cent. The reports of Ramsay, Israel, Krönlein, Kümmel, Rumbel, Bangs, Facklan, and Garceau demonstrate more successful results, presumably from a better selection of cases and an improved technic. Garceau, in a series of 101 cases quoted from various sources, finds the mortality to be 17 per cent. Kelly reports 57 cases with 4 deaths, establishing a primary mortality of 7 per cent.

The kidney is exposed by an oblique incision extending approximately from the last rib to the crest of the ilium. Upon bringing the kidney outside of the wound the vessels are ligated with strong catgut. Considerable difference of opinion is entertained regarding the advisability of removal of the ureter if diseased. This procedure is recommended by some on account of the frequent development of fistula and lumbar abscess, with possible danger of further dissemination of the disease. It is believed by many that the ureter, even though partially diseased, should be retained because of the increased danger and extent of the operation. Tuberculous sinuses arising from this source sometimes disappear after a few months. No objection is made to the removal of a portion of a diseased ureter, and cauterization of the distal end with pure phenol when unattended by special difficulty or too great prolongation of the operation.

CHAPTER LXXII

TUBERCULOSIS OF THE BLADDER

THIS condition, in the great majority of instances, is secondary to tuberculous change in other parts of the genito-urinary system. It may occur as a result of either ascending or descending infection. It is probable that the larger proportion of cases of bladder tuberculosis take place as an extension from a primary lesion in one kidney. Involvement of the bladder may occur as a result of ascending infection from portions of the genital system, in accordance with Baumgarten's law regarding the flow of the secretions. It is extremely doubtful, however, if the original source of infection in any considerable number of cases is traceable to the external genitals. In other words, the primary infection in all portions of the genito-urinary tract is usually hematogenous rather than exogenous in origin.

Though of rare occurrence, primary tuberculosis of the bladder is sometimes observed. It must be remembered, as previously stated, that the term primary, as applied in this connection, refers simply to the genito-urinary tract, exclusive of infection in other parts of the body. Primary vesical tuberculosis is rather more common among females than in the opposite sex, and, according to Fournier, is occasionally due to infection from the female genitals. The pathologic changes relate essentially to the formation of small grayish nodules, which enlarge, caseate, assume a yellowish appearance, and eventually ulcerate. The ulcerations often exhibit an irregular contour on account of the coalescence of multiple tubercle deposits. They vary not only in their lateral distribution, but to some extent as well in depth. Though superficial, in many instances involving merely the mucosa or

submucosa, in exceptional cases they penetrate the vesical wall, and produce perforations into the rectum or vagina. The ulcers are usually surrounded by a zone of more or less intense hyperemia. In fact, before ulceration has taken place the only deviation from the normal macroscopic appearance may consist of reddened, irregular patches of mucous membrane.

Symptoms and Diagnosis. The symptoms are often of slow development. They may remain unrecognized for a considerable period or they may suggest merely a varying degree of vesical irritability. Complaint is rarely made of pain in the beginning of the affection, but later this becomes a prominent symptom. Early attention is usually called to the condition by the frequency of urination. Examination of the urine at this time discloses the presence of a variable amount of pus, and sometimes of blood. The latter may be recognized as an occasional red bloodcell, or in some cases as a distinct hematuria. A few drops of clear blood may make their appearance at the end of urination. Failure to explain the bladder irritation, and the presence of blood and pus by the demonstration of stone in the bladder or of other recognized pathologic condition, suggests immediately the probability of tuberculous infection. This hypothesis is substantiated by the discovery of bacilli in the urine, although their non-recognition upon microscopic search of the sediment constitutes no negative evidence as to their presence. The diagnosis may be definitely established by a positive result of animal inoculation.

Cystoscopy, even at an early period, may yield information of almost pathognomonic character. Irregular reddened patches of mucous membrane may be recognized, which are frequently situated in the trigonum. In case of descending infection from one kidney there is usually observed, as already described, a distinct reddening and dilatation, with or without ulceration of the ureteral orifice. It may be assumed that the absence of dilatation and ulceration at the mouth of both ureters, with tuberculous nodules and ulcerations in other portions of the bladder is prima facie evidence that the infection is either ascending in character or primary in the bladder. Meyer reports a single instance of contraction of the ureteral orifice in tuberculosis of the corresponding kidney.

After the tuberculous lesions in the bladder undergo the process of ulceration, the general type of the symptoms assumes a greater degree of severity. The desire to urinate is more frequent and imperative. Sleep is sometimes well-nigh impossible, as the patient is awakened at brief intervals by urgent vesical discomfort. Pain is often very intense, and may be accompanied by considerable tenesmus. Though the bladder capacity often becomes much diminished, the retention of a variable amount of residual urine may take place. Incontinence sometimes occurs if the ulcerative process involves the neck of the bladder. The rapidity of the development of symptoms varies somewhat with the location of the ulcerative changes. If the trigonum is involved, the evolution of clinical manifestations is considerably more rapid than when the process does not invade this region. After ulceration has become established, a secondary infection almost inevitably supervenes, and adds to the sufferings of the patient, already sorely afflicted. Appetite and nutrition become impaired, and nervous disturbances pronounced.

Treatment.-The treatment of bladder tuberculosis is attended by much more gratifying results than in former years. In early states the management of the vesical affection itself, exclusive of the surgical indications relating to operation upon other portions of the genitourinary tract, should be based upon the principles of nutrition and rest. As in other tuberculous conditions, the utmost importance attaches to the establishment of the best possible hygienic environment. Rest, as a rule, is more imperative than in any other tuberculous infection, although moderate exercise may sometimes be permitted if carefully supervised. The patient, in the event of suitable weather conditions, should be exposed to the open air for prolonged periods, but the fullest conception of the principles of outdoor living is capable of fulfilment only in regions where sunshine, blue skies, and an invigorating atmosphere predominate.

The climatic conditions appropriate to the successful management of pulmonary tuberculosis are those most likely to influence favorably the course of tuberculous processes in other parts of the body.

Treatment with the bacilli emulsion, or, in case of mixed infection, with other bacterial vaccines, may occasionally be attended by favorable results.

The local treatment of vesical tuberculosis as generally employed is most unsatisfactory. The injection of various solutions into the bladder is likely to be productive of considerable pain and discomfort. In the presence of a very acid urine, the injection of mild cleansing solutions, as boric acid, sometimes exerts temporarily a soothing effect upon the inflamed mucous membrane. The injection of iodoform suspended in olive oil has been more or less employed, with varying reports. Agents directed to the relief of the bladder symptoms should be selected not only with reference to the acuteness of the clinical manifestations, the condition of the urine, the presence or absence of mixed infection, but primarily to the stage of the tuberculous process. Nodular tuberculosis is not attended by secondary infection, and scarcely calls for local applications of any kind. Instrumentation of the bladder at this period should be absolutely avoided, as the topical solutions do not come in actual contact with the local tuberculous process, while added opportunity is afforded for the introduction of secondary microorganisms into the bladder. Unnecessary irritation is often induced, and the course of the tuberculous disease thereby hastened.

Rest and attention to the general health are of especial importance at this time. Diluents should be administered, and excesses of all kinds enjoined, especially indulgence in alcohol, coffee, or highly spiced food. Urotropin is of some utility in case of an alkaline urine, especially if bacilluria is present, although this rarely precedes ulceration unless as a result of careless catheterization. If the urine is highly acid, alkaline diuretics are indicated, to which tincture of hyoscyamus may be added in the event of extreme vesical irritability. After the ulcerative process has become established and secondary infection has supervened, considerable benefit may be obtained from the intelligent use of various strong antiseptics. Solutions of corrosive sublimate, as originally advocated by Guyon, have been quite extensively employed. Garceau recommends the early instillation of a solution of 1 : 5000 into the bladder in case of vesical tuberculosis in the female. With increasing toleration for the drug the strength is increased up to 1: 500. If the pain

is severe an injection of cocain or eucain is advised as a preliminary procedure. He also practises the application of solid silver nitrate to the diseased surface by means of the cystoscope, with the patient in the knee-chest position. Etherization is sometimes necessary for the initial exploration and application. Tuberculous granulations are reported to have been destroyed by this method, and the process of healing decidedly stimulated. The application of silver nitrate in solution to the tuberculous bladder of males has been attended by much less favorable results. Rovsing, of Copenhagen, has obtained remarkable results by the injection of 5 per cent. solution of phenol into the bladder subsequent to cocainization.

The surgical treatment of vesical tuberculosis relates to the curetment of tuberculous ulcers, excision of portions of the bladder, and cystotomy.

Curetment is practised through a large cystoscope, and is applicable only to large active granulations covering a localized area of ulceration. If curetment is performed, it is usually necessary to cauterize the base of the ulcer with the silver nitrate. The operation is impracticable in most cases, and is attended by the disadvantage of possible further dissemination of the infection.

Excision of tuberculous ulcers, or even of a considerable portion of the wall of the bladder, has been practised in occasional instances, but the proper scope of its application is very limited. An important objection to its more general use is the fact that the ulcerative process involves with great frequency the vicinity of the ureters, in which locality excision is rarely permissible.

Cystotomy is the operation of choice on account of its comparative safety, and the immediate relief afforded to the patient, whose sufferings have been well-nigh intolerable. It is especially indicated in severe continuous bladder discomfort, with almost incessant efforts toward urination. The torture resulting from advanced tuberculosis of the bladder is almost instantly relieved by the opportunity provided for immediate evacuation of the urine.

For women the infrapubic operation is recommended by some surgeons, the vagina being regarded the natural route for drainage. It would appear, however, that while vaginal cystotomy has obvious advantages, a decided objection to its employment relates to the fact that operation through this channel is especially likely to invade the area of active tuberculous ulceration, and open up fresh avenues of infection. This objection does not obtain to the same extent in the suprapubic operation. In 1902 Dr. C. A. Powers reported a case of suprapubic drainage for advanced tuberculosis of the bladder upon a patient of Dr. S. A. Fisk, who subsequently came under my observation. As the case is somewhat unique in view of the excellent result attending the operation, extracts of Dr. Powers' report are appended. The patient was a man, fifty years of age; his wife and two daughters had died of pulmonary phthisis, and one son was the subject of existing tuberculous infection.

"The patient is of rather spare physique, who appears to be between sixty and sixty-five years of age. Examination of the chest negative. Vesical discomfort and tenesmus are urgent. He urinates every halfhour, both day and night. He takes three-quarters of a grain of morphin daily. His bladder capacity at this time is about one ounce; there

is about one-half ounce of residual urine. The urine is pale, neutral, its specific gravity 1014. It contains bacteria, bladder epithelium, mucus, and a little pus. Tubercle bacilli are sought, but not found. Cocain examination for stone is negative; the introduction of the searcher causes slight bleeding. So far as one can judge, there is no other tuberculous lesion in the genito-urinary tract."

After the lapse of two years the patient again came under observation. His condition had grown progressively worse. There was marked spasm at the neck of the bladder; urination was performed every ten minutes, day and night; hematuria was constant. grains of morphin were taken daily.

Four

"He was examined under chloroform December 26, 1896. Bladder capacity, about six drams. Cystoscopic examination revealed an irregular ulcer, three-quarters of an inch in diameter, at the neck of the bladder posteriorly. This ulcer bled very easily. No stone was found. After prolonged search tubercle bacilli were found in the urine."

Permanent suprapubic drainage was performed. The bladder was found not larger than an English walnut. The wall was greatly thickened, intensely congested, and studded here and there with miliary tubercles.

"There was an irregular ulcer the size of a penny at the neck posteriorly, rather more on the left side. The ulcer was gently curetted, and its base cauterized with pure phenol. It bled pretty freely. The bladder was drawn up and its edges stitched to the skin. It seemed to resemble in size and shape the finger of a glove. The orifices of the ureters were not seen. A large drainage-tube was placed in the bladder, care being taken that its end should not touch the posterior wall, and the bladder was tightly sewn about it. The outer wound was partially closed.

"The patient was out of bed on the tenth day, and at the end of three weeks was wearing a permanent tube and urinary receptacle. At that time his morphin had been decreased to two grains daily. A month later he resumed his occupation, that of traveling auditor for a large national corporation. During the two or three months immediately following the operation there was occasionally moderate leakage about the tube. The tube itself was a soft-rubber catheter, No. 30 of the French scale, having a velvet eye at the end, as well as at the side. It was carefully adjusted and held well in place. Twice daily the patient removed and boiled the entire apparatus and washed out his bladder. His relief from suffering was marked, and he was quite comfortable. His spirits returned, he gained in flesh and strength, and was able to decrease his morphin to something less than a grain daily.

"The patient continued from year to year in a comfortable and generally satisfactory condition. At no time did I think it wise to recommend removal of the tube and closure of the fistula. I saw and examined him yearly, as once a year his business brought him to Denver for two or three weeks. I last saw him in the summer of 1901, four and one-half years after operation. At that time he was in better weight and general health than in many years. He was comfortable, except for the nuisance of the urinary fistula."