CHAPTER XXIV THE DIAGNOSIS OF DISEASES OF THE BLADDER (Part 4)

history, on palpation, on the cystoscopic appearances, and on the microscopic examination of shreds in the urine and tissue removed from the bladder. Malig- nancy is distinguished from benignity only by the greater pre- ponderance of pain and induration of the tissues in the former. Certain distinguishing characteristic features will be taken up with each disease. Lincoln Davis (Annals of Surgery, April, 1906), from an analysis of forty-five cases occurring in the Massachusetts General Hospital, thinks that the important diagnostic feature of malignancy of bladder tumors is the infiltration of the underlying bladder wall, and that the recurrence of epithelial tumors does not mean necessarily that they are malignant. The electric cys- toscope with water-distended bladder is especially well adapted to the inspection of bladder tumors and very beautiful pictures are obtained of the villi of a papillomatous growth floating in the bladder fluid like the tentacles of a sea anemone. 31 482 DISEASES OF THE BLADDER Benign Tumors Papilloma. — Papillomata are the most common of all vesical tumors. The name papilloma is given to pedunculated tufted tumors, but the shape does not necessarily indicate their patho- logical structure, so that it happens that papilloma, although com- monly made up of submucous connective tissue — a fibroma, and therefore benign — may be an outgrowth of the epithelial tissue of the mucosa and therefore malignant. The benign papilloma is made up of a framework of connective tissue richly supplied Fig. 190. — Papilloma (Fibroepithelioma) of the Bladder. (Knorr.) with blood-vessels and covered with pavement bladder epithelium. It has a branching, villous appearance, the villi are often of extreme thinness and resemble chorionic villi, or they may be short and stunted and some may be covered with white phosphatic deposits. The villi may be so short that a papillomatous growth may appear through the cystoscope to be smooth on first inspection ; in this event it looks white, differing from the smooth reddish or reddish- white surface of an epithelioma. These growths are generally single in their early stages and the base never reaches downward beyond the submucosa. They vary in size from a pea to a hen's egg, the latter being rare, and are more commonly found in the neighborhood of the ureteric orifice, outside the trigone. The mouth of the ureter NEW GROWTHS OF THE BLADDER 483 nearer the tumor is reddened and is converted into a furrow instead of being a little slit. The surrounding mucosa of the bladder is generally reddened and swollen. If the pedicle is long the growth will float about and is likely to plug the internal orifice of the urethra, and therefore cause retention. The more sessile the tumor and the further it is situated toward the posterior wall, the less likely is this result to occur. The first symptom of papilloma is blood at the end of micturition ; later the amount of blood lost may be alarming. An ache in the kidney on the side of the body on which the tumor is situated is a symptom of the advanced stages when the growth has increased in size. This ache is thought to be due to ascending infection of the ureter and kidney, with or without hydronephrosis. Impeded urination occurs if the tumor obstructs the urethral orifice, and cystitis may be a late result. The diagnosis rests on these symp- toms, on the finding of a tumor by vaginal palpation of the bladder base, and on the cystoscopic appearances as described above. The microscopic examination of pieces of tissue passed in the urine or removed by the alligator forceps will alone settle the diagnosis of the sort of tumor present. Fibroma and Myoma. — These benign tumors are of rare occur- rence. A fibroma or fibroid polyp is made up of connective tissue, it is usually pedunculated and has a smooth or slightly lobulated surface. Its pedicle is well vascularized, but the tumor itself is not. The latter fact may be the reason that these tumors are apt to undergo myxomatous degeneration. Only a few cases of myoma of the bladder have been described. They begin in the muscular coat and develop into the cavity of the bladder either as a sessile or as a pedunculated growth. In one reported case the myoma was on the outside of the bladder. Adenoma. — This is a rare benign epithelial tumor of the glandular type; it is sessile or stalked, and has a smooth, lobulated, or villous surface. The sessile growth, as in the case of the fibroid polyp, can be enucleated easily from the bladder wall. Malignant Tumors Carcinoma. — There are two sorts of primary cancer of the bladder, one squamous-celled, and the other cylindrical-celled. The disease begins as a small nodule either of the encephaloid, scirrhus, or 484 DISEASES OF THE BLADDER colloid type, and has a tendency to remain localized in the bladder for a long time. Later, multiple tumors are found, and ulceration, cystic degeneration, and gangrene occur. The bladder wall sur- rounding and under the tumor is indurated. The surface of the tumor may be covered with villi, which are more vascular than in the case of the benign growths; the growth is apt to be sessile. The disease extends from the base of the bladder, its usual situa- tion, to the ureters, often closing one or both orifices and causing renal disease and it either forms a tumor in the bladder or infiltrates the bladder wall and the surrounding tissues. The symptoms are the same as in papilloma and the diagnosis is made in the same manner. Much induration of the tissues in the bladder base points toward carcinoma and constant pain in the region of the blad- der, and frequency of micturition, are characteristic symptoms. Cystitis, with pain in other regions, as in the back and thigh, and emaciation, are late manifestations. The exact diagnosis is made by the microscopic examination of a portion of tissue either from the urine or removed from the bladder through the cystoscope. Sarcoma. — Primary sarcoma of the bladder is extremely rare, although more frequent than in men. It may occur at any age. The tumors are of rapid growth, usually multiple. They are sessile and tend to grow out through the urethra. They are red or blackish in color and have a smooth surface. FUNCTIONAL DISTURBANCES OF THE BLADDER As has been pointed out already, any disease that interferes with the normal physiology of the trigone and neck of the bladder is apt to cause bladder symptoms, as, for instance, hyperemia of the trigone or trigonitis, and dislocation of the neck of the bladder. In these days of cystoscopy we find many instances of frequency of urination where the only discoverable abnormality is injection of the mucosa of the trigone. A concentrated urine from lack of sufficient ingested fluids, urine containing an excess of uric acid, crystals of oxalic acid, or turpentine, cantharides or other irritating substances, is a cause often of frequency of micturition. So also may be a urethra of caliber insufficient to drain the bladder freely and speedily. FUNCTIONAL DISTURBANCES OF THE BLADDER 485 Irritability of the bladder has been the term that has in the past cloaked a multitude of sins of omission in diagnosis. In hysteria the secretion of large quantities of limpid urine with consequent frequency of micturition alternates with scanty high-colored urine. Spasm of the detrusor fibers of the bladder with the involuntary discharge of urine occurs sometimes in this disease, and hysterical retention is frequent. When there is spasm of the neck of the bladder in hysteria there may be great difficulty in starting urination. Incontinence may occur with an attack of epilepsy. In the case of locomotor ataxia there is lack of control over the bladder, beginning as a delay in starting micturition; after the flow has begun it stops suddenly, then starts again, and when the bladder seems to be emptied urine is passed into the clothes. In this disease there may be also partial or complete retention with incontinence from over distention, or vesical tenesmus. Retention and incontinence occur in PoWs disease and in in- juries of the brain and spinal cord, and also in general paralysis of the insane. Retention is noted as a constant symptom in multiple sclerosis. Where the passing of large quantities of urine is due to mental influences, as in the case of apprehension and worry, and not to organic nervous disease, the frequency of micturition is limited to the day-time, for as a rule such a patient sleeps all night without rising to empty her bladder. Incontinence of urine is of two sorts, that which occurs in over- distention of the bladder, the drop-by-drop kind, with incessant dribbling, and the incontinence in the form of intermittent evac- uations of large quantities of urine. The first kind is due to any cause which distends the bladder with urine, the cause being found among the functional and organic diseases of the bladder; the second is supposed to be due to faulty innervation of that organ. The latter kind is most frequent in children. Many of these children are quite normal as to their urinary functions during the day and the incontinence is nocturnal only ; others, a smaller proportion, not only wet their beds at night, but experience pressing calls to urinate during the day, and if not attended to at once, wet their clothes. (See Enuresis, Chapter XXVIIL, page 578.)