Acute Prostatitis. — By far the commonest cause of acute inflammation of
the prostate is the extension of a gonorrheal urethritis to the prostatic urethra,
and thence into the substance of the organ. The gonorrhea may be acute or
chronic ; the infection may be due to the gonococcus alone, or there may be a
mixed infection with other pyogenic microbes. Infection usually follows the
prostatic ducts, or may occur through injuries of the mucous membrane due
to instrumentation during acute posterior urethritis. Alexander lays much
stress upon the frequent occurrence of prostatitis as the result of irrigations
of the anterior urethra during acute gonorrhea. My own experience is at
variance with this view. I have seen as many instances of acute prostatitis
in cases where no irrigations had been used, as in those subjected to active local
treatment.

Other causes of acute prostatitis are vesical and prostatic calculi, ulcerating
tumors of the bladder, the cystitis of prostatic hypertrophy, vesical tubercu-
losis, trauma from the passage of dirty instruments into the bladder or of
clean instruments in the presence of anterior urethritis. Sexual excess, mas-
turbation, contusions of the perineum, or the irritation produced by horseback
or bicycle riding, may produce a catarrhal posterior urethritis, even hyperemia
of the prostate ; that they are ever the sole exciting causes of prostatic abscess



DISEASES OF THE PROS! A I I 615

appears to me doubtful. I bave uevjer 3een prostatic absa pt as the

resull of g< rrhea, tuberculosis, or as a complication of the cystitis of senile

hypertrophy or of the cystitis <ln<' to insufficiency of the bladder from other
causes. The impression thai acute prostatitis, or even prostatic abscess, may
be caused by apparently trifling conditions depends upon tin- fact that a very
chronic or latenl posterior urethritis of gonorrheal origin may be lighted up
into an acute inflammation very easily. The gonorrhea may antedate the pros-
tatic infection many years ; the patient may believe himself well. A oighl -pent
in alcoholic and sexual debauchery, ;i long horseback or bicycle ride, may be
followed at once by a rekindling of the chronic process and an acute prostatitis.

Prostatic abscess occurs, though rarely, as ;i complication of the acute ex-
anthemata, variola, scarlatina, measles, etc.; the infection in these cases is
presumably hematogenous.

Pathological Lesions. — Acute infection of the prostate may involve the
glandular tissue merely, or the muscular substance, or both. In the first case
three results are possible: ( 1 I The inflammation may run a short course, end-
ing in resolution and complete recovery. (2) The acute symptoms may sub-
Bide, having behind a chronic inflammation of the glandular follicles. (3 ) The
process ends in suppuration; small abscesses are formed in several glandular
follicles; these rapidly grow and coalesce, forming an abscess which involves
one or both sides of the prostate, and included within its fibrous capsule. Such
an abscess may rupture into the urethra, the rectum, the ischio-rectal fossa or
perineum, the bladder, the connective-tissue planes of the pelvis (space of
Retzius), or even into the peritoneal cavity, with fatal results. In a large pro-
portion of cases the rupture occurs into the urethra. Rare avenues are the
obturator foramen, along the posterior sheath of the rectus, through the in-
guinal canal.

In the cases involving both muscular and glandular substance the condi-
tions are more grave. Diffuse suppuration of the entire gland may result
Rupture into the urethra or rectum is the most favorable outcome. In other
cases a diffuse necrotic inflammation of the pelvic connective tissues, purulent
peritonitis, septic thrombosis of the prostatic plexus of veins, septicemia, or
pyemia may end life. In some cases thrombosis of the veins of the bladder
occurs, and phlegmonous pericystitis. A painful, tender tumor is then formed
behind the pubes, extending a greater or less distance toward the umbilicus,
together with profound septic symptoms, dysuria, and retention. The out-
come of these conditions depends upon the intensity of the septic poisoning,
and upon whether the process remains localized and is opened or breaks in a
favorable situation or becomes diffuse. In the cases which do not die, fistulous
tracts often remain in the perineum, or communicate with the rectum or with
the urethra, or both. In the cases of pericystitis a contracted cicatricial blad-
der remain-, i Sec Bladder.)

Symptoms and Diagnosis of Acute Prostatitis. — Acute Gonorrheal
Prostatitis. — In these cases the symptoms of acute posterior urethritis will have



616 THE PEOSTATE

preceded the prostatic involvement for days or weeks. If the prostate becomes
involved in the course of a chronic posterior urethritis, there will be a history
of an old uncured gonorrhea with acute exacerbations. In this latter group
the exciting cause may be prolonged sexual excitement, coitus, acute alcoholism,
overfatigue, the passage of a sound, or other source of local irritation. (See
also Gonorrhea.) The involvement of the prostate is indicated in severe cases
by a chill, a rise of temperature, and a rapid pulse, prostration, and other
septic symptoms. Such an onset usually indicates that the process will end in
suppuration. Alexander states, from his own experience, that in cases of pros-
tatic abscess the original septic symptoms, including fever, often subside in
a few days, though the abscess is still developing. The general symptoms of
constitutional depression are usually marked. In several cases I have observed
great mental depression, amounting almost to acute melancholia. Locally, the
patient will complain of increased frequency of urination, of a sense of weight
and fullness in the rectum and perineum, of pain in the sacral region. Defe-
cation is painful, and the sensation of a large foreign body in the rectum is
present. Urination becomes more and more frequent, painful, and difficult.
If an abscess forms, retention of urine is the rule. The passage of a catheter
is difficult and very painful. Rectal palpation reveals the prostate much en-
larged, tender, hot, and throbbing, and either hard and elastic or, if an abscess
has approached the rectal surface, boggy or actually fluctuating. The abscess
may be confined to a single lobe, or involve both sides of the gland. If not
opened, the abscess ruptures into the urethra, the ischiorectal fossa, or burrows
along the urethra and perineum, or into the rectum, rarely into the bladder.
Perforation into the connective-tissue planes of the pelvis or into the peritoneal
cavity is fortunately rare. Rupture into the urethra may occur during the
straining efforts to urinate, or as the result of passing a catheter for the relief
of retention. This will be indicated by the discharge of considerable pus with
the urine, sometimes also from the meatus independent of urination. Rupture
of the abscess is followed by marked relief from the symptoms. By rectal
massage, pus in quantity may sometimes be pressed out of the abscess cavity,
and made to appear at the meatus. If the opening is small, it may close or
drain imperfectly. In this event septic and painful symptoms may recur,
sometimes with the formation of new and more serious lesions; and as long
as the abscess cavity remains unhealed and in communication with the urethra,
there is always danger of renewed infection. A certain proportion go on to
spontaneous healing. The abscess may rupture into the rectum. In these
cases gas and feces may enter the urethra and appear in the urine, or the urine
may enter the rectum at each urination. In some cases an opening will form
into the rectum, and also perforate the perineum. I had one patient who, as
the result of a prostatic abscess, continued for many months to pass gas through
a small perineal fistula. Cure occurred in this case without operation on the
fistula. I have another patient who has at intervals, for years, passed gas and
feces per uretliram. The fistula closes at times and again breaks down.



DISEASES 01 THE PROS I A I I 617

The occurrence of pronounced septic symptoms and < -• »i 1 1 j » l« -i < - retention "i
urine is mi indication for operative interference by a perinea] incision, even
though fluctuation ie doubtful <t inappreciable on rectal palpation. Prosta-
tectomy is indicated in many cases.

In the cases <>f acute prostatitis which do not end in suppuration the symp-
toms are similar in character, though less severe. < 'hills and pronounced septic
symptoms are usually absent. Retention of urine is transient or does not occur.
Dnder resl and suitable treatmenl the swollen prostate regains its normal con-
dition in ;i few weeks. Iii other cases the disease becomes chronic.

Chronic Prostatitis. — The course of chronic prostatitis following abscess of
the prostate is sometimes such as has already been indicated namely, the con-
tinued presence of sinuses or the occurrence of acute attacks of inflammation,
Bometimes causing the patient merely more or less marked urinary discomfort,
sometimes ending in the formation of an abscess requiring incision. In some
eases the continuance of the symptoms is due to the presence of small, unhealed
abscesses in the substance of the gland, with occasional retention of pus. Many
of these eases are diagnosticated as eases of relapsing posterior urethritis. The
patients suffer from frequent urination, pyuria, from perineal pain and dis-
comfort. They often have a chronic urethral discharge. The surgeon will
hear in mind that when a prostatic al»si — ruptures into the urethra, spon-
taneous cure may or may not occur. Unless the symptoms rapidly subside, a
perinea] incision and proper drainage is necessary. 1'nder such circumstances
we often find smaller or larger abscess cavities in the gland, separated by
trabecular of more or less infiltrated prostatic tissue, the condition being quite
unfavorable for spontaneous cure.

Chronic Cicatricial Prostatitis the Result of Prostatic Suppura-
tion. — Tn some cases of suppurative inflammation <>f the prostate, nature affects
a cure of a certain kind. The suppurative lesion is healed at the expense of
more or less complete destruction of the glandular substance and the produc-
tion of firm scar tissue. On palpation these prostates feel small, hard, and
often nodular. These patients suffer from symptoms which vary somewhat
in different cases. In some no symptoms at all are observed; in other- the
patients complain of difficult urination: the stream is hard to start, and is
expelled with but little force; there may in a few eases be dribbling of urine
or an insufficient Madder. Tn others the symptoms are those of chronic pos-
terior urethritis. A decided disturbance of the psychic sphere may be present
These patients are neurasthenic, often hypochondriacal. They mav become
prematurely impotent. (See also Impotence.) The only treatment seems to
be a perineal section, division with a knife of the cicatricial prostatic ring, and
the subsequent passage of large sounds. This condition may be differentiated
from senile atrophy of the prostate, since it occurs in young or middle-aged,
not in elderly men.

Chronic Follicular Prostatitis, Parenchymatous Prostatftis. — Tn
certain cases of acute gonorrheal prostatitis the symptoms subside without sup-



618 THE PROSTATE

puration, but the patient is left with a chronic posterior urethritis and a more
or less extensive infection of the ducts and glandular follicles of the prostate.
Such cases have often been complicated by epididymitis and infection of the
seminal vesicles. Posterior urethritis is present in all cases. In some of these
the infection of the prostate gives neither definite signs nor symptoms, and
passes unrecognized. The symptoms are those of an intractable posterior ure-
thritis, and often of a coexistent seminal vesiculitis with recurrent attacks of
epididymitis. Rectal palpation may reveal nothing abnormal about the pros-
tate except a little tenderness. In other cases the patients will suffer from
pain and tenderness in the perineum, from recurring attacks of acute prosta-
titis and posterior urethritis. In these rectal examination will reveal a pros-
tate larger than normal, and more or less tender. Expression of the prostatic
secretion will show a greater or less admixture of pus.

The subjective symptoms vary in different cases. If the prostate is much
enlarged they will have a feeling as though a foreign body was in the rectum,
together with moderate rectal pain and tenesmus. They will have, in addition,
the signs and symptoms of chronic posterior urethritis. (See Gonorrhea.) The
symptom-complex is thus often due to several coexisting lesions — namely, pros-
tatitis, posterior urethritis, seminal vesiculitis, and recurrent attacks of epi-
didymitis. There is often disturbance of the sexual functions, nocturnal pol-
lutions, frequent erections, usually with premature ejaculation, later on partial
or complete impotence, with or without absence of sexual desire. Changes in
the semen are observed. (See Pathological Changes in the Semen.) Nearly
all these patients suffer from fairly marked psychical disturbances. They
become neurasthenic, hypochondriacal, and mentally depressed. The prog-
nosis of this form of chronic prostatitis is not very favorable. These un-
fortunates continue to suffer indefinitely, and are not greatly benefited by
treatment.

Prostatorrhea. — Prostatorrhea is hardly to be regarded as a disease, though
often associated with chronic inflammation of the seminal vesicles. When ex-
isting alone, the symptoms consist of a discharge from the urethra of normal
prostatic secretion. (See Functions of the Prostate.) The discharge occurs
after urination, during straining at stool, or at other times. The quantity
of discharge is usually small — merely a drop or two of milky fluid. In rare
cases it may be larger, and may amount to a drachm or two in twenty-four
hours. The patients are nearly all neurotic or neurasthenic individuals, fre-
quently masturbators or sexual perverts. They usually believe that they are
suffering from seminal losses (spermatorrhea), and are much disquieted
thereby. The condition is sometimes attributed to sexual excesses. That it
ever follows normal coitus, however frequent, in an otherwise healthy indi-
vidual, appears to me doubtful.

Tuberculosis of the Prostate. — Tuberculosis of the prostate may be (1) pri-
mary in the gland itself; (2) secondary to tuberculosis in distant organs —
namely, the lungs, the peritoneum, etc.; (3) the infection is secondary to



DISEASES OF THE PROS! A I E 619

fcuberculosia of other portions of the gsnito urinary tract. In the primary i
the infection may be tuberculous from the start, or may be ingrafted upon a
chronic gonorrhea] prostatitis. The third group forma the most common type,
the prostatic invasion being secondary t<> tuberculosis of the epididymis or of
the kidney, the former being more common.

Occurrence. — As in other forms of tuberculosis, young adults with an
hereditary or acquired tuberculous predisposition are most often affected.

Pathological Lesions. — In tin- primary cases the lesions of the prostate
arc the mosl pronounced. In the cases complicating tuberculosis of the lungs
or peritoneum, death usually occurs before the prostatic lesion is far advanced.
Hence, in these the condition of the prostate is of only secondary importance.
Tuberculous lesions of the prostate consist in the formation of nodule- of
tuberculous granulation tissue, which undergo the regular changes observed
in tuberch — namely, caseation, softening, the formation of tuberculous abscesses
and fistula?, often followed here by secondary infection with pyogenic organisms.
In some cases (lie caseous material is replaced by calcareous deposits and cica
trization; even spontaneous cure is possible. The infection i- usually at firs!
unilateral, so that when both sides of the prostate are involved the lesion i-
older and more marked on one side than on the other. This is notably true
when the prostatic infection is secondary to a unilateral tuberculous epididym-
itis. AVhcn the infection takes place just beneath the mucous membrane of the
prostatic urethra, early ulceration produces very marked symptoms, and usually
abundant bacilli in the urine, so that an early diagnosis is easy in these cases.
When central tuberculous nodules break down they may perforate in any of
the directions mentioned under Prostatic Abscess — i. e., into the urethra, peri-
neum, rectum, etc. Though extremely slow in their progress, these prostatic
abscesses, when once they have perforated into the urethra or rectum, speedily
become a source of imminent danger from urinary infiltration and mixed in-
fection with pus cocci.

Symptoms and Diagnosis. — Tn the group of cases in which the tuberculous
infection is ingrafted upon a chronic gonorrheal posterior urethritis, the in-
vasion with tubercle is not, as a rule, attended by any sudden change of symp-
toms. The patient gradually gets worse in spite of treatment, and examination
of the prostate discloses a nodular enlargement, usually of one lateral lobe. In
other cases bleeding from the prostatic urethra may tirst attract the surgeon's
attention to the probability of a tuberculous infect ion. Tn the cases not pre-
ceded by gonorrhea the patient usually presents himself, suffering from a
chronic posterior urethritis for which there is no apparent cause. Gradually
the signs and symptoms of a tuberculous lesion are developed.

Tn that group secondary to phthisis or tuberculosis of the peritoneum the
symptoms of vesical irritation, with pyuria, sometimes hematuria, are grad-
ually developed, usually when the patient's general condition is already quite
hopeless.

In the group of cases secondary to tuberculous epididymitis the presence



620 THE PEO STATE

of an enlarged, nodular, hard, usually painless epididymis upon one side is
followed or accompanied by vesical irritation, the appearance of pus and
shreds in the urine, sometimes hematuria. Rectal examination discloses a
nodular prostate.

The following are the data upon which the diagnosis may be based : A
tuberculous personal or family history. The presence of other tuberculous
lesions, either distant or of other parts of the genito-urinary apparatus, notably
of the epididymis. The extreme chronicity of the disease. The presence of
tubercle bacilli in the urine. The utter futility of ordinarily successful treat-
ment. The fact that such treatment only aggravates the symptoms. The intro-
duction of a sound or catheter and irrigation of the bladder is followed by an
exacerbation of all the symptoms, by increased pain and frequency, a hemor-
rhage, an attack of epididymitis, etc. The irregular nodular enlargement of
one or both lobes of the prostate. The formation of a tuberculous abscess or
the existence of a tuberculous fistula as the result of such an abscess. The
occurrence of one or more sharp attacks of prostatic bleeding. These are the
data whereby we arrive at the diagnosis of tuberculosis of the prostate.

Progxosis. — The prognosis of prostatic tuberculosis is bad, though the
course of the disease is very slow. Death comes from dissemination of tubercle,
from exhaustion, from abscess formation with septic infection or urinary infil-
tration, from kidney tuberculosis, or from preexistent tuberculous lesions of
the lungs. By hygienic measures, life out of doors in a suitable climate, etc.,
cures are possible in a few cases. A few operative cures have been reported
from incision and curettement of tuberculous prostatic abscesses.

Prostatic Calculi. — Prostatic stones may originate from one of two sources:
(1) From concretions formed in the prostatic ducts; (2) from ordinary vesical
calculi which become impacted in the prostatic portion of the urethra. Such
calculi may originally lodge in such a manner that a portion of the stone
projects into the bladder. The continued growth by deposition of phosphates
may cause such stones to become firmly fixed, so that a cutting operation may
be necessary for their removal.

Prostatic calculi originating in the prostatic ducts (corpora amylacea) are
quite common in elderly men, though they rarely grow to a size larger than
that of a pea, and seldom give rise to any symptoms. I have repeatedly de-
tected them in the prostates of old men by means of X-ray pictures, since they
usually contain enough phosphates to cast a definite shadow. When these con-
cretions are multiple, they may cause atrophy of the prostatic substance, so
that a considerable cavity is formed, containing numerous small stones, readily
palpated per rectum, a grating sensation being imparted to the examining
finger. When such calculi enter and remain in the prostatic urethra they
produce the same symptoms as ordinary calculi in the same situation.

Symptoms axd Diagnosis. — The symptoms produced by prostatic calculi
may be simply those of chronic prostatitis. They may cause prostatic abscess
or urinary obstruction, or in many cases the symptoms of vesical calculus.



DISEASES 01 THE PROSTA1 E 621

The diagnosis i- to be made by the seaicher, by recta] palpation, and by X
examinal ion.

Hypertrophy of the Prostate — Adeno-fibroma of the Prostate. — -I luring ad
winced life, between the ages of fifty and seventy years, the most importanl
and commonest disease of the prostate is the so-called senile enlargement or
hyperl rophy.

Occurrence. — A large proportion of all old men have enlarged prostat
Such is the case among seventy-five per ccnl of men sixty years old. Only
about fifteen per cent, however, Buffer inconvenience therefrom. Symptoms
develop rarely before forty-five or after seventy years, usually between fifty
and sixty.

Causation. — Many theories have been formulated to account for prostatic
enlargement. None of them, so far as I am aware, have stood tin- test of
cure t'u I investigation. Among such may be mentioned arterio-sclerosis I < Juyon i :
analogy to fibro-myoma of the uterus ( Velpeau, Thompson i ; sexual senility
i White and Martin); chronic congestion, due to :i sedentary mode of life, to
sexual excess, to continence, to improper modes of coitus — i.e., coitus reser-
vatus, interruptus, etc. — to chronic gonorrheal posterior urethritis.

Lesions. — The lesions consist of a hyperplasia of the glandular and mus-
cular elements of the prostate. This may involve both structures equally or be
confined chiefly to cither the glandular or muscular substance. In addition
there is an interstitial inflammation with an increase of fibrous tissue, with,
from time to time, acute inflammatory attacks. If the glandular hyperplasia
is excessive the tumor will be soft. If muscle ami fibrous tissue are notably
increased the gland will be hard. Between these two extreme- there are grada-
tions. The enlargement may be symmetrical; it may he confined chiefly to
• me lateral lobe, more rarely to the median lobe. In exceptional cases a nodu-
lar, sharply circumscribed glandular tumor may be formed. In the cases in-
volving merely the median lobe the hypertrophy i< largely muscular and fibrous;
glandular elements are few in this portion of the organ. There may thus be
formed a rounded, sessile, or pedunculated tumor, projecting into the bladder
at the urethral orifice, causing obstruction to urination. Such a projecting
middle lobe may reach a considerable size, and form a pedunculated, movable
tumor within the bladder as large as a hen's egg. It may act like a ball valve.
so that the more violent the muscular effort of tin individual to empty the
bladder the more firmly is the tumor pressed against the urethral orifice. Ab-
solute retention is frequenl in such cases. In some cases "I' genera] hyper-
trophy the deformity consists in the formation of a rounded, semicircular,
projecting shelf, or of a complete collar around the urethral orifice, or of a
bilateral projection on either side of the orifice so that its shape is changed to
an irregular slit. In all these cases intravesical pressure merely serves to close
the urethra more tightly. More frequenl than these intravesical enlargements
are hypertrophies of the lateral lobes. These form a readily palpable tumor
projecting into the rectum. One lobe may be larger than the other, but in



622



THE PEOSTATE






the average case rectal palpation finds a prominent, rounded mass, of elastic