MORBID ANATOMY - TUBERCULOSIS OF THE PROSTATE.
This is essentially the same as in tuberculosis of other organs and tissues. The characteristic gray and yellow tubercles, cavities, diffuse infiltration and miliary deposits, cretaceous degeneration, fibro-scle rotic change, and cicatrization of cavities are all found in different cases at different stages of the disease. It is a noteworthy fact that the more pronounced lesions are likely to be found in primary tuber culosis of the prostate, or iu that form which is secondary to disease of contiguous and correlated organs. Patients with prostatic tuber culosis secondary to pulmonary or other serious forms of tubercular disease die from the general affection as a rule long before the prostatic tuberculosis has time to develop serious lesions.
A greater or less degree of enlargement of the prostate is likely to be found sooner or later in pros tatic tuberculosis. Enlargement ap pears earlier in cases in which the periprostatic lymphatics and glands are primarily involved, or in which there is primary interstitial deposit, than in those in which the first manifestation of the disease consists of a tubercular prostatitis limited primarily to the mucous and submucous tissues of the prostatic urethra. The enlargement may be diffuse, or limited to one or the other lobe. Rarely, if ever, is it symmetrical. The enlargement is due to two factors : First, a deposit of tubercular elements, and second, consecutive inflamma tion and interstitial proliferation of young connective tissue. It is obvious that the ordinary features of prostatic tuberculosis may at any time be modified by acute inflammation or abscess from mixed infection or traumatism.
In primary prostatic tuberculosis the enlargement is likely to in volve both lobes, although unequally. In the secondary form of the disease one lobe only may be affected, although later in the course of the disease both may become involved. In cases secondary to tuberculosis of the testicle, or in which one testicle only is enlarged as a condition secondary to a deposit in the prostate, only one lobe of the prostate is likely to be implicated, at least primarily. In some cases in which the prostatic disease is secondary to general tubercu losis, gray grauulomatous deposits may be the initial process. It would appear, however, that most often the initial deposit consists of characteristic yellowish granulomatous nodules. These undergo sooner or later more or less softening, and perhaps become liquefied, forming the so-called tubercular abscess, the characters of which may closely approximate ordinary abscess or true suppuration, provided secondary infection with pus microbes occurs. The caseating nodules
or the yellowish granulomatous nodules may remain comparatively quiescent for a long time. In cases in which secondary mixed infec tion occurs, and pus microbes play the most important role, the pro cess may assume a more or less acute form and a mistaken diagnosis is likely to be made.
Primary tubercular deposit most generally occurs about the acini of the glands. It may, however, first invade the submucous tissue of the prostatic urethra. The deposit soon undergoes casea tion, with the final invasion of the epithelium of the prostatic urethra and resulting ulceration and perforation of greater or less extent. This constitutes the so-called tuberculo-ulcerative prostatitis, and is the form in which a positive diagnosis is most easily made. In other instances a caseating cavity at some distance from the mucous membrane softens and burrows from the free surface, finally opening into the urethra. Abscess cavities and ulcers of the prostatic urethra are soon followed by secondary mixed infection and perhaps by in filtration of urine, urinary abscess, and fistula. These lesions present no tendency to cicatrization and spontaneous cure. When the entire gland or one entire lobe is involved, the process may extend chiefly toward the rectum. Nodules are found in the substance of the gland and are perceptible on rectal exploration. These may be softened down and with or without secondary mixed infection form tubercular abscesses which open into the periprostatic cellular tissue, constituting chronic periprostatic abscess, and eventually into the rectum. They may burrow upward and laterally, forming large tubercular cavities in the prerectal tissues. In other instances they may open into the urethra, after which ordinary urinary abscess forms. Several caseat ing foci may coalesce, forming one large irregular cavity with rigid and perhaps eventually calcareous walls. Calcareous transformation or fibro-sclerotic change of the walls of the cavities with resorption of their contents and eventually fibroid degeneration and contraction of the entire mass occur exceptionally and result in a spontaneous cure. In such cases the condition of the prostate is one of atrophy, cicatricial contraction, and partial destruction of the normal glandular and muscular tissue.