Pain.-Pain almost invariably accompanies cancer of the prostate, and may be the first symptom to awaken the suspicion of the existence of malignant disease. The pain may be referred to the prostate, that is, to the perineal region,-to the rectum, to the back over the region of the kidney, to various portions traversed by branches of the sciatic nerve, to the region of the bladder, or to the glans penis. It may apparently arise directly from the

Fig. 259. Total removal of prostate. Neck of bladder stitched to membranous urethra, prostate having been removed (redrawn from Pierre Duval).

prostate, or indirectly from the pressure of glands that may have become infected. As has been said, it may be the first symptom to give rise, in the mind of the observer, to the suspicion of malignant disease, and as it may occur before metastasis into the neighboring lymphatics has taken place. Persistent pain occurring in an old prostatic, without other explanation to account for it, should ordinarily lead to early surgical intervention.

Hematuria. Next to pain, bloody urine, occurring perhaps in 50 per cent. of cases, is the most common symptom in cancer of the prostate. Careful use of the cystoscope will determine in any given case the cause of the bloody urine.

Physical Examination.-The amount of residual urine is of no particular diagnostic value. Cases of cancer of the prostate have been reported in which hardly any residual urine was present-in one case only a tablespoonful. This is not remarkable in view of the fact that cancer may occur without sufficiently increasing the size of the prostate to cause marked obstruction to the urinary outflow. It must also be remarked that almost all these cases give a history of previous gonorrhea or injury.

The size and feel of the prostate, as ascertained by rectal touch or by urethral examination, are probably not in themselves of any great diagnostic value, except as a means of comparison. These prostates may feel hard, nodular, or even soft. A sensation conveyed to the rectal touch as of a bunch in the prostate, or the feel of a cyst, the contents of which cannot be removed by massage of the gland, is considered by some as diagnostic of canExaminations made to compare the size and consistency at different times may thus be of value. In an old prostatic whose gland has remained of about the same proportion for a long time, as determined by rectal or urethral examination, a sudden increase in size is indicative of malignant disease or inflammatory exacer bation. Cancer of the prostate is more likely to arise in the lateral lobes or in one of them rather than in the so-called third lobe.

cer.

Prognosis. In these cases the prognosis is, of course, grave, and where metastasis has begun, almost invariably fatal. The writers believe that if the diagnosis is made early enough, the cancer may be eradicated by surgical interference. Almost all the cases reported as having been operated upon have done badly so far as cure is concerned. In the writers' case, previously referred to, the recovery which took place after the operation was in all probability due to the fact that the prostate was removed before the cancer had time to cause glandular metastasis.

Treatment. The treatment may be considered under three heads-preventive, palliative, and curative.

Preventive. The ultimate analysis of the question of preventive

treatment seems to lead to the conclusion that if gonorrhea or any urethral inflammatory process could be prevented in the first place, cancer of the prostate would become much less frequent, for it is now well established that chronic posterior urethritis is a very frequent complication of acute urethritis. More and more evidence is being brought out to demonstrate that chronic posterior urethritis and chronic prostatitis go hand in hand; that the latter plays a causative rôle in the formation of the so-called prostatic hypertrophy, and that this in turn, reasoning from analogy, plays a part in the formation of cancer. It would seem also that more prolonged and careful treatment of chronic posterior urethritis and prostatitis would tend to prevent the so-called hypertrophy and, secondarily thereto, the cancer.

Palliative. From the literature on the subject it will be seen that in most recorded cases of cancer of the prostate the diagnosis has been made only after metastasis had taken place and general systemic infection occurred. Consequently the operations attempted in the hope of effecting a cure have proved failures. Something may be said, however, in favor of operations performed for the purpose of prolonging life, or, more particularly in the later stages of the disease, for the relief of symptoms, especially pain. From the writers' experience with palliative operations in tuberculosis and cancer occurring in other portions of the genitourinary tract, they conclude that such operations are justifiable in prostatic carcinoma, but they believe that they should not be attempted if they are likely to make the progress of the disease more distressing to the patient.

Curative. So far, the only curative procedure known consists in removing the cancerous prostate before metastasis has taken place. Now that this condition is receiving more attention, it is to be hoped that an earlier recognition will result in the recovery of a larger number of patients.

In certain forms of cancer of the prostate total extirpation of the prostate, with amputation of the prostatic urethra, as illustrated in the method of Proust (figs. 257, 258, and 259), may be found necessary.

CHAPTER XXVIII

THE TESTICLE AND EPIDIDYMIS

ANATOMY

The testicle is a compound tubular gland of complicated structure. It produces a secretion, the spermatozoa, which form the essential of the seminal discharge.

The testicle is invested by a reflection of the peritoneum. This gives it its outer or serofibrous coat, which is not applied close to the surface of the organ, but is derived as it passes from the abdominal cavity into the scrotum; this is known as the tunica vaginalis.

The gland is inclosed and limited by a strong, thick capsule called the tunica albuginea. This is a dense, unyielding membrane of white color; it is composed of compact bundles of white fibrous tissue that interlace in various directions. Its inner layer is richly supplied with blood-vessels and is sometimes I called the tunica vasculosa.

In the interior, fibers from the tunica albuginea are prolonged from the posterior border for a short distance into the gland, so as to form the complete vertical septum called the corpus highmorianum, or the mediastinum testis. This septum contains the larger blood-vessels of the gland.

From the front and sides of the mediastinum are given off numerous slender fibrous cords and imperfect connective-tissue septa that radiate from the mediastinum toward the opposite wall of the albuginea, with which the ends of the septa blend. In this manner the gland is divided off into from 100 to 200 more or less imperfect lobes. The septa, although made up of connective tissue, also contain a few smooth muscle-fibers and transmit branches of the mediastinal arteries to all parts of the gland structure. They also inclose certain large connective-tissue cells, the cytoplasm of which is rich in metaplasm.

a, The testis and epididymis with their investing membranes seen from in front, b, seen from the lateral surface; c, the testis, epididymis, and the proximal portion of the vas deferens. The tunica albuginea has been completely removed from the epididymis and partly from the testis; the tubuli contorti of the lowest lobule of the testis have been isolated (Sobotta and McMurrich).