Tuberculosis of the Urinary Organs

IN a large proportion of cases of tuberculosis of the urinary and genital system the sequence of events is as follows :-First the kidney is affected, then the ureter and bladder; later the vesicula, prostate, vas deferens, epididymis, and testis may be involved in the male subject. In the great majority of cases the bladder symptoms predominate, so that the case is often sent to the surgeon with the diagnosis of tuberculous bladder. Primary tuberculosis of the bladder is so rare that it may almost be said not to exist, and yet I have seen one or two cases in which, though the bladder showed signs of disease and tubercle bacilli were found in the urine, I was unable to obtain evidence of di5ease in either kidney. It is stated in textbooks that a frequent source of infection of the bladder is the epididymis. Before admitting this mode of infection in a given casc, the surgeon ought to investigate the condition of the kidneys, when he will be surprised to find how often they are involved. Let me give an example. A gentleman, aged 44, presented himself with a tuberculous infection of the left epididymis, with some nodules in both lobes of the prostate. Tubercle bacilli were found in the urine. There was some frequency of micturition, and the cystoscope sthowed some involvement of the bladder. It was assumed that his bladder condition was secondary to the tuberculous epididymis. Ureteral catheterisation, lhowever, oil several occasions showed a moderate degree of diuresis on the right side, in the urine of which a few pus cells and tubercle bacilli were found. rhere was an etntirely unsuspected lesion of the right kidney, which may well have been the cause of the bladlder condition and of the involvement of the prostate and epididymis. Further, I have seen several times a tuberculous epididymis follow on infection of the kidney, and a good many of my cases show the double lesion. I am becoming more and more convinced that in many cases involvement of the prostate, vesicula, ani(i epididymis is secondary to infection of the kidney. In a certain proportion of cases there has been an antecedent demonstrable tuberculous affection elsewhere in the body, such as tuberculous glands in the 255