Clinical Types of Onset. The disease is usually encountered in the following ways: (1) A young man free from venereal taint presents himself for examination because of a tender lump in one of his testicles, and routine rectal examination reveals nodules in the prostate. (2) A young man complains of symptoms of irritable bladder, pain in the back of one loin, and the passage of cloudy urine, the disease being found in one kidney and ureter and corresponding lobe of the prostate. (3) A young man who has suffered for some years from chronic urethritis and prostatitis which has defied all treatment finds his symptoms increasing in severity, and begins to pass blood and pus at the end of micturition. The prostate becomes nodular, and tubercle bacilli are found in the urine or prostatic secretion. The course is prolonged over several years, and is marked by periods of latency. If the primary focus in kidney or testicle can be removed the nodules in the prostate may shrivel up into cretaceous masses well walled off by fibrous tissue, or even be absorbed altogether, so that it is possible to speak of cure, but the disease is very likely to be lighted up again by any indiscretion in sexual or general hygiene. More often the course is steadily downward, neighbouring organs becoming involved, and the patient is finally carried off either by secondary infections and associated toxæmia, or by the destruction of both kidneys from tuberculosis. Diagnosis. The diagnosis of tuberculosis of the prostate depends on the age of the patient (twenty to forty-five), a history of family disease or life passed in a tuberculous household, the character of the prostate itself as described above, the finding of foci elsewhere, especially in the epididymis, kidney, bladder, and vesiculæ, and the finding of tubercle bacilli in the prostatic secretion or the urine. It seldom presents much difficulty in secondary cases. In a young man there are only two common causes of an enlarged prostate-chronic urethritis and tuberculosis. In chronic urethritis the venereal history is a guide, and the prostate in the early stages is enlarged evenly and is smoothly rounded off, and does not present the pea-like nodules and irregularities of tuberculosis. In the later stages, when fibroid indurations are left, these are not so hard or clearly defined as tuberculous nodules, but appear to shade off into the softer prostatic tissue. Associated nodules in the epididymis are little guide, as they might have been due to the urethritis, but if a nodule in the epididymis has broken down and left a scar there is seldom much doubt that the disease is tuberculous. The onset of the disease in the course of a case of chronic urethritis could only be suspected if tubercle bacilli were found in the prostatic secretion, if multiple hard nodules were detected by rectal examination, and by the detection of tuberculous foci elsewhere. In men between forty and fifty the disease has to be distinguished from carcinoma, which is seldom difficult if the stone-like hardness of carcinomatous nodules be remembered, and their fixity to surrounding structures, especially if there are no tuberculous nodules elsewhere, and no pyuria or bacilluria. A prostatic stone or a phlebolith, which, in addition to being stony, are smooth, rounded, and movable, should not be taken for a tuberculous nodule. Treatment. The same hygienic, dietetic, and tonic treatment should be adopted as in tuberculosis elsewhere (see p. 293), and in most cases all local interference should be avoided, especially any unnecessary urethral instrumentation with its risks of setting up secondary infection, nor is the use of instillations into the deep urethra advisable as recommended by the French school. Pain and irritability of the bladder can often be controlled by the exhibition of sandal-wood oil, but in some cases suppositories of belladonna, antipyrin, and morphia may be required. Retention of urine may necessitate the passage of a catheter. For purposes of treatment it is necessary to determine(1) The primary focus. (2) The extent of the disease. The keys to successful treatment are : (1) Removal of the primary focus, if the disease be unilateral in testicle or kidney. (2) Tuberculin vaccinations. It is so rare to meet with a case of pure primary prostatic tuberculosis that excision of the prostate itself for this disease is seldom feasible, and those who have tried it report disappointing results. In the majority of cases the primary focus is in one testicle or one kidney, and it is found by experience that if this focus be removed the disease in the prostate tends to die out, though if both testicles or both kidneys be diseased it is too late for operation. Suitable doses of tuberculin are given till the tuberculoopsonic index is raised to well above the normal, when nephrectomy or orchidectomy may be performed, as much as possible of the ureter or vas being removed at the same time. The patient is then given tuberculin injections at regular intervals as detailed in Ch. IV, Sect. III, and under such treatment the results have been encouraging. If a cold abscess appears it is of the utmost importance to prevent it from bursting on to an infected surface, with the production of a chronic fistula that is not likely to heal. Immediately an area of softening is detected the surgeon should cut down upon the prostate from the perinæum, evacuate the abscess, scrape its walls clean, flush it out with strong perchloride of mercury solution (1:200), and stitch the wound up completely without drainage. The wound should heal by first intention, and if the pus re-accumulates the process can be repeated as often as necessary till the abscess is cured. CHAPTER VI. PROSTATIC CALCULI. 1. OF PROSTATIC ORIGIN. Classification. a. Phosphatic concretions around "amyloid" bodies. b. Cretaceous deposit in a tuberculous mass. 2. OF VESICAL ORIGIN. a. Calculi impacted in the deep urethra. دو was Primary phosphatic concretions.-The normal prostate from youth upwards contains minute sand-like bodies that lie free in the acini of the gland. These are rounded, colourless, yellow or black, resembling grains of sand or black pepper, and are of a gritty consistency. The name "amyloid given to these bodies as they give the amyloid reaction, that is to say, they turn blue with iodine and red with methyl violet. They consist of a structureless material deposited in concentric rings, a material which, according to Posner, consists of an albuminoid material and lecithin, the latter giving the amyloid reaction. By the deposit of calcium phosphate and carbonate around these bodies as a nucleus stones of considerable size are sometimes formed. These stones may be single, but are usually multiple; they are smooth, rounded, and sometimes facetted, and are seldom much larger than peas; they are generally discovered only at autopsy in elderly people. They lie loose in cystic cavities, which contain a milky fluid, or in abscess cavities containing pus. They usually lie latent and give rise to no symptoms, but they may set up chronic prostatitis with a feeling of weight in the perinæum or actual pain, increased frequency of micturition, and the passage of prostatic threads and pus. Rarely they give rise to a chronic abscess, which may produce retention of urine, or burst into the rectum and set up a fistula. The diagnosis is made by rectal examination and by the X rays. The prostate feels enlarged and may be hot and slightly tender, one or more rounded stones being felt in isolated areas, or the whole gland may be turned into a bag of stones which grate and click together beneath the finger. An Xray photograph shows a number of small shadows collected together in front of the bladder area. The diagnosis has to be made from calcified tuberculous deposits, nodules of carcinoma, phleboliths and urethral calculi. If the stones be causing symptoms of chronic or acute inflammation the prostate should be exposed by the perineal route and the stones removed, or the prostate be removed as a whole. |