TUBERCULAR ULCERATION OF THE BLADDER.
The symptoms of primary tuberculosis of the bladder are very characteristic. They are nearly always thought at first to be due to stone, though the differences are marked. A young male, * sixteen to twenty-five years of age, often without any venereal history but with a family tendency (usually maternal) to tubercle, suddenly ex periences a pain in the glans or mid-penis while urinating. There is an almost immediate increased frequency of micturition in the day. In 76 per cent. of my cases, frequency of micturition and penile pain were the first symptoms noticed, but in the smaller number, in which I suspect a vesical deposit secondary to some extra-urinary tubercu lar focus sloughed out, hemorrhage was the onset symptom. Soon the night is much disturbed by constant calls to empty the bladder. These symptoms are followed in a variable time according to the acuteness of the disease, from a few days to a few months, by the appearance of blood in the urine. The blood is often profuse and very bright at one time or other in the course of the early stage, from sloughing out of the deposits; but these attacks are for the most part transitory, and the patient usually only sees a few drops of blood follow the end of the stream of urine, strained out as it were by his efforts to get rid of "something." The stream of urine is often ar rested, but if the cause for this is inquired into carefully, it will be ascertained that the patient checks it voluntarily on account of the spasm and pain. The sudden cessation, therefore, is not due to the abrupt plugging of the urethral orifice with a stone. After a few months the bladder becomes contracted, so that it cannot contain more than 6 to 8 ounces, and if the surgeon forces in more by means of a syringe, "the distention reflex" is so great that the patient will often kick or groan even when all corneal sensation has been abol ished by ether. The urine from the very first contains traces of pus, and this increases rapidly to a thin but distinctly visible deposit. The secretion is more or less murky, of a light color, of normal speci fic gravity, and it remains feebly acid or neutral until the surgeon makes it alkaline by interference. At first there are well-marked
periods of quiescence, often for a fortnight or more at a time, and in these periods the irritability, pain, and blood disappear, or nearly so. It will be noted how readily the bleeding is re-started—a few hours after an extra exertion, or a sudden chill to the body, as in bathing or getting wet, a sharp attack of hemorrhage takes place, clots and bright blood being freely passed. To a superficial observer the early symptoms of primary vesical tuberculosis are very like those of stone in the bladder. The same irritability, the same glans pain after urination; the blood, pus, and murky urine; the stop pages in the stream, and the periods of quiescence appear in both diseases. There are, however, points of difference in the patient, in his symptoms, and in his urine, which will at once lead to the exis tence of stone being doubted. His youth, his family history; the distressing irritability of the bladder at night; the sudden and cause less appearance of bright hematuria not increased by exercise nor checked by rest; the sudden relief of the suprapubic pain and the rapid disappearance of the glans pain after the evacuation of the bladder; the persistent post-scrotal pain; the very light, acid, murky, scentless, puriform urine which is passed at the very outset of the trouble; and finally, the fact that the periods of quiescence are uninfluenced by violent exercise, point to the tuberculous and not to a calculous nature of the disease.
The progress of the case, however, will probably dispel any doubt, for the epididymis will become implicated, and the prostate will then be felt, per rectum, knobby or shotty from the deposition of tubercle; or the kidney will become painful and swollen and the temperature will rise at night. If an incision is made into the kidney, a quantity of inodorous caseous pus will be evacuated, to the great relief of the patient and the amelioration of the bladder symptoms.