In extreme cases of tubercular abscess the entire gland is repre sented by a pus sac. This may or may not invade the urethra. When it does so, the urine enters the cavity, decomposition, local and perhaps septic infection, and a more or less acute urinary abscess may result. The sinuses which form as a result of tubercular ab scess may burrow in various directions. They most often open upon the perineum in the neighborhood of the anus ; their next most fre quent direction being toward the rectum, into the cavity of which they finally open. They have been known, however, to open in the hypogastric region or some distance away upon the abdominal walls, or thighs. A small primary focus or perhaps several small tubercu lar foci may remain quiescent in the prostate for many years, possi bly for an indefinite period. This explains the extremely slow pro gression of many cases in which a diagnosis of prostatic tuberculosis is made, admitting that quite a proportion at least of such diag noses are correct. The rule is, however, that general infection and a fatal result occur sooner or later. It is obvious that a fatal result occurs much earlier in cases in which the prostatic disease is secon dary to tuberculosis of other and more important organs.
It is not easy to determine the primary seat of infection in prostatic tuberculosis. It is often a very perplexing problem to decide whether the primary deposit occurred in the prostate or in some other organ or tissue of the body. Even when secondary to tuberculosis of contiguous and correlated organs and tissues, it is not always a simple matter to determine the precise relation between the prostatic and the contiguous disease, e.g., if the prostatic tuberculosis is associated with a similar process in the testicle, it is not always easy to determine which organ was the primary seat of the disease. From a clinical standpoint, it is probably most generally believed that the prostatic disease is secondary to that of the epididymis. In many cases, how ever, it seems logical to infer that the tubercular infection has trav elled from the prostatic urethra via the ejaculatory duct and vasa deferentia to the epididymis. This may be inferred when the symp toms of prostatic disease precede for some time the morbid changes in the testicle, and where both epididymes are involved at about the same time. It must be remembered, however, that small tubercular
nodules and slight•infiltration of the epididymis may exist for a long time prior to the development of prostatic symptoms without attract ing the attention of the patient, the first manifestation of disease from the objective standpoint being referable to the urinary function. From a pathological standpoint, it is said to be fair to infer that when the process in the prostate is far advanced and that in the testis is in significant, the prostatic tuberculosis may be considered to be the primay condition. This, however, is not to be accepted without qualification, inasmuch as the process in the testicle is always slow, often comparatively innocuous, and not likely in a large proportion of cases to go on to extensive destruction unless some source of mixed infection occurs.
The condition of the spermatic cord is apparently not a fair crite rion from which to decide the primary or secondary relation of the prostatic to the testicular disease where these two conditions coexist. It would appear that infections of all kinds may expend their violence upon what may be termed from a practical standpoint the two ex tremities of the seminal tube, the cord remaining healthy. Tubercu lar adenitis and lymphangitis are very important factors in prostatic tuberculosis. As Lannelongue pointed out, the lymphatic glands be tween the bladder, prostate, and rectum may be the point of depar ture. In such cases speedy softening with early opening into the rectum may occur. In some cases of prostatic tuberculosis there is general genito-urinary infection, primary or secondary. The kid neys, bladder, and ureters may be involved, the infection having travelled up from the prostate to the kidneys or vice versa. Instead of this gradual extension of the disease upward or downward, the kidneys may be the primary seat of tubercular deposit, the prostate presenting secondary tuberculosis as a consequence of bacillary in fection either by the urine or in a more roundabout way through the general circulation.