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 PHYSICIANS AND 
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 IN THE 
 
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 SCHOOL OF MEDICINE OF COLUMBIA UNIVERSITY 
 
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WU^-^ i- 
 
 
 A STUDY 
 
 OF THE 
 
 TUMORS OF THE BLADDER 
 
 Witli Original ContriMtions and Drawings 
 
 BY 
 
 ALEX, W. STEIN, M.D., 
 
 SURGEON TO CHARITY HOSPITAL, GENITO-URINARY AND VENEREAL DIVISION. 
 
 PROF. OF VISCERAL ANATOMY AND PHYSIOLOGY AT THE N. Y. 
 
 COLLEGE OF DENTISTRY, ETC., ETC. 
 
 NEW YORK 
 WILLIAM WOOD & COMPANY 
 
 27 Great Jones Street 
 1881 
 

 Copyright by 
 
 WILLIAM WOOD & COMPANY, 
 
 1881. 
 
 H. O. A Industrial School, 
 Blectrotypers and Printers, 
 1S9 E. 76TH Street. 
 
PREFACE 
 
 Four cases of tumor of the bladder have come 
 under my observation within a few years. Two of 
 these were followed to their fatal termination. 
 Both were instances of primary cancer; in one case 
 the tumor was an encephaloid, in the other it was a vil- 
 lous epithelioma. Autopsies were fortunately obtained 
 in both cases, the specimens were preserved and care- 
 fully examined microscopically by Carl Heitzmann, 
 M.D,, to whom also I am indebted for the drawings 
 which accompany the histories of the cases herein 
 recorded. The other two cases, both male, were only 
 temporarily under observation ; in one, the diagnosis 
 was clearly made by physical examination and then 
 the patient disappeared ; in the other, the tumor was 
 not made out by the touch, but the frequent micturi- 
 tion, blood-tinged urine, extreme tenderness of a 
 certain portion of the bladder to the contact of in- 
 struments, together with the occasional escape with 
 the urine of floccuient fleshy particles, left little doubt 
 as to the existence of a vesical growth. With this 
 personal experience I began an inquiry as to the 
 exact status of the literature upon tumors of the 
 bladder. Although our subject required considerable 
 research, having to seek chiefly in medical journals 
 
iy TREFACE. 
 
 for the information desired, the field explored proved 
 full of interest and replete with valuable information. 
 I have endeavored to make this monograph as com- 
 plete as possible in every practical detail bearing on 
 the nature, symptomatology, diagnosis, and treatment 
 of the disease of which it treats, and trust that it may 
 prove of some value as a contribution to the surgery 
 of the bladder. 
 
 Alex. W. Stein. 
 
 30 West Fifteenth Street, 
 
 Nov., 1S81. 
 
CONTENTS. 
 
 PAGE 
 
 Bibliography vii. 
 
 Classification of Tumors i 
 
 Fapillomata — Villous Growths — Structure — Varieties — Nature — Frequen- 
 cy — Age — Sex i-6 
 
 Polypi — Varieties — Structure — Frequency — Sex — Age 7-ii 
 
 Carcinomata — Epithelioma — Villous — Encephaloid — Scirrhus II-13 
 
 Primary and Secondary 14-17 
 
 Locality — Age 1 3 
 
 Myoviata — Faye — ^Volkmann — Chiarri 2S-32 
 
 Myo-carc no-sarcoma, Billroth 28-29 
 
 Sarcomata — Primary and Secondarj^ — Spindle-celled — Round-celled — 
 
 Villous 33-35 
 
 £ony Tumors 36 
 
 Etiology 36 
 
 Symptomatology. 
 
 Hainaturia — Only Symptom — Time of Appearance — Quantity of Blood 
 
 with Urine — Causes Producing — Absence of . . . 36-40 
 
 Irritable Bladder — First and Only Symptom — Absence of — Depending 
 
 upon 40-42 
 
 Pain — Absence of — Location and Character of 42 
 
 Jietention and Incontinence of Urine 43 
 
 Diagnosis. 
 Protrusion of Growths from }»Ieatus — Spontaneous Expulsion of 
 
 Growths 43-44 
 
 Accidental Removal of Growths by Catheter 45 
 
 Value of Microscopic Examination of Urine in Villous Tumors. ... 46 
 
 Fibrinuria as a Feature 47 
 
 Value of Microscopic Examination of Urine in Cancer 48-49 
 
 Physical Examitiation — Bimanual Palpation — Introduction of Hand into 
 
 Rectum — Exploration by Catheter 50-5 1 
 
 Di'atation of Female Urethra 52-54 
 
 Dilatability of Female Urethra — Digital Exploration of the Interior of 
 Bladder 56-57 
 
 Differential Diagnosis between Benign and Malignant Growths — Between 
 
 Calculi and Tumors , . .57-59 
 
vi CONTENTS. 
 
 Duration and Prognosis. 
 
 Non-malignant — Malignant Tumors 60-62 
 
 Treatment. 
 
 Operations performed on Females 63-71 
 
 Operations performed on Males I'^-'l 
 
 Results of Operations on Females 11^19 
 
 Results of Operations on Males 79~So 
 
 Methods of Operating 07t Females — Bloodless Dilatation of Urethra — Inci- 
 sion of Urethra — Kolpo-cystotomy S2-83 
 
 Methods of Opei-atiiig on Males — Perineal Cystotomy — Supra-pubic Cys- 
 totomy — With or without Cystorrhaphy S4-S9 
 
 Avoidance of "Wounding Peritonseum — Prevention of Urinarj' Infiltra- 
 tion — Urethral Drainage by Suction S6-90 
 
 Palliative Treatment — General and Local Astringents — Anodynes — Injec- 
 tion of Bladder by Hydrostatic Pressure 91-92 
 
 Conclusions - 93 
 
 Illustrations. 
 
 Benign Villous Tumors — Hudson 5 
 
 Microscopic Appearance of Same 6 
 
 Polypus — Fleming S 
 
 Fibrous Polj-pus — Gersuny. 10 
 
 Medullary Cancer — Original 21 
 
 Microscopic Appearance of Same 22 
 
 Villous Cancer — Original 26 
 
 Microscopic Appearance of Same : . . . 27 
 
 Myo-carcino-sarcoma — Biilroth 30 
 
 Myoma — Volkmann 31 
 
 Female Urethral Dilator, Original 55 
 
 Forceps and Scissors — Simon 82 
 
BIBLIOGRAPHY. 
 
 1747. Warner. Polypus. Cases in Surgery, 4th edition, 17S4; 
 
 and Philosophical Transactions, 1790. 
 1797. Baillie. Polypus. Morbid Anatomy. 
 1800. Walter. Polypus. i\Iedico-Chir. Trans., vol. 41. 
 1817. Langstaff. Cancer. ]vIedico-Chir. Trans., vol. 8. 
 
 1822. Bingham. Cancer. Diseases of Bladder. 
 
 1823. Le Cat. Fungus. Howship, Urinary Organs. 
 
 1830. Dessault. Polypus, Villous. Chopart, Maladies des Vois 
 Urinaires, 2 vols. 
 
 1834. Pleininger. Papilloma. Wiirtemberg Med. Corr. Blatt, No. 
 
 23- 
 Civiale. Gaz. de Med., Paris, No. 52. 
 
 1835. Crosse. Polypi. Formation, etc., Urinary Calculi. 
 
 1836. Springall. Villous. Guy's Hosp. Rep., series i, vol. i. 
 
 1838. Hutchison. Fungoid. Med.-Chir. Rev., vol. vi. 
 Willis. Pendulous Growth. Urinary Diseases, London. 
 
 1839. Langstaff. Fungus. Zvled.-Chir. Rev., vol. iii. 
 Mendalgo. Cancer. Giornal di Venezia, Maggio, Junio. 
 
 1842. Barlow. Fungus. Guy's Hosp. Rep., series i, vol. vii. 
 Warner, by Douglass. Villous. Lon. Med. Gaz., February. 
 Douglass. Tumor. 
 
 Howship, by Douglass. 
 
 Civiale. Maladies des Org. Genito-Urinaires. 
 
 1843. Contini. Cancer. Annal. Med. Chir. del Metaxa, vol. 9. 
 
 1845. Theinemann. Polypus. Amer. Journ. Med. Sc, July. 
 Vache. Polypi. L'Experience, No. 327, October. 
 
 1846. Bulley. Fungus. London Times, August ist. 
 
 1847. Bentley, for Kingdon. Carcinoma. Trans. Path. Soc. 
 
 London, vol. i. 
 
A-IU 
 
 BIBLIOGRAPHY. 
 
 1847. Hiltscher. Carcinoma. Oest. Med. Wochensch., No. 46. 
 1S49. Kestevan. Fungoid. London Med. Gaz., November. 
 
 185 1. Beith. Cancer. Trans. Path. Soc, London, vol. iii. 
 Holthouse. Fungus. " " " " March i8th. 
 
 1 85 2. Stanlej^, by Savory. Polypus. London Times and Gaz., 
 
 July 31st. 
 1854. Gibbon. Cancer. Trans. Path. Soc, London, vol. v., series 2. 
 Shaw. Villous. " 
 Holt. Cancer. 
 Thompson. Cancer. " " 
 Hutchinson. " " 
 
 Ohm. Tumor. Deutsche Klin., 24. 
 
 1855. Pollock. Cancer. Trans. Path. Soc, vol. 6. 
 Gibb. " " " " " 6. 
 
 1856. Sibley. A^illous. " " " " 7. 
 
 1 85 7. Stewart, by Hutchinson. A-^illous. London Times and Gaz., 
 
 May 2d. 
 Lloyd, by Hutchinson. Tumor. London Times and Gaz., 
 
 May 2d. 
 Cock, by Wilkes. Villous. Lon. Times and Gaz., May 9th. 
 Partridge. " " " " " " 2d. 
 
 Hooper. " " " " " " " 
 
 Thompson. '' Trans. Path. Soc, London, vol. 8. 
 
 Ellis. Cancer. Boston Med. and Surg. Journ., January 22d. 
 Jackson. " " " " " " " 29th. 
 
 1858. Lambl. Villous Cancer. Virchow's Arch., Bd. xv. 
 
 1859. Paulus. Cancer. Zeitschr. f. Chir. u. Geburtsh., xi., 14, 
 
 p. 264. 
 i860. Coulson. Cancer. London Lancet, August 25th. 
 
 Clarke. " London Times and Gaz., August iSth. 
 
 Bryant, by Hicks. Villous. Trans. Path. Soc, London, 
 
 vol. xi. 
 Senftleben. Sarcoma. Arch. f. Klin. Chir., Bd. i. Heft i. 
 Watson. Villous Cancer. Edinb. Med. Journ., June. 
 Hilton. Polypi. J. Cooper Foster's Surgical Diseases of 
 
 Children. 
 Gibb. Cancer. Trans. Path. Soc, London, vol. xi. 
 
BIBLIOGRAPHY. ix 
 
 1862. Bernadet. Fungus. Bull, de la Soc. Anat., April. 
 O'Connor. Cancer. Trans. Path. Soc, London, vol. xiii. 
 Heath. " " " " " " " 
 
 1863. Brown. Villous Cancer. Edinb. Med. Journ., May. 
 Sage. Cancer. British Med. Journ., February 7th. 
 Rankin. Epithelioid. British Med. Journ., August 22d. 
 Holmes. " Trans. Path. Soc, London, vol. xiv. 
 
 1864. Holmes Coote. Cancer. Med.-Chir. Trans., vol. 47. 
 Nash. Villous. British Med. Journ., March 26th. 
 Sanders. Cancer. Edinb. Med. Journ., September. 
 
 1S65. Potain. Polypus. Gaz. des Hop., No. 15. 
 
 1867. Ramskill. Growth. British Med. Journ., June ist. 
 Bastian. Scirrhus. Trans. Path. Soc, London, vol. 18. 
 Thompson. Villous. " " " " " " 
 
 Cancer. " " " " " " 
 
 Fleming. " Genito-Urinary Diseases. 
 
 Polypus. 
 Encephaloid. " 
 
 1868. Hicks. Tumor. London Lancet, May 30th. 
 Guersant. Polypus. Gaz. des Hop., No. 23. 
 
 Nunn. Villous Epithelioma. Trans. Path. Soc, London, 
 
 vol. 19. 
 Birkett. Polypi. Med.-Chir. Trans., vol. 41. 
 Hewitt. 
 
 Cooper. " " " " " " 
 
 Petit. " " " " " " 
 
 1869. Heilborn. Krebs. Inaug. Diss., Berlin. 
 
 Dickenson. Cancer. Trans. Path. Soc, London, vol. 20. 
 
 1870. Reeves. Polypus. Boston Med. and Surg. Journ., August 
 
 25th. 
 Anderson. Cancer. British Med. Journ., January 22d. 
 Murchison. Villous. Trans. Path. Soc, London, vol. 21. 
 Thompson. Vascular Tumor. " " 
 Jackson. Polypus. Boston Med. and Surg. Journ., August 
 
 25th. 
 
 1871. Faye. Fibro-myoma. Schmidt's Jahrb., Bd. 53, 
 Guillon. Polypi. Pitha-Billroth, allg. u. spec. Chir., Bd. 
 
 3, Abt. 2. 
 
X BIBLIOGRAPHV. 
 
 1872. Smyth. Cancer. British Med. Journ., July 20th. 
 Ashhurst. '' Philadelphia Med. Times, April 15th. 
 Bishop. Polypus. Gross' Surg., Philadelphia. 
 Gersuny. Polypus. Arch. f. Klin. Chir., Bd. 13. 
 Galignani. Villous Cancer. Luglio. ann. univer., p. 127. 
 
 1873. Guilhaud. Cancer. These sur I'anat. etc. de la Vessie, 
 
 Paris. 
 
 1874. Marsh-Beck. Polypoid. Trans. Path. Soc, London, vol. 
 
 XXV. 
 
 1875. Simon. Polypi. Arch. f. Klin. Chir., vol. 18. 
 Billroth. Myo-sarc. and Myo-carcin. Arch. f. Klin. Chir., 
 
 vol. 18. 
 Wilkes. Villous. Wilkes and Moxon, Path. Anat. 
 Bryant. " Bryant's Surg. 
 
 Freund. Cancer. Virchovv's Arch., Bd. 64. 
 Goetz. Cancer. Bull, de la Soc. Anat., Paris, November. 
 Herrgott. Tumor. Rev. Med. de I'Est, September, p. 141. 
 
 1876. Mass. Polypi. Berlin. Klin. Wochenschr., No. 4. 
 Kocher. Papilloma. Centralbl. f. Chir., April ist. 
 Volkmann. Myoma. Arch. f. Klin. Chir., Bd. ix. 
 Schatz. Fibro-myxoma. Arch. f. Gynakol., Heft x. 
 Chambard. Cancer. Bull, de la Soc. Anat., November. 
 Boyer. " " " " 
 
 Poisson. Fungus. " " " " February. 
 
 Langlebert. " " " " " March. 
 
 a a J II u a u a 
 
 Levertin. Cancer. Hygiea, 38, October. 
 " Fibroma. " December. 
 
 1877. Fagg. Epithelioma. Two cases. Trans. Path. Soc, Lon- 
 
 don, vol. 28. 
 
 Butlin. Scirrhus. Trans. Path. Soc, London, vol. 28. 
 
 Winckel. Papilloma. Billroth's Handbuch Frauenkrank. 
 
 Brainwell. Cancer. London Med. Times and Gaz., De- 
 cember 22d. 
 
 1878. Alexander. Villous. London Lancet, August 17th. 
 Stimson. Sarcoma. New York Med. Record, November 
 
 26th. 
 Ultzmann. Villous. " Ueber Hematuria. " 
 
BIBLIOGRAPHY. xi 
 
 1878. Marchand. Sarcoma. Arch, f. Klin. Chir., Bd. xxii. 
 
 Cancer. " " " " " 
 
 Harrison. Encephaloid. On Urinary Organs. 
 
 Villous Cancer. 
 Avezon. Cancer. Bull, de la Soc. Anat., February. 
 Phillipart. " Presse Med., xxx., No. 22. 
 
 1879. Humphry. Papilloma. Med. -Chir. Trans., vol. 62. 
 Norton. " Two cases, British Med. Journ., 
 
 May 31st, 
 
 Heath. Villous Sarcoma. London Times and Gaz., De- 
 cember 13th. 
 
 Hudson. Polypi. Dublin Med Journ., June. 
 
 Morris. " British Med. Journ., May 31st. 
 
 Bryant. Growth. 
 
 Godson. Polypus. " " " April 26th. 
 
 Brenneke. Fibro-myxoma. Arch. f. Gynakol., April 12th. 
 
 Thornton. Sarcoma. British Med. Journ., May 31st. 
 
 Sanger. Secondary Sarcoma. Arch. f. Gynakol., Bd. xvi. 
 
 Ahlfeld. " " " " " " 
 
 1880. Marcacci. Villous. London Medical Record, May 15th 
 
 and December 15th. 
 Davies-CoUey. Villous. London Lancet, December i8th. 
 Hicks. Cauliflower-like Mass. London Lancet, May 30th. 
 Soltmann. Secondary Sarcoma. Jahrb. f. , Kinderhlkde., 
 
 Bd. xvi., H. 3 and 4. 
 
 1881. Barton. Care. Papilloma. Dublin Journ. Med. Sc, Feb- 
 
 ruary. 
 Treves. Villous. London Lancet, April 30th. 
 Davies-Colley. Shaggy Epithelioma. London Lancet, 
 
 April 30th. 
 Hill. Epithelioma. British Med. Journ., May 14th. 
 
 Villous. 
 Lancaster. Cancer. Coulson's Diseases of Bladder. 
 Coulson. 
 
 Belfield. Myoma. Wien. Med. Wochenschrift, May 19th. 
 Thomson. Myxoma. British Med. Journ., March 12th. 
 Stein. Villous Cancer. 
 " Encephaloid. 
 
TUMORS OF THE BLADDER 
 
 Tumors of the bladder may be classified as follows : 
 
 r Papillomata, or villous growths. 
 
 „ . „ , Myxomata, or mucous polypi. 
 
 Benig-n Growths. -{ -r-^ . m. i • 
 
 *= Fibromata, or nbrous polypi. 
 
 Myoraata. 
 
 f r Epithelioma, villous. 
 
 A/r T '*. r- 4.-U I Carcinomata. J. Encephaloid. 
 Malign t G-rowths. ■< \ ^ ^ 
 
 I i Scirrhus. 
 
 1^ Sarcomata. 
 
 I have brought together and classified sixt}' cases of 
 benign papillomatous, villous, and polypoid growths. In 
 addition to these, I find casual mention made of a few 
 cases said to have been recorded by the older writers 
 (Lusitanus, Sylvius, Kirchner, Rolin, Collison), but of 
 these I have no data. Again, our numbers might be still 
 further increased by the addition of a few cases undoubt- 
 edly benign, but which, being simply designated as fungi^ 
 without further description as to structure, etc., could not 
 be properly classified, and were excluded. 
 
 PAPILLOMATA, OR VILLOUS GROWTHS. 
 
 These tumors, as their name indicates, present usually 
 the characters of a true villous structure, closely resembling 
 the villi of the chorion. To be appreciated, they must be 
 examined under water; when out of water, they collapse 
 
2 TUMORS OF THE BLADDER. 
 
 into a comparative!}- small bulk, but placed in water, the vil- 
 losities are floated out and present a beautiful and charac- 
 teristic appearance : the larger villi branch out from the 
 central mass, and from these smaller villi are seen sprouting- 
 out, and from these again still smaller ones often arise. The 
 form of the villi is variable, some being thick and short, 
 others long, club-shaped, and others still long and filament- 
 ous. In minute structure, each villous is composed of a 
 capillarv loop, covered bv a scanty epithelial investment, 
 which does not grow within the delicate framework of 
 connective tissue (see Plate ii., Fig. 2). 
 
 There are several varieties of villous growths which 
 vary in shape and appearance. 
 
 They may present as numerous villous processes without 
 a distinct tumor, that is, the villi grow directly from the 
 mucous membrane without an)- base. This was well 
 shown in a case of Mr. Murchison ; the base of the blad- 
 der and portion surrounding the orifice of the ureters 
 was studded with numerous long, delicate, villous proces- 
 ses, nowhere forming a distinct tumor, and his case is 
 further interesting in that on the mucous lining of the 
 pelvis and cahxes of both kidneys were also found numer- 
 ous long villous processes. They were from one to sev- 
 eral lines in length, covered externally with a thin layer of 
 epithelium, and included a capillary vessel full of blood. 
 Mucous lining of ureters was free from disease. Death 
 was caused from uraemia due to obstruction of ureters by 
 clots of blood derived from the villous processes above. 
 
 Some of these growths appear as pendulous tumors 
 hanging from the mucous membrane by a distinct stalk, 
 or pedicle, and terminate in numerous filamentous proces- 
 ses (see Plate i.). Others are sessile, and occur somewhat 
 less frequently than the preceding variet}'. They may 
 appear either as soft, loose, shaggy, villous tufts, project- 
 ing more or less from the mucous surface, or they may 
 
TUMORS OF THE BLADDER. 3 
 
 have a more solid basis structure, and present a warty or 
 cauliflower-like appearance. 
 
 Villous tumors of the bladder have long been regarded 
 as malignant in their nature, principally, perhaps, on the 
 authority of Rokitansky, who wrote an essay on this sub- 
 ject, an abstract of which can be found in Paget's lectures 
 on Surgical Pathology, vol. 2. And while it cannot be 
 denied that malignant growths do sometimes take on a 
 villous character, or that simple villous growths may 
 become malignant, examples of which we find both among 
 carcinomata and sarcomata, such growths are rare. A care- 
 ful study of the cases I have collated will show that villous 
 growths are usually benign. In structure, they do not 
 partake of the character of malignant tumors. In their 
 origin and in the manner of their development, they are as 
 innocent growths. The course and duration of the com- 
 plaint is not in accordance with that generally observed in 
 malignant disease. They are strictly local, do not invade 
 adjacent tissues, there is no glandular involvement, and 
 there are no secondary deposits occasioned in other or- 
 gans of the body. They do not cause death from malig- 
 nant cachexia, but from hemorrhage or from the conse- 
 quences of mechanical obstruction to the outflow of urine. 
 ■ These facts are very evident after a careful study of the his- 
 tory, course, symptoms, and termination of many cases of 
 villous disease on record. 
 
 I have collated thirty cases of papillomatous or villous 
 growths. Sixteen occurred in the female and fourteen in 
 the male, that is, the frequency of occurrence in the two 
 sexes was about equal. With respect to age, the youngest 
 subject was two and three-quarter years old, in two 
 others the subjects were impubic. After that, however, 
 none appeared before the age of thirty-two. Seventeen 
 were between thirty-two and fifty years of age. The 
 oldest patient was seventy. Villous growths are as often 
 multiple as single ; the two classes of cases were found in 
 
^ TUMORS OF THE BLADDER, 
 
 just equal proportion. As many as twelve distinct tumors 
 were found in one case, and in several the vesical walls 
 were said to be studded with numerous villous growths- 
 They are more frequently pedunculated than sessile. They 
 are generally small, but vary in size from that of a pea to 
 a goose egg, or a small orange ; and in one of Simon's 
 cases the papilloma filled two-thirds of the cavity of the 
 bladder which he successfully removed b}' the scoop. 
 They are very rarely situated on the anterior wall. Their 
 usual point of attachment is the trigone and near the ure- 
 ters ; of the two openings, the right ureter by predilection. 
 
 An interesting and typical case of benign villous growths 
 is reported by Dr. R. S. Hudson in the Dnl?. Joiirn. Med. 
 Sc, June, 1879, fjfom which our Plates i. and ii. are taken. 
 The structural character of these simple tumors is here 
 well shown, and may be examined in contrast with the 
 microscopical appearances of villous epithelioma as shown 
 in our original drawing (Plate viii.). 
 
 Plate i.. Fig. i. Bladder half original size. Dr. Hudson 
 says, " It will be seen that there are eight tumors, each con- 
 nected b}" a narrow pedicle, which might be ligatured, 
 avulsed, or treated with the ecraseur. The large tumor at 
 the fundus has been reflected so as to show more distinctly 
 the pedicle from which it springs. All were coated with 
 2. thick layer of phosphatic deposit like brownish mortar. 
 When this layer was removed and a portion of the tumor 
 floated out in water, its true character was seen : delicate, 
 lace-like growths springing from a firm, fleshv pedicle. 
 To the right will be seen the enlarged projecting bundles 
 of anh3'psrtrophied bladder not unlike the column::e carneEe 
 of the ventricles of the heart. The openings of the ureters 
 may be seen, but the ureters themselves, owing to the 
 obstructed flow of urine, were dilated to the size of the 
 cesophagus." 
 
 Plate ii.. Fig. i represents a portion of the tumor under 
 an inch object-glass. 
 
TUMORS OF THE BLADDER. 
 
 V 
 
 ^>. ''p)i.:J 
 
 
 Plate I.— Eight benign villous growths. Case of Dr. R. S. lludion—Dud- 
 lin Medical J otirnaL 
 
TUMORS OF THE BLADDER. 
 
 Plate II. Fig. i. 
 
 WinA X 40 diam. 
 
 I' 
 
 W^M 
 
 W. 
 
 f A 
 
 
 
 Fig. 2 
 (= A, Fig. I, 
 X 310 diam.). 
 
 Microscopic appearances of Dr. Hudson's benign villous growths. — Dublin 
 Medical yournal. 
 
TUMORS OF THE BLADDER. 7 
 
 Fig. 2, A portion of the same under a quarter of an 
 inch object-glass. " The thin-walled capillary vessels of 
 irregular diameter may be seen coursing through the 
 growth, the whole surface being covered with a columnar 
 or polygonal epithelium. The epithelium is, however, on 
 the surface, homologous; not within the subjacent connective 
 tissue, heterologous, which is characteristic of epithelioma- 
 tous growths." 
 
 POLYPI. 
 
 The mucous polypus or benign myxoma is a soft, smooth, 
 succulent, oedematous-looking, pediculated growth, resem- 
 bling nasal polypus. It grows from the mucous surface, 
 and is composed chiefly of the elements of that structure, 
 with a stroma of loose connective or filamentous tissue. 
 The structure of the fibrous polypus is indicated by its 
 name ; it is firmer and more fleshy or fibrous in consistence 
 than the mucous polypus-, has a reddish-blue or dark-red 
 color, and proceeding from the submucous connective 
 tissue, it pushes the mucous membrane before it. These 
 tumors, mucous and fibrous, project into the interior of 
 the bladder either as long pendulous bodies (PI. iii.) or as 
 globular, pyriform, or irregularly-shaped outgrowths. 
 
 Of the polypoid growths, mucous and fibrous, I have 
 found thirty, which shows that these growths are not 
 as rare, compared with the papillomata, as is generally 
 believed ; the two classes of growths appearing nearly in 
 an equal number of cases. With respect to sex, our num- 
 bers are almost equally divided, sixteen being male and 
 fourteen female. While polypi may occur in advanced 
 life, one having presented at the age of seventy-three, 
 they are generally found at an earlier period of life than 
 any other kind of tumor. Especially is this true of mucous 
 polypi which have occurred at the ages, respectively, of 
 five, two, and two years ; twenty-two, eighteen, and thirteen 
 months. Winckel found two mucous polypi in the bladder 
 
TUMORS OF THE ELADDER. 
 
 Plate III. 
 
 Polypus, from Christopher Fleming's " Diseases of Genito- Urinary Organs.' 
 
TUMORS OF THE BLADDER. o 
 
 of a female child who died thirty-six hours after birth ; 
 one was situated at the superior fundus (an exceptional 
 position) ; was very vascular, soft, pediculated, semi-glob- 
 ular, and somewhat larger than a pea ; the other, a smaller, 
 growth, came from the lower portion of the bladder. 
 
 Polypi are by far more frequently single than multiple. 
 In size they vary from a nut to that of the fist. From 
 Jackson's patient a piece was removed the length of the 
 finger, and after two days, another piece, eight inches long 
 and thick as the thumb, was twisted off. In their manner 
 of attachment they are occasionally peculiar. In one 
 instance (Stanley) the growth stretched transversely 
 across the fundus, behind the aperture of the ureters, and 
 was attached on either side, but free in the centre. In 
 another (Thompson) there were two growths, each the size 
 of a small fig, with a slender stalk, one and a half inches 
 long, which joined to form a common pedicle connected 
 with the trigone. In a third (Petit), a pyramidal-shaped 
 tumor the size of the fist was attached by a very delicate 
 pedicle. In still another (Thomson), the cavity of the 
 bladder was almost obliterated by a myxoma. From the 
 upper and right side of the cavity hung a mass resembling 
 a bunch of Hambvirg grapes. Like the papillomata in 
 their point of attachment, they have a predilection for the 
 trigone, and are probably found more frequently near the 
 urethral orifice than the former. 
 
 Pure fibrous tumors are not common. Gersuny relates 
 a very interesting case of vesical turnor in a man aged 
 forty-nine, which he attempted to remove by perineal cys- 
 totomy, but failed. The man died, and at the bas-fond 
 towards the right there was found projecting into the 
 bladder a diverticulum with an inclosed tumor. A quite 
 wide orifice communicated with the interior of the cyst, 
 the edges of which being pushed back, a firm elastic tumor 
 about the size of a hen's egg fell out. It was nearly glob- 
 ular, with a smooth surface, having, however, several 
 
10 TUMORS OF THE BLADDER. 
 
 converging furrows leading to a point, from which origi- 
 nated a pedicle one and a half inches long, and not the 
 diameter of a quill (Tl. iv.. Fig. 2). The tumor which was 
 attached to the interior of the diverticulum was torn off 
 b}' very slight fraction. The vertex of the bladder was 
 found to be in communication with a pus cavity above, 
 and this again with another cavity containing a stone the 
 size of a walnut, egg-shaped, weighing two drachms, and 
 having- for its nucleus the broken end of a catheter (PL 
 iv., Fig. i). A represents the abscess cavity, which com- 
 municates posteriorly with the bladder, V, and anteriorly 
 with the cavity containing the stone, C. D shows the 
 diverticulum, which projects with its contained tumor 
 into the cavit}^ of the bladder. At F is the opening into 
 the diverticulum, through which a portion of the tumor is 
 seen. The tumor consisted of undulating connective 
 tissue and numerous spindle cells, with round nuclei. 
 This patient had suffered with blennorrhoea for eight years, 
 and gave history of having had retention of urine several 
 times, the last time requiring supra-pubic puncture, which 
 opening was not allowed to heal for three weeks. Some 
 time after the puncture was made, one day, while cathe- 
 terizing himself, an inch of the distal end of a flexible 
 catheter broke off and remained lodged in the urethra, as 
 he said, just behind the scrotum. Attempts to remove the 
 same proved ineffectual. This case is remarkable : first, in 
 the peculiar development of the tumor ; second, in the 
 formation of a diverticulum at the vertex of the bladder, 
 occasioned, no doubt, by the supra-pubic puncture ; and 
 third, in the wandering of the catheter fragment into this 
 cavity and forming the nucleus for a stone. 
 
 Somewhat analogous to the above, as regards the exist- 
 ence of an abscess cavit}^ in connection with the bladder, 
 is the case of Stanley. Here the growth was so 
 situated as to fall over and obstruct the urethra in 
 the act of micturition, and the urine being driven into the 
 
TUMORS OF THE BLADDER. 
 
 II 
 
 Plate IV. FiG. i 
 
 Fibrous pol>'pus inclosed in a diverticulum. —Gersuny, Arch.f. kl Chir., Bd.13. 
 
j2 TUMORS OF THE BLADDER. 
 
 imperfectly-closed orifice of the urachus, this tube was 
 gradually reopened until the urine reached the vicinity of 
 the umbilicus, where an abscess formed, which, being 
 opened, gave exit to both pus and urine, and for a number 
 of days before death all the urine was discharged through 
 the opening in the abdominal wall. The patient was a 
 male child, aged thirteen months. 
 
 Gersuny also mentions and gives the drawing of a 
 cysto-fibroid, which was found post-mortem by Prof. 
 Ernst in the bladder of a boy aged fifteen. The tumor 
 was of the size of an apple, and attached by a thin pedicle 
 to the fundus. 
 
 CARCINOMATA. 
 
 Cancer of the bladder may present under the forms of 
 epithelioma, encephaloid, villous, and scirrhus, and, as I 
 believe, in the order of frequency mentioned. Upon this 
 matter, however, a very wide discrepancy of opinion pre- 
 vails among writers. I need only refer to such eminent 
 authorities as Gross and Coulson, who have most recently 
 written on the subject. The former says : " The usual vari- 
 ety of carcinoma met with in the bladder is the epithelial ; 
 what was formerly known as scirrhus, is nothing more than 
 the firm, infiltrating form of epithehoma. . . . The encepha- 
 loid form is of the same nature, but its stroma is more deli- 
 cate and more vascular." On the other hand, Coulson says : 
 " Encephaloid is the most usual form, scirrhus has occurred 
 less frequently, and only a few cases of epithelioma have 
 been placed on record." It is, unfortunately, impossible to 
 reconcile these opposite statements. Our researches do 
 not accord with the view expressed, " that only a few cases 
 of epithelioma have been placed on record." On the con- 
 trary, it would seem that, taking vesical tumors collec- 
 tively, epithelioma exists in at least a good percentage of 
 cases. With regard to the propriety of designating the 
 cancers as epithelial, encephaloid, and scirrhus, it may be 
 
TUMORS OF THE BLADDER. 
 
 13 
 
 said that these terms have at least, clinically, not been 
 abandoned, and if there is any foundation for such a classi- 
 fication, it applies for tumors pf the bladder as well as for 
 other parts of the body. This is shown by the variation 
 vesical tumors present in regard to their mode of growth, 
 histological characters, clinical history, etc. For example, 
 descriptive of epithelioma, we have: ist. One or more 
 small, submucous, circumscribed nodules, or points of 
 induration. In a primary cancer (Thompson), there were 
 five or six masses, varying in size from a pea to a horse 
 bean, and unconnected with each other. 2d. It may pre- 
 sent as an ulcerated surface, with elevated and indurated 
 edges. In Nunn's patient, there was a large, ragged ulcer, 
 and only the anterior third of the walls of the bladder was 
 free from epitheliomatous disease. In several of our cases, 
 the epithelial, or so-called "bird's nest" aggregations, so 
 characteristic of epithelioma, is distinctly mentioned, and 
 with the exception, perhaps, of the enlargement of abdom- 
 inal glands, there is in these cases no secondar}^ deposition 
 of cancerous material. 
 
 Corresponding to the encephaloid variety, we have the 
 history of a more rapid disease, a decided tumor project- 
 ing into the interior of the bladder, often attaining an 
 enormous size, with a soft sprouting, fungoid, or cauli- 
 flower-like appearance, and in structure composed of an 
 abundance of cellular elements, with a scanty stroma. In 
 some instances, the tumor was found broken down in fatty 
 and caseous degeneration, and presented a dirty, ragged 
 ulceration with fungating edges. In the patient of Sept. 
 Gibbon, the tumor was the size of two fists, arising by an 
 extended base from the anterior surface. At the posterior 
 surface, the mucous membrane was studded with numer- 
 ous wart-like medullary growths. Section of growth pre- 
 sented white, pulpy, pear-like appearance, except in the 
 centre, which was softened and broken down, containing 
 buff-colored, offensive pus. 
 
J . TUMORS OF THE BLADDER. 
 
 Villous cancer is a form of epithelioma. It is a soft, 
 spongy mass, projecting from the wall of the bladder, and 
 havino- on its svirface those peculiar vascular processes 
 from which it derives its name. It differs from the benign 
 villous growth, mainl_y in that the latter is limited to the 
 mucous membrane, and its villous processes have but a 
 scantv epithelial covering, through which the capillary loop 
 within can be distinctly seen, while the villous cancer has 
 a deeper origin in the connective tissue, constituting a 
 thickening of the vesical walls, or forming a tumor which 
 may be recognized by external palpation. Its villi have 
 an abundant epithelial investment, by which the interior 
 of its structure is obscured or rendered invisible ; but most 
 prominentl}" is its malignant nature manifest by the infil- 
 tration of its base and villi with closeh-packed epithelial 
 cells (see Plate viii.). 
 
 Scirrhus of the bladder is undoubtedly rare. Bastian 
 and Butlin have each reported a case which they regard 
 as typical of the disease. In the first patient, the base 
 and anterior wall of the bladder were thickened and infil- 
 filtrated with cancerous material. The mucous mem- 
 brane was entire and healthy, though raised, and irregular 
 on the surface. There was no distinct tumor. In the 
 patient of Butlin, there was a uniform infiltration -of all 
 the coats of the bladder ; its capacity was so much dimin- 
 ished that it could onl}' hold an ounce of fluid ; and owing 
 to the stiffness of its walls did not admit either of contrac- 
 tion or dilatation. Its mucous membrane was corrugated 
 and inflamed. The bladder was very adherent to sur- 
 rounding parts by extension of the disease, and could only 
 be removed by free use of the knife. It had eaten deeply 
 into the pelvic bone, on the right side, the body of which 
 was, in great part, destroyed. Microscopic examination 
 showed that the cancer was not only of the hard variety, 
 but quite deserved the name of scirrhus. The cells were 
 generally of smaller size, with much smaller nuclei than 
 
TUMORS OF THE BLADDER. 
 
 15 
 
 usually occur in the medullary cancer of the bladder. 
 The stroma consisted for the most part of very firm and 
 abundant fibrous tissue. In both the above cases, secon- 
 dary deposits were found in the abdominal glands, liver, 
 kidneys, beneath the peritoneum, and beneath the parietal 
 pleura. 
 
 Cancer of the bladder may be primary or secondary ; 
 that is, the malignant growth may originate directly in the 
 tissues of the bladder, or this viscus may become involved 
 by extension of the disease from, neighboring parts. 
 
 As a primary affection, cancer of the bladder is not com- 
 mon. As secondary to the disease in the female sexual 
 organs, prostate, rectum, etc., literature affords an ample 
 number of cases. Out of 4,777 autopsies (3,043 male, and 
 i,734female) recorded at the Pathological Institute of Ber- 
 lin, from 1859 to 1868, Max Hilborn found 37 cases of cancel", 
 of which 33 occurred in women, and four in men. Out of 
 the 37 cases, the disease was secondary in 30, primary in 
 7. In 29 of the secondary cases, the extension occurred 
 from the uterus, and in one from the rectum. Of the 
 7 primar}^ cases, 4 occurred in women, 3 in men. As 
 among the 4,777 subjects, 3,043 were male, and 1,734 female, 
 the vesical cancer occurred 15 times oftener in women 
 than in men ; but the percentage of primary cancer was 
 i2'/o against 75/^ in men. 
 
 According to Winckel, out of 2,505 autopsies of women 
 made at the Dresden Krankenhaus, there were 73 vesical 
 cancers. That is a percentage of nearlj^ 30 against 20 
 recorded in Berlin. 
 
 Secondary cancer is infinitely more common than pri- 
 mary. It is much more common in women than in men, 
 while primary cancer seems to be more frequent in men 
 than in women. 
 
 Secondary cancer of the bladder in women is almost 
 without exception an extension of the disease from its 
 favorite seat, the pars cervicalis uteri. The frequency of 
 
J 5 TUMORS OF THE BLADDER. 
 
 cancer of the uterus and the portio vaginalis uteri with 
 its tendency to spread towards the bladder accounts for 
 the frequency of vesical cancer in the female. 
 
 In men, as a secondary disease, cancer is generally an 
 extension from the prostate, rectum, or vesiculse semi- 
 nales. 
 
 That epithelioma is the most common variety of cancer 
 found in the bladder must be inferred from its greatest 
 frequency in women as a secondaiw affection from the 
 uterus, for which organ epithelioma has so great a predi- 
 lection. But this is true, not only for the secondary cases, 
 but also for the primar}'. Indeed, it is exceptional to find 
 other than epithelial or villous cancers originating in the 
 Avails of the bladder. As has been said, they occur more 
 frequently in men than in women. In at least sixteen of 
 our cases the primary origin of the cancer in the bladder 
 cannot be doubted, though I have been circumspect in my 
 selection of them. Of these, ten are male and six female. 
 It is not always easy to determine whether a given tumor 
 is primarv or secondarj' to the bladder, and this question 
 is too often disposed of at first glance. From our number 
 of cases collected, I have excluded several announced as 
 " primary cancer," which, on account of extensive involve- 
 ment of neighboring parts could not be accepted as such 
 without much doubt. Thus, in one instance of reported 
 primary vesical cancer, it is said "the neoplasm involved 
 the abdominal parictcs, rectum, and several coils of small iji- 
 testine, thozigh it did not implicate either the vesical or intesti- 
 nal mucous m£mbra7ier I should think it almost impossible 
 to say where such vast disease had its origin. i\gain, that 
 the bladder is quite as subject to invasion by metastasis 
 as other organs of the body is a circumstance apparently 
 not kept in vicAv. In some of our cases, the disease in the 
 bladder was undoubtedly recent, and insignificant as com- 
 pared vv'ith the cancerous development elsewhere. Thus 
 we have an instance of " two or three small masses of en- 
 
TUMORS OF THE BLADDER. \y 
 
 cephaloid in the bladder, while no part of the left kidney 
 could be found, and a mass of encephaloid occupied its 
 place." If the extent of disease is any index, in this case 
 it is quite possible that the kidney and not the bladder (as 
 stated) was the original seat of the disease. But, on the 
 other hand, we may err in the opposite direction, and re- 
 gard all cases secondary in which the rectum, prostate, or 
 vesiculce seminales happen to be continuously affected with 
 the bladder. In other words, I would say, that primary 
 cancer of the bladder may be more common than is gen- 
 erally supposed, and that the disease, instead of originating 
 in the vagina, uterus, rectum, or prostate, these parts are 
 secondarily affected by extension of the disease from the 
 bladder. There is nothing irrational in the acceptance of 
 these premises, and some of our cases make such a conclu- 
 sion inevitable. When the disease is said to have " appa- 
 rently involved the prostate," or to have " extended up to 
 it," or " within half an inch of it," or when the tumor is 
 said to have attained considerable size, become ulcerated, 
 etc., within the viscus, while, without, it had simpl}' created 
 adhesions with the outer surface of the uterus, rectum, 
 colon, or small intestine, the natural conclusion is, that the 
 disease, originating in the bladder, would have involved 
 these parts had not death arrested its progress. In not 
 a few cases were such adhesions found between the blad- 
 der, uterus, vagina, intestines, abdominal walls, and some- 
 times ulcerative communication existed between these 
 organs. In one case such a communication existed 
 between the base of the bladder and uterus, the latter 
 serving as an outlet for the urine, which was constantly 
 dribbling away during life. In another, fasces were passed 
 with the urine. 
 
 Again, the cancer may develop simultaneously at several 
 points, as in the case of Hutchinson, in which were numer- 
 ous masses of medullary C3.ncQV perfectly distinct from each 
 other in the submucous tissue of the vagina, rectum, and- blad- 
 
1 8 TUMORS OF THE BLADDER. 
 
 dcr. I mention these facts as showing that it is often diffi- 
 cult to determine the real origin of cancer of the bladder. 
 
 The most frequent locality of cancer appears to be on the 
 posterior wall, the next most common seat is the trigone. 
 Sometim.es the attachment is simply given as "on the 
 body," rarely is the vertex mentioned as the seat of the 
 disease. 
 
 With reference to age, cancer of the bladder would 
 appear to occur in greatest frequency between the ages of 
 forty and fifty, fifty and sixty, thirty and forty, sixty and 
 seventy-five, and twenty and thirty. Our oldest patient 
 was seventy-five years old. Billroth had a case of m3"0- 
 carcinoma in a bo}^ aged twelve, but cancer rarely occurs 
 before the twentieth year. A unique case is reported by 
 Smyth of medullary cancer in a child four years old, 
 which is in several respects interesting. The symptoms 
 were frequent micturition and hcematuria, but there was no 
 •complaint Avhatever of pain or tenderness in the abdomen. 
 April loth, there was sudden discharge of arterial blood, 
 followed by purulent matter, the result, no doubt, of the 
 giving way of an abscess. For some days there was a free 
 discharge of muco-purulent matter tinged Avith blood. 
 May 29th, after a very restless night, she uttered a most 
 piercing shriek, followed by syncope, and she died in three 
 liours. Abdomen only part examined, bladder much hy- 
 pertrophied, a cyst of an abscess was discovered on 
 the left, inferiorly, upon the edges of which w^ere 
 phosphatic depositions. Interior of viscus was filled with 
 soft, broken-down, medullary matter, resembling, in fact, 
 pounded cerebral substance. Under microscope, cancer 
 cells were discernible. Kidneys were secondarily affected. 
 
 Before passing to the consideration of other varieties of 
 tumor, I will here record two cases of primary cancer 
 which have come under my observation, and which pre- 
 sent features of much interest. The first is that of L. F., 
 German, aged 44; shoemaker. Never had any serious 
 
TUMORS OF THE BLADDER. 
 
 19 
 
 illness ; has always enjoyed good health, when at the 
 age of twenty-three, he found, on waking one morning, a 
 considerable quantity of clotted blood in his bed ; had no 
 pain. Four years afterward (when twenty-seven), noticed 
 for the first time blood in his urine. It appeared without 
 any assignable cause, and remained only a day. Ten years 
 afterward (when thirty-seven), noticed bjood in his urine 
 the second time, which continued some days and disap- 
 peared upon taking medicine. Ever since, however, blood 
 has appeared in the urine at intervals, with some pain in 
 micturition. He remained in this condition up to August, 
 1879, when blood appeared constantly in the urine, some- 
 times in small and sometimes in large quantities ; clots 
 also now appeared for the first time ; micturition also 
 became frequent and painful. Admitted to Charity Hos- 
 pital December 3d, 1879. Anaemic and weak, complains of 
 palpitation of the heart on least exertion. Has pain in 
 his right lower extremity ; micturition very frequent and 
 painful, thinks he could pass a pailful of water, but 
 only a few drops come away at a time. The pain in mic- 
 turition is at the neck of the bladder and at the glans penis. 
 Almost every time he urinates he finds clotted blood in 
 the urine. Has noticed that, while passing water, the 
 stream will suddenly become arrested and start again in a 
 moment, preceded by a clot of blood. Has pain behind 
 the pubes. Urine sp. gr. 1.012 neutral, dark-red, holds 
 about forty per cent of albumen and contains a thick de- 
 posit of pus, blood-corpuscles, and epithelium. A stric- 
 ture was found, five and three-quarter inches from meatus, 
 admitting 16 A. December loth, thinks he feels better ; 
 pain in hypogastrium and thigh gone. December 13th, 
 during the night, was unable to pass water; the bladder 
 became distended and painful ; in the morning, a large clot 
 came away, after that the urine again flowed freely. Janu- 
 ary 6th, always complains of more or less pain in region of 
 right buttock and thigh. Passed a large clot of blood this 
 
^Q TUMORS OF THE BLADDER. 
 
 morning, previous to which had much pain over hypogas- 
 trium. Transferred to Ward 6. In this ward he was in 
 bed most of the time, and was given ergot, gallic acid, 
 iron, etc., but his condition remained unimproved. The 
 patient was seen by me for the first time in March, when 
 bv palpation and catheterization 1 distinctly recognized a 
 tumor at the trigone, involving especially the right side 
 of the bladder. Three days previous to death, patient 
 became semi-comatose, emitted an offensive urinous odor, 
 and fibrillary contractions of the muscles of the arms and 
 neck were observed. Rectal alimentation was necessary, 
 patient's jaws resisting all efforts to open them. Death 
 ensued March 28th, 1880, at 6 p.m. 
 
 Autopsy by Dr. Holmes. — Onl}^ bladder, ureters, and 
 kidneys were examined. Bladder was contracted, and 
 contained about 3 ij. of urine. Projecting from the tri- 
 o-one and right wall of the bladder is a mass, circular in 
 form, about four and one-half inches in diameter, consider- 
 ably elevated, with convex lobulated surface, presenting 
 numerous sulci or depressions, and covered with shreds of 
 tissue. The entire mass is rather pale, and in the contracted 
 condition of the bladder almost completely fills its cavity, 
 being about the size of the fist. Mucous membrane else- 
 where is thickened and pale. See Plate v. Ureters : left 
 normal, right moderately dilated and thickened. Kid- 
 neys : right is smaller than normal ; external surface is of 
 deep color and covered with blackish-red ecch3'-motic 
 spots. On section, find the kidney in condition of hydro- 
 nephrosis. What remains of cortical portion — a very nar- 
 row rim — is very firm, pale-red, and shows the same ecchy- 
 motic condition as the external surface. The lining 
 membrane of the dilated pelvis and calyces is very pale. 
 On cutting through the cortical portion at several points, 
 small masses of secondary cancerous deposit are found ; 
 they are about the size of a split pea. Left kidney is swoL 
 len, deep-red color, and shows hemorrhages on surface 
 
TUMORS OF THE BLADDER. 
 
 21 
 
 Plate V. 
 
 Primary Encephaloid Cancer. 
 Original drawing from one of the author's cases. 
 
22 
 
 TUiMORS OF THE BLADDER. 
 
 Plate VI. 
 
 X 400. 
 Microscopic appearance of encepnaloid tumor (PI. V.). 
 
TUMORS OF THE BLADDER. 2^ 
 
 and on section. The cortical substance is markedly swol- 
 len ; Malpighian bodies prominent and deep-red. The 
 P3^ramids, deeply congested, columns of tubules can be 
 traced almost everywhere ; appear broader than normal, 
 and have gra3'ish-yellow color. 
 
 Microscopic appearances. — The tumor was examined by 
 Dr. Carl Heitzmann, who found it to consist of delicate 
 fibrous connective tissue, inclosing large and numerous 
 alveoli (Plate vi.. A), which latter are filled with large and 
 irregular epithelia. The connective tissue framework is 
 crowded with globular, mostly homogeneous corpuscles, 
 at some places to such an extent that the fibrous structure 
 of the connective tissue is obscured (B). The epithelia 
 within the alveoli are coarsely granular, supplied with 
 large nuclei, either single or multiple. Diagnosis : medul- 
 lary cancer. 
 
 The second patient was that of a lady, aged sixty -nine. 
 Some time during the month of August, 1880, while in the 
 country, and lying in bed one afternoon by the open win- 
 dow, a thunder-storm came on, and during a vivid flash of 
 lightning, felt, as she said, "a shock of electricity, which 
 passed through me from head to foot." Soon after she 
 got up, passed water, and saw that it contained blood. The 
 urine continued to be tinged with blood, though slightly, 
 for about two weeks, during which time she kept her bed, 
 according to her physician's advice, but she had no pain 
 or inconvenience of any kind. After two weeks, she left 
 her bed, and the hematuria disappeared spontaneously. 
 From this time to November nth, there had been no re- 
 currence of hemorrhage, but on this day the urine again 
 became tinged with blood. November 12th, urine free 
 from blood, color pale, quite clear ; no appearance of any 
 abnormality to naked eye ; no albumen with heat and acid. 
 November 20th, sharp hemorrhage commenced to-day ; 
 urine contains large clots ; is obliged to empty bladder 
 every twenty minutes to one and a half hours, with con- 
 
24 TUMORS OF THE BLADDER. 
 
 siderable bearing-down pains, owing to the presence of 
 clots in the bladder. Gallic acid, ergot, turpentine, iron 
 chloride, aromatic sulphuric acid were administered freely 
 and m large doses, but apparently without any effect. The 
 hemorrhage continued, and the patient became thoroughly 
 aneemic and much exhausted. December 9th, extreme 
 nausea and irritability of stomach ; refuses all medicine 
 and nourishment : pulse rapid and feeble, prostration ex- 
 treme ; stniiulants and nourishment administered by rec- 
 tum. For several da^-s little hope was entertained of her 
 recovery. She rallied, however, m a most marvellous 
 manner: the blood gradually disappeared from the urine 
 without any remedies ; stomach returned to its normal 
 condition , appetite improved rapidly, and the good old 
 lad}^ became once more herself. December 21st, appetite 
 good ; cheerful, and hopeful for the future ; urine pale, 
 feebly alkaline ; no blood ; very little free pus, but quite 
 large flakes of mucoid material, impregnated with triple 
 phosphates, exist in the water, and there is alwa3''S the 
 same slimy material deposited in the chamber or in the 
 bottle of urine brought for examination. She now com- 
 plains of frequency of micturition, and a severe burning at 
 the vesical neck at the completion of the act. This is the 
 first time she has complained of any pain other than the 
 bearing down hitherto experienced, consequent upon the 
 expulsion of clots. January i6th, 1881, has continued 
 about the same since last report. Sometimes there is con- 
 siderable frequency of micturition, with pain ; while, again, 
 she is capable of holding water several hours, and there 
 is absolute freedom from pain during micturition. Gelat- 
 inous particles still float in the urine, and slimv deposit 
 continues, but not nearl}^ so much as before. There has 
 also been an occasional reappearance of the hsematuria, but 
 not for some eight or ten da3^s ; is to sit up a few hours 
 dail}'. January 21st, had considerable pain in region of 
 left kidnev, extending downward over the left side of 
 
TUMORS OF THE BLADDER. 
 
 25 
 
 bladder. Applied turpentine stupes, which gave partial 
 relief. Nevertheless, she continued to complain of con- 
 siderable pain, especiall}^ over left side of bladder, and 
 extending down the thigh, for some ten days afterward. 
 At times the pain would be slight, and again quite sharp. 
 There had been an occasional recurrence of the hsema- 
 turia, blood appearing, perhaps, at one micturition, while 
 at the next the urine would be perfectly clear. February 
 loth, has been sitting up a few hours almost daily since 
 January i6th. Has taken iron, quinine, etc., but during 
 the past five or six da3-s there has been more or less blood 
 in the urine nearly all the time. Is very nervous, and ap- 
 petite is again failing rapidly. Again proposed a digital 
 exploration of the interior of the bladder, with the view 
 of possibly effecting the removal of the tumor. Hoping, 
 however, to become stronger in a few days, she requested 
 that the examination should be again deferred. February 
 13th, hemorrhage agam profuse ; passes water every tAvent}" 
 or thirty minutes ; considerable bearing-down pains from 
 the accumulation of clots in the bladder ; excessive nau- 
 sea; unable to retain an}- thing on stomach, excepting very 
 small quantity of champagne. Nutritive and stimulating 
 enemata were given, but she sank rapidly, and died at 
 8 A.M., February 15th, 1881. 
 
 ■Autopsy made Feb. 17th. Only bladder and left kidney 
 examined. Bladder found distended with soft clots, its 
 walls much atonied, being extremely thin at the vertex. 
 Mucous m.embrane vascular throughout. A tumor was 
 found, situated directly over the orifice of the left ureter. 
 It was about four and a half inches in diameter, and pro- 
 jected from the surface about an inch. It was attached 
 by a broad base, nearly equal in diameter with the rest of 
 the tumor, and its surface presented the shaggy appear- 
 ance characteristic of villous growths (see Plate vii.). On 
 the opposite side, the coats of the bladder are also infil- 
 trated with cancerous material. Left ureter dilated and 
 
26 
 
 TUMORS OF THE BLADDER. 
 
 Plate VII. 
 
 Primary Villous Cancer. 
 Original drawing from one of the author's cases. 
 
TUMORS OF THE BLADDER. 
 
 27 
 
 Plate VIII. 
 
 X 200. 
 
 Microscopic appearance of villous cancer (PI. VII.). 
 
28 TUMORS OF THE BLADDER. fc 
 
 hypertrophied, especially at entrance into bladder. Left 
 kidney small, pelvis dilated, pyelitis and C3^stic change 
 commencing in the organ itself. Right kidney was acci- 
 dentally returned into abdomen without examination. Ya- 
 gina, uterus, rectum, and neighboring organs were entirely 
 free from disease. Microscopic examination by Dr. C. 
 Heitzmann found the tumor to be composed of a rather 
 coarse, fibrous connective tissue, highly vascularized, and 
 sprouting on the surface into numerous bud-like elon- 
 gations (Plate viii.. A), varying in length from o.oi mm. 
 to 3-4 mm. Most of the buds are covered with a single, 
 irregular, columnar epithelium ; the elongations them- 
 selves, as well as the subjacent connective tissue, is 
 infiltrated with numerous, partly globular, partly oblong 
 corpuscles (B). Within the connective tissue are seen 
 alveoli of small size (nests, C), containing a number of 
 epithelia: the latter are mostly provided with only one 
 nucleus. Diagnosis, villous cancer. 
 
 MYOMATA. 
 
 Myomata occur very rarely in the bladder. The follow- 
 ing are, no doubt, the only instances of this new-formation 
 that can be found in literature, 
 
 Myo-carcinovia. — Virchow, in his work on " Geschwiilste," 
 makes allusion to this form of tumor in the description of 
 a myo-carcinoma, which was situated on the posterior wall 
 of the bladder, towards the point of the trigone. The 
 greater part of the tumor was apparent in the submucous 
 tissue ; but its deeper portion was continuous with the 
 muscular coat. Microscopic examination showed a great 
 resemblance to a genuine myoma. The portion lying in 
 the submucous tissue showed entirely the structure of 
 scirrhus. 
 
 Faye mentions a case of supposed fibro-myoma. The 
 tumor was situated between the anterior wall of the blad- 
 der and the fascia transversalis. It was eisrhteen to 
 
TUMORS OF THE BLADDER. 20 
 
 nineteen centimetres long, sixteen to seventeen broad, and 
 ten centimetres thick. It was so intimately connected 
 with the vesical wall, that it seemed to have its origin 
 therein, though Faye says it is possible that it originated in 
 the subperitoneal connective tissue. 
 
 Myosarcoma and carchioma. — A patient of Billroth, aged 
 twelve years, was troubled for ten months with frequent 
 and painful micturition. The urine remained feebly acid, 
 slightly cloudy, but contained nothing characteristic on 
 microscopic examination, except a moderate quantit}^ of 
 pus-corpuscles, and a few cells of bladder epithelium. A 
 tumor was felt through the abdominal walls, about the 
 size of the fist. It could also be felt through the rectum. 
 The tumor, which was successfully removed by supra- 
 pubic incision, had its origin from the posterior Avail, and 
 extended towards the top of the bladder. It was eight 
 centimetres long, four broad, and eighteen in circumfer- 
 ence in one direction, and thirteen in another : its base was 
 seven centimetres. Its surface was nodulated ; it was 
 smooth and not ulcerated. It took its origin distinctly 
 from the muscular coat, and was, therefore, a myoma, but 
 the tumor had undergone a sarcomatous, and, in places, a 
 carcinomatous transformation. (Plate ix., shows the rela- 
 tive size, form, seat, etc., of tumor.) 
 
 The next three cases are instances of pure myoma. The 
 first is Volkmann's patient, aged fifty-four. For six months 
 has suffered from tenesmus, strangury, sharp pains in 
 glans penis during micturition, and hemorrhage, with pro- 
 duction of large clots. Urine contains neither mucus nor 
 pus-corpuscles. Bimanual examination reveals a hard, elastic, 
 and easily movable tumor in the upper part of the bladder, 
 about the size of a hen's ^%%. The tumor was unsuccess- 
 fully removed by supra-pubic incision. It was 8.25 cm. 
 long, 6.5 broad, 21.5 cm. in longitudinal, and 17.75 i^i 
 transverse circumference. The pedicle was half an inch 
 long, and of the thickness of the little finger, and attached 
 
30 
 
 TUMORS OF THE BLADDER. 
 
 Plate IX. 
 
 :;^\\ 
 
 
 
 Billroth's Myo-sarcoma and Carcinoma. — Arck, f. Klin. Chir., Bd. i8. 
 
TUMORS OF THE BLADDER. 
 
 31 
 
 Plate X. 
 
 Yolkmann's Myoma. — Arch, f, Klin. C/iir., Bd. 19. 
 
,^ TUMORS OF THE BLADDER. 
 
 to the vertex anteriorly, and a little to the left. The 
 tumor was of the size and form represented at Plate x., 
 and microscopic examination found it to be a pure 
 myoma. Dr. H. Chiarri, prosector to the Rudolfs-Spital, 
 Vienna, found, post-mortem, two cases of pure myoma, 
 which are described by Belfield, in the Wien. Med. 
 Wochschr. The first was a female, aged fifty, who died of 
 bilateral pleuro-pneumonia. On the outer surface of the 
 contracted bladder, and on the left side of its base was a 
 firm, sharply-defined tumor the size of a nut, imbedded in 
 the loose, perivesical areolar tissue. It had the shape of 
 an egg with its longitudinal axis directed vertically, and 
 had a smooth surface. It was two centimetres long, one 
 centimetre thick, and two centimetres broad. On remov- 
 ing the surrounding adipose tissue, there appeared four 
 thm cords (Strange), which could be traced from the under 
 surface of the tumor into the muscular coat of the bladder, 
 and consisted partly of sm.ooth muscular fibres, and in 
 part of blood-vessels. These cords led through an elhpti- 
 cal gap, fifteen millimetres long and eight millimetres wide, 
 in the external muscular layer into the inner layers of the 
 muscular coat, which made it evident that the tumor had 
 its origin therein. It had no connection with the uterus, 
 which also had a myoma the size of a bean on the anterior 
 surface of its fundus beneath the peritoneum. 
 
 The second subject was a male aged seventy-four, who 
 died of pneumonia. There was considerable enlargement 
 of the middle lobe of the prostate, which was otherwise 
 only slightly tumefied. The muscular coat of the bladder 
 was considerably hypertrophied, and its mucous mem- 
 brane was in a condition of catarrhal inflammation. The 
 left ureter was greatly dilated, and the corresponding 
 kidney hydronephrotic ; the right kidney was not changed. 
 The cause for the dilatation of the left kidney and the 
 hydronephrosis was the existence of a small tumor covered 
 with mucous membrane, just below the orifice of the 
 
TUMORS OF THE BLADDER. 33 
 
 left ureter which it compressed. The tumor was tuber- 
 ous, and could be enucleated (ausschalbar). It had a 
 diameter of seven millimetres. Both these tumors had 
 their origin, undoubtedly, from the muscular tissue of the 
 bladder. They were carefully examined under the micro- 
 scope and with the proper reagents, and were found to be 
 composed of organic muscular fibres, with a little connec- 
 tive tissue and blood-vessels. It is interesting to note the 
 coincidence of a myoma of the uterus in one case, and the 
 hypertrophied condition of the prostate in the other. 
 
 SARCOMATA. 
 
 Sarcoma is one of the rarest diseases of the bladder ; 
 there are but few authentic cases on record. The first of 
 these was recorded by Senftleben in i860. A woman, aged 
 twenty-nine, was troubled with irritable bladder, inconti- 
 nence, and hsematuria. She had noticed that in straining at 
 stool a reddish fleshy mass appeared at the meatus, which 
 she herself cut away several times without pain. When she 
 applied for treatment, the hypogastrium was tender on 
 pressure, an inguinal gland on the right side was as large 
 as a walnut. The urethra had been dilated by the tumor 
 sufficiently to admit the index finger. Examination re- 
 vealed a soft elastic tumor attached by a broad pedicle to 
 the posterior and upper part of the bladder. A piece of 
 the tumor was torn away and examined microscopically by 
 Billroth, who declared it to be a spindle-celled sarcoma. 
 The greater part of this mass was afterward removed, but 
 the patient died on the fourth day from purulent perito- 
 nitis, the bladder having been perforated during the oper- 
 ation. Autopsy revealed another tumor which had its 
 origin from the intermuscular connective tissue. 
 
 Marchand s patient, a female, aged fifty-seven, had suf- 
 fered for two years with vesical catarrh ; there had been 
 considerable strangury and tenesmus vesicas, and every 
 half-hour a few drops of thick, highly foetid urine, contain- 
 3 
 
34 TUMORS OF THE BLADDER. 
 
 ing shreds of tissue, were passed. TJiere was never any 
 Juematiiria. After bloodless dilatation of the urethra the 
 finger discovered a tumor on the lower and posterior 
 wall of the bladder. It was found that the tumor and the 
 vesical wall were in firm connection with the uterus, and 
 for that reason no attempt was made at extirpation. Pa- 
 tient died of exhaustion. P. M. Posterior wall and trigone 
 of the bladder was occupied by a tumor the size of an 
 apple (Borsdorfer Apfel). The principal mass was situated 
 in the right half of the bladder, while in the centre and 
 towards the left the greater portion of the tumor was 
 broken down and had a deep ragged ulcerated sulcus. 
 Tumor occupied pretty much the entire thickness of the 
 vesical wall, had its origin from the intermuscular connec- 
 tive tissue, and microscopically presented the structure of 
 a round-celled sarcoma. The anterior wall of the vagina 
 and of the uterus, which v/ere connected to the bladder by 
 a firm structure, were entirely unaffected. The rest of 
 the bladder was scarcely thickened. There were meta- 
 static deposits in the lung, hydronephrosis, pyelonephri- 
 tis, etc. 
 
 Heath reports the case of a female aged thirty-nine. 
 Passed little blood zvith urine at various times for several years, 
 complained of constant desire to micturate, but in doing so ex- 
 perienced no pain or difficulty, although evidences of inflamma- 
 tion were most marked. The urethra was dilated and the 
 right side of the bladder was found to be occupied by a 
 villous growth, situated on a hardened base. Some of the 
 ■growth was torn away. Patient died from general exhaus- 
 tion. Inner surface of bladder was found to be covered 
 with villous processes coated with phosphatic deposits. 
 Several growths external to the bladder were found. 
 Microscope showed new-growths to be medium-sized, 
 round-celled sarcomata, and the villous growth in the 
 bladder rested on a hardened base made up of round cells 
 rather larger than granulation cells. Kidneys were ex- 
 
TUMORS OF THE BLADDER. 35 
 
 tensively diseased, and a tubercular mass undergoing case- 
 ation was found in the lungs. 
 
 Knowsley Thornton speaks of having scraped away a por- 
 tion of a small growth from the bladder with his nail which, 
 under the microscope, proved to be a round-celled sarcoma. 
 
 Stimson exhibited (New York Pathological Society) the 
 bladder of a man aged sixty-three, who had complained of 
 frequent and painful passage of bloody urine. There was 
 a sarcoma three inches in diameter, attached by a pedicle 
 as thick as the finger to the posterior wall and about four 
 inches above the vesical neck. 
 
 As secondarily affecting the bladder we have three cases, 
 all occurring in female children, and originatmg in the 
 vagina. The first case (Sanger) is a typical round-celled 
 sarcoma (sarcoma medullare) situated on the anterior co- 
 lumnas rugorum vaginae of a girl three years old, which 
 later attacked the bladder and caused death by perforation 
 and peritonitis. The second (Ahlfeld) was a congenital 
 fibro-sarcoma, which filled the vagina with polypoid 
 growths and also affected the bladder. The third (Solt- 
 mann) was a girl two and a half years old with a mucous- 
 membrane sarcoma of the vagina, characteristic in its 
 grape-like form, leaving the uterus free and attacking the 
 bladder. 
 
 From the above cases, few as they are, we learn that 
 sarcoma, like carcinoma, may be primary or secondary to 
 the bladder ; that it may be of the spindle-celled or of the 
 round-celled variety, and that it may take on the villous 
 form. With regard to frequency it will appear that sar- 
 coma of the bladder as found in Uterature is rare. Never- 
 theless, seeing the resemblance between round-celled sar- 
 coma and encephaloid cancer in regard both to their 
 clinical and physical characters, and in the absence of. 
 microscopical data, we are with Gross in the belief, that 
 probably many tumors formerly described as encephaloid 
 cancer, belonged to the variety of soft sarcomata. 
 
^6 TUMORS OF THE BLADDER. 
 
 Tumors sometimes undergo calcareous transformation. 
 Civiale mentions the case of a negro aged fifteen whom 
 Middleton twice subjected to lithotomy without finding a 
 stone. At the autopsy they discovered a bony cyst the 
 size of a chestnut. In 1828 a woman appeared at L'Hotel 
 Dieu with S3^mptom of stone. Dupuytren examined this 
 patient without finding anything. She died of cystitis, and 
 there was discovered a pediculated tumor the size of a 
 large turkey's Ggg entirely ossified. 
 
 The etiology of tumors of the bladder is obscure. Civi- 
 ale and other writers have endeavored to attribute their 
 origin to some continued local irritation, as the prolonged 
 use of the catheter, the presence of calculi, etc., but I think 
 upon insufficient grounds. In the majority of cases it is 
 impossible to assign any injury or irritation as the exciting 
 cause, and in those not very common cases in which cal- 
 culi co-exist with the new-formation, the evidence is strong 
 that the concretion was formed subsequent to, rather than 
 before the development of the tumor. 
 
 SYMPTOMS. 
 
 All tumors of the bladder present, more or less, sooner 
 or later the triple symptoms — hsematuria, irritable bladder, 
 and pain. We shall take up those symptoms in the order 
 mentioned, and consider them as they apply to each form 
 of vesical growth. 
 
 HcBJuaturiayr^iries in respect to constancy, time of appear- 
 ance, and quantity of blood lost, with the nature of the 
 tumor. In villous growth it is always a most prominent 
 and unfailing symptom ; it is never absent during the entire 
 course of the disease. This is to be expected in consider- 
 ation of the peculiar structure and vascularity of these 
 growths, made up as they are of delicate capillary loops 
 which are constantly subjected to friction and injury by 
 the powerful contractions of the bladder. The hcematuria 
 appears early. It is often the first and sometimes the only 
 
TUMORS OF THE BLADDER. -ly 
 
 symptom throug-hout the complaint, as in the patients of 
 Partridge and Hooper. The first was a man not in bad 
 health, with no pain, and beyond the bleedmg had no in- 
 dications of bladder or renal disease. After death from 
 ■cholera, there was found a pedunculated polypus covered 
 over its whole surface with long villi. When the speci- 
 men was fresh, the villi were very florid and congested. 
 The mass was about the size of half a walnut and attached 
 by a pedicle of the thickness of a crow quill to the trigone. 
 The mucous membrane of the bladder was perfectly 
 healthy. 
 
 Hooper's patient, male, aged thirty-four. About four 
 months before death, without any premonitory symptom, 
 observed blood in the urine ; it was unattended with 
 pain or any other symptom. The bleeding continuing, 
 applied a month later for medical advice. He described 
 the quantity of blood which had been lost as very great 
 and his appearance was exceedingly blanched and pale. 
 He had not lost flesh, had good appetite, no pain any- 
 where, and excepting the haematuria there were no indi- 
 cations of vesical disease. Remedies were given to arrest 
 bleeding, but without avail. The man sank from sheer 
 bloodlessness. P. M. Every organ in the body was found 
 healthy, with the exception of the bladder. Near the 
 opening of the right ureter was a peculiar tufted growth 
 about the diameter of a sixpence, and one-eighth of an inch 
 in depth or thickness, and in its vicinity were two or three 
 much smaller and more vascular-looking tufts, but possess- 
 ing the same general characters. Capacity of bladder was 
 normal and its coats healthy. 
 
 In villous growths, blood may appear in the urine at the 
 beginning, during, or at the end of micturition. In the 
 commencement of the disease, it is often observed that the 
 first half or two-thirds of the urine passed is perfectly 
 clear, while that which appears towards the last is bloody, 
 or it may be that the flow remains clear to the end, a few 
 
-,3 TUMORS OF THE LLADDER. 
 
 drops of almost pure blood being expelled with the coup 
 de piston. The latter phenomenon is undoubtedly due to 
 the injury inflicted upon the tumor by the powerful ex- 
 pulsive effort of the bladder at the end of micturition, and 
 by the forcible squeezing of the tumor into the vesical ori- 
 fice at this time. For this reason, too, even if the urine is 
 tinged throughout and from the beginning, that which 
 comes last invariably contains most blood. 
 
 The quantity of blood lost varies from a mere parenchy- 
 matous oozmg to a free hemorrhage. In the first case, the 
 urine will be simply tinged with blood ; in the latter, it 
 will be of a dark-claret or venous-blood color, and contam 
 numerous and large clots. The amount of hemorrhage is 
 usually commensurate with the size of the tumor, although 
 death has resulted from sheer loss of blood from a growth 
 not much exceeding the size of a pea. 
 
 The hasraaturia is apt to be intermittent, especially at 
 first. In the beginning of the complaint, it may be noticed 
 that the urine is tmged with blood, but in a few daj^s all 
 signs of hemorrhage disappear, and the unpleasant visitor 
 is forgotten for possibly some weeks or even months, when 
 it reappears. Thus it may come and go several times, 
 each time the intervals becoming shorter, until the hemor- 
 rhage recurs every other day, every day, and, finally, with 
 every micturition. With the increase in the frequency, 
 there is also generally an increase in the quantity of blood 
 passed. 
 
 The hemorrhage seems to come often without any 
 assignable or exciting cause. The urine may be perfectly 
 clear one day, while on the next, under circumstances of 
 rest, quiet, and treatment, precisely the same active hemor- 
 rhage may ensue. This was notably observed in my pa- 
 tient with villous cancer who had had continued and quite 
 profuse hemorrhage for nearly three weeks, during which 
 time she was constantly under the free use of internal 
 astringents, with apparently no effect. Her stomach re- 
 
TUMORS OF THE BLADDER. 2g 
 
 belled ; she refused all food and medicine, and fell into a 
 condition of collapse ; but from that time the hemorrhage 
 commenced to diminish, and in a few days ceased spon- 
 taneously, without any treatment whatever. Nor does 
 exercise necessarily bring on a hemorrhage, as shown in 
 Dr. Hudson's patient, who walked a distance of nine miles, 
 yet neither that day, nor for three days afterwards, did 
 any appreciable amount of blood appear. 
 
 In cancer, hemorrhage, although a prominent symptom, 
 does not occur until later in the disease, because these 
 growths do not bleed until some ulceration has taken 
 place, or until, perhaps, the simple epithelioma has devel- 
 oped into a villous growth by the sprouting of vascular 
 processes on its surface. Hence, when hasmaturia exists, 
 it is usually associated at once (Dickinson's case a remark- 
 able exception) with irritable bladder. In fact, frequent 
 micturition, pain, and even catarrh of the bladder may 
 exist for some time before hsematuria occurs. Indeed, the 
 latter symptom sometimes remains absent to the end, as in 
 the followmg instructive cases. 
 
 In the patient of Sept. Gibbon, thei-e had been difficulty 
 in voiding urine for nine months. Afterwards, urine was 
 drawn off by catheter, but he had no hcBinaturia. Death 
 occurrmg from cancerous cachexia, the bladder was found 
 occupied by a medullary growth about the size of two fists. 
 
 In Ashhurst's patient, the walls of the bladder were infil- 
 trated with cancerous material, and the abdominal parie- 
 tes, rectum, and several coils of small intestine were 
 invaded, but there had been an entire freedom from hasma- 
 turia. The immediate cause of death was attributed more 
 to pulmonary disease, not cancerous, than to the vesical 
 cancer. 
 
 In Sanders' patient, there was extensive dentritic cancer, 
 involving the whole interior of the bladder, obstructing 
 completely the left ureter, patient passed fragments of can- 
 cer, and yet there was no hsematuna at any time. 
 
^O TUMORS OF THE BLADDER. 
 
 Rankin's patient had been passing large quantities of 
 blood, but for at least twenty-four days previous to death 
 had no hemorrhage. Lower part of abdomen was occu- 
 pied by a tumor the size of a child's head. Evidently the 
 bladder consisted of a sclid mass, by the occupation of its 
 left wall by an encephaloid cancer. Iliac glands were 
 cancerous, and the vesiculae seminales and adjacent parts 
 were agglutinated into a large supplementary tumor. 
 Whole mass weighed three pounds. 
 
 With regard to the constanc)'^ of h^ematuria in the other 
 varieties of tumor, it may be said to depend, as in cancer, 
 largely upon the presence or absence of surface erosion, 
 or ulceration, injury inflicted by instrumentation, etc. 
 
 Fibrous polypi are not nearly as prone to bleed as mu- 
 cous polypi, and hemorrhage is much less characteristic of 
 the latter than of villous growths. 
 
 Marchand's sarcoma and Billroth's mixed tumor were 
 both large, yet in neither was there ever an}^ hemorrhage ; 
 nor was the hemorrhage other than slight in the sarco- 
 mata of Senftleben and Heath. 
 
 In Volkmann's pure myoma, the urine became towards 
 the last very bloody ; but this was accounted for, after 
 death, in the ulcerated and gangrenous condition of the 
 tumor at its surface. 
 
 Irritable Bladder and Pain. 
 
 We have mentioned haematuria first, because it is the 
 most characteristic symptom, not because it is usually the 
 first that appears ; for although in a certain proportion of 
 villous growths bloody urine is the first symptom that 
 attracts attention, in a majority of these cases, as par 
 excellence in all the other varieties of vesical tumor, symp- 
 toms of irritable bladder precede the appearance of blood 
 in the urine. In fact, frequency in micturition is often the 
 only symptom that exists for months. This becomes more 
 and more annoying with the progress of the disease, until 
 
TUMORS OF THE BLADDER. 
 
 41 
 
 finally the bladder never feels entirely empty, and the 
 desire to void urine is almost constant. The presence of 
 blood in the urine always aggravates the irritability of the 
 bladder, and if this has not existed as an independent 
 symptom, it is sure to be a feature associated with hsema- 
 turia. 
 
 But what an incomprehensible organ the urinary blad- 
 der is ! So simple in structure, so complex m mechanism I 
 How easily, and from what insignificant causes is it 
 excited to irritability ! And yet how tolerant at times of 
 irritation, and even of extensive structural changes within 
 its walls ! 
 
 The following cases related by J. Matthews Duncan are 
 very instructive examples illustrating the occasional toler- 
 ance of the bladder to disease. 
 
 "A woman died under my care from perimetric abcess 
 and tubercular peritonitis. The perimetric abscess was a 
 consequence of parturition, and it burst into the ileum. 
 Simultaneously, with the diminution of the abscess, the 
 urine became bloody and carried with it a large amount of 
 pus. I never doubted that the abscess had burst through 
 the bladder. Pus was never observed in the stools. A 
 post-mortem examination was held, and there was found 
 no communication between the bladder and the abscess. 
 The bladder was only slightly contracted, and the whole 
 of its mucous membrane was dark-red, in a state of the 
 highest degree of catarrhal inflammation : secreting pus, 
 and also exuding blood. The woman had no irritability 
 of bladder ; she never complained of that organ." 
 
 " Another case is that of a patient with great hsematuria. 
 The case was diagnosed as being not one of disease of the 
 bladder, on account of the physical examination revealing 
 a healthy condition, so far as it could be made out. The 
 woman died suddenly, and the bladder was found to be 
 everj'where dark-red ; and on its internal surface there 
 were several nodules of soft cancer." 
 
^2 TUMORS OF THE BLADDER. 
 
 As a rule, the amount of irritation and functional dis- 
 turbance created by a growth in the bladder depends 
 upon its location and size. Tumors situated near the 
 vesical neck, even if small are more apt to give rise to 
 trouble than larger ones situated at the vertex. An 
 instance of extensive disease at the vertex of the bladder, 
 with remarkable immunity from severe symptoms, is given 
 by Ultzmann. A cancer, the size of the fist, situated at 
 the vertex of the bladder, perforated the abdominal wall 
 above the symphysis, and formed a vesico-abdominal fis- 
 tula, through which urme escaped as if from a spring. 
 Throughout this destructive process, the pain was always 
 very moderate. The patient died of septicaemia after 
 the right inguinal glands became so much infiltrated and 
 enlarged as to obstruct the circulation in the lower ex- 
 tremity and transform the leg into a swollen, shapeless 
 mass. 
 
 In malignant growths, characteristic lancinating or 
 darting pains may be looked for in the region of the blad- 
 der ; but the absence of this symptom in several of our 
 grave cases (Heath, Smyth, Ashhurst, Stein) shows that 
 pain is not pathognomonic of vesical cancer. Benign 
 growths are never in themselves painful, though by their 
 presence they give rise to disturbances which often occa- 
 sion much suffering and distress. If pain is not associated 
 with frequent micturition at the outset, it very soon be- 
 comes a feature of the complaint. It is usually located at 
 the vesical neck and perinaeum, or commencing here, radi- 
 ates in all directions ; but especially does it extend along the 
 urethra to the glans penis, and towards the rectum. It is 
 always worse during the final act of micturition; and if 
 clots have accumulated, or have become impacted m the 
 vesical orifice, the expulsion of these is always attended with 
 severe bearing-down pains, tenesmus, and spasm. Often 
 enough in simple growths, there is no pain excepting dur- 
 ing free hemorrhage and the formation of clots in the 
 
TUMORS OF THE BLADDER. 43 
 
 bladder, which, when expelled, afford rest and freedom 
 from suffering. Sometimes there is a more or less steady 
 pain in the region of the buttock and back of the thigh, on 
 the side corresponding to the seat of the disease, probably 
 caused by pressure of the tumor upon the sacral nerves. 
 Later on, also, there may be pain in the region of the 
 kidney, shooting downward toward the bladder. This, 
 too, is usually on the side with the vesical growth. This 
 pam may be purely reflex ; but if persistent, is suspicious 
 of a hydronephrotic condition or structural change in the 
 kidney. Sometimes there is a sensation during micturi- 
 tion as if something was forced against the neck of the 
 bladder, Pediculated growths are often so situated that 
 they lie over the vesical orifice or are propelled in that 
 direction during the evacuation of the bladder; and it 
 thus happens that the flow of urine is sometimes momen- 
 tarily interrupted, which, in the absence of stone, is a 
 characteristic symptom of pediculated tumors. Further- 
 more, these growths sometimes become engaged in and 
 block up the vesical orifice, either partially or completely, 
 occasioning spasm, much difficulty in micturition, and 
 retention of urine, requiring constant catheterization. On 
 the other hand, they may occasion incontinence from the 
 gagging and dilatation of the vesical orifice. 
 
 DIAGNOSIS. 
 
 In point of diagnosis in the female, the most unequivocal 
 evidence of the disease is not unfrequently obtained from 
 the protrusion of the growth at the meatus. This was 
 manifest in the cases of Warner, Pleininger, Warner, Thei- 
 nemann, Shaw, Senftleben, Guersant, Birkett, Bishop, 
 Marsh, Schatz, Winckel, Godson, Barton. In one or two 
 instances, the protrusion was incomplete, that is, the 
 growth extended into the urethra, but not beyond ; in 
 all the others, the tumors appeared external to the mea- 
 tus. In some cases, the protrusion was constant, but most 
 
44 TUMORS OF THE BLADDER. 
 
 frequently the growths appeared only with straining at 
 stool or during micturition. Pleininger's patient was an 
 exception to this rule ; she had prolapsus of rectum dur- 
 ing stool, and the projecting mass from the urethra, 
 which was of the form and size of a strawberry, always 
 returned with the descent of the gut. In some instances, 
 the urethra was enormously dilated by the descending 
 growths, sometimes only at its upper portion, some- 
 times its entire length. In Schatz's patient, the lower 
 fourth of the urethra had retained its normal calibre, but 
 the canal behind this was dilated to the diameter of the 
 finger, in which projected a tumor the size of a goose's egg. 
 In Theinemann's patient, a polypus the size of a hen's egg 
 protruded from the urethra, which could readily be entered 
 with the two fingers. In Marsh's patient, the polypi so far 
 distended the urethra that " at first this canal was mistaken 
 for the vagina." 
 
 In all doubtful or obscure cases, the passage of portions 
 of a growth with the urine is a most fortunate circumstance, 
 as it affords not only positive evidence of the existence of 
 a tumor, but, which is still more important, may determine 
 the propriety of attempting its removal. This is happily 
 not a very unfrequent occurrence. Kocher, Bryant, Bren- 
 necke, Thompson, Harrison, Hill, Ultzmann, Dickinson, 
 Alexander, Sanders, Hicks, Marcacci, Senftleben, Volk- 
 mann, Winckel, and others, make special mention of having 
 observed portions or fragments of tumor in the urine. 
 Winckel's patient showed him a mass of warty bodies, 
 nearly the size of a hazel-nut, and in quantity sufficient to 
 fill a medium-sized tumbler, which had come away, from 
 time to time, by the urethra, and it was said that eight 
 months afterwards a mass came away large enough to fill 
 a glass of one hundred grammes capacity. The portion of 
 Volkmann's tumor thus passed was the size of the little 
 finger. 
 
 The spontaneous expulsion of portions of tumor is gen- 
 
TUMORS OF THE BLADDER. 4- 
 
 erally followed by great relief to the patient, and in some 
 instances permanent cure has thus been effected. Ultz- 
 mann speaks of an elderly man, much exhausted from hee- 
 maturia, from whom villous masses came away ; the patient 
 remaining- well three years afterward. Bryant mentions a 
 case of Hicks' in which a large mass was passed with ap- 
 parently similar result. But the most remarkable instance 
 is that of Brennecke. A woman, aged thirt3'-four, found 
 herself in the sixth month of her fourth pregnancy, in the 
 beginning of May, i§76; for about three weeks suffered 
 with an intense vesical catarrh, and occasionallv with sud- 
 den stoppage in the evacuation of urine. Dr. B. was called 
 to see her on account of some bearing-down pains. After 
 fifteen or twenty hours of tormenting pain, there was ex- 
 pelled from the urethra a tumor fully the size and shape of 
 the kidney of a new-born child. From that moment the 
 symptoms of vesical catarrh ceased. The pregnane}^ went 
 on to full term, and she gave birth to a living boy. The 
 report was made April 12th, 1879, ^^^ the woman remained 
 well up to that time. The tumor is said to have been a 
 fibro-myxoma originating from the mucous membrane or 
 the submucous tissue of the bladder. 
 
 Small polypoid or pediculated growths becoming ac- 
 cidentally engaged in the eye of a catheter have been 
 removed by avulsion and have thus served to establish 
 the diagnosis, and in some cases permanent recovery 
 seems to have resulted. Mass says he has removed 
 mucous polypi in this manner from three patients. The 
 first, a man aged fifty -three, suffered with repeated hsema- 
 turia, etc. On washing out the bladder, the outflow of 
 urine was suddenly arrested by the impaction in the eye of 
 the catheter of a mucous polypus of the size of a hazel-nut, 
 with a short, broad pedicle; a second and similar growth 
 was removed at the same sitting and in the same way. The 
 patient remained free from a repetition of the hsematuria. 
 In the second patient, aged thirty-three, a large single 
 
46 TUMORS OF THE BLADDER. 
 
 catheter was passed, to which was attached an arrange- 
 ment of elastic tubing, and a funnel, by means of which fluid 
 could be injected or withdrawn from the bladder at plea- 
 sure. After a few injections, an elongated polypoid growth 
 was caught in the eye of the catheter and extracted as in 
 the former case. In the third patient, aged thirty-eight, 
 injections were made in the same manner, and a small po- 
 lypus with a long thin pedicle soon stopped up the eye of 
 the catheter and was removed, 
 
 Ultzmann refers to a man, aged sixty, with haematuria, 
 dysuria, etc. He introduced a metal catheter, and re- 
 moved bloody urine, and in attempting to withdraw the 
 instrument, felt that it was held ; removing it, however, 
 he saw projecting from the eye of the catheter a villous 
 growth three centimetres in length. The man did not 
 suffer any more from dysuria or hsematuria. Six months 
 later he died, as it was said, from disease of the stomach. 
 
 Mr. Bryant also, while catheterizing a female child, ac- 
 cidentally pulled away a small villous growth which had 
 become caught in the eye of the instrument. 
 
 All the forms of tumor found in the bladder, papillomata, 
 polypi, sarcomata, carcinomata, and even myomata, have 
 manifested their presence by the appearence of small frag- 
 ments of their structure in the urine, but this is a special 
 attribute of villous growths, both simple and malignant, 
 whose characteristic appearance can generally be recog- 
 nized under water by the unaided sight. If the particles 
 are small, and the urine very bloody, it may be very difficult 
 to find them. They should always be sought for, if possi- 
 ble during the intervals of hemorrhage, when the urine is 
 clear. From coagula, however, they may be distinguished 
 in that they are of a lighter color, and have a more firm, 
 fleshy consistence. 
 
 With regard to the histological data, obtained by the 
 microscopic examination of minute particles of villous 
 tissue, it is not to be expected that the villous structure 
 
TUMORS OF THE BLADDER. 47. 
 
 will always present its characteristic appearance un- 
 changed. This may be expected when larger portions 
 have recently been detached and . removed fresh with the 
 urine; but the filamentous shreds, so often found, have 
 been detached by a slower necrotic process, and no longer 
 present the perfect capillary loop, with its epithelial cov- 
 ering. Distinct and well-preserved villi are more apt to 
 be. found as coming from benign villous growths than from^ 
 villous cancer, because the former, having a thinner epi- 
 thelial covering, its structure is more apparent ; it is less 
 frequently subjected to the disintegrating influence of 
 ammoniacal urine, and the field of observation is not so 
 apt to be obscured by the presence of pus, ammonio-mag- 
 nesian phosphates, etc., as it is in malignant disease. 
 
 Ultzmann calls attention to a condition of urine known 
 as fit^nuria as an important diagnostic feature in villous 
 growths. According to this writer, the urine when first 
 passed, although very watery (diinnfliissig) and of a red- 
 dish-yellow color, coagulates after a few minutes into a 
 glutinous mass, which can scarcely be drawn from the 
 glass. It is especially to be noticed that such urine does 
 not contain much blood, as shown by the color, which is 
 not blood-red, but a yellow-reddish hue, and, therefore, the 
 quantity of coagulum is not in proportion to the quantity 
 of blood present in the urine. Furthermore, the coagula 
 are formed in a few seconds after the urine has passed, 
 and may subsequently be rendered fluid by a little shak- 
 ing ; while blood not only requires a longer time to coag- 
 ulate, but does not become fluid by stirring. Ultzmann 
 says that he has observed this condition of urine in three 
 cases of villous growths. 
 
 In my own patient with villous cancer, I observed this 
 remarkable condition of urine almost constantly during 
 her illness ; at times even when it could scarcely be said 
 that the urine was colored, light particles of coagula were 
 found floating therein in abundance, and when picked out 
 
48 TUMORS OF THE BLADDER. 
 
 and placed under the microscope, presented an extremely 
 delicate interlacing network of fibres, in the meshes of 
 which were crystals of triple phosphates. The urine con- 
 tained remarkably few pus-corpuscles, and the reaction was 
 never more than feebly alkaline. Ultzmann's theory with 
 respect to this phenomenon is, that, owing to the powerful 
 spasmodic contractions of the bladder, the return circula- 
 tion from the villi is interfered with, and turgescence of 
 the vascular loops occurs. If the blood-pressure is very 
 great, the vessels rupture, and hemorrhage ensues ; if the 
 tension is not sufficient to cause rupture of the vessels, a 
 transudation of plasma occurs, whose fibrin coagulates on 
 the emission of the urine. This increased vascular tension 
 also accounts for the presence of more albumen in the 
 urine than would correspond to the quantity of blood and 
 pus present. w 
 
 With regard to the evidence furnished by the micro- 
 scopic examination of the urine in cancer, it may be said 
 that, when associated with hsematuriaand other symptoms, 
 the presence of numerous and irregularly-shaped epithe- 
 lial cells is highly confirmatory of the existence of cancer, 
 but the presence in the urine of such epithelia is sometimes 
 very misleading, and the microscope cannot be relied upon 
 as a means of diagnosis, unless tangible fragments are passed 
 with the urine — a circumstance not of frequent occurrence 
 in this class of tumors. Dickinson says, " No isolated or 
 detached cells found in the urine can be regarded as proof 
 of cancer in the urinary tract ; while the absence of such 
 cells present no argument in favor of the freedom of the 
 bladder or kidneys from malignant disease. Under cir- 
 cumstances of irritation and disturbance, large cells, pre- 
 senting quite the ideal of cancer cells of all shapes and 
 character, regular and irregular, rounded, angular, and 
 elongated, are occasionally thrown off in abundance from 
 various parts of the urinary mucous membrane. Patients 
 who, upon the evidence of urine presenting such appear- 
 
TUMORS OF THE BLADDER. 
 
 49 
 
 ance, have been convicted of cancer, have been known 
 to get well and remain so." Sir Henry Thompson says, 
 " Some of the best ' cancer cells ' I ever saw in my life were 
 collected from a patient's urine and placed under the 
 microscope by an eminent microscopic observer, for the 
 purpose of a very important consultation. After a careful 
 examination of the patient, I admitted the beauty and perf ec. 
 tion of the microscopic observation, but on larger grounds 
 denied the existence of cancer in the bladder, and the ulti- 
 mate result, happily for the patient, confirmed that view 
 and disproved the cell." 
 
 In the four cases of tumor which have come under my 
 observation, frequent and daily examinations were made, 
 and in only one, in which flocculi were visible to the naked 
 eye, was ever any positive evidence of the disease mani- 
 fest in the urine. Exceptional then, as this is, the two fol- 
 lowing cases of Dickinson and Sanders are interesting 
 instances in which the diagnosis of cancer was clearly 
 made by the microscope. The first is especially instruct- 
 ive in that the presence of the growth was recognized 
 even before there were any subjective symptoms pointing 
 to the disease. 
 
 On July 24th, 1868, Dr. Dickinson was called upon to 
 examine some blood-tinged urine which contained small, 
 soft, buff-colored lumps, that had very much the appear- 
 ance of fibrinous coagula, for which they were at first 
 mistaken. These masses had drawn attention by briefly 
 obstructing the urethra during their passage. The urine 
 had been passed by a man aged fifty-one, in robust and 
 vigorous health. Excepting what had been observed in 
 the urine, there had been no symptoms pointing to the 
 urinary organs, or to any other part of the body, as the 
 seat of disease. On placing a portion of one of the soft 
 hiasses under the microscope, it was found to belong to a 
 malignant tumor, apparently of the encephaloid kind ; but 
 so complete was the absence of bladder symptoms, and so 
 4 
 
CO TUMORS OF THE BLADDER. 
 
 perfect the apparent health of the patient, that this view 
 of the case was at first received with incredulity ; but 
 towards the end of August it was found that carriage 
 exercise, to which the patient had been much used, had to 
 be given up in consequence of the pain it produced. The 
 bladder became the seat of more or less constant pain, and 
 at intervals of from two to three weeks, irregular lumps of 
 soft matter, looking very much like cerebral tissue, mixed 
 with blood and phosphatic deposit, and of all sizes up to 
 a culinary bean were passed, always with great relief of the 
 pain. Blood was now frequently passed, and as the winter 
 approached, the general health gradually broke down. The 
 bladder became exceedingly irritable, and micturition was 
 attended with some pain. The patient was gradually 
 worn out by his sufferings, and died March 24th, 1869. 
 There was no autopsy held ; but as he says, it is not possi- 
 ble to doubt either the seat or nature of the tumor. 
 
 Sanders' patient, male, aged forty-three, passed frag- 
 ments of cancer, sometimes of small size, like mere shreds, 
 at other times forming C3dindrical plugs about an inch 
 long, which often became impacted in the urethra and 
 obstructed the flow of urine. There was no hsematuria at 
 any time. The post-mortem showed extensive, dentritic 
 cancer, involving the whole interior of the bladder. 
 
 In the male, there is often, much difiEculty in ascertain- 
 ing the presence of a tumor in the bladder. The ordinary 
 digital examnnation is often fruitless. If the tumor is 
 large, and situated at the vertex, it may be felt through 
 the abdominal parietes ; if situated at the bas fond, and is 
 sufficiently large, or has infiltrated the coats of the bladder, 
 it may be recognized by the finger in the rectum. But 
 tumors rarely grow from the superior fundus of the blad- 
 der ; and, what is of still greater importance, those tumors 
 which are most amenable to radical treatment by extirpa- 
 tion, and which it is especially important to discover as 
 early as possible, are usually soft, pediculated growths, 
 
TUMORS OF THE BLADDER. cr 
 
 which do not involve the thickness of the vesical walls, 
 and which readily escape recognition by ordinary rectal 
 examination. Even in the female, where the bladder is 
 certainly more accessible to palpation through the vagina, 
 such tumors constantly escape detection. 
 
 In the male especially, but also in the female, the bi- 
 manual method of palpation should always be instituted. 
 This consists in introducing one or two fingers as far as 
 possible into the rectum, or into the vagina, and while 
 palpating, an assistant, with both^ hands flat on the hypo- 
 gastrium, presses downwards and backwards with the 
 ball of the hand ; the surgeon now crowds one hand under 
 the hands of the assistant, and thus manipulates the growth 
 between his fingers. In this manner, Volkmann felt a 
 tumor through the rectum, which was situated at the ver- 
 tex of the bladder, and which before had entirely eluded 
 his search. If necessary, the entire hand, if not too large, 
 can be introduced into the rectum, when the moderately 
 distended bladder is easily recognized as a fluctuating 
 tumor behind the prostate, and may be thoroughly pal- 
 pated for the detection of a foreign growth. This exami- 
 nation can scarcely fail to afford intelligence of the pres- 
 ence of a tumor. The patient should be angesthetized, 
 and the introduction of the hand into the rectum should 
 be very gradual, passing first two, then three and four 
 fingers, and finally, the entire hand. The introduction is 
 facilitated by pressure with the other hand over the abdo- 
 men ; and unless the hand is very large, which, perhaps, 
 should not exceed nine inches in circumference, or its 
 introduction is too rapid, the sphincter will remain intact, 
 and no incontinence of fseces or other trouble will super- 
 vene. 
 
 In exploring the interior of the bladder, a short-beaked 
 catheter or sound should be employed, because it admits 
 of greater freedom of movement, and can be better made 
 to sweep over the walls and fundus of the viscus. The 
 
5: 
 
 TUMORS OF THE BLADDER. 
 
 exploration should always be conducted with the finger in 
 the rectum or vagina, and, if possible, still further assisted 
 by crowding down the bladder by pressure from above. 
 We will thus rarely fail to make out the presence of a 
 tumor. Certain small, soft growths, not offering any resist- 
 ance to the instrument, and small tumors situated on the 
 anterior wall have more than once escaped the tactiLS 
 erudittLs ; but ordinarily, the deviation of the beak of the 
 instrument to one side or the other, the obstacle encoun- 
 tered in its movements^the thickness and consistence of 
 the structures interposed between the finger and the in- 
 strument, the production of pain by the impingement of 
 the sound against the tumor, the hsematuria induced by the 
 manipulation, especially if the tumor is of the villous 
 variety, will all tend clearly to define, not only the exis£- 
 ence of a tumor, but also its location, mobility, and, to 
 a certain extent, its size. 
 
 But whatever difficulty may present in obtaining the 
 desired information in the male, in the female all doubt 
 may be set aside by dilating the urethra and making the 
 bladder accessible to direct exploration. It is thus scarcely 
 possible to overlook the presence of a tumor in the blad- 
 der ; and if there is any suspicion even of the existence 
 of a growth, such an examination should be made at once, 
 and the result will be that much suffering will be avoided, 
 and, perhaps, many a life saved. 
 
 The principal objection that might be urged against this 
 method of diagnosis is the danger of producing laceration 
 of the urethra and permanent incontinence of urine. I 
 cannot deny that serious accidents have happened even in 
 experienced hands, but when we know with what instru- 
 ments this operation is often performed we can only wonder 
 that more women have not been injured for life. Every 
 conceivable instrument that is capable of stretching, from 
 the various branched uterine dilators of EUinger, Atlee, 
 etc., down to even sequestrum and bullet forceps, have been 
 
TUMORS OF THE BLADDER. 53 
 
 employed at one time and another as dilators for the deli- 
 cate female urethra. Is it to be wondered at that the 
 vesical sphincter is ruptured by such rude manipulation? 
 The dilatation of the female urethra is one of the import- 
 ant operations in surgery, and requires, even with the 
 most approved instrument, the exercise of every care, good 
 judgment, gentleness and patience. Digital dilatation, a 
 method adopted by some surgeons, is not much safer. 
 Several cases are known to me, in which very troublesome 
 incontinence of urine has followed this practice. In a 
 patient of my own, the urethra was suddenly torn when 
 every care was being taken to avoid it, and although the 
 woman ultimately recovered, for weeks she suffered with 
 incontinence, and I was much concerned as to whether she 
 would ever regain the control of her sphincter, 
 
 Simon, who did so much to popularize this operation, 
 used a series of plug-shaped specula of seven different sizes, 
 ranging from three-fourths to two centimetres in diameter. 
 These are introduced and withdrawn one after the other, 
 until the required dilatation is attained. The greater 
 safety of these plugs over the sharp edged dilators above 
 mentioned is too apparent to need comment. But I think 
 we have a better substitute in an instrument which I had 
 constructed about a 3^ear and a half ago, and which has 
 since been freely used by myself and others in this city 
 with every satisfaction, and with absolutely no ill report 
 irom any source. Its advantages require but to be pointed 
 out to be at once appreciated. It consists (Plate xi.. Fig. 
 i) of a metal tube three and a half inches in length, with 
 an obturator, elastic and conical at the point, which pro- 
 jects an additional inch beyond the distal end, and which 
 serves to facilitate the introduction of the instrument. 
 One inch from the proximal end is a handle that supports 
 a graduated bar and thumb screw, by means of which the 
 expansion of the instrument is effected. When closed it is 
 •thirty-nine millimetres in circumference, and is capable of 
 
t^j^ TUMORS OF THE BLADDER. 
 
 expansion to six and a half centimetres. Fig. 4 represents 
 a vertical section of the instrument closed. At Fig. 2 it is 
 seen expanded to fifty millimetres, and Fig. 3 shows a verti- 
 cal section in complete expansion, viz., six and a half cen- 
 timetres. From this it will be seen that the expansive 
 force of the instrument is distributed as equally as possible 
 over all parts of the circumference of the urethra by smooth 
 rounded blades, and not upon two or three points or sides 
 of the canal. Furthermore, the dilatation can be effected 
 very gradually, and with absolute precision, the degree of 
 expansion being determined by the graduated bar with the 
 greatest accuracy, even to a millimetre. 
 
 In this manner we conform to the conditions by which 
 alone a maximum degree of dilatation without laceration 
 can be attained. Indeed, the tearing or rupturing of the 
 urethra, which with other instruments is almost inevitable 
 when thorough dilatation is effected, and the incontinence 
 of urine which such an injury often entails, will by this, if 
 by any method, be avoided. 
 
 Owing to the peculiar conformation of the instrument, it. 
 creates very little pain, even when dilated to its utmost 
 capacity. I have operated in this way a number of times 
 without using any anaesthetic. The instrument is also an 
 admirable speculum by which a most satisfactory view of 
 the interior of the bladder can be obtained by means of 
 reflected light. 
 
 The following would be the method of procedure in a 
 suspected case of tumor of the bladder. The patient being 
 on the back or on the side, and anassthetized, the instrument 
 is introduced and rapidly dilated to a point at which 
 some resistance is felt, when the dilatation is proceeded 
 with more slowly and cautiously, the canal being stretched 
 a few millimetres at a time, the force exerted being in in- 
 verse proportion to the resistance to be overcome, and a 
 sufficient interval of time always allowed to elapse for the 
 tissues to relax before further dilatation is made. In this. 
 
TUMORS OF THE BLADDER. 
 
 55 
 
 Plate XI. 
 
 Author's female urethral dilator and speculum. 
 
r5 TUMORS OF THE BLADDER. 
 
 manner the instrument is gradually expanded to the cir- 
 cumference of the index finger, or if need be to its fullest 
 capacity, which is six and a half centimetres. 
 
 It must not be forgotten that the dilatability of the 
 female urethra varies much with the individual and with 
 age. In some persons, the expansion can be carried to the 
 fullest extent of the instrument, with little pain and with 
 little delay, while in others, the rigidity of the meatus, 
 which is the narrowest and most unyielding part of the 
 urethra, is extreme, and the danger of laceration great. 
 According to Simon, the highest degree of complete in- 
 nocuous dilatation is 6.3 centimetres in circumference, 7 
 centimetres at the furthest ; in girls of from 11 to 15, it is 
 reached at a circumference of 4.7 to 5.6 cenrimetres ; in 
 girls of from 15 to 20, at 5.6 to 6.3 centimetres in circum- 
 ference. 
 
 While this is, no doubt, the safe limit, we must know 
 that the urethra is capable of much greater dilatation, 
 without producing permanent incontinence. In the case 
 of Winckel, finger and instrument had been in the bladder, 
 the urethral mucous membrane was fissured, and yet none 
 of the one hundred and fifty grammes of water injected 
 after the operation escaped from the bladder. In the 
 case of Schatz, although during the operation the ure- 
 thra was dilated to an extent admitting two fingers, 
 she could retain her water one hour after the operation, 
 and afterwards two and three hours ; from the seventh 
 day she micturated once at night and twice during the 
 day. There was pain only on the first day during mictu- 
 rition. We could cite other instances in which both in- 
 dices were inserted into the bladder without any serious 
 injury resulting. 
 
 Simon always divided the meatus with scissors before 
 commencing dilatation, making two lateral slits of one- 
 quarter centimetre in the upper margin, and one down- 
 wards of a half centimetre in depth. With the instru- 
 
TUMORS OF THE BLADDER. 57 
 
 Tnent just described, I have thus far had no occasion to do 
 this, but if the parts are at all rigid, there is no objection to 
 slitting the meatus, while the urethra is thereby just so 
 much shortened, and the finger can be introduced further 
 into the bladder. 
 
 The urethra being dilated, the instrument is withdrawn, 
 the index and middle fingers are introduced into the ure- 
 thra and vagina respectively, and simultaneously carried 
 up until arrested by the urethro-vaginal septum. By pass- 
 ing the middle finger into the vagina, the index can be ad- 
 vanced at least one centimetre further into the bladder than 
 by the usual way of exploring. With supra-pubic pressure 
 made with the other hand, the finger can sweep over the 
 mucous surface and the presence of a growth, its location, 
 size, and extent of attachment may be exactly determined. 
 If desired, a small portion of the tumor may be detached 
 or scraped off with the finger-nail or sharp spoon, and 
 submitted to further examination by the microscope, or 
 the bladder may be illuminated by reflected light thrown 
 in through the speculum. 
 
 With regard to the question of diagnosis as between 
 simple and malignant growths, the former do not produce 
 the same pathogenetic changes in the surroundirg mucous 
 membrane of the bladder as do the malignant tumors ; 
 hence, there are rarely any secondary symptoms of inflam- 
 mation or catarrh of the bladder (except as set up by the 
 surgeon's unnecessary and prolonged instrumental man- 
 ipulation), and at the autopsy the mucous membrane is 
 generally found healthy. In the two cases of myoma, 
 also, it is interesting to note the comparative absence from 
 the urine of products of inflammation. Billreth's boy suf- 
 fered for ten months with frequent and painful micturition, 
 and yet the urine remained feebly acid, and contained but 
 a moderate quantity of pus. Volkmann's man suffered 
 with frequent micturition, tenesmus, hemorrhage, and 
 strangury for six months, but had neither pus nor mucus 
 
c8 TUMORS OF THE BLADDER. 
 
 in his urine. The vesical trouble was entirely due to the 
 obstructive effect produced by so large a tumor, and at the 
 autopsy the mucous membrane was found healthy. 
 
 In villous growths especially, the intermittent character 
 of the symptoms is a peculiar feature. The improvement 
 which is at once manifest with the cessation of hemor- 
 rhage, and the absence of any pain or discomfort during 
 the interv^als of hemorrhage, are characteristic. 
 
 In malignant tumor, we have the existence of cancer of 
 the uterus, prostate, or other surrounding organ, or, per- 
 chance, at some remote part of the body, to point to the 
 disease in the bladder, or there may be a decided heredi- 
 tary tendency to cancer. The touch is more certain to 
 recognize the presence of a nialignant growth, because 
 these tumors are more frequently solid, and infiltrate the 
 coats of the bladder. A comparison of the duration of 
 the complaint with the character and severity of existing 
 symptoms, will mark a more rapid progress than is ob- 
 served in benign tumors. 
 
 The secondary symptoms of chronic inflammation or 
 catarrh of the bladder are characteristic ; hence, all the 
 symptoms are more distressing and more enduring. 
 
 But, while the more aggravated the secondary symp- 
 toms the less the probability of the same being caused by 
 other than malignant growths, these symptoms may attain 
 such a degree of intensity as to mask the original disease, 
 and render diagnosis difficult ; especially so in the absence 
 of the most characteristic symptom — hsematuria — as ob- 
 served in the cases above cited. But hsematuria is excep- 
 tionally absent, and this, together with the other symptoms 
 mentioned, the lancinating and darting pains, the glandu- 
 lar involvement, and the appearance of cancerous cachexia, 
 will make the diagnosis of cancer conclusive. With refer- 
 ence to the appearance of cancerous cachexia, however, I 
 should say that this is at times very deceptive. Those 
 suffering from non-malignant tumors often present an ap- 
 
TUMORS OF THE BLADDER. eg 
 
 pearance not unlike that observed in cancerous infection. 
 In consequence of the prolonged hemorrhage, pain, dis- 
 turbed rest, and impaired nutrition, the subjects become 
 fearfully anaemic, and present an appearance which might 
 be easily attributed to cancerous infection. 
 
 If the seat of the tumor is not accessible to the sense of 
 touch or appreciable by instrumental contact, no frag- 
 ments of tumor have passed the urethra, and the urinary 
 sediments have afforded no clue to the existence of a for- 
 eign growth, the diagnosis must be made from the gen- 
 eral symptoms s.ud/>er viani exclusionis. The resemblance 
 in symptomatology between stone and vesical growths is 
 such that in a large proportion of cases the patients were 
 sounded for calculus. But while irritable bladder, hcema- 
 turia, and pain are prominent symptoms, common to both 
 affections, they behave in a manner characteristic of each. 
 
 In stone, irritable bladder is an earlj-and constant symp- 
 tom ; the heematuria is a later manifestation ; the hemor- 
 rhage appears after exercise, and disappears with rest, and 
 the quantity of blood in the urine is usually small. Pain 
 is particularly felt with movement, with jolting, and after 
 micturition, and disappears with rest in the horizontal 
 position. The urine also soon contains mucus and pus. 
 With tumor, irritable bladder is a later manifestation, and 
 is sometimes entirely absent. H^ematuria usualh^ appears 
 early ; it is often the first and only symptom throughout. 
 It occurs independent of movement, and is often profuse ; 
 even while at rest in bed. Pain is not occasioned or ag- 
 gravated by movement or position ; but sensitiveness of 
 the urethra and pain at the glans penis is perhaps more 
 severe than in stone ; while the urine, during the intervals 
 of hemorrhage, may be perfectly clear and free from any 
 sign of disease. Pediculated growths often produce a sud- 
 den stoppage in the fiow of urine, as is also observed in 
 calculus ; it may be that the tumor has engaged in the 
 vesical orifice, or that the urethra has become obstructed 
 
5o TUMORS OF THE BLADDER. 
 
 by a clot of blood, which being passed with some strain- 
 ing, the urine again flows freely. 
 
 The spongy texture of certain tumors, especially villous 
 growths, affords an attractive surface for the deposition of 
 phosphatic salts, which concretions, imparting the sensa- 
 tion of grittiness, and at times even giving the click of a 
 calculus, have deceived surgeons into the belief of the pres- 
 ence of a stone. If the incrusted tumor is movable, such 
 a mistake is still more easily made. 
 
 Duration and Prognosis. 
 
 The duration of life, after a tumor has once commenced 
 to develop, depends upon the nature of the growth. The 
 two principal sources of danger to life, in non-malignant 
 tumors, is from the loss of blood, and from the effects of 
 mechanical obstruction to the outflow of urine. When 
 death is not caused by hsematuria, the autopsy always 
 reveals extensive anatomico-pathological changes in the 
 urinary tract. Situated, as these growths so often are, 
 over the opening of the ureters or at the vesical neck, that 
 is, at the outlets of the kidneys and bladder respectively, 
 they cannot fail to act obstructively to these channels, and 
 produce, in natural sequence, hypertrophy of the bladder, 
 dilatation of ureters, hydronephrosis, structural change 
 in secreting substance of kidney, uraemia, and death. It 
 may, therefore, be said that, while for simple tumors the 
 prognosis is good, especially in women, as the growths are 
 accessible and capable of complete extirpation ; if uninter- 
 fered with, the prognosis is no better than for cancer ; in- 
 deed, they may prove even more rapidly fatal by their local 
 effects than would ensue from constitutional infection in 
 malignant disease. Nevertheless, there is abundant evi- 
 dence that simple growths may exist in the bladder for 
 many years, during which the individual may enjoy con- 
 tinued health. Hudson relates a case of a man aged sixty- 
 iive, who, when fifty-four years of age, eleven years before 
 
TUMORS OT^ THE BLADDER. 6l 
 
 death, first observed his urine to be discolored, and about 
 this time had obstruction to flow of urine ; the bladder 
 was found to be distended with blood-clot, which was 
 broken down with a catheter and removed by the help of 
 Clover's syringe. After the lapse of time, cystitis super- 
 vened and blood used to come away with the urine in 
 large quantity. Nitrate of silver injections were made 
 under chloroform at intervals for several weeks. After 
 this, he was completely cured and continued in good 
 health for nearly eight years. In 1875, he again had blood 
 in his urine at intervals of three or four days. Pain and 
 frequent micturition were his most prominent causes of 
 complaint. Clots were rarely seen in the urine. For 
 three months previous to death, the hsematuria had en- 
 tirely ceased, portions of phosphatic deposit were occa- 
 sionally voided, appetite was fair, a suppository required 
 only every third night, and to all appearances he was 
 gradually improving, when he died suddenly, probably 
 from disease of the heart. (Plate i. shows the bladder 
 with its contained growths.) 
 
 Mr. Humphrey relates a case in which there had been 
 recurring hemorrhage for a period of seven or eight 
 years. During intervals of months, and once a year, the 
 urine was quite clear and the patient suffered but little. 
 He died after a period of excessive hemorrhage. There 
 was a pedunculated, villous growth of the size of a walnut 
 near the orifice of the right ureter, and a smaller sessile 
 growth of same nature a short distance from it. Mr. 
 Humphrey also mentions that in the museum of St. 
 George's Hospital is a specimen of a solitary villous 
 growth attached by a narrow base to the neck of the 
 bladder, from a gentleman aged eighty-one. The first 
 attack of hsematuria, lasting eight months, was twenty 
 years before death. There was no return for four years, 
 after which there were returns at intervals. In another 
 specimen, where the base of the growth is large, hemor- 
 
52 TUMORS OF THE BLADDER. 
 
 rhage occurred nine years before death ; there was appa- 
 rently no return, and no symptoms until two months 
 before death. In another case (Specimen 2,006, College 
 Physicians and Surgeons, London), a quantity of blood is 
 said to have been passed sixteen years before death. No 
 return took place till six or seven years before death ; 
 then subsiding, recurred after three years ; it again sub- 
 sided to recur two years before death. 
 
 In malignant tumors, however, the course of the disease 
 is generally more rapid and more certainly fatal ; for now 
 there is not only an additional element to contend against 
 — the cancerous infection, but the local disease itself is 
 much more serious. In addition to the effect which can- 
 cers have in common with simple tumors to act injuriously 
 upon the urmary tract m opposing the free escape of 
 urine, the former are prone to soften, ulcerate, break 
 down, and setting up catarrhal irritation in the bladder 
 and kidneys, soon wear out the strength and vitality of the 
 patient. In soft cancer, the duration of life after the mani- 
 festation of the first symptom rarely exceeds one or two 
 years. In the case of Pollock, hsematuria occurred only 
 six days defore death, though the bladder was half filled 
 with a fungoid mass. Other cases terminated fatally in 
 three four, five, eight, and nine months. Dickinson dis- 
 covered evidence of malignant disease in the urine m a 
 robust, vigorous man, eight months before death. Excep- 
 tionally, the disease may last three or four years. My 
 patient, with medullary cancer, gave a history extending 
 over a period of seventeen years ! 
 
 In epithelioma, the progress is slower. In the case of 
 Hill, in which there was quite extensive disease, it is said 
 that until about four months before death there were no 
 symptoms of urinary disease. But this is a rare case ; as 
 a rule, the disease lasts from one to three years, and excep- 
 tionally five, six, eight, and nine years (Davies-Colley,Nunn» 
 Clark, Lambl, Thompson). The long duration of some 
 
TUMORS OF THE BLADDER. 63 
 
 cases of vesical cancer can only be accounted for in the 
 supposition that malignant tumors are sometimes develop- 
 ed from long-, pre-existing, benign growths which, having 
 remained for a long time innocuous, or else, having already 
 occasioned serious organic changes in the urinary tract, 
 require but the cancerous development to run rapidly to 
 a fatal termmation. My case of medullary cancer above 
 referred to, with a history of seventeen years, renders 
 such a conclusion almost inevitable. 
 
 Treatment. 
 
 Tumors of the bladder have been so much looked upon 
 as a 7iole me tajigere, that it may be instructive to note what 
 has been done and what may be done in this department 
 of surgery. The following is a concise resume of the 
 operations that have been performed for the removal of 
 tumors from the bladder, up to the present time. They 
 are mentioned m a chronological order as regards females 
 and males respectively, and will serve to show the various 
 methods and manoeuvres that have been successfully em- 
 ployed. 
 
 Operations Performed on Females. 
 
 1750. The first operation we can find on record for the 
 rem.oval of a tumor from the bladder was performed by 
 Warner in 1750. The subject was a woman aged twenty- 
 three. On June 24th, after lifting a great weight, she was 
 seized with pain in the back, and afterwards, retention of 
 urine which lasted until the 29th, when she was relieved 
 by catheterization. Nearly three years afterward she 
 appHed to Mr. Warner and stated that she had never been 
 able, from the moment of the accident, to void a drop of 
 urine without the assistance of a catheter, and she had 
 often lost blood in considerable quantities. A polypus of 
 some size projected into, and sometimes at the external 
 orifice of the urethra. An incision was made in the left 
 
54 TUMORS OF THE BLADDER. 
 
 side of the urethra about half way to the bladder, 
 the mass drawn forward by a thread previously passed 
 through it, and a ligature applied to its base which was 
 very broad. On the sixth day the tumor, which is given 
 as the size of a turkey'^ egg, came away, and the patient 
 recovered perfectly. 
 
 1823. In Howship's work on the urine, of this date, a 
 case is related of a fungous tumor of the bladder which a 
 French surgeon, M. Le Cat, attempted to remove. He 
 cut into the bladder, and with his forceps pulled away and 
 crushed several fungi at two different sittings. The wo- 
 man died in two days after the second operation. 
 
 1834. Pleininger removed from a female, aet. two and 
 three-fourth years, a strawberry-like mass which projected 
 into the urethra. The canal was dilated and the mass re- 
 moved by ligature. Further examination by rectum and 
 by sound revealed the presence of other tumors, but no 
 further operative attempt was made. The child became 
 emaciated and finally died of peritonitis. Autopsy re- 
 vealed numerousflocculent excrescences over the base and 
 posterior surface of the viscus and also others of a cartila- 
 ginous consistence and of the size of an almond. 
 
 1844. Theinemann. Female, aet. forty-five, a tumor, the 
 size of a hen's egg, with a pedicle one-third of an inch 
 thick, was followed into the bladder by the urethra which 
 had already been sufficiently dilated by the tumor, and a 
 ligature was thrown around the pedicle by means of two 
 elastic catheters and then, with a proper canula, constricted 
 it as far within the bladder as he could reach. On the 
 third day, the ligature was tightened, and on the sixth day 
 the polypus fell off and the patient recovered completely. 
 1846. Guillon is said to have removed from the bladder 
 of a female a pediculated growth seated at the vesical 
 neck, by carrying a silver wire around it by means of a 
 slightly bent catheter. 
 
 1858. Birkett applied a strong silk ligature around the 
 
TUMORS OF THE BLADDER. 65 
 
 root of a polypus which protruded from the urethra of a 
 child five years old. She was very weak, and a few days 
 after the tumor sloughed, considerable pyrexia supervened, 
 and she died. A number of polypi were found in the blad- 
 der. 
 
 1859. Senftleben attempted the extirpation of a sarcoma 
 through the urethra, which had already been dilated by 
 the tumor large enough to admit the index finger. An 
 attempt was made to seize the base of the tumor with for- 
 ceps and draw it out; this, however, did not succeed, and 
 because of the great friability of the tumor it had to be 
 removed piecemeal ; its broad base, however, could not be 
 so removed. The hemorrhage was very insignificant. 
 Patient died on the fourth day after the operation from 
 purulent peritonitis. On examination there was found on 
 the right side of the fundus a perforation large enough to 
 admit the index finger; this was made during the at- 
 tempt at extirpation. 
 
 1864. Bryant, in the British Medical Journal, May, 1879, 
 says that, fifteen years before, he removed a growth from 
 the bladder of a female with the ecraseur, and the patient 
 was still quite well eight years afterwards. 
 
 1864. Morris, in the same journal, refers to a female, ast. 
 fifty-six, from whom he took away a large growth with 
 the ecraseur ; all the immediate symptoms were relieved, 
 though she died eventually of hydronephrosis. 
 
 1868. May. Braxton Hicks. Female, ast. sixty. The 
 urethra was dilated ; the finger passed, and a caulifiower- 
 like mass, the size of a small orange, was found attached to 
 the posterior wall of the bladder, as much of the mass as 
 could with safety be removed was taken away by the for- 
 ceps, and with the wire-rope ecraseur. This had the effect of 
 restraining the bleeding and other symptoms. Six months 
 afterwards, however, the bladder became more irritable 
 and the urine bloody ; the urethra was again dilated and 
 S 
 
56 TUMORS OF THE BLADDER. 
 
 the tumor found not to hav^e recov^ered its original size ; a 
 strong- solution of tannin was applied with benefit. 
 
 1868. June. Guerssant. Female child, set. twenty- 
 two months. A small tumor, like a nut, projected from the 
 urethra, it was seized,/drawn forwards, and a metallic 
 thread was passed as far as possible round the neck of it, 
 after gaining access to it by dividing the urethra with the 
 scissors. The thread was gradually and slowly tightened 
 by a serre-noeud, but broke before the tumor was separated, 
 so the operation had to be finished by the ecraseur. The 
 child gradually lost strength, and though the bladder 
 symptoms improved, the soft parts became inflamed and 
 there was sloughing. Diarrhoea supervened, and she died 
 exhausted on the eighth day. 
 
 1869. A. R. Jackson. Female, set. iovty. Fibrous po- 
 lypus. December, 1869. A sponge-tent was introduced 
 and left in four hours, after which, the finger being intro- 
 duced, a tolerably dense mass with a smooth surface was 
 felt occupying the lower part of the bladder and pressing 
 against and somewhat into the vesical orifice of the ure- 
 thra. A larger tent was introduced and the husband in- 
 structed to remove it in four hours, and should tumor 
 again appear to secure it against return. On withdrawal 
 of the tent, the tumor appeared, it was seized with the 
 forceps and fingers, but in making traction it broke off in 
 the urethra. The portion removed was a fleshy-looking 
 imass about the thickness and nearly the length of a finger. 
 Two days after, the tent was again introduced, the tumor 
 r.appeared at the urethral orifice, it was grasped and drawn 
 •out about two inches and by twisting it like a rope, a por- 
 tion of growth eight inches long and of the thickness of the 
 ttbumb was removed. Very little bleeding attended the 
 operation. Several fragments came away during four or 
 five days succeding. April 30th, 1870, patient fully regained 
 general health and the incontinence from which she had 
 been suffering since the operation was improving. (The 
 
TUMORS OF THE BLADDER. 6/ 
 
 incontinence was no doubt occasioned by the slow method 
 which was adopted in dilating the urethra.) 
 
 1869. Simon. Female, aet. seventy; urethra dilated, 
 finger discovered a pediculated villous growth behind the 
 urethra, the most accessible portion of the tumor was 
 seized and twisted off by forceps, while its infiltrated base 
 was scooped out with a sharp spoon. The reaction was 
 insignificant, although the lesion to the vesical mucous 
 membrane must have been considerable. Patient left the 
 bed on the fourth day and remained perfectly well five 
 years afterward. 
 
 1869. Winckel. Female, set. thirty-nine. Urethra di- 
 lated with index of left hand, near the orifice of right 
 ureter was felt a large movable soft villous growth, small 
 pieces of which were detached bv the movements of 
 the finger. After this, the bladder was injected with 
 -about one hundred and fifty grammes of warm water, 
 and by means of the finger and forceps all appreciable 
 prominences were removed from the posterior wall of the 
 bladder. The sphincter contracted in such a manner that 
 after withdrawal of the finger none of the injected fluid 
 escaped. Patient made a complete recovery ; saw her two 
 years after the operation and there was no sign of a re- 
 lapse. 
 
 1872. C. S. Bishop (related by Gross, Surgery, second 
 edition). Female, set. fifty-six ; removed a cyUndrical 
 vascular polyp nearly three inches long ; it had a globalar 
 head eight lines in diameter, and was attached by a narrow 
 pedicle to the bas fond of the bladder. Finding a portion 
 of tumor projecting from meatus, he ligated it. The next 
 day applied a silver wire around its neck, and at the expi- 
 ration of forty-eight hours he removed the mass by rotat- 
 ing a double canula upon its axis. 
 
 1874. Simon. Female, ^t. 40 ; had urethra dilated sev- 
 eral times, and small portions of tumor twisted off by for- 
 ceps. Two vears after first discovery of tumor, patient 
 
58 TUMORS OF THE BLADDER. 
 
 came to Simon, who, April 14th, dilated the urethra, and 
 found that two-thirds of the bladder was occupied by a 
 tumor. With a sharp spoon he scooped out and removed 
 a large portion of the growth. In the course of about an 
 hour and a half, the spopn was introduced into the bladder 
 about twenty times, and the scraping made under the 
 guidance of the finger. Patient had only a little pain 
 after the operation and perfect continence of urine. The 
 bladder was washed out with luke-warm water daily. 
 The urine soon acquired an acid reaction, and in five days 
 patient left the bed. On April 28th, the operation was 
 repeated, and again considerable portion of tumor re- 
 moved. Eight weeks after the first operation, when the 
 patient left the hospital, there were no papillary promi- 
 nences apparent to the touch, but at the place where the 
 tumor had been, there was felt an uneven, rather hard sur- 
 face, covered with mucous membrane. The urine was 
 acid ; the bladder pains had disappeared ; could hold 
 water five hours, and the general condition of the patient 
 was excellent. This case is especially interesting as show- 
 ing what can be done even with very large and sessil'^' 
 tumors of the bladder. 
 
 1874. Simon. Female, set. 44. July ; urethra dilated ; all 
 over the internal surface of bladder, as far as finger could 
 reach, there were warty or papillar}' projections. A sharp 
 spoon was introduced, and as much as possible of the new- 
 formation removed. The patient was quite well after the 
 operation, and in the middle of August the symptoms were 
 much better. But, he adds, the next time she will have to 
 submit to an operation through the vesico-vaginal septum. 
 
 1873 to 1876. Schatz. Female, set. 18. The posterior 
 three-fourths of the urethra was found dilated to the dia- 
 meter of the fmger, by the projection from the bladder of 
 a tumor the size of a goose's egg. The tumor had its ori. 
 gin by a pedicle of about four centimetres in thickness 
 from the right antero-lateral wall, one to two centimetres 
 
TUMORS OF THE BLADDER. gg 
 
 above sphincter. So much of the tumor as could be 
 reached was removed by the ecraseur, and the remainder 
 separated in smaller portions by means of the finger. 
 Patient recovered, and had no trouble for about a year. 
 In August, 1874, she returned with about the same symp- 
 toms as at first, and the operation with the ecraseur was 
 repeated. She was up in a few days. December, 1875, 
 gave birth to a child. January loth, 1876, found that the 
 tumor had not grown much beyond the size of a hazel-nut. 
 January 20th, incised the right side of the urethra, and in- 
 verted the posterior wall of the bladder with the tumor 
 through the urethra by means of several threads previ- 
 ously passed through the tumor from the vagina, and after 
 cutting out the growth in two portions, united the edges 
 of the wound with ten silk sutures. Although during the 
 operation the urethra was dilated to the extent admitting 
 two fingers, the patient retained her water one hour after 
 the operation, and, afterwards, two and three hours ; from 
 the seventh day she micturated once at night and twice 
 during the day. There was pain only on the first day dur- 
 ing micturition. The patient recovered rapidly. Micro- 
 scopic examination found the tumor to be a benign myxo- 
 ma. 
 
 1876 to 1878. Wm. Alexander. Female, set. 44. The ure- 
 thra was in such relaxed condition that the finger could be 
 inserted into the bladder without the infliction of much 
 pain. The floor of the viscus was extremely rough and 
 irregular. These irregularities were of various heights ; 
 a few were as much as a quarter of an inch from base to 
 apex, and one seemed to be nearly an inch in height. This 
 large one, on the left side of the bladder, had a rounded, 
 enlarged apex ; the apices of the others were thin and 
 pointed. July, 1876, the urethra was dilated with an anal 
 speculum ; the wire of an ecraseur was passed around the 
 Taase of the largest growth, and the same cut through ; in 
 trying to get it out, others were displaced from their place 
 
70 TUMORS OF THE BLADDER. 
 
 of growth by the movements of the finger, and all nodules 
 that could be felt were scraped off with the finger-nail, and 
 the bladder washed out with a weak solution of perchloride 
 of iron. There was not an excessive amount of hemor- 
 rhage during the operatipn, but the urine contained a good- 
 deal of blood for the first week. She had incontinence of 
 urine for two days only, during which scraps of the tumor 
 came away. There were about two dozen small growths 
 removed, and five or six growths were lost. The patient 
 soon resumed her work as cook in a very good condition. 
 In October, 1877, she had a relapse. Numerous soft 
 growths were felt upon and beyond the trigone; about a 
 dozen small arborescent growths were easily removed by 
 the finger-nail, and several small growths came away the 
 same evening. October 19th, urine was perfectly clear; 
 pain on micturition was almost gone ; health was good, and 
 system well nourished. May, 1878, agam removed a large 
 mass of growths. Recovery was more rapid and more 
 perfect than on either of the previous occasions, and the 
 urine has continued clear ever since, August 17th, 1878. 
 
 1879. Christopher Heath. Female, a2t. 3-9. Urethra 
 was dilated with a four-bladed dilator and the finger. 
 Right side of bladder was occupied by a villous growth, 
 situated on a hardened base. Some of the growth was 
 torn away (villous sarcoma). Patient died May 25th, from 
 general exhaustion. 
 
 1879. Godson. Female, set. sixty. A polypus the size 
 of a walnut was found protruding from the urethra and 
 connected with a narrow pedicle with the fundus of the 
 bladder, which viscus was partially inverted. Catgut liga- 
 ture was applied and the tumor separated with scissors. 
 
 1879. Incision Urethro-Vaginal Septum. A. T. Norton. 
 Female, ast. thirty, January 3d, 1879. Dilated urethra with 
 the finger and discovered a papilloma, in size about one 
 square inch and coated with phosphates, not much raised 
 above the mucous surface, but very hard, and situated oa 
 
TUMORS OF THE BLADDER. 71 
 
 the trigone about half an inch from the sphincter. It was 
 impossible to remove the growth through the urethra. 
 The spring scissors were inserted, one blade into the bladder 
 nearly up to the tumor and the other into the vagina, and 
 closed ; the front wall of the vagina was then incised cen- 
 trall}^ to within half an inch of the uterus. The vagina 
 which was not incorporated in the growth was dissected 
 from the bladder, the growth was seized with the vulsel- 
 lum forceps, drawn forwards, and excised with the scissors. 
 Bleeding was arrested by the actual cautery and the lateral 
 flaps of the vagina were approximated by sutures. No 
 hemorrhage of importance took place. The temperature 
 remained below normal and the pulse rose to one hundred 
 and twenty. Severe vomiting was persistent until the 
 tenth day after the operation. After the tenth day, she 
 was considered out of danger, was making good progress, 
 took food well, and was cheerful. On the twelfth day, 
 when apparently in health, she vomited, and shortly after- 
 ward fell asleep, in which sleep she died from syncope at 
 a time when she was recovering from the operation. 
 
 1879. ^^^- Norton says that soon after the above experi- 
 ence he had an opportunity of operating a second time, in 
 a similar manner, without any untoward symptom. Tumor 
 was situated on the front wall of the bladder ; it was one 
 inch long, one-half inch wide, and three-quarter inch above 
 the level of the mucous membrane. It did not infiltrate 
 the tissues of the bladder. Structure, fringed papilloma. 
 The opening in the bladder was allowed to remain for a 
 month and then it was closed by the ordinary method. 
 
 Operations Performed on Males. 
 1827. Civiale, while manipulating with his trilabe with 
 a view of removing a calculus from the bladder, acciden- 
 tally tore away a soft, pedunculated mass about the size 
 of a pea. This accident at first gave him some uneasiness 
 as to the possible result ; but no untoward symptom 
 
j2 TUMORS OF THE BLADDER. 
 
 appearing, he conceived the idea of having recourse to 
 this manoeuvre for the removal of small growths at the 
 neck of the bladder, which he put into successful practice 
 in several cases. In a man aged seventy, he used the 
 trilabe three times, at intervals of*some days, each time 
 taking away a small portion until he had removed a mass 
 the size of a large walnut. The man died three months 
 afterward from typhoid fever. The method of operating, 
 as recommended by Civiale, consists in opening the instru- 
 ment in the bladder, drawing it forward as far as possible 
 so that the blades of the same lie in contact with the vesi- 
 cal neck, when by turning the instrument from side to side 
 the excrescences fall between its blades and are crushed. 
 In a few days the necrosed portion is carried off with the 
 urine. 
 
 Covillard (Obs. latro-chir. p. 93, mentioned by Crosse) 
 performed cystotomy for a tumor in the bladder the size 
 of a nut. " Je la mouchait avec les tenettes, ceque reussit 
 de sorte qu'en moins de huit ou dix jours, la dite tumeur 
 termin'a par suppuration," and in a month the patient was 
 convalescent. 
 
 1830. Perineal Cystotomy. Dessault. Chopart mentions 
 a man at the I'Hotel Dieu, from whom D. extracted a cal- 
 culus, and afterwards finding a pediculated growth, he 
 seized it and twisted it off. There was no hemorrhage, 
 and the patient left the hospital perfectly cured. 
 
 1834. Crosse performed perineal cystotomy for the re- 
 moval of a villous growth, upon a male child two years 
 old. On removing the knife after the necessary incisions 
 were made, a mass of tumors, connected together like a 
 bunch of grapes, and resembling in appearance and struc- 
 ture ordinary nasal pol3^pi, protruded through the wound ; 
 as many of these as were accessible were cut off, but upon 
 introducing the finger into the bladder, it was found that 
 much of the diseased mass remained attached by a broad 
 base, and it was not deemed advisable to make any further 
 
TUMORS OF THE BLADDER. 73 
 
 attempt for its removal. After forty-four hours of inces- 
 sant suffering, the child died. 
 
 1 87 1. Gersuny attempted to remove a tumor from a man 
 aged forty-nine, by perineal cystotomy, but the growth 
 was beyond reach in a diverticulum, and the operation 
 failed. The day following, the patient felt better than be- 
 fore the operation, and afterward made no complaint of 
 any kind, but refusing all nourishment, he gradually be- 
 came exhausted, and died after the sixth day. 
 
 1874. Perineal and Supra-pubic Cystotomy. Billroth. 
 Boy, £et. twelve. Lateral incision was made ; finger intro- 
 duced into bladder, and a tumor found nearly the size of 
 the fist, with an uneven surface projecting from the pos- 
 terior wall and extending towards the top of the bladder. 
 Owing to its size, it was impossible to extract tumor 
 through the perinseum. A supra-pubic incision Avas made 
 without injury to peritonseum, and to give sufficient room 
 both recti muscles were cut across at their insertion ; a 
 transverse incision was also made into the Bladder. Bill- 
 roth found that the use of the ecraseur was not practica- 
 ble, and decided to tear the tumor with his finger-nail 
 near its base, and to cut out the remainder from the wall 
 of the bladder, after passing a ligature around to check 
 the bleeding. In dissecting out the pedicle, it was found 
 that the tumor took its origin from the muscular coat. 
 Two arteries were tied, and the ligatures brought out 
 through the upper incision. The wound in the bladder 
 was not closed, but a drainage tube was drawn through 
 the bladder and brought out at the perineal incision. On 
 the fifth day, the wound -was granulating freely, and there 
 being no more danger of infiltration, the drainage-tube 
 was removed. In thirty-four days, the wound had closed, 
 and the patient was discharged cured. Tumor is seen at 
 Plate ix. 
 
 1874. Perineal and Epicystotomy. Volkmann. Male, set. 
 fifty-four. Membranous urethra was opened on the raphe 
 
y. TUMORS OF THE BLADDER. 
 
 of the perineum, and the finger passed into the bladder. A 
 tumor was found, of the consistence of a uterine polypus, 
 and about the size of a lemon, attached by a pedicle to 
 vertex of bladder. Epicystotomy was now made, the 
 bladder being opened by incision one and one-quarter 
 to one and one-half inches long, made on the finger, passed 
 through the perineal wound. Peritonseum not visible ; 
 the tumor appeared at once, its surface covered with 
 dilated veins, and on scratching through the pedicle, which 
 was of the size of the little finger, the growth was removed 
 by traction with forceps, assisted by pressure from the 
 rectum. The wound in the bladder and abdominal walls, 
 after washing with carbolized water, were closed with su- 
 tures ; the whole abdomen enveloped in carbolized gauze, 
 and a drainage-tube placed in the perineal wound. The 
 following day, abdomen became tender ; peritonitis devel- 
 oped, and death ensued on the third day after operation. 
 Autopsy revealed peritonitis, diffuse purulent infiltration 
 of subserous areolar tissue of abdominal wall ; muscular 
 coat of bladder moderately hypertrophied ; mucous mem- 
 brane swollen, showing a number of old and recent ecchy- 
 moses, but otherwise healthy. At the situation of the 
 pedicle, which is four lines long, the muscular coat is 
 exposed on the posterior wall. Volkmann beheves the 
 extravasations of blood to have been caused by the rectal 
 explorations. No sign of inflammation about the inci- 
 sions. The size and form of the tumor is represented at 
 Plate X. 
 
 1874. Kocher. Male, ast. thirty-four. Began to suffer 
 in the spring of 1874, with a constant desire to micturate 
 and incontinence. In June, these symptoms changed to a 
 violent burning pain and increased desire to pass water. 
 Urine of intolerable odor, and contains blood and pus. 
 A piece of tumor which came out proved to be a papillary 
 growth. December 31st, urethra was opened by a T- 
 shaped incision. A vertical cut in the mesial line and a 
 
TUMORS OF THE BLADDER. j c 
 
 horizontal one, after Nelaton's pre-rectal method. The 
 urethra was opened on a grooved staff and the finger 
 introduced into the bladder. On its posterior wall was felt 
 the soft, tufted, fungoid mass of the new-growth ; a large 
 sharp scoop, bent at an angle, was introduced against the 
 finger, whereby it was forcibly scraped off. The hemor- 
 rhage was pre tty severe, but was arrested by cold water 
 injections. No dressing was applied. The wound healed 
 in six weeks, and in fifteen months the patient was consid 
 ered as quite cured. 
 
 1877. Humphry. Male, ast. twenty -one. A mass could 
 be felt in the bladder above and behind the pubes. Suf. 
 fering being extreme, made an incision into the bladder as 
 for lateral lithotomy, and found a firmish tumor, with a 
 ragged surface, attached by a pedicle to near the orifice of 
 right ureter. Partly by finger and partly by forceps, the 
 pedicle was torn through, and the tumor was extracted 
 with lithotomy forceps. The root of the pedicle was 
 scraped out with the finger-nail. After a day of compar- 
 ative ease, the pain returned with great severity, requiring 
 the subcutaneous injections of morphia, which had to be 
 increased to large doses, and continued for more than two 
 months. Then the pain diminished and gradually sub- 
 sided. The wound healed, and the patient completely 
 recovered, and was quite well eighteen months after the 
 operation. 
 
 1880. Davies-CoUey. Male, 2et. thirty-two. Opened 
 the bladder by the usual incision for lateral lithotomy. 
 At first nothing could be felt. Then a slight projection 
 was made out on the left side of the fundus, and a cord- 
 like process running from it. In a short time the free end 
 of this process, with a soft pinkish tuft of villi attached to 
 it, was seen at the deeper part of the wound. This was 
 seized with the forceps, drawn out, and the pedicle cut 
 with a pair of scissors close to the wall of the bladder. 
 No other growth could be felt. There was but little 
 
y5 TUMORS OF THE BLADDER. 
 
 hemorrhage during- the operation, and some which oc- 
 curred in the evening was readily arrested by the injection 
 of iced water into the bladder. He made a rapid recov- 
 ery. In two weeks, the urine ceased to flow from the pe- 
 rinceum, and soon after>vards the wound healed. When 
 last seen, two months after the operation, there had been 
 no return of the hemorrhage. The irritability of the blad- 
 der had ceased, and he was in the enjoyment of perfect 
 health. The tumor grew from the posterior wall of the 
 bladder, at a point about three inches from its neck, 
 and one inch to the left of the middle line. It consisted 
 of a fibrous stalk, one-sixth of an inch thick and two inches 
 long, and terminated by branching filaments from half an 
 inch to three-quarters of an inch long. These filaments 
 contained capillary loops, invested by many layers of 
 epithelium of a cylindrical shape. 
 
 1880. Supra-pubic Cystotomy. Marcacci. Male, set. 
 fifty-four. An incision thirteen centimetres in length was 
 made, commencing one centimetre above the upper mar- 
 gin of the symphysis pubis, and extending through the 
 linea alba. The bladder was found to be enormously dis- 
 tended, its whole interior being filled with a large neoplas- 
 tic mass ; this was removed. The wound in the bladder 
 was brought together with four catgut sutures ; that in 
 the abdomen with interrupted metallic sutures, and the 
 whole dressed antiseptically. The patient progressed 
 favorably during the first ten days, when, on the removal 
 of the metallic sutures, the wound being apparently healed, 
 a few drops of urine escaped from the openings where the 
 sutures had been. All attempts to cure these urinary fis- 
 tulce failed. Patient died within two months after the 
 operation from extravasation of urine, pelvic abscess, and 
 peritonitis. M. considers that the cause of death was due 
 to the too early absorption and destruction of the catgut 
 sutures, which probably lost their holding power before 
 the wound in the bladder had become consolidated. 
 
TUMORS OF THE BLADDER. 
 
 n 
 
 1880. Berkeley Hill. Male, set. sixty-three. Not with 
 any expectation of effecting- a cure, but of affording relief, 
 the lateral incision as for stone was made, the finger 
 introduced, and a soft mass, about as large as a marble, 
 projecting from the floor of the bladder on the right side, 
 was brought away in a lithotomy forceps. By free injec- 
 tions of cold water, several such masses were washed out 
 along with much stinking pus and mucus. The patient 
 was but little relieved by the operation, and death oc- 
 curred on the third day from exhaustion, consequent on 
 the irritation of bladder and from cachexia of a malignant 
 tumor, which was found in the bladder after death. 
 
 Perhaps not altogether irrevelant to the operations 
 above recorded is one performed by Liston (related by 
 Robt. Knox, M.D., Lon. Med. Times anei Gaz., August 2d, 
 1862), for the removal of a cyst from the bladder of a man 
 suffering with difficulty in discharging his urine. Liston 
 passed a catheter and felt a soft, yielding but obstructing . 
 body in the prostatic portion of the urethra. This readily 
 gave way before the catheter, which then passed into the 
 bladder, but on being withdrawn it was followed by the 
 foreign body, which immediately reoccupied its former 
 position. Liston opened the bladder above the pubes, 
 and as the incision was made, there escaped from the 
 bladder a body resembling a cyst or false membrane of 
 the shape of the interior of the bladder. The wound was 
 closed, the patient recovered and lived for some time. 
 
 From the foregoing we learn that thirty-four operations 
 have been performed for the removal of tumors from the 
 bladder : twenty-three upon females and eleven upon 
 males. 
 
 In seventeen of the former, the growths were removed 
 through the urethra by previous bloodless dilatation of 
 the canal, and in six by incision of the urethra or of the 
 vesico-vaginal septum. The subjects varied in age from 
 twenty-two months, two and three-quarter and five years 
 
78 TUMORS OF THE BLADDER. 
 
 to seventy years. The growths removed have included 
 papillomata, myxomata, myomata, and sarcomata. The 
 tumors have been removed by simple torsion and avulsion, 
 by ligature, silk, and catgut, silver wire, bv ecraseur and 
 by scooping, out with a sharp spoon. Excepting the method 
 of scooping, in which the hemorrhage is sometimes consid- 
 erable, the loss of blood in the other operations was insigni- 
 ficant. Of the seventeen patients from whom the growths 
 were removed by urethral dilatation, ten recovered. In 
 this number we include the cases of Guillen, Bishop, and 
 Godson, in which, although the result is not absolutely 
 stated, the phraseology is such that there can be little 
 doubt as to their successful termination. Two cases are 
 reported as much improved bv the operation and five ter- 
 minated fatally. After the six cutting operations, three re- 
 covered and three died. We thus find, after both opera- 
 tions, a total of thirteen recovered, two improved and eight 
 died. 
 
 Let us now examine to what degree, in the fatal cases, 
 the operations may be regarded as having been the imme- 
 diate cause of death. In the patient of Le Cat we have no 
 data other than that she died in two days after the second 
 operation. In Heath's case, a portion of sarcoma was torn 
 away and the patient died a month after, from general ex- 
 haustion. In the case of Morris, the patient improved by 
 the operation, but died eventually, he does not say when, 
 evidently at some remote period, from hydronephrosis. 
 In Guerssant's child, aged twentj^-two months, the bladder 
 symptoms improved, but the child weakened, had diarrhoea, 
 and died exhausted on the eighth day. Norton's patient 
 died on the twelfth day when apparently in health ; she 
 vomited, and shortly afterwards fell asleep in which sleep 
 she died from syncope at the time when she was recover- 
 ing from the operation. 
 
 In these four cases, certainly it cannot be said that the 
 operation caused or precipitated the fatal termination. 
 
TUMORS OF THE BLADDER. p^g 
 
 Neither is this at all evident in the patients of Pleininger 
 and Birkett ; both of those were children, aged respectively 
 two and three-quarters and five years. The first little suf- 
 ferer remained unrelieved by the operation, because nu- 
 merous growths were left behind. " She became emaciated 
 and finally died of peritonitis." It does not appear how 
 soon after the operation death ensued, but from the lan- 
 guage we may reasonably infer that the peritonitis had no 
 connection with the operation. The other patient was a 
 very weakly child, and a few days after the tumor came 
 away, considerable pyrexia supervened and she died. It 
 may, therefore, be said that in but one of the eight fatal 
 cases in the female can the operation be positively held as 
 the immediate cause of death. In this case (Senftleben), 
 the bladder was perforated during the attempted removal 
 of a sarcoma, and the patient died on the fourth day from 
 purulent peritonitis. 
 
 With regard to the size and character of the growths 
 that may be successfully removed through the urethra, 
 some are given as the size of a goose's egg, turkey's egg, 
 etc., which have been removed by ligature, ecraseur, etc. 
 But the most noteworthy operation, as showing what can 
 be done even in the least promising of cases, is that of 
 Simon, who successfully scooped out from the walls of the 
 bladder a sessile tumor that had occupied two-thirds of 
 the cavity of that viscus. 
 
 The male bladder has been opened for the removal of 
 tumors eleven times : eight times through the perinasum, 
 including in this enumeration Covillard's operation, about 
 the precise nature of which, however, we have no data ; 
 twice jointly through the peringeum and above the pubes, 
 and once above the pubes only (not including Liston's 
 successful removal of a cyst). Of these eleven opera- 
 tions, six proved successful and five fatal. Of the success- 
 ful cases, five recovered after perineal cystotomy and one 
 after both perineal and supra-pubic cystotomy. Of the 
 
3o TUMORS OF THE BLADDER. 
 
 deaths, three occurred after perineal cystotomy, one after 
 both perineal and supra-pubic cystotomy, and one after 
 supra-pubic cystotomy. The ages of the subjects operated 
 upon varied from two to sixty-three years. 
 
 These statistics would show apparently a mortality of 
 nearly fifty per cent, but a more careful examination will 
 show that such a percentage of deaths is probably much 
 in excess of what may be expected. In the first place, the 
 case of Hill cannot be included in the results, as militating 
 against the operation, for this was not done with any idea 
 of effecting a cure, but simply as a palliative measure, 
 with the hope of affording temporary relief from intense 
 suffering due to malignant disease in a subject sixty-three 
 years old, alreadv worn out and cachectic. The case of 
 Gersuny was very exceptional in that the tumor was 
 inclosed in a diverticulum of the bladder and was alto- 
 gether bej'ond reach. Besides, the tumor had been of so 
 long standing that it had given rise to other serious changes 
 in the vesical walls, which, even m the event of the suc- 
 cessful removal of the tumor, would have rendered recov- 
 er}" impossible (see Plate iv., Fig. i). In the child of Crosse, 
 the growths were but partially removed, hence recovery 
 could not have been expected. In the cases of Volkmann 
 and Marcacci, the cause of death was the imperfect closure 
 of the vesical wound. In both, the w^ound in the bladder 
 and abdomen was closed with sutures. In the first case, 
 death occurred on the third day from peritonitis and dif- 
 fuse purulent infiltration of subserous areolar tissue. In 
 the latter, the vesical wound was brought together with 
 catgut ligatures, and the abdominal wound with metallic 
 sutures. Patient did well at first, but died within two 
 mionths from extravasation of urine, pelvic abscess and 
 peritonitis, because, as Marcacci thinks, of the too early 
 absorption and destruction of the catgut sutures, which 
 probably lost their holding power before the union of the 
 wound in the bladder had become firmly established. The 
 
TUMORS OF THE BLADDER. gl 
 
 question might here be asked, if, when the imperfect 
 closure of the bladder was first manifest by the appearance 
 of the supra-pubic urinary fistula, the fatal complications 
 might not have been averted had the bladder been 
 opened in perinseum. 
 
 In this connection, it may also be noted that a 
 number of post-mortem examinations indicate that the 
 cases of successful removal of tumors from the bladder 
 might have been multiplied by an early operation. In 
 some cases, the bladder has been actually opened and 
 yet no attempts were made for the removal of an existing 
 tumor. Perhaps the earliest example of this is recorded 
 of Petit, of whom it is said that, although he did not re, 
 move the polypus, the operation of opening the bladder 
 was not attended with any bad result, and a year after- 
 wards, on post-mortem examination, it was discovered that 
 there was a polypus the size of a fist in the bladder, of a 
 pyramidal figure and attached by a very delicate pedicle. 
 Although this man, aged twenty-eight, is said to have died 
 of phthisis, there is probably little doubt that his life would 
 have been prolonged by the removal of the growth which 
 apparently could have been most easily accomplished. 
 Gross alludes to two operations for stone, one Deschamp's, 
 the other his own, in which the calculi were extracted, but 
 the neoplasms which were afterwards found were not in- 
 terfered with. He does not say why, but speaks of his 
 own case as a tumor situated on the anterior wall of the 
 bladder, lobulated and sessile. From a reference to the 
 histories and drawings given of several of our cases, such as 
 those of Springall, Barton and Hudson, in which for some 
 reasons no operation was attempted, it will be seen that 
 the removal of the growths could have been most easily 
 accomplished, and, as it would seem, with every prospect 
 of success. 
 
 The foregoing citation of the various methods adopted 
 for the removal of tumors from the bladder leaves 
 6 
 
82 
 
 TUMORS OF THE BLADDER. 
 
 little more to be said in regard to treatment. The 
 choice of an operation, however, will depend upon the 
 seat, nature, and size of the growth. In the female, owing 
 to the shortness and dilatability of the urethra, tumors 
 
 may be removed by this channel 
 with comparative ease and safety. 
 The urethra being dilated in the 
 manner already laid down, the left 
 index introduced and the tumor 
 recognized, a long, slender pair of 
 forceps or scissors may be guided 
 along the finger to the pedicle of 
 the growth, and the same twisted 
 off or cut away. Fig. i represents 
 the forceps used by Simon for this 
 purpose. They are very long, 
 S-shaped (A), and their branches 
 are scissors-like, either toothed (^), 
 or with a smooth edge (c). If the 
 tumor is not removed in this way, 
 it may be treated by ecrasement, 
 or ligature, as may be deemed 
 most expedient. Sessile or flat 
 growths may be extirpated by the 
 knife, or by means of sharp spoons 
 especially constructed for the pur- 
 pose. The instrument so success- 
 fully employed by Simon is de- 
 picted at Fig. 2. It is long 
 j'iG. I. Fig. 2. handled; A, the edge, is very sharp, 
 
 and the spoon is bent at a right 
 angle to the handle, <5 and c. The growth is scraped or cut 
 away by pressing the part to be taken off against the 
 edge of the spoon with the finger. This operation is 
 always attended with prett}' free hemorrhage ; but this 
 maybe kept under control by means of iced water, injected 
 
TUMORS OF THE BLADDER. 83 
 
 into the bladder, or the application of a pledget of lint 
 soaked in perchloride of iron to the base of the tumor, 
 and the bladder afterwards washed. 
 
 If the tumor is not accessible, or is too large to admit of 
 removal after bloodless dilatation of the urethra, the canal 
 may be further enlarged and shortened by incision. This 
 was done successfully, as we have seen, by Warner, who 
 divided the left wall of the urethra half-way to the blad- 
 der, and also by Schatz, who incised the right side of the 
 urethra and inverted the posterior wall of the bladder 
 with the tumor through the urethra by means of several 
 threads previously passed through the tumor from the 
 vagina. 
 
 If lateral incision of the urethra is not made, the tumor 
 may be reached by kolpo-cystotomy. In regard to this 
 operation, Simon recommends that the incision through 
 the vagino-vesical septum should be T-shaped. He says 
 that by a long incision through the whole length of the 
 urethra to the mouth of the uterus the bladder cannot at 
 all, or but very little be introverted. The inversion of the 
 vertex and the upper part of the fundus, however, is 
 obtained after a transverse incision of three centimetres 
 in length into the anterior wall of the vagina, one-quarter 
 to one-half centimetres in front of the anterior lip of the 
 OS uteri; and, still better, when, besides the transverse 
 incision, a second one is made at right angles directly 
 toward the urethra, so that a T-shaped incision results. 
 By the exercise of some traction in the direction of the 
 vagina with a fine double hook inserted into the mucous 
 lining of the bladder, and a simultaneous pressure over 
 the hypogastrium, the interior of the bladder is made so 
 completely accessible by inversion, that the most compli- 
 cated and most difficult operation can be performed with 
 the same facility as on the surface of the body. The 
 tumors may be extirpated with scissors, knife, and even 
 the galvano-cautery can be used. After the internal wound 
 
34 TUMORS OF THE BLADDER. 
 
 has cicatrized, the vesico-vaginal incision may be closed 
 by the usual method. 
 
 In the male, the tumor ma}' be reached either through 
 the peringeum or from above the pubic symphysis. It 
 would scarcely be to4:he purpose now to institute a close 
 inquiry into the relative advantages and disadvantages 
 respectively of suprapubic and perineal cystotomy. For 
 the removal of tumors of the bladder, the selection of an 
 operation can rarely be a matter of choice, but must depend 
 upon the location, mode of attachment, and size of the 
 growth. The perineal operation will, perhaps, be more 
 frequently adopted; i, because of the usual seat of tu- 
 mors in the lower portion of the bladder, which, in the 
 absence of great hypertrophy of the prostate, are gen- 
 erally sufficiently accessible from this point, and, espe- 
 cially if pediculated, are easily enough removed ; 2, 
 because the operation itself is considered less hazardous 
 than is the opening of the bladder from above ; 3, 
 because, if after perineal cystotomy the tumor proves to 
 be inaccessible or too large to be thus removed, and supra- 
 pubic cystotomy is found necessary to reach it, the peri- 
 neal incision will not diminish, but rather increase the 
 chances of recovery, by affording free drainage for the 
 urine in the most depending position. It is said of Frere 
 Come (i 758-1 778), whose high operations for stone were 
 so successful that, in order to prevent urinary infiltra- 
 tion, he was in the habit, before performing epicystot- 
 omy, of opening the urethra in perinseum. The value of 
 perineal drainage was also appreciated by Civiale, who, 
 according to Bransby Cooper (Coulson, p. 476), while 
 engaged in the high operation for stone, accidentally 
 wounded the peritonseum, and fearing extravasation of 
 urine into the peritoneal cavit}', opened the bladder 
 through the perinseum, and the patient recovered. In 
 Billroth's case, the preliminary perineal incision proved 
 eminently satisfactory. 
 
TUMORS OF THE BLADDER. 85 
 
 Sometimes, however, the most available method of reach- 
 ing the tumor will be from above the pubes. In addition 
 to the freedom from hemorrhage, absence of danger of 
 wounding the rectum and ejaculator}^ ducts, etc., statistics 
 show that for calculi above two ounces in weight the 
 results after the high operation are m.ore favorable than 
 after lateral lithotomy — a fact which has an important 
 practical bearing on the possibilities of success in the 
 removal of tumors by the supra-pubic method. But 
 without further dwelling upon the relative advantages of 
 the two operations, the fact, that in the high operation the 
 parts are freely exposed to view, is an advantage which 
 must, in certain difficult cases, supersede every other con- 
 sideration. 
 
 Preparatory to the operation, the supra-pubic region is 
 to be shaved, the bladder, after being evacuated of urine, 
 is distended with, perhaps, a one-quarter per cent solution 
 of carbolic acid, and if necessary or desirable, the bladder 
 may be still further raised above the pubes by distending 
 the rectum with a colpeurynter or a few sponges. The 
 patient is placed in the recumbent posture, with the pelvis 
 elevated above the level of the loins and shoulders, so 
 that the abdominal viscera shall gravitate away from the 
 bladder. The surgeon, standing to the left of the patient, 
 makes an incision from three to four inches in length, com- 
 mencing immediately over the pubes, upwards in the 
 mesial line and down to the aponeurosis of the abdominal 
 muscles. The linea alba being exposed, this structure is 
 divided at the upper border of the pubes, sufficiently 
 to admit a grooved director upon which the linea alba and 
 fascia transversalis are slit up to the requisite extent, per- 
 haps one and a half or two inches. The bladder will now 
 be felt at the bottom of the wound as a soft fluctuatmg 
 tumor, still coA^ered, however, by areolar tissue, which 
 may be divided with a few touches of the knife or separated 
 with the handle of the scalpel ; but the areolar tissue con- 
 
85 TUMORS OF THE BLADDER. 
 
 nection between the bladder and symph3^sis should be lett 
 as much as possible intact, because it forms the best barrier 
 against the infiltration of urine or pus. The bladder being- 
 now fairly exposed, it should be secured by ligature or 
 transfixed by a tenacukim before it is opened ; otherwise, 
 when the incision is made it will collapse out of sight and 
 embarrass the surgeon in the succeeding steps of the 
 operation. The bladder being held in position, a vertical 
 incision is made, the margins of the vesical wound held 
 apart while the tumor is drawn out if possible, and removed 
 either by avulsion, ecraseur, knife, or galvano-cautery. 
 The incision in the bladder should be as small as possible, 
 but always clean cut and free enough for eas}^ access to 
 the growth, as stretching of the wound implies more or 
 less bruising or laceration which, when the edges are 
 brought together, will correspondingly interfere with the 
 union by first intention. If the external longitudinal inci- 
 sion affords too limited a field for operation, the wound 
 may be enlarged by two small, transverse cuts immedi- 
 ately above the pubes, without separating entirely the 
 insertion of the recti muscles. Billroth, in order to obtain 
 sufficient room, was obliged to divide both recti at their 
 insertion. But this is to be avoided, if possible, because 
 such wounds require a longer time to heal and are apt to 
 lead to the formation of abdominal hernia. 
 
 The dangers apprehended from supra-pubic cj^stotomy 
 are, wounding the peritonEeum, and urinar}' infiltration of 
 connective tissue. The danger of wounding the peritonae- 
 um is not so great as is generally supposed. Out of 478 
 cases of supra-pubic lithotomy collected by Dr. Dulles 
 {Amer. Jour. Med. 5^., July, 1875), in only 13 had this mem- 
 brane been wounded and of these 3 cases were fatal. Even 
 for the removal of large tumors, the bladder can be so dis- 
 tended as to present above the pubes, and opened without 
 endangering the peritonaeum. Garson {Edin. Med. Journ.y 
 Oct., 1 878) has shown that the bladder can be as easily raised 
 
TUMORS OF THE BLADDER. g? 
 
 above the symphysis by distending the rectum as by in- 
 jecting the bladder, and that, in case where it is not advis- 
 able to distend the bladder to a large size, distention of 
 the rectum by a colpeurynter is all that is required to 
 make the parts suitable for the operation. Petersen, of 
 Kiel, by numerous experiments, substantiates these ob- 
 servations, and finds that, with the bladder and rectum 
 moderately distended, the line of reduplication of the 
 peritongeum, as shown by measurements on the cadaver, is 
 thus displaced upward to the distance of about five and 
 one-half centimetres, and can thus be kept out of the way 
 of injur}^ In children, it will be remembered the bladder 
 is almost an abdominal viscus ; but if it is desirable to dis- 
 tend the rectum, this can be done with one or two sponges, 
 previously attached to a string, to prevent them from 
 passing beyond reach. 
 
 With reference to the question of urinary infiltration, 
 this is a danger to be apprehended as well after perineal 
 as after supra-pubic cystotomy ; but the danger of septic 
 infection is, perhaps, less after epicystic infiltration, be- 
 cause it is less confined and more accessible to our inter- 
 ference than when the urine has infiltrated the peri-pro- 
 static and cirumrectal areolar tissue. 
 
 The prevention of urinary infiltration involves the con- 
 sideration as to the best way of dealing with the vesical 
 wound. Shall it be stitched or shall it be left open? 
 Both methods have their strong advocates, and both have 
 shown excellent results. If we turn to our present expe- 
 rience in epicystotomy for the removal of tumors, we find, 
 on the one hand, the success of Billroth, by the open 
 method, and, on the other hand, the failures of Volkmann 
 and Marcacci, by the closed method. Although Volk- 
 mann operated in a manner similar to Billroth in making 
 the preliminary perineal incision, in his case, as in Mar- 
 cacci's, purulent infiltration and peritonitis occurred from, 
 as it is said, imperfect closure of the vesical wound. 
 
38 TUMORS OF THE BLADDER. 
 
 Prof. Trendelenburg, Rostock {Berlin. Klin. Wochenschr .^ 
 No. I, 8i), reports four successful cases of supra-pubic 
 lithotomy, which he treated by the open method with ab- 
 dominal decubitus. At the completion of the operation, he 
 washes out thoroughly the wound and the bladder with 
 carbolic solution, and then relies altogether on the efhcacy 
 of drainage, which he secures by inserting through the 
 wound and into the bladder a T-shaped drainage tube, its 
 peculiar shape preventing its falling out, and employing 
 the abdominal decubitus on air cushions. He considers 
 infiltration of urine impossible under this management. 
 
 On the other hand, excellent results have been attained 
 after the high operation for stone with stitching of the 
 vesical wound. Although we have been unable to obtain 
 statistics, our German brethren, especially, appear just 
 now to have a predilection for this particular procedure, 
 and we have every reason to expect that with good 
 depending drainage and thorough Listerism, many a good 
 result will follow the same operation for the removal of 
 tumors. The time, however, has not yet come when 
 it would be judicious to express a positive opinion as to 
 the safest method of dealing with the vesical wound ; we 
 must await further experience. But it will, no doubt, be 
 impracticable to adopt a uniform practice in all cases. 
 Among other things, we shall have to be governed much 
 by the condition of the vesical walls. In one of my own 
 cases, for instance, the vertex of the bladder had become 
 so attenuated by distention from blood-clots that, had the 
 viscus been opened from above, a perfectly water-tight 
 closure of the wound by sutures could not, I am convinced, 
 have been accomplished. 
 
 As an absolute water-tight closure of the vesical wound 
 is a conditio sine qua izon, to union by first intention, as 
 soon as the sutures are applied, the bladder should be 
 moderately distended with water to see that this has been 
 accomplished. 
 
" TUMORS OF THE BLADDER. 89 
 
 With the view of preventing urinary infiltration, Vidal 
 de Cassis suggested dividing the supra-pubic cystotomy 
 into two separate operations : the first to consist in mak- 
 ing the abdominal section down to the bladder, and some 
 days after the establishment of surrounding adhesive in- 
 flammation, to open the bladder. Nelaton is said to have 
 once operated in this manner, but the patient, seventy- 
 eight years old, had so much pain that the bladder had to 
 be opened on the third day. I cannot find that this pecu- 
 liar method has since been repeated. 
 
 T. Gaillard Thomas has very recently made a success 
 of clamping the lips of the vesical incision between those 
 of the abdominal wound, and it may be that we have by 
 this method the prospect of better results than those 
 hitherto obtained by sewing up the opening and return- 
 ing the repaired viscus to the pelvic cavity. This new 
 procedure was effected on the occasion of a laparotomy, 
 performed on a lady, aged thirty-eight, for the removal 
 of a large multilocular ovarian cyst. The abdominal 
 walls being laid open to the extent of about three and 
 one-half inches in the median line, Thomas found the 
 bladder greatly expanded over, and extensively attached 
 to the anterior surface of the ovarian tumor. He attempted 
 to define this attachment by passing a long catheter into 
 the bladder, but the tumor pressed so firmly against the 
 pubes that it could not be introduced beyond that point. 
 He now made an incision through the anterior wall of the 
 bladder, and passing the index finger of the left hand, he 
 was able for the first time to determine the upper limit of 
 the adherent viscus, and succeeded in separating it from 
 its extensive attachments. After this the tumor was re- 
 moved in the usual way ; its pedicle cut, ligated, and 
 returned to the peritoneal cavity. With Peaslee's needle, 
 he applied silver sutures to the abdominal wound, until 
 the same was closed from above downwards to the open- 
 ing in the bladder. He now passed the needle through 
 
go TUMORS OF THE BLADDER. 
 
 the abdominal wall ; then through one vesical wall, through 
 the other, and, lastly, through the opposite abdominal 
 wall, and so continued to do, until the whole opening in 
 the bladder was traversed by sutures. The sutures were 
 then twisted, care being^taken to lift the bladder well up 
 to the surface, and the operation was completed. A Sims' 
 sigmoid catheter was kept in the bladder. The sutures 
 were removed on the tenth day, and the case progressed 
 favorably until the fourteenth day, when a slight oozing of 
 urine was discovered from an opening not larger than a 
 cambric needle in the line of the incision ; but this minute 
 opening was closed by the application of an additional su- 
 ture, and at the end of three months, the patient went 
 home entirely well. 
 
 If after epicystotoray the drainage of the bladder is to be 
 secured by the retention of a catheter per urethram, the 
 method suggested by Chiene, of Edinburgh, for the cure 
 of obstinate urinary fistulcC — the value of which I have re- 
 cently had opportunity to verify — commends itself for 
 adoption also after supra-pubic cystotomy. It is as follows : 
 A flexible, perfectly smooth-eyed catheter is introduced 
 and fixed to the penis with sticking-plaster. Care is taken 
 that the eye of the instrument is just within the neck of the 
 bladder. To this catheter an India-rubber tube is fixed, of 
 sufficient length to reach, without being strained, over the 
 side of the bed to the floor. It then passes into a bottle. 
 The bottle and tube are filled with carbolized water before 
 attaching the apparatus to the catheter. Care is taken 
 that no air can get in at any of the joints. It is well to 
 introduce a piece of glass-tubing at a convenient part for 
 observing the direction of the flow. In order to keep the 
 India-rubber tube steady in the bottle, a piece of glass- 
 tubing is attached to its extremity. If the glass tube ex- 
 tends beyond the neck of the bottle, any folding of the 
 India-rubber tube at this point will be prevented. A 
 siphon action is in this way established, with a suction 
 
TUMORS OF THE BLADDER. gi 
 
 power, the strength of which depends on the height of the 
 column of water, and which will draw the urine into the 
 eye of the catheter as it passes drop by drop from the 
 openings of the ureters into the bladder, and a constant 
 slow current of water will pass along the tube into the 
 bottle. The bottle is allowed to overflow into a basin, 
 which as it fills can be emptied without displacing the 
 apparatus. The bladder is kept constant!}' empty. Care 
 must be taken not to have too great a fall, or the suction 
 of a piece of mucous membrane into the eye of the cathe- 
 ter will cause uneasiness and plug the catheter. The 
 height of the hospital bed is generally sufficient, and in 
 some cases even a less height is all that is required. 
 
 Palliative Treatinent. 
 
 With regard to the treatment of malignant tumors, there 
 is no reason why a timelj" operation may not, in certain 
 cases, prolong life ; but, as a rule, cancerous tumors will 
 admit at most of but palliative treatment, such as alleviation 
 of pain, controlling hemorrhage, and making life as endur- 
 able as possible. Pain, irritation, and spasm should be 
 allayed as completely as possible by the free administra- 
 tion of anodynes, as by so doing we not only afford the 
 necessary relief from suffering, but keeping both mind and 
 body in a condition of quiet and rest, we diminish greatly 
 the tendency to hemorrhage. Conditions that tend to the 
 determination of blood to the pelvic organs should be 
 avoided, the patient should lie with the pelvis somewhat 
 elevated and the bowels must be kept free. As to the 
 efficacy of ergot, gallic acid, turpentine, iron, sulphuric 
 acid, matico, alum, etc., in restraining hemorrhage from 
 tumors of the bladder, we are not enthusiastic ; they seem 
 to have occasionally served their purpose, but they must 
 always be administered freely, and even then the}- will often 
 disappoint. Local astringents and styptics are of much 
 more value. Cold-water irrigation, ice-bags applied to 
 
g2 TUMORS OF THE BLADDER, 
 
 the hypogastrium or perinasum, or ice introduced into the 
 rectum or vagina is often of much service. The topical 
 application of sol. zinci chloridi, argent, nitrate, iron, alum, 
 etc., have proved of marked success in checking hemor- 
 rhage. In injecting the^ bladder, it must always be re- 
 membered that the greatest care is to be taken during 
 catheterization to avoid touching or bruising the tumor with 
 the instrument, which always provokes more or less hemor. 
 rhage, and may thwart the very object it is sought to 
 attain. In the introduction of the instrument, the eye of 
 the catheter should reach just within the vesical orifice and 
 no further. 
 
 In some cases, the bladder may be more advantageously 
 injected by means of a fountain syringe or rubber-bag 
 syringe without the aid of a catheter, and simply by hy- 
 drostatic pressure, as recommended by Zeissl. The pa- 
 tient is placed in the recumbent posture, with nates raised; 
 the penis is brought up against the abdominal wall without 
 undue stretching; the nozzle of the irrigator is introduced 
 into the urethra and there held in such a manner that re- 
 gurgitation of fluid from the meatus cannot take place; the 
 stopcock is opened and the urethra becomes distended; the 
 sphincters yield, and the fluid enters the bladder. Hunter 
 McGuire, Professor of Surgery in Virginia, mentions a case 
 of malignant vascular tumor of the bladder, where the soft 
 gum catheter gave rise to serious bleeding and to severe 
 urethral fever. Nothing gave the patient so much comfort 
 as the use of this rubber-bag syringe. He not only em- 
 ployed it morning and night to wash out the bladder of 
 the blood, mucus and pus that collected there ; but 
 sometimes an injection of simple warm water stopped the 
 pain and vesical tenesmus better than anything else. Sev- 
 eral times the bleeding was stopped by adding alum to the 
 water. I have myself practised this method of injecting 
 the bladder in many cases during the past few years, and 
 often with much less pain and discomfort to the patient 
 than when the catheter was used. 
 
TUMORS OF THE BLADDER. g. 
 
 Conclusions. 
 
 From the foregoing observations and statistics 1 think 
 we may formulate our conclusions as follows : 
 
 I St. In a few remarkable instances in the case of women, 
 apparent recovery seems to have resulted from a sponta- 
 neous expulsion of growths from the bladder. But in 
 general it may be said that tumors of the bladder, if unin- 
 terfered with, are inevitably fatal. And, although they 
 may exist for several years without creating much distress, 
 a fatal termination almost invariably ensues in a few weeks 
 or months from the outbreak of active symptoms. 
 
 2d. Death results most frequently from hemorrhage, and 
 from the effects of mechanical obstruction to the outflow 
 of urine. Hence the indication would be to remove the 
 growth while the general condition of the patient is yet 
 .favorable for an operation ; before the subject has become 
 exhausted from loss of blood, or the kidneys and bladder 
 have become so much diseased as to make recovery im- 
 possible, even in the event of the successful extirpation of 
 the growth. 
 
 3d. In women, because of the accessibility of the blad- 
 der to direct exploration, there is no excuse for temporiz- 
 ing, and the surgeon should lose no time in acquiring an 
 exact knowledge as to the existence, nature, etc., of the 
 tumor, and, if practicable, attempt its removal as early as 
 possible. 
 
 4th. The results thus far attained by surgical interfer- 
 ence, in the cases of women, could scarcely be more satis- 
 factory, and excepting one instance in which the bladder 
 was accidentally perforp.ted, it does not appear that the 
 fatal termination was precipitated by the operation in any 
 of the cases. 
 
 5th. In the male, the propriety of operative interference 
 must necessarily always be a more serious question ; be- 
 cause of the occasional uncertainty of diagnosis, and because 
 
g. TUMORS OF THE BLADDER. 
 
 of the gravity of the undertaking necessary for the removal 
 of the growth. Nevertheless the results, thus far attained 
 by operation, are most encouraging and in every way jus- 
 tify a repetition of the same. 
 
 6th. From a number of autopsies made, we learn that the 
 successful operations might have been multiplied first in 
 those cases in which no operation was attempted, although 
 the growths could have been easily removed and with ap- 
 parently every prospect of success ; and again in those in 
 which the operation was too long deferred and which, it is 
 reasonable to assume, would have terminated successfully, 
 had the same been undertaken at an earlier period. 
 
 7th. Given a positive diagnosis of tumor, the absence of 
 severe secondary symptoms should be no excuse for de- 
 ferring the operation. On the contrary, the earlier the 
 growth is removed the better the prospects of complete 
 recovery. With a healthy bladder and kidney, cysto- 
 tomy is not so dangerous an operation as to warrant 
 any delay. 
 
 8th. Evidence strongly pointing to the existence of a 
 tumor with severe catarrhal symptoms or with spasm of 
 the bladder and much suffering, will often justify an oper- 
 ation; for, if a tumor is found, its extirpation will afford 
 the only chance for life ; and if no growth exists, or the 
 bladder is occupied by an irremovable cancer, the cystot- 
 omy may at least afford temporary relief from suffering. 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
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 RD 670 St3 C.1 
 
 A study of *he t'jrro''S of *he b'adder 
 
 2002266601 
 
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