process does not yield to any form of palliative treatment, an operation is indicated. The gland may be approached from the perineum and any diseased area thoroughly curetted, or it may be exposed by suprapubic cys totomy. If, however, the patient has deposits elsewhere in the body suffi ciently pronounced to give rise to phys ical signs and if the general health be poor, operative treatment is not to be recommended.
Tumors of the Prostate.
Cysts of the prostate have been re corded, but they are of such rare occur rence that they are to be considered surgical curiosities. The forms that have been described are hydrops of the sem inal vesicles, dermoids, and echinococcic cysts. These almost invariably cause re tention of urine after they have reached a sufficient size to occlude the urethra by pressure. Upon examination by the rec tum a fluctuating swelling may be de tected. They are treated either by as piration of the fluid, or by incision and drainage.
CARCINOMA.—Carcinoma of the pros tate is also a rare affection. It occurs in two forms: a slowly-growing, circum scribed tumor, limited to the gland itself, and a diffuse infiltration of the prostate and base of the bladder which develops rather rapidly.
The symptoms of carcinoma of the prostate are those of obstruction from hypertrophy, except that they run a more rapid course. Carcinoma gives rise to more pain, however, than does senile enlargement, and as soon as ulceration occurs there is hmmaturia. Carcinoma of the prostate is exceedingly hard to the touch, and the inguinal mesenteric and retroperitoneal glands are occasionally affected. The most prominent features are the hardness of the prostate, the se verity of the pain and its wide distribu tion, and the rapid course, with the de velopment of cachexia. The cystoscope may be of assistance in reaching a con clusion.
Treatment. — The treatment of car cinoma of the prostate is chiefly pallia tive. The different indications are to be met as they arise. Excessive pain must be met by morphine internally or by sup pository. Operations for the removal of a prostate in malignant disease have either proved fatal at the time from the operation or have had an early recur rence.