scopic examination is difficult excepl by suprapubic incision and direct inspec-
tion of the bladder.
History of the Development of the Disease and the Symptoms in Detail. â The
symptom-complex of bladder tuberculosis consists of painful and frequent uri-
nation, hematuria, and pyuria. In the later stages of the disease anemia, loss
of flesh and strength, accompanied by irregular fever and occasional chills,
finally exhaustion and death from toxemia, loss of sloop, pain, oto.
Disturbances of Urination. â Sinee the kidney is first affected in many
cases there will be polyuria. The quantity of urine may also be increased by
reflex irritation from the bladder. (See Polyuria in Renal Tuberculosis.) In
the majority of eases the patient will gradually develop frequency of urination
day and night After weeks or months pain will be added during urination,
and a continual dull sense of discomfort in the sacral region. The pain and
frequency are influenced neither by rest nor by exercise. As time goes on the
pain and frequency will increase; the patient may be obliged to urinate twenty
or thirty times a day, and always with steadily increasing discomfort, until in
the advanced stages of the disease, spasmodic pain of an agonizing character
will be fell almost continuously. The acts of urination may be repeated ewrv
five minutes. The pain is most severe when the prostatic urethra and internal
urinary meatus are affected. In these cases the mortal agony endure. 1 is not
exceeded by any other form of suffering. In the rare eases where the dis
is confined to the upper part of the bladder, pain is by no means so marked,
and may even be absent. Tn exceptional cases the onset of the disease is char-
acterized by painful and frequent urination of an intermittent character, last-
ing for days or weeks, subsiding and recurring after longer or shorter interval-.
sometimes months, even year-, finally to become continuous and more and more
severe. The pain is felt during urination along the urethra and in the glans
penis, and is of a burning character. In addition there is severe spasmodic
pain at the end of the act felt in the glans and prostate, as the sphincter squ<
the inflamed or ulcerated prostatic urethra. The pain continues as a burning
596 TUBEECULOSIS OF THE BLADDER
sensation in the perineum for several minutes after urination, and slowly sub-
sides, to be renewed when the patient is again obliged to urinate. In rare
cases there is frequency but no pain. In others pain may be the initial symp-
tom before any frequency is observed. In advanced cases the pain is continu-
ous and may radiate to the kidney region or into the groin and thighs.
Hematuria. â In about ten per cent of the cases an attack of hematuria is
the initial symptom. It may be slight or severe, and may or may not be accom-
panied by pain. For the differential diagnosis between renal and vesical he-
maturia, see Kidney and Cystoscope. In some cases a number of attacks of
hematuria will occur at intervals, before any symptoms of bladder irritation
develop ; such intervals may be weeks, months, or even years. During the early
stages of the disease these attacks of bleeding are very common. Usually the
amount of blood lost is small. In the later stages there may be no hematuria,
but when the prostatic urethra is ulcerated hemorrhage is almost sure to occur.
I have seen such patients who bled at every urination for many months. In
the later stages deep ulceration of the bladder wall may erode a vessel of some
size and cause serious, even dangerous, bleeding, though this is rare.
The Urine. â The quantity of urine passed does not vary from that observed
in kidney tuberculosis â i. e., there is moderate polyuria, as a rule. The pres-
ence of tuberculosis appears to be inimical to alkaline fermentation of urine,
so that an acid reaction is usually preserved except in advanced cases with
mixed infection. Unless the kidney is also involved there are usually no
marked changes in the specific gravity, content of urea, and salts. (See the
Urine in Renal Tuberculosis.)
Tubercle Bacilli. â Tubercle bacilli may be found in a proportion of cases
which vary directly with the patience, care, and skill of the observer. ( See
Tubercle Bacilli in Urine.) The presence- of bacilli, however, does not establish
the exact site of the disease.
Pyuria. â In the early stages, if the kidney is not furnishing pus, the urine
may be clear, or only show the evidences of a slight catarrhal cystitis â namely,
pus cells and epithelia from the bladder in moderate number. Later, blood
will appear and the quantity of pus will steadily increase with the progress of
the disease. In the later stages, cheesy material, bits of necrotic mucous mem-
brane, or even muscle, may be evacuated. The pyuria will be very marked
indeed. The appearance of pyogenic organisms in the urine belongs to the
later stages of the disease. In one of my own cases the bladder was extensively
ulcerated and streptococci were present in the urine in large numbers. Bacillus
coli, the ordinary pyogenic forms, proteus, and others may be present.
The cystoscopic appearances in bladder tuberculosis have been sufficiently
indicated elsewhere. They are the most certain means of diagnosis.
Incontinence and Retention of Urine. â Among the symptoms which may
appear in the course of bladder tuberculosis are incontinence and retention of
urine. Several forms of incontinence are possible. The patients may have a
constant desire to urinate, so that as fast as a drachm or two of urine collects
in the bladder it is involuntarily expelled. This is common to both sexes in
the later stages of the disease, [ncontinence from overflow may occur when th<-
patient suffers IV 'etention <ln<' to swelling of the prostate. The vesical
Bphincter ma\ be destroyed by ulceration, producing continuous dribbling of
urine Retention may occur early in the disease from irritation of the pros
tatic urethra causing spasm of the vesical sphincter. When the prostate is
tuberculous the swelling of the gland may cause mechanical obstruction. The
mi! infrequent occurrence of prostatic abscess may cause retention. Rarely the
detrusor muscle may be so far destroyed or infiltrated thai the patienl loses
the power to empty his bladder, wholly or partly. A- in other conditions a
large collection of clotted blood in the bladder or :i single firm clol of moderate
size may block the urethral orifice.
Disturbances of General Health. â During the early stages, patients
retain their flesh ;m<l strength, unless other foci of tuberculosis are producing
serious toxemia. As the disease progresses and they begin to suffer from con-
stanl pain, they become gradually weaker, more and more emaciated and anemic.
During the terminal stages the progressive deterioration is rapid. Exceptions
occur. I have seen a man with tuberculosis of the bladder and both kidneys
who appeared to be in fair health ;i few weeks before he died.
Fever is rarely presenl until the disease is far advanced. It may be <>l a
hectic type or an irregular fever of moderate severity, sometimes associated
Among the symptoms sometimes observed in early tuberculosis of tlie pros-
tate and prostatic urethra, produced in part by the local irritation, is an in-
creased libido sexualis. This may be observed in certain cases even late in
the disease when the patients have become weak and emaciated. It i- also said
to he not uncommon in tuberculosis of the lungs. Some of these patients copu-
late industriously up t<> a short time before death.
I'lie recognition of the complications of bladder tuberculosis â perforations,
stone, abscess of the prostate, pyogenic infections â is discussed sufficiently
Diagnosis. â Some diagnostic hints, in addition to whal has already been
transcribed, are perhaps worthy of record. It cannot be to., strongly accen-
tuated that, by fairly good observers, discuses of the kidney and of the bladder
are often confounded. This applies not so much to the genito-urinary specialist,
or genera] surgeon, as to the average practitioner of medicine. In young
adults, when gonorrhea and vesica] calculus can be excluded, a slowly develop-
ing pyuria with irritation of the bladder is strongly suggestive of tuberculosis
of the genito-urinary tract. A careful search should be made in such cases
for positive signs of the disease. The lungs, the testes, the prostate, the seminal
vesicles,, and the kidneys should each receive attention. Cystoscopy will often
do much to render the diagnosis clear in doubtful cases. Many varieties of
cystitis are quickly improved by local treatment. Bladder tuberculosis is al-
most invariably made worse by instrumentation and bladder irrigations.
598 TUBERCULOSIS OF THE BLADDER
Simple Ulcer of the Bladder. â Simple ulcer of the bladder is a rare condi-
tion. If situated near the trigonum, the symptoms may resemble those of
tuberculosis. The cystoscopic picture will show a rounded ulcer ; the base
covered usually with clean granulation tissue ; the edges not undermined. There
will be no scattered tubercles in the vicinity. The shallow, superficial ero-
sions noted in the severer forms of cystitis are part of a diffuse process involv-
ing the entire bladder. The erosions will be scattered over the mucosa here
and there. Tuberculous lesions in other organs will be absent ; pyogenic organ-
isms will be present ; tubercle bacilli absent. Stone in the bladder is to be
excluded by the searcher and cystoscope. Cancer of the bladder occurs in
advanced life. There is bloody urine; later, pyuria. The painful symptoms,
however, are usually developed at a stage when either a palpable tumor can
be felt or when the cystoscope renders the diagnosis plain. (See Tumors of the
Bladder.) Papilloma of the bladder is attended by bleeding; the painful
symptoms are usually slight or absent. The cystoscope or the passage of a
villous process clears up the diagnosis.
The duration of life varies greatly. In some cases these patients live for
many years; in others the progress of the disease is rapid. They may die in
less than a year. The average duration of life is about three years.
Treatment of Tuberculosis of the Bladder The most hopeful therapy of
tuberculosis of the bladder is to remove the other foci, kidney, or testis and
epididymis, in other cases prostate and seminal vesicles, and, if he survives,
to send the patient to live out of doors under the most favorable hygienic con-
ditions. It is to be borne in mind, that after the removal of a tuberculous
kidney the bladder lesions, if slight, improve or get well in many cases. Su-
prapubic drainage is useful to allay the intolerable suffering of the later stages
of the disease.
Tl MORS OF THE BLADDER
The bladder is one of the rarer sites of primary tumor development. The
frequency of tumors of the bladder i- variously estimated al from <>.l'."> to 0.40
per cenl of all tumors. Primary tumors of the bladder are more than twice
as frequenl among nun as among women. Tli<' greatesl number occur after
the thirtieth year of life. Certain forms arc, however, observed only in child-
hood â i. c, mucous polypi or myxomata. The favorite locality for all bladder
tumors is the vicinity of the trigonum and the ureteric orifices; broadly, the
lower half of the bladder. As elsewhere, the tumors may be: I I I Primary, in
the bladder. ( - ) Secondary, when the bladder is invaded by tumors originating
in neighboring organs ; the prostate in male-, the uterus and adnexa in females;
the rectum. (3) Metastatic. The second group is very common, the third
very rare. Thompson observed a metastatic nodule in the bladder in a case
of generalized melano^sarcoma originating in the eye.
Secondary Tumors. â The secondary tumors are, for the most part, carcinom-
ata. Bladder symptoms form almost regularly a part of the clinical picture in
advanced cases of carcinoma of the uterus and rectum. Cancer of the prostate
usually invades the 1 (ladder, and the symptoms produced are much the same
as those observed in primary cancer of the bladder; often, even at autopsy, we
may be unable to distinguish the origin of the growth, except that primary can-
cer of the prostate usually runs a much more rapid course, and infects the
pelvic lymph nodes very early. Primary cancer of the bladder Avail i- of
slower growth, and does not so soon produce lymphatic infection ami metastasis.
Primary Tumors of the Bladder. â Primary tumors may belong to many
tumor group-. Of these, however, only two are at. all common â i.e.. benign
papilloma or villous tumor, sometimes becoming malignant, and carcinoma.
The others are much more rare.
Kiister classified primary tumors of the bladder, according to their origin,
into ( 1 ) tumors originating in the mucous membrane and submucous connective
tissue; C2) tumors originating in the infrequent glandular structures of the
bladder wall; ( â "Â» ) tumors originating in the muscular wall of the bladder.
Villous Tumob, Papillaby Fibboma, Fimbriated Papilloma. â Among
the tumors originating in the mucous membrane ami submucous tissue, by far
the most frequent is the so-called villous tumor, papillary fibroma, fimbriated
papilloma. The following brief but classic description was given by Thomp-
TUMORS OF THE BLADDER
son : " The most obvious characteristic of the growth is a structure in which
the vesical mucous membrane is developed into fine papilla?, which consist of
long fimbriated processes of extreme tenuity, and usually form a group arising
from a small circumscribed base. This last-named part contains other and more
solid structures than those which enter into the papillae themselves. Sometimes
the processes are almost single, threadlike forms, arranged side by side and
undivided for a considerable distance ; others are bifid, generally more com-
pound still; some may be described as digitate, and occasionally the processes
radiate and suggest forms resembling those of leaves. Immersed in fluid, the
long, fimbriated growths float out like slender-leaved aquatic plants in deep
water, and when removed to the air collapse and form a soft mass resembling
a small strawberry."
The villous tumors appear to possess a peculiar quality of propagating them-
selves by contact â i. e., where a villous growth has been long in contact with
the opposite wall of the bladder, a new tumor may appear at this point.
Under the microscope the tumor is seen to have a basement substance of
connective tissue prolonged as delicate processes into the innumerable villi.
Each villus contains also a vascular loop, which is prolonged to its tip. The
epithelial covering consists of one or several layers of cylindrical, or polygonal,
or fusiform epithelial cells. In some tumors the branching is less highly de-
Fig. 193. â Villous Epithelioma of the Bladder.
Cystoseopic picture (Keyes, after Albarran.)
Fig. 194. â Small Tumor of Bladder with
Uneven Surface. (Nitze.)
veloped, and they may then resemble a cauliflower, a cockscomb, or a raspberry
(see Fig. 193, also Fig. 194). For the most part, the villous tumors are
pedunculated so long as they remain benign. The connective-tissue stem arises
from the submucosa, and extends a variable distance into the interior of the
bladder. In some cases solitary or multiple villi spring directly from the blad-
der wall; such villi or groups of villi may be scattered thickly or sparingly
over a considerable surface.
Fibroma. â Fibrous polypus of the bladder is a rare tumor, and purely
benign. For the most part these are pedunculated growths, consisting of firm
SIMPLE I Y&1 - 601
fibrous tissue covered by normal mupous membrane. They usually produce
no symptoms unless they grow large enough to obstruct the interna] meatus like
;i ball valve.
Polypi.â Sofl polypi, mucous polypi, sometimes true myxomata, have been
observed in the bladders of children. Thej occur, as do the fibromata, in the
Fig. 195. â Villous Tumob <>k the Bladder. Fig. 100. â Villous Tumor of the Bladder
On the right a villous process denuded of more Highly Magnified. On the left a mass
epithelium. < in the left the same covered of epithelial cells. On the right a large villous
with epithelium. (After UJtzmana.) process the vessels filled with blood corpuscles.
vicinity of the internal meatus. They are, as a rule, pedunculated, and in
little girls may prolapse through the urethra. Sometimes such tumors are
multiple, and may cover a considerable area of bladder wall.
Sarcomata. â Sarcomata are very rare in the bladder. Nearly all the
forms of sarcoma have, however, been observed in the bladder as massive, s< -
silo, or as pedunculated growths. In one case (Marchand) metastases occurred
in the lungs. In general, metastases appear late, if at all. In both carcinomata
and sarcomata the patients die rather from the effects of the primary tumor than
from generalized dissemination. When the sarcomata are sessile the tumor
may reach a considerable size before encroaching much on the bladder cavity.
The surface of the tumor is usually smooth; ulceration occurs late, it' at all.
Myomata. â Tumors consisting of striped, and others of unstriped, muscular
fibers occasionally occur in the bladder. They may be sessile or pedunculated.
They may be submucous, interstitial, or subperitoneal. Symptoms arc rarely
produced unless the t uiuor c;i uses uiecli;iuic;il interference with urination.
Dermoid Cysts. â Occasionally dermoid cysts rupture into the bladder. They
are rarely primary in the bladder wall. The ovary is their usual origin. The
characteristic passage of hair, oil, etc., in the urine establishes the diagnosis.
Simple Cysts Simple cysts of the bladder wall are sometimes observed.
They are rarely of much sic^iificance.
TUMOKS OF THE BLADDEE
Echinococcus Cysts. â Echinococcus cysts occasionally rupture into the blad-
der. The diagnosis is to be made by finding hooklets in the urine. (See
Fig. 197. â Multiple Villous Papilloma of the Bladder.
Histologically: True benign papilloma. (Albarran.)
THE EPI1 IIKI.IAL TUMORS OF THE BLADDER
The Epithelial Tumors of the Bladder, Adenoma and Carcinoma. â The aden-
omata may occur in any pari of the bladder, even al the apex, where no glandu-
lar elements are normally found. The microscopic appearances are those of
adenoma, fibro adenoma, rarely cyst adenoma, as described under Tumors.
They form nodular or flat growths, and may reach a considerable size. They
are seldom pedunculated.
Cancer of the bladder may occur in any part of the bladder, though many
of them originate in the prostate; though less frequent, they are also observed in
women. Primary cancer of thÂ«' blad-
der wall occurs t'<>r the most part as an
J\ infiltrating form of tumor â carcinoma
\. i nod n Hare, more rarely carcinoma al-
veolare, occasionally scirrhus. In the
medullary form the tumor invades the
muscular wall of the bladder and forms
a fungating, ulcerated, nodular, un-
even intravesical growth, with necrotic
areas here and there. A deposit of
earthy phosphates and other -alt- often
occur- upon the raw surface-. Infiltra-
tion spreads slowly until a large part
of the bladder is involved. The rend-
Fig. 198.â Myxosarcoma in the Bladder of a
Y<>i \>; Girl having rui Gross Appear-
ANCF.S OF MUCOUS POLYPI. (Afte All >:irrall. )
FlC. 100. LOBULATED EPITHELIOMA >>} I"H1
Bladder. (Keyes, after Albarran*)
encv toward the production of villous projections and cauliflowerlike masses is
marked. In some eases the entire bladder is converted into a nonelastic and
contracted maâ of cancerous tissue. During the later stages hemorrhages into
the substance of the tumor, necrosis, deep ulceration, occasionally leading to
perforation into neighboring organs, occur. Portions of necrotic tumor tissue
may be extruded with the urine. A severe complicating cystitis is usually
TUMORS OF THE BLADDER
developed, leading to the deposition of earthy salts and incrustation of the
tumor surface. Pressure ujjon the ureters is often followed by hydronephrosis
or pyonephrosis. Pyelonephritis is a common complication. In those cases
where early obstruction to urination occurs at the vesical neck, retention of
urine with dilatation and atony of the bladder may take place.
Many carcinomata are believed to result from cancerous degeneration of
the base of a villous tumor of the bladder. Clinically, this is a highly impor-
tant fact to bear in mind. The extirpation of a villous tumor should include
a considerable area of apparently healthy muscular wall, since the projecting
portion of the growth may be purely a papilloma, while its base has undergone
cancerous degeneration, requiring rather liberal extirpation.
It may be well to note here that the views of surgeons are somewhat at variance
in regard to the malignant degeneration of villous tumors of the bladder, and
as to the relative frequency of benign and malignant growths. Kuster, Nitze, and
other German surgeons consider that such degeneration is rare, and believe that
many really benign villous tumors have been called cancers as the result of the
erroneous interpretation of the microscopic appearances. The French school, on
the other hand, Guyon, Albarran, and others, as well as many American surgeons,
including Keyes, believe that such degeneration is the rule, and that many tumors
diagnosticated as papillomata are really cancers from the start, wholly or in part.
Thus, among 132 tumors, Albarran found 100 cancers and 21 papillomata.
Symptoms and Diagnosis of Tumors of the Bladder. â Villous Tumor. â The
most constant and characteristic symptom of villous tumor of the bladder is
hematuria. The bleeding occurs in attacks of irregular duration and at irregu-
lar intervals. Neither the begin-
ning, severity, nor duration of
these attacks are influenced by
exercise or rest, or by medication.
The bleeding is as likely to occur
in the night, when the patient is
asleep, as in the day, when he is
working or exercising. The hem-
orrhage may render a single urin-
ation bloody, the next urine passed
being clear, or it may last con-
tinuously for days, weeks, or
months. Usually it stops as sud-
denly as it commenced, and may
not recur for months or even
years. The amount of blood lost
may be slight, moderate, or con-
siderable. It is rarely so profuse
-Alveolar Carcinoma of the Bladder. . . -.
(After Keyes.) on any one occasion as to induce
SYMPTOMS AND DIAGNOSIS 01 TUMORS 01 THE BLADDER 605
a profound anemia or endanger life. Usually the larger tin- tumor the more
profuse the bleeding, yel to this rule there are many exceptions; a small tumor
may I Â» 1< -< -Â« I actively. Unless the bleeding i- so profuse thai clots form in the
bladder and cause dysuria or retention, hematuria is the solitary symptom
observed, sometimes for a long period. During the attack the urine may be
evenly bloody, or in slight attacks the first portion of urine passed will be clear,
the lasl few drachms alone being blood-tinged or consisting of pun- blood. The
absence of any other symptom but hematuria coming on in the ways described
enables us usually t<> exclude vesical stone as a cause of bleeding. In rare
cases, when the tumor, though still small, Is so situated that it readily overlies
the internal meatus, the patient may have difficull urination, or oven retention.
In -nine cases, iii addition to blood, the patienl will pass fragments of necrotic
tumor tissue; less often fresh masses of villi, recognizable as such under the
microscope. The particles are usually small, and often pass unnoticed in tin-
urine. In other cases quite large clumps of tumor shreds will 1><- passed at
frequent intervals. Cases are recorded where spontaneous cure of small villous
tumors has taken place in this way. The whole tumor has been extruded, and
has not recurred. In most cases no such cure takes place; new villi sprout
from the base of the growth, and the symptoms return. A- time goes on, the
attacks of bleeding are repeated, and usually become more frequent and severe.
The patient- become anemic and weak, and are likely to die of intercurrent
diseases. The course of the disease is often prolonged over many year-. When