Part 51

CHRONIC PROSTATITIS.

Causes. Follows acute. Same causes less potent. Lesions: as in acute, or sclerosis, and abscess. Symptoms: delayed urination, last glairy or purulent, constipation, defecation followed by urethral discharge, little genital ardor, rectal palpation, tenderness of prostate to hand or catheter, atony of hind limbs. Treatment: open air life, idle, milk or succulent diet, saline laxatives or enemata, avoid generative excitement, castrate, check masturbation, iodine, camphor, antiseptic irrigations.

Causes. The acute disease often subsides leaving an indolent chronic inflammation of the organ. Apart from this, the causes are essentially those of the acute, but acting with lessened force or on a less susceptible system. Thus indoor life and overfeeding, with constipation and urine of a high density, calculus, irritant diuretics, the frequent incautious use of the catheter, infection from the catheter or otherwise, intense and frequent generative excitement, and exposure to cold are all occasional factors. Old age is a common concurrent cause.

Lesions. As in the acute form these indicate three successive, independent or concurrent forms, follicular, interstitial and suppurative.

With the distinctively =follicular= form the gland is usually enlarged and of a deep red color, but soft and friable, and when compressed exudes from its follicles and gland ducts a whitish muco-purulent glairy liquid. With the =interstitial= changes, which are often an advance on the follicular, the organ may be enlarged or shrunken, but the connective tissue has undergone a thickening and sclerosis which renders the mass firm and resistant, and which may have extended to the tissues in the immediate vicinity. In the =suppurative= form or stage, foci of suppuration are found throughout the gland substance, bulging out on its surface and even encroaching on surrounding tissues.

Symptoms. These are by no means obtrusive. There may be some delay in the discharge when the animal attempts to urinate, and the last drops of the urine, white and purulent or glairy, may be passed with evident pain. There is a tendency to constipation with painful straining to defecate. Compression of the prostate during defecation presses out its muco-purulent contents so that there is a greater urethral discharge following this act than at other times. This is also more abundant from the compression of the abdomen when the animal is lying down. This discharge is easily distinguished from semen by the absence or almost complete absence of spermatozoa and the abundance of spermatic crystals, precipitated by ammonia phosphate. In the earlier stages there may be undue generative excitement, erections, and even seminal discharge, with or without the movements of masturbation but in advanced cases genital ardor is usually defective or there may be practical impotence. Conclusive evidence is obtained by rectal exploration, when the enlarged, or irregularly shaped and tender prostate can be easily recognized. If a sterile catheter is passed the pain caused as it touches the prostate is significant.

In the dog the affection may last for years, and tends to advancing atony of the hind limbs. A temporary arrest of the affection is often misleading, though the urine may be clear and normally discharged, yet manipulation may show a gradually advancing abscess, and when this bursts, usually into the urethra, all the symptoms become aggravated and cystitis, urethritis and general infection are to be dreaded.

Treatment. This is far from satisfactory yet in certain purely follicular or catarrhal cases it may prove successful. An open air life, without exertion, and a milk and farina diet are desirable, yet any tendency to costiveness must be obviated by saline laxatives and enemata. The avoidance of generative excitement must be secured, not only by restraining stud animals from service, but by keeping them well apart from all females of the same species. Even castration may be sometimes resorted to with advantage. Stallions given to masturbation must be restrained by net or otherwise. Any disease of the rectum, anus, urethra or bladder should be corrected, and undue exposure to cold prevented. Lafosse advises to slaughter butcher animals for food. Hertwig recommends iodine ointment on the anus and perineum of affected dogs. It must be borne in mind that the affection is maintained by infective microbes yet it is difficult to reach and deal with these thoroughly and effectively.

As an anaphrodisiac may be given camphor, or camphor bromide, ergot or potassium bromide, along with the mild stimulating antiseptic eucalyptol or copaiba. But the irrigation of the urethra, bladder and as far as possible the prostate with such antiseptic solutions as potassium permanganate (1:10000) or silver nitrate (0.5 to 1:100) or zinc chloride (1:100) is desirable. These should be injected into the urethra so as to reach the bladder, the contents of which they will render antiseptic and thus protect the organ against the transported microbes of the prostate. In man iodoform, europhen, and ichthyol are made into a bougie with gum, palm butter or other soluble liquifiable agent and inserted in the urethra as far as the prostatic part. Similar agents are used as suppositories or enemata. Hertwig’s iodine ointment on the perineum may be advantageously replaced by sinapisms.

HYPERTROPHY OF THE PROSTATE.

In old dogs. Causes: age, overfeeding on albuminoids, rectal impaction or irritation, calculus, cystitis, urethritis, productive inflammation, trophic derangement when function declines. Lesions: hypertrophy general or partial, hard or soft, condensed or with sacs of pus, red or pale. Infective cystitis. Calculi. Symptoms: straining before urine comes, small or weak stream, sudden check, last part purulent or mucous, incontinence, triple phosphate, ammoniacal odor, crystals and dark color imply calculus. Diagnosis: by rectal exploration, and catheterization. Treatment: palliative, moderate, farinaceous, laxative diet, warmth, correct contiguous troubles, iodine, castration, extirpation of prostate.

This has been seen almost exclusively in old dogs, among the domestic animals.

Causes. Age and good living, more particularly on highly albuminous food, may be adduced as the most prominent. Perhaps even more important are continued irritation in adjacent organs such as the rectum, bladder and urethra. It is the old, pampered dog that above all suffers from atonic, overloaded rectum, proctitis, piles, calculus, cystitis, and stricture, and the constant local pelvic congestion caused by one or other of these tends to a hyperplasia of the prostate. Again atheroma which is especially a disease of the aged is regarded as a cause of both cystitis and prostatic hypertrophy. Chronic inflammation in the prostate has been claimed as a factor, but contested on the ground that inflammation never increases normal growth though it may cause degeneration. The exudate of inflammation, tends, however, on its temporary arrest, to undergo organization, and such organization inclines to assume the structure which is normally built up by the adjacent trophic cells. The products of inflammation may, therefore, well contribute to hypertrophy, and above all to the increase of the simpler tissue represented by the fibrous framework of the gland. The congestion attendant on excessive venery has also been incriminated, and this too has been denied on the ground that the hypertrophy is not found in the young animals and men in which the generative ardor is greatest and most frequently aroused and gratified. Thompson’s idea is that the prostate, like the ovaries and womb, is especially prone to morbid growths and developments at the time when in advancing age, the normal generative functions are undergoing a rapid decline. The two conditions may well be recognized without considering them as mutually excluding each other as causative factors.

Lesions. The enlargement is usually general, but it may predominate in the right, left or median lobe, the latter as a rule exercising greater compression of the urethra so that this is often marked in the worst cases. The hyperplasia may feel firm and resistant or it may be more or less soft from sacs of muco-purulent fluid imprisoned by the obstruction of the outlet canals. On the surface and on section the general appearance of the gland is pale, bloodless and uniformly solid. This comes from the great hypertrophy of the fibro-muscular stroma which has in many cases compressed the parenchymatous or secreting structure so as to cause its atrophy. The presence of calculi (mainly phosphatic) in the follicles is not uncommon.

The complication of infective cystitis is frequent, the congestion, redness, ecchymosis, maculation, puckering and thickening of the mucosa, the granular degeneration and desquamation of the epithelium, the exposure of a raw vascular surface, the discoloration of the urine by mucus, pus and blood, and the formation of ammonia and other products of decomposition, becoming marked phenomena. Vesical calculus is not uncommon, the slowness of the exit current of the urine retarded by the enlarged prostate, tending to prevent its impaction in the orifice and thus minimizing one of the most prominent symptoms.

Symptoms. Among the earliest symptoms, is some modification in the act of micturition. Straining a few seconds before urine comes, retention, incontinence and dribbling, discharge in a small or weak stream, and sudden arrest of the flow and the last few drops may contain muco-pus showing abundance of spermatic crystals, on the addition of ammonia phosphate. Impaction of the rectum tends to occur sooner or later, the animal making little effort to unload the viscus, and the overdistended organ becoming more and more atonic, congested and catarrhal and reacting injuriously on the urinary organs. Incontinence may be especially marked during sleep, the sphincter being sufficiently controlled by volition during waking hours. Retention may be at first temporary from excitement and later more continuous by reason of the greater compression of the neck by the enlarged and indurated prostate. With the advance of the disease the urine shows abundance of triple phosphates, and becomes ammoniacal and fœtid. A dark or bloody color of the discharge and the presence of crystals suggest calculus.

An accurate diagnosis can only be had by rectal examination. The great enlargement of the prostate, in the absence of heat and tenderness is characteristic. Enlargement is usually uniform, though it may be concentrated on the right, left or central lobe. The passage of the catheter may be obstructed, but is not specially painful at the prostatic region as in prostatitis. From =vesical calculus= it is distinguished by the fixity of the swelling on the neck of the bladder as contrasted with the mobility of the stone inside that half-filled organ. From =stricture= it is differentiated by the fact that the obstruction offered to the catheter and the swelling of the prostate exactly correspond in position, that the stream is lessened in force rather than simply reduced in size, and that the history of the case shows no antecedent cause for stricture.

Treatment. This has been considered as mainly palliative. Special care of the general health and above all of the diet which should be moderate, farinaceous and laxative, protection against cold and wet, the correcting of any coexisting trouble of the urinary or generative organs, and the removal from all sources of generative excitement are important elements. Occasional small doses of Epsom or Glauber salts in draught or enema obviate rectal hyperæmia. Ergot, potassium iodide internally, and iodine or mercurial ointment to the perineum have had little good effect. Möller claims to have secured improvement from the injection into the prostate at intervals of fourteen days, of a solution of two parts each of tincture of iodine and iodide of potassium, and sixty parts of distilled water. A small hypodermic syringe is used and the injection is made through the rectum directly into the substance of the prostate. Glass has adopted the recent surgical alternative of castration, with the result of marked relief from the active symptoms in a number of cases, but with a more rapid advance through emaciation and marasmus to death in three or four weeks in others. We would suggest a careful antiseptic castration in such cases, to obviate any added trouble from absorbed toxins or sepsis.

For the human subject, Lydston strongly advocates removal of the enlarged prostate by surgical means in strong, vigorous subjects, with healthy bladder and kidneys. The difficulty of such an operation in the dog is greatly enhanced by the relatively greater length of the pubio-ischiatic symphysis, and the lessened diameter of the pelvic cavity. Yet with the comparative immunity of the dog from suppuration, and the hopelessness of the case without such radical measure, and with the rigid application of an antiseptic technic, the operation would appear to be fully justified. It would be contra-indicated in all advanced cases, in which the prostate was the seat of active suppuration with discharge into the urethra, in cases complicated by urethritis, cystitis or nephritis, in cases in which there is marked prostration from sepsis or absorbed toxins, and generally in old, worn out and cachectic animals.

Short of this, in cases complicated by cystitis, antiseptics by the stomach and as injections into the bladder are desirable. Eucalyptol in doses of ten minims four times a day, or beta naphthol, guaiacol, or phenol have been used in man. As injections mercuric chloride 1:20,000; boric acid, saturated solution; or carbolic acid ·5:100 (Lydston) may be used warm several times a day.

TUBERCULOSIS OF THE PROSTATE.

This is a common seat of tubercle in generalized tuberculosis in cattle, and may give rise to the same urinary troubles as chronic prostatitis or hypertrophy of the organ. In a remarkable case recorded by Frauenholz the tuberculous prostate of an ox weighed 10½ lbs. and had contracted adhesions to surrounding pelvic organs. Section of the mass showed numerous centres of extensive caseous degeneration. In such cases the generalized tuberculosis is the important fact and the prostatic disease is only an unusually intractable complication. If less generalized, the implication of the testicle or epididymus is strongly suggestive, and examination of the urine may detect the tubercle bacillus, or the tuberculin test may develop the characteristic febrile reaction.

CANCER OF THE PROSTATE.

Lafosse records as colloid cancer a case of diseased prostate in an ox, in which the mass approximated to the size of the human head, and was made up of numerous cavities the largest not over 1½ inch in diameter, and all intercommunicating, and containing a gluey, or gelatinoid liquid with numerous small round cells and a few multinucleated giant cells. No evidence is given of the implication of even the adjoining lymph glands, so that the case was probably only an enlarged cystic prostate.

Fournier records a case in a three year old horse, which on necropsy showed a ruptured bladder, general peritonitis, and an enlarged prostate, involving Cowper’s glands. Nocard identified its cancerous nature by microscopic examination. Yet there is not a word of the implication of adjacent lymph glands.

Goubaux says prostatic cancer is common in dogs.

PROSTATIC CYSTS.

These are not at all uncommon as a complication of hypertrophy of the prostate, the ducts having become obstructed and the follicles indefinitely distended. The case described by Lafosse as cancer of the prostate of a bull is strongly suggestive of such retention cysts.