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 ■ On tumours Of the bl 
 
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 ON 
 
 TUMOURS or THE BLADDER 
 
BY THE SAME AUTHOR. 
 
 STUDENT'S CHEA.P EDITIONS. 
 
 Clinical Lectures on Diseases of tlie Urinary Organs 
 
 Delivered at University College Hospital. Seventh Edition, 8vo. 2«. 6d. 
 
 Lectures on some Important Points in coanection with the 
 Surgery of the Urinary Organs. 8vo. 2^. ed. 
 
 The Diseases of the Prostate : their Pathology and Treatment ; 
 
 Co'mprising the Jacksonian Prize Essay for 1860. Eifth Edition, 8vo. 2.s. Gd, 
 
 The Pathology and Treatment of Stricture of the Urethra and 
 Urinary Pistulae. 
 
 The Jacksonian Prize Essay for 1852. Third Edition, 870. 10s. 
 
 Practical Lithotomy and Lithotrity ; 
 
 Or, an Inquiry into the best Modes of Removing Stone from the E'adder. 
 Third Edition, 8vo. 10s. 
 
 The Preventive Treatment of Calculous Disease, and the Use of 
 Solvent Remedies. 
 
 Second Edition, fcp. 8vo. 2s. Gd, 
 
^ / 
 
 
 ON ^ 
 
 TUMOURS OF THE BLADDER 
 
 THEIE 
 
 NATURE, SYMPTOMS, AND SURGICAL TREATMENT 
 
 PEECEDED BY 
 
 A CONSIDERATION OF THE BEST METHODS 
 
 OF DIAaNOSING ALL FOEMS OF VESICAL DISEASE, INCLUDING 
 
 DIGITAL EXPLORATION AND ITS RESULTS 
 
 [ii\ vLTxmttaxi^ lUttstratioits 
 
 BY 
 
 Sir HENEY THOMPSON, RE.C.S., M.B.Lond. 
 
 SURGEON EXTBAORDDTAKY TO H. M. THE KING OP THE BELGIANS 
 
 PROFESSOR OF SURGERY AND PATHOLOGY TO THE ROYAL COLLEGE OF SURGEONS 
 
 CONSULTING SURGEON TO UNIVERSITY COLLEGE HOSPITAL, ETC. 
 
 PHILADELPHIA 
 BLAKISTON, SON, & CO. 
 
 1012 WALNUT STREET 
 1884 
 

 
PEEFACE, 
 
 A CONSIDEEABLE PORTION of this work is formed 
 by the matter of two lectures given by me at the 
 Royal College of Surgeons in June of the present 
 year. Of these lectures the medical journals pre- 
 sented condensed reports, embracing about one-half 
 of the original composition. 
 
 I now present the lectures entire, although not 
 preserving the exact form in which they were 
 delivered, since numerous additions were rendered 
 necessary, in order to elucidate the subject treated 
 of more fully than it is possible to do in the narrow 
 limits allotted to oral communications. Besides 
 these, I have appended notes, histories, tables of 
 cases, etc., as well as many illustrations from micro- 
 scopic and other specimens exhibited by me in the 
 College Theatre. 
 
 London : 35 Wimpole Stkbet, W. 
 July 1884. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/ontumoursofbladdOOthom 
 
CONTENTS. 
 
 ■HAPTER PAGE 
 
 I. DIAGNOSIS 1 
 
 n. DIGITAL EXPLOEATION OF THE BLADDER. . 17 
 
 IIL TUMOURS OF THE BLADDER: THEIR PHYSICAL 
 CHARACTERS AND INTIMATE STRUCTURE. 
 SYMPTOMS AND SIGNS OF THEIR PRESENCE 39 
 
 IV. OPERATIONS FOR THE REMOVAL OF TUMOUR, 
 
 AND THEIR RESULTS: CASES AND TABLE , 71 
 
LIST OF PLATES. 
 
 fLATK 
 
 I. Section of Healthy Mucous Membrane, made 
 
 DIEECTLY AFTER DEATH, FROM THE APE : SHOW- 
 ING Natural Folding of the Membrane in 
 THE emptied Condition of the Bladder, 
 and the resemblance the Fold bears to a 
 Papilla: x 160 To face p. h^ 
 
 II. Fimbriated Papilloma, showing two of the 
 slender Papillomatous Processes or, so 
 called, ' Villi ' : x 160. (From Case 15 of 
 the Table) „ 59 
 
 III. Fibro-Papilloma : under a Low Power ( x 80) 
 
 to show general Arrangement of Struc- 
 ture. (From Case No. 4 op the Table) . „ 60 
 
 IV. Fibro-Papilloma : under High Power ( x 340), 
 
 showing a Capillary Vessel and a few 
 Non-striped Muscle-Fibres. (From Case 
 No. 4 OF the Table) „ 60 
 
 V. Example of the ' Transitional ' Type op 
 Tumour : showing the Ground-Substance 
 infiltrated with variously-shaped Cells; 
 
 AND numerous BLOOD- VESSELS RUNNING TO 
 
 the Surface : one has given way, and 
 EFFUSED Blood is well shown at the 
 highest point : x 160. (From Case No. 12 
 of the Table) „ 61 
 
 VI. Epithelioma : showing Ingrowth of Epithe- 
 lium AND A ' Nest ' in the Centre op the 
 Section : x 160. (From Case No. 6 of the 
 Table) „ 62 
 
TUMOUES OF THE BLADDER. 
 
 CHAPTER L 
 
 DIAGNOSIS. 
 
 Necessity for systematic inquiry into and observation of symptoms — • 
 Scheme for examining them — Physical examinations — Relief of 
 obscure and painful symptoms — A case — Tactile examination of 
 interior of bladder — A case resulting in removal of vesical tumour 
 — Considerations as to the best means of accomplishing it. 
 
 It is a fact which now begins to appear somewhat 
 surprising, that, until a very recent period, the subject 
 of tumours of the bladder has received a compara- 
 tively small share of attention, either from patholo- 
 gists or from practical surgeons. The former have 
 noticed these morbid products, chiefly to remark on 
 their rarity ; the latter have alluded to them chiefly, 
 as, for the most part, beyond the power of art to re- 
 move. Yet there is little doubt that these growths 
 are by no means uncommon, and recent experience 
 is teaching us that surgical treatment may often 
 greatly palliate, and sometimes successfully extirpate, 
 the disease. 
 
2 ON TUMOURS OF THE BLADDER 
 
 It must be admitted that these cases are almost 
 invariably somewhat difficult to identify, especially in 
 an early stage. Hence the reason why so little in- 
 formation has hitherto been acquired respecting them. 
 But of late years, keener observation and analysis 
 of the signs and symptoms of disease have led to the 
 discovery of various morbid conditions not before 
 suspected to exist ; and it is owing to this fact that 
 the presence of tumours in the bladder has been 
 verified, and that the frequency of their occurrence 
 has been demonstrated. 
 
 Before commencing a study of the various pro- 
 ducts which are grouped under the title of tumour, 
 I shall consider the important preliminary inquiry of 
 how best to ascertain their presence in the bladder, 
 and separate the signs and symptoms proper to them 
 from those of other affections, whether obvious and 
 simple, or unusual and obscure. 
 
 In all cases of disease, whatever its seat or nature, 
 our first object in examining a patient is to form a 
 diagnosis of his disease by investigating its pheno- 
 mena. The account which he gives of his sensations 
 is critically received and noted ; the physical signs 
 which relate to the performance of function, as well 
 as those which denote some change in form and 
 structure, are observed, and the secretions are chemi- 
 cally and microscopically examined. 
 
 These data being obtained, the diagnosis is 
 
DIAGNOSIS 6 
 
 generally clear. If it is not so, the defect is rarely due 
 to our want of scientific knowledge of disease, but to 
 our inability to obtain the facts required in the par- 
 ticular case. Thus the diagnosis of heart and lung 
 diseases was very obscure, although their pathology 
 was well understood, until the practice of auscultation 
 and percussion revealed facts which had not been 
 hitherto attainable during life. Hence it is now 
 rare to meet with serious disease of those organs 
 which, after adequate examination, can be termed 
 obscure. 
 
 But in affections of the kidney and bladder, 
 accessible as these organs are to inquiry, the one by 
 sounding, the other through its secretion, it is still by 
 no means uncommon to meet with a group of symp- 
 toms indicating serious disease, of which the diagnosis 
 is by no means clear. The disease shall have existed 
 for months, or even for years ; careful examinations 
 shall have been made by several observers, and yet, 
 not only shall there be no agreement among them 
 as to the nature of the affection, but differences of 
 opinion may exist as to its locality ; for example, as 
 to whether the bladder or the kidney is the chief seat 
 of the malady. 
 
 These obscure diseases, as already intimated, are 
 for the most part chronic in their character. There 
 is rarely any question of obscurity when dealing with 
 acute disease, since the local pain and other signs, as 
 
 B 2 
 
4 ON TUMOURS OF THE BLADDER 
 
 well as the condition of the urine, mostly suffice to 
 indicate the organ which is aiFected. 
 
 It is for the purpose of facilitating the study of 
 our subject, that I shall now endeavour to sketch, 
 more fully than I have elsewhere hitherto done, a 
 systematic mode of inquiry respecting those derange- 
 ments of the urinary function which are to be 
 regarded either as signs or symptoms of disease 
 affecting any part, at least, of the bladder and ure- 
 thra. My object is to enable the student to arrive, 
 by the shortest route, first, at the true facts of the 
 case ; and, secondly, at the conclusions which those 
 facts warrant. 
 
 In pursuance of this plan, let me premise that 
 the male sex of the patient is always to be under- 
 stood ; modifications which are obvious and therefore 
 not specified being requisite in cases of the other 
 sex. 
 
 The first fact to be regarded in commencing an 
 investigation relative to any morbid condition aficct- 
 ing the urinary organs is, that, with very rare excep- 
 tion, the act of micturition is always -more frequent 
 than natural. But it is particularly important to 
 note whether that frequency is manifested more by 
 night or by day, during rest of the body, or during 
 movement, or any other circumstance which may thus 
 afi'ect the function. 
 
 Secondly^ we are next to inquire whether pain is 
 
DIAGNOSIS 5 
 
 felt ill micturition, and if so, whether before, during, 
 or after the act ; what is its character — acutely smart- 
 ing, evanescent, dull, or continuous • also, what is 
 the precise seat of the pain — in the penis, above the 
 pubes, or elsewhere. 
 
 Thirdly^ has hlood been seen in the urine ? is it 
 brownish and intimately mixed, or not mixed, and of 
 a bright red colour ? Has the stream been observed 
 to commence with urine apparently normal, or with 
 only a faint red tint, and to end in deep red, evidently 
 charged with blood. Is the blood augmented by, or 
 does it occur after, exercise? 
 
 Fourthly^ the character of the stream is to be 
 observed, whether it is small or full, irregular in 
 form, feeble or forcible, continuous or the reverse, 
 issuing in part or wholly by fistulous channels. 
 
 Fifthly^ is the urine cdtered in appearance from 
 the healthy standard, or, as observed by precise tests, 
 in its physical or chemical qualities ? It is import- 
 ant to observe whether the first issue of the stream 
 contains, or is preceded by, an obviously muco-puru- 
 lent discharge. Is the amount of urine passed large 
 or small in quantity ? Are the normal constituents 
 large or the reverse? or are any unnatural elements 
 present, as albumen, sugar, &c. ? What morganic 
 deposits, crystalline or other, are met with, and what 
 organic materials are found as regular or occasional 
 deposits in the urine ? — leading to the whole subject 
 
6 ON TUMOURS or THE BLADDER 
 
 of urine analysis, whicli it cannot be necessary to 
 pursue further in this place. ^ 
 
 Sixthly, inquiry must be made for the presence 
 of pain in the back, loins, and hips, past or present, 
 permanent or transitory, and for the occurrence of 
 periodical attacks, obviously renal. 
 
 Lastly, signs of dropsy and other complications of 
 imperfect renal function must be sought. 
 
 The prosecution of these inquiries, and especially 
 made in this order, decides for a great number of 
 cases the condition of the patient, but it will not do 
 so in all. Physical exammation is in some cases ne- 
 cessary : it is so when the stream of urme is habi- 
 tually small, when micturition is frequent, painful, 
 and difficult, when also it is feeble in elderly men ; if 
 obstruction is manifest in any case, if the urine be 
 persistently alkaline and muco-purulent, if red blood 
 is passed in the urine, and especially if symptoms of 
 irritated bladder are also present. 
 
 The steps of physical diagnosis are very simple, 
 easy of performance, and, although often much 
 dreaded by the patient, entail only a moderate degree 
 of pain when properly executed, and rarely any risk 
 of exciting febrile or other disturbance if they are 
 employed under certain conditions, e.g. with exceeding 
 gentleness, not during the presence of local inflam- 
 
 ' See Clinical Lectures, by the Author, Lect. XXIV. 7th edition. 
 London : Churchill, 1883. 
 
DIAGNOSIS 7 
 
 mation, and with due precautions for the patient 
 afterwards. 
 
 Adequate patency of the urethra is determined by 
 passing a soft bougie of moderate size ; ability of the 
 bladder to empty itself by the natural efforts by pass- 
 ing a flexible catheter immediately after the act of 
 micturition ; the presence of a foreign body by intro- 
 ducing a small beaked sound and prosecuting the 
 search in a systematic but delicate and gentle manner. 
 The condition of the prostate and base of the bladder 
 is ascertained by rectal examination with the finger, 
 searching there for hypertrophy, cancerous deposit, 
 and for calculus in exceptional circumstances, such 
 as impaction, irregular situation, unusual size, &c. 
 Examination of the perineum and scrotum, as well as 
 palpation and percussion of abdomen in the supra- 
 pubic region, and in both renal regions, in the line of 
 the ureters, for retained urine, tumour, enlargement, 
 fluctuation, points of tenderness, &c. 
 
 The outline of an exhaustive scheme of research 
 has thus been presented ; one which suffices for the 
 solution of a very large proportion of all the cases 
 which occur in practice. I think it may be fairly 
 said to be adequate to the solution of ninety- nine out 
 of one hundred, so far as a rough numerical estimate 
 be possible. 
 
 But it follows that the most patient application of 
 the inquiry described sometimes fails to reveal the 
 
8 ON TUMOUES OF THE BLADDER 
 
 cause of symptoms ; although it may, and often does, 
 arouse suspicions as to what that cause may be. 
 Thus, the evidence available in an exceptionally 
 obscure case may point in the direction of impacted 
 calculus, which is associated usually with extremely 
 painful and frequent micturition, and muco-purulent 
 or occasionally blood-stained urine ; or may indicate 
 the presence of a growth within the bladder (not can- 
 cerous deposit in its walls, which is readily recognised 
 from the rectum), such growth being usually asso- 
 ciated with loDg-continued or repeated bleeding, and 
 sooner or later depositing in the urine organic debris, 
 the structure of which may determine its character. 
 In either case no permanent relief is attainable with- 
 out operation. 
 
 Besides the conditions named, there may be, as in 
 the cases of elderly men who are unable to pass any 
 urine without very frequent catheterism, another 
 cause, not very infrequent, of the most distressing 
 cystitis ; one that is rarely amenable to relief by 
 ordinary treatment, because the cystitis itself is main- 
 tained by the very agency, the catheter, without 
 which the patient's existence is impossible. A vicious 
 circle of actions is thus set going, which can only 
 move from bad to worse. In all the conditions 
 described the patient's fate is sealed ; but even this 
 grave fact does not disclose all the severity of his 
 lot ; since it is almost inevitable that the fatal event 
 
DIAGNOSIS 9 
 
 must arrive through severe and protracted suffering. 
 The painful experience which I have necessarily had 
 of so much misery of this kind, and for which, in the 
 later stages of disease, little relief is afforded except 
 through the influence of narcotics, has long impressed 
 me strongly with the desire and the hope of finding 
 the means of escape for some of these patients, 
 equally from the fatal issue and from the suffering 
 which precedes it. 
 
 Fifteen years ago (January, 1869), for a man 
 about 60 years of age, in University College Hospital, 
 I first opened a bladder with the sole view of afford- 
 ing relief in a case of painful cystitis of the kind 
 described, no crisis of retention being present ; by 
 making a suprapubic opening and maintaining a 
 tube there during some weeks, in order to drain and 
 relieve the bladder. I repeated this proceeding in 
 six other cases, affording some relief, but with less 
 of permanent benefit to patients than I had hoped 
 to attain. The opening was ill-placed for drainage 
 purposes ; it became very sore from contact with 
 urine, and kept the patient for the most part confined 
 to his room. But the last case in which I did this 
 operation was so remarkable, and impressed me so 
 strongly, that from that time I determined on a 
 different course for the future ; and this at length 
 issued in the plan which I have now put in practice 
 nearly four years, and the results of which I shall lay 
 
10 ON TUMOUES OF THE BLADDER 
 
 before you without any reserve to-day. But first, I 
 shall ask you to listen to a very brief report of the 
 case just referred to. 
 
 Mr. C. was aged 31 when first seen by me in 1870. 
 During the previous six years has had occasional attacks of 
 bleeding. The urine always more bloody at the end of the 
 stream than at the beginning. The vesical origin of the 
 blood was on this ground suspected at that time. 
 
 After two or three visits, he took a sea voyage for hirf 
 health, and thought himself cured. But he came again in 
 October 1874, having had several fresh attacks recently. I 
 sounded him, and felt nothing ; some fusiform cells were 
 observed in the urine, and are sketched in the note-book at 
 that visit. 
 
 1876. Has continued to bleed, and more frequently. 
 Found three ounces of residual urine, and advised use of 
 catheter daily ; which was found to check bleeding, as when 
 there was no straining there was no blood. 
 
 1877. Passes shreds of organic tissue ; sounded, nothing 
 felt ; weaker ; micturition frequent and painful. 
 
 1878. Sufferings so great in micturition that I resolved 
 to make a suprapubic opening into the bladder to rest and 
 drain it, and enable him to obtain some sleep, which has 
 been terribly broken by constant straining. The operation 
 afforded some relief, but he gradually became weaker, and 
 sank about a month afterwards. 
 
 At the autopsy a single pedunculated tumour was found 
 in the bladder ; it resembled in form and size an ordinary 
 fig. It could have been easily removed had the suprapubic 
 opening been enlarged (see fig. 1). 
 
 It was clear to me from this case that the ordinary 
 sound, ' a lengthened finger ' in practised hands, as I 
 had often and truly termed it to my class, had proved 
 
DIAGNOSIS 11 
 
 incapable of giving me sufficient information relative 
 to the presence of a considerable growth within the 
 
 JplQ, 1. — Fimbriated Papilloma, with narrow peduncle. From case 
 of Clark, xt. 38. (Museum of University College, No. ],.500.) 
 
 bladder. Supposing that I could but once have put 
 my real finger there, instantly discovering, as I 
 should have done, that easily removable tumour : 
 how different would have been the issue of that 
 unhappy case ! He might have been enjoying life 
 and health to-day. What then was to prevent me 
 in future, under circumstances of equal gravity and 
 like obscurity, from determining the presence or 
 absence of such a growth, by the direct sense of touch, 
 as I could so easily have done there, had the necessity 
 for applying it ever occurred to me ? The questions 
 therefore naturally presented were : Might it not be 
 possible to examine with my finger the whole in- 
 terior surface of the bladder ; and, if so, from what 
 region could such exploration be most easily and 
 safely accomplished — from the perineum, or from 
 above the pubes ? After experiment on the dead 
 body the answer seemed not doubtful. With a small 
 
12 ON TUMOUKS OF THE BLADDER 
 
 opening into the membranous urethra from the 
 perineum, just large enough to admit the finger 
 to arrive at the neck of the bladder, and making 
 at the same time firm suprapubic pressure, I could 
 explore without difiiculty every portion of the surface 
 described. If then by means of anaesthesia I could 
 attain that degree of fiaccidity and inertia in the 
 living body which is natural to the dead subject, 
 why should I not be able to effect as easily the 
 exploration in the former case as in the latter ? 
 
 Opportunity for making the experiment soon 
 occurred, partly in the course of a lithotomy case or 
 two ; and finally in the person of a patient who came 
 under my care in 1880, with severe and obscure 
 symptoms. At the outset of this case I met with a 
 small calculus and crushed it, but subsequently found 
 another, as I thought, impacted, not being able to re- 
 move it by the lithotrite. It was with the object of 
 ascertaining the real state of the case that I decided 
 thus to explore the bladder, and did so in November 
 of that year. I invited Dr. Seegen, of Vienna, and 
 Dr. Paggi, of Florence, who happened to be in town, 
 as well as Mr. Ceely, of Aylesbury, to be present. 
 Having made the median incisions, and complete 
 fiaccidity of the abdominal muscles having been 
 attained by the influence of ether, I felt as soon as the 
 finger entered the bladder that there was no difiiculty 
 in exploring the whole interior, and soon detected the 
 
DIAGNOSIS 13 
 
 presence, not of a stone, but, to my surprise, of a single 
 pedunculated tumour of considerable size, with a 
 thick coating of phosphates deposited on the surface. 
 It had been this coating, together with the immobility 
 of the mass as previously determined by a lithotrite, 
 which had suggested to me the presence of impacted 
 calculus. I seized the tumour with a small lithotomy 
 forceps and twisted it off at the neck. The patient, 
 contrary to my expectations, made a rapid recovery; 
 had no return of the growth or any sign thereof, and 
 has enjoyed excellent health and activity ever since, 
 as he does at this day. That operation took place in 
 the autumn of 1880, now nearly four years ago. I 
 waited a year and a half before presenting this man 
 and his history to the fellows of the Royal Medical 
 and Chirurgical Society, and before proposing also 
 to make his case a precedent to be followed system- 
 atically in obscure cases for the future, having at 
 this second date adopted the operation in three other 
 cases of chronic bladder disease, which, however, 
 were not examples of tumour in any form. The 
 case, with diagram of the growth removed, forms 
 No. 1 in the Table of Cases at the end of this 
 volume. 
 
 I then determined to regard the systematic exa- 
 mination of the bladder by means of the finger as a 
 desirable, and indeed as a necessary, proceeding in 
 obscure disease believed to affect the bladder, when 
 
14 ON TUMOURS OF THE BLADDER 
 
 other means, including careful sounding under ether, 
 had failed to detect the cause. And in order to 
 distinguish the new method, I termed it ' Digital 
 Exploration of the Bladder,' and under this name I 
 made the first published account of it, not in this 
 country, but in La Semaine Medicale of Paris, in 
 June 18, 1882; specifying also the cases in which it 
 might be deemed applicable. 
 
 In the surgical proceeding itself there is nothing 
 new, nor did it ever occur to me that it could be 
 claimed in that sense by any modern surgeon. Like 
 others I had often opened the urethra from the peri- 
 neum for stricture, for chronic and obstinate urinary 
 fistulte, for impacted calculus, for calculus sacculated 
 m front of the neck of the bladder, and once after 
 lithotrity when the patient could pass no urine except 
 by catheter, and was unable to introduce the instru- 
 ment, &c. But the object with which I have recently 
 proposed to operate is a new one, inasmuch as it is 
 solely the exj^loration of every part of the bladder 
 with the end of the fino;er, in order to diag-nose its 
 condition, and not by any means necessarily to per- 
 form any further operation, unless indeed this should 
 turn out to be required by the discovery of a tumour 
 or other condition admitting of surgical treatment. 
 To effect this purpose, then, it was extremely impor- 
 tant to determine what is the shortest and easiest 
 route for the surgeon, and at the same time by what 
 
DIAGNOSIS 15 
 
 method would the smallest amount of risk to the 
 patient be incurred. 
 
 At first sight it appeared that an incision involv- 
 ing the neck of the bladder must be necessary, and 
 that the operation must therefore be some form of 
 cystotomy. Happily experiment proved that no such 
 extended incision would be required, and that a section 
 carried from the perineum to the urethra, in other 
 words ^ external urethrotomy,' would suffice for my 
 purpose.^ Now, this is a procedure almost without 
 risk. The mere section of parts from the perineal 
 surface in the median line, down to any part of the 
 urethra anterior to the 23rostate is one of the simplest 
 and least dangerous of surgical operations. If in 
 addition to the section, the prostatic urethra together 
 with the wound have to form a route for the repeated 
 introduction of instruments, and for the removal of 
 a tumour, the risk is increased in proportion to the 
 amount of work to be done ; but even then the fresh 
 danger incurred does not arise from the urethral 
 lesion so much as from the process of detaching the 
 growth from the walls of the bladder. 
 
 ^ It fell to my lot to write a brief history of that operation for my 
 earliest Jacksonian prize essay in 1851, and I recorded there that it 
 was practised in the end of the seventeenth century by Richard Wise- 
 man in this country, and that at about the same period, and subse- 
 quently, it was known and practised in France, under the name of the 
 ' boutonniere,' by Tolet, Colot, Petit, Ledran, and others. By all 
 these it had been adopted to give an outlet to retained urine, and 
 to relieve impassable stricture. My purj^ose, however, was wholly 
 different, as is seen above. 
 
16 ON TUMOURS OF THE BLADDER 
 
 In lithotomy the urethral route, and particularly 
 the neck of the bladder, are injured by forcible ex- 
 traction of a large and rough calculus, but nothing 
 analogous to that dangerous process occurs in the 
 removal of tumour. 
 
 Old, however, as is the surgical proceeding in 
 question, whether in modern language it be termed 
 ' external urethrotomy,' or, as with the older French 
 surgeons, the quaint term of the ' boutonniere ' be 
 adopted (the term itself shows how very simple 
 even at that period they considered it), the mode of 
 performing it appears to me, after a considerable 
 experience, not altogether a matter of indifference. 
 I shall in the first place, however, premise that there 
 is no longer any doubt that the median incision of the 
 perineum opens a shorter road to the neck of the 
 bladder than an incision commenced from any lateral 
 part of that region, although the question has been 
 raised. Considering this point to be determined, I 
 shall describe in the succeeding chapter the steps 
 of the proceeding which appear to me the most de- 
 sirable to be followed in order to attain the end 
 proposed with ease and safety. 
 
DIGITAL EXPLORATION OF THE BLADDER 17 
 
 CHAPTER 11. 
 
 DIGITAL EXPLORATION OF THE BLADDER. 
 
 Mode of performing — Conditions which may be met with— Draining 
 the bladder — Exploration in women — Results of exploration in 
 forty -three cases — Brief reports of each. 
 
 The Operation. — The position of the patient, and 
 the general accessories necessary, are those require-cl 
 for lithotomy. 
 
 After ether has been given, a median staff with a 
 short curve, wide and deeply grooved, is passed into 
 the bladder, and the patient is brought down to the 
 edge of the table, the feet and hands are attached by 
 anklets and wristbands and held by two assistants in 
 the usual manner, another holding the staff. The 
 surgeon, being seated, introduces into the rectum his 
 left forefinger, so as to feel with its tip the position of 
 the grooved staff, separated by intervening tissues, 
 and to verify the apex of the prostate, on which he 
 may place the point of his finger as a guide. He may 
 take the handle of the staff with his right hand and 
 place it m the position required, before returning it 
 to the hand of the assistant. Maintaining his left 
 
 c 
 
18 ON TUxMOURS OF THE BLADDER 
 
 index in the position described, the operator then 
 makes, with a long, narrow, straight -backed bistoury 
 (fig. 2), a vertical incision through the skin and 
 
 Fig. 2. 
 
 cellular tissue in the middle line, say in the raphe, 
 about an inch and a quarter long, the lower extremity 
 of the incision terminating about three quarters of an 
 inch above the anus. He next enters the bistoury, 
 with its cutting edge upwards, in a horizontal direc- 
 tion, at the lower part of the incision, just above the 
 upper border of the bowel and parallel with it, and, 
 guided partially by the proximity of the left index 
 there, directs the point inwards until it arrives at the 
 membranous part of the urethra, which it penetrates, 
 entering firmly the groove of the staiF. Contact 
 being distinct, he incises the urethra on the staff for 
 a few lines by a backward and forward movement of 
 the point, and then withdraws the bistoury, cutting 
 slightly perhaps a little of the tissues upwards as he 
 does so, avoiding as far as possible any section of the 
 bulb itself, and making room enough only for the 
 finger to enter. He now inserts in the groove of the 
 staff the tapering gorget-like director (which may be 
 itself grooved in order to enter on the back of the 
 knife which has been employed, and before the latter 
 
DIGITAL EXPLORATION OF THE BLADDER 19 
 
 has been removed) (fig. 3), and presses it gently 
 inwards along the urethra to the bladder, and he 
 
 Fig. 3. 
 
 may at the same time remove the left index from 
 the rectum and take the staff in that hand, so as to 
 handle the two instruments simultaneously. The 
 staff is withdrawn, the director maintained in place 
 by the right hand, the left index is slowly and gently 
 insinuated along the director through the neck of the 
 bladder, when the director is withdrawn. The tip of 
 the exploring finger is now in ordinary circumstances 
 felt free in the cavity of the bladder, and not unfre- 
 quently at once comes into contact with and recognises 
 the morbid condition for which the exploration was 
 undertaken. Whether or no, the operator, maintain- 
 ing the index in its place, and firmly pressing it into 
 the cavity of the bladder, rises from his seat if neces- 
 sary, and stands so that by means of his own right 
 hand he can make firm suprapubic pressure, and 
 bring the upper surface of the bladder into contact 
 with the left index. This is easily accomplished if 
 
 c 2 
 
20 ON TUMOURS OF THE BLADDER 
 
 anassthesia is complete, that is, renders the abdominal 
 muscles quite inert and flaccid. He rapidly ascertains 
 the presence or absence of tumour ; if absent, he will by 
 slightly changing the point of suprapubic pressure, 
 and also as far as he can, the direction of the tip of 
 the left index, carefully examine bit by bit the whole 
 internal surface of the bladder. He will first be ac- 
 quainted with the condition of the mucous membrane 
 lining the cavity, and observe whether it possesses the 
 smooth satin-like surface, so characteristic of the vesi- 
 cal lining membrane in health, or whether it is more 
 or less roughened or velvety in places, for such con- 
 ditions rarely aifect the entire area. He may find on 
 the contrary an irregular surface elevated in places by 
 interlacing lines of fibres, with corresponding depres- 
 sions and interstices, the signs of hypertrophy of the 
 muscular coat ; while the existence of inequalities 
 in the surface of any kind, such as small papillae, or 
 so-called ' villi,' is at the same time determined. 
 
 Further examination with the finger-nail may 
 detach from the walls some rough-feeling material ; 
 and a more or less substantial film may be found, to 
 which earthy deposits adhere, like a false membrane 
 which may be peeled off^ and removed. In other cases a 
 complete scale of phosphatic crust may be encountered, 
 rather closely attached to a roughened portion of 
 the wall, and be separated from it without difficulty. 
 And sometimes the finger may discover a small cal- 
 
DIGITAL EXPLORATION OF THE BLADDER 21 
 
 cuius half exposed, half hidden, occupying partially, 
 or almost completely, a little sac, or lodged in a 
 crevice, as it were, and merely protruding from be- 
 tween two hypertrophied folds or rugae, which hold 
 it in a position where it has perhaps defied both the 
 sound and the lithotrite. All forms of prostatic out- 
 growth are met with ; their interference with the vesi- 
 cal function can be studied, in the relations which 
 they hold as to size and situation to the neck of the 
 bladder ; some of them being thus possibly rendered 
 amenable in a slight degree to surgical treatment after 
 such recognition has been made, as is partially illus- 
 trated by a case. No. 41, at the end of this chapter. 
 
 Indeed, it is difficult to say at present what may 
 not be found, as fresh experiences have brought to 
 light conditions to some extent not heretofore recog- 
 nised, of which I have yet to speak. Hence there are 
 few occasions, I confess, which for me have excited a 
 more lively interest, than the moment at which my 
 finger enters a bladder, the condition of which has 
 been a theme of keen inquiry and speculation, for 
 some months or even for years before. 
 
 Almost certainly, at that moment the cause is 
 revealed, and the practical surgeon only can under- 
 stand, if I permit myself to say how grateful is the 
 sense of satisfaction when it is suddenly discovered 
 that the event has amply justified the procedure, and 
 that the cause of years of suffering is judged after 
 
22 ON TUMOURS OF THE BLADDER 
 
 examination to be safely within our power to remove. 
 I doubt whether the keenest hunter in quest of ad- 
 venture, or most indefatigable and hardy explorer of 
 an unknown continent, realises, after long and patient 
 toil, happier moments following success, than does 
 the operator, who, after protracted care and research, 
 tracks to a hidden source the cause of certainly im- 
 pending death, and is able to save the victim ! 
 
 To return, supposing it is at once apparent from 
 the examination just described that tumour is pre- 
 sent, the operator must next deliberately study its 
 size, form, situation, and mode of attachment to the 
 bladder. This is an extremely important matter, 
 and will be considered, as well as the best mode of 
 removing the growth, in the next chapter. 
 
 On the other hand, no growth having been found, 
 the next steps of the proceeding will depend on what 
 other morbid or irregular condition has been revealed. 
 Supposing that either some calculus or other matter 
 has been removed, or that the bladder and urethra are 
 to be maintained in a state of rest in order completely 
 to suspend their functions for a few days, free exit for 
 the urine must be secured. For this purpose a soft but 
 stout indiarubber tube, with a clear calibre of a fourth 
 of an inch, having a lateral as well as a terminal 
 opening, and about six inches long, is to be fastened 
 with one end (smoothly bevelled) just within the 
 bladder, the remainder occupying the wound, and 
 
DIGITAL EXPLORATION OF THE BLADDER 23 
 
 protruding so as to convey the urine direct to some 
 vessel suitable to receive it. If the object of treat- 
 ment is that last described, the tube should remain 
 a week or so, unless its presence occasions pain, in 
 which case a soft large catheter may be tried ; or, as 
 sometimes happens, it is better after the first or second 
 day to dispense with any instrument, and allow the 
 urine to take its course through the wound. If, how- 
 ever, the tube produces little or no irritation, it should 
 remain several days, until the bladder has been rested 
 and drained, say at least for a week ; even a longer 
 period is sometimes advantageous ; see Cases 5, 8 
 and 43. The relief from frequent habitual cathe- 
 terism thus afforded to a patient who for months 
 perhaps has been compelled to use a catheter 
 twelve times or more frequently every day is so 
 great that he often desires the period of drainage 
 to be prolonged, and thus the term of rest to be 
 extended. To a man who has for some months 
 before never enjoyed two consecutive hours of sleep — 
 and in some of these long-standing cases the term of 
 rest does not even reach one hour — the ability to lie 
 unmoved and be undisturbed for an unlimited period 
 of time constitutes an indulgence which he appreciates 
 to the utmost, and which has often the happiest effect 
 on his digestion, his strength, and his spirits. I have 
 seen some very remarkable examples of relief arising 
 from the process, and relief of a permanent character. 
 
24 ON TUMOUES OP THE BLADDER 
 
 It will be natural in this place to advert for a few: 
 moments to the analogous operation in the female 
 when dealing with obscure forms of disease for the 
 purposes of diagnosis and treatment. In order to 
 accomplish a digital exploration of the female bladder 
 all that is needful is sufficient dilatation of the urethra 
 to admit the introduction of the index finger, which 
 may be accomplished by means of a three-bladed 
 dilator or otherwise, after which the facility for 
 examining is of course greater than that attained 
 after perineal incision in the male. Dilatation, how- 
 ever, always comprehends, I think, in whatever way 
 it is rapidly performed, a certain amount of splitting 
 or rupture of the urethra, which, however, I have 
 never known to be followed by any permanent injury. 
 I have thus examined five cases of women for the 
 purpose of diagnosis, and have found tumour in two, 
 and removed both without any further enlargement 
 of the opening. 
 
 It has been objected by some that when the pro- 
 state is largely hypertrophied, especially in a fat sub- 
 ject, it is not possible to explore the bladder by means 
 of the proceeding here described. Hypothetically the 
 objection appears important, but my experience shows 
 that the difficulty supposed is rarely considerable ; 
 in only one instance have I failed to reach the whole 
 of the internal surface of the cavity. 
 
 If only the ansesthesia is complete, our purpose is 
 
DIGITAL EXPLOEATION OF THE BLADDER 25 
 
 effected mncli more easily than most persons would 
 a jyriori imagine. In fact, before such anaesthesia had 
 become possible, digital exploration of the bladder 
 would not have been proposed, and certainly could 
 not have been accomplished. It is one of the many 
 applications of surgical art which ovv^e their origin solely 
 to that influence. For if absolute and complete flac- 
 cidity of the abdominal muscles is thus attained, it 
 is surprising how the contents of the pelvis can be 
 pressed down towards the perineum by a strong and 
 determined assistant, and can be reached by the opera- 
 tor, however large the prostate. But if the etherist 
 permits the patient any power of resisting with the 
 abdominal muscles, the effort is hopeless, and failure in 
 the attempt to explore is, I believe, more likely to arise 
 from that circumstance than from any other. 
 
 Further, it cannot be frequently necessary to 
 make a digital exploration in cases of very large pro- 
 state, inasmuch as the cause of symptoms is generally 
 sufficiently patent, and therefore does not call for 
 further inquiry. 
 
 The bladder, however, may require to be drained 
 in advanced disease of this kind ; and this is often 
 done with great and permanent benefit ; for which 
 purpose the small urethral incision suffices. To this 
 proceeding the enlarged prostate offers no impedi- 
 ment ; but complete exploration of the bladder in 
 such a case is not required, unless unusual symptoms 
 
26 ON TUMOURS OF THE BLADDER 
 
 are present, which the enlargement and consequent 
 obstruction do not suffice to explain. 
 
 Results. — I shall now present, in brief terms, a 
 list of all the cases on which I have performed digital 
 exploration of the bladder, forty-three in number. 
 In twenty of these tumour was found. These latter 
 cases will only be named here, since the details con- 
 cerning them will be fully given at the close of the 
 fourth chapter. The object of the following record 
 is to indicate all the various conditions for which 
 the operation of digital exploration was resorted to, 
 and the results which followed its performance. 
 
 On carefully analysing these cases there appear to 
 be four chief forms of vesical disease, in which the 
 operation of opening the urethra for the purpose of 
 withdrawing the urine altogether by an artificial 
 route, and so suspending the functions both of the 
 bladder and urethra for a time, may render, good 
 service. Then, besides these, there remains a fifth 
 class of cases, namely, those in which the operation is 
 undertaken solely with the view of exploring, when 
 the presence of tumour may be strongly suspected. 
 
 The first class consists of those cases, not un- 
 frequently met with, in which all the symptoms of 
 chronic cystitis have existed for a long period, and 
 in a severe degree, and which persist in spite of 
 long -continued and appropriate treatment ; while at 
 the same time it is understood that the absence of 
 
DIGITAL EXPLORATION OF THE BLADDER 27 
 
 material cause for the cystitis, such as stone, stric- 
 ture, vesical incompetence, &c., has been ascertained. 
 Examples are Cases 2, 24, 31, and 43. 
 
 The second class of cases includes those exam- 
 ples of prostatic hypertrophy and of atony of the 
 bladder, in which that organ must be emptied by th-e 
 catheter many times m the twenty-four hours, and 
 in which painful chronic cystitis is obviously aggra- 
 vated, if not maintained, by the necessary process of 
 relief. These are usually cases in which the disease 
 has existed for years, and which have arrived, to all 
 appearance, at the latest stage, unless complete relief 
 can be afforded. Examples are seen in Cases 5 
 and 34. 
 
 The third class embraces those cases, less rare 
 perhaps than they have been supposed to be, in which 
 the existence of impacted calculus or of adhering 
 calculous matter may be suspected, or may be known 
 to be present by sounding. Examples are seen in 
 Cases 3, 4, 7, 22, and 36. 
 
 In the fourth class I place those cases in which 
 painful and very frequent micturition or bleeding, 
 separately or combined, may have long existed ; 
 without signs of cystitis, the urine being clear, free, 
 or nearly so, from mucous or purulent deposit ; 
 furthermore, the cause of these symptoms has baffled 
 the most careful inquiry. On exploration being made 
 no organic change is discovered, no light is obtained 
 
28 ON TUMOURS OF THE BLADDER 
 
 on the diagnosis of the case, but the functions of the 
 bladder and urethra are suspended for a week or so, 
 and the patient gets well more or less completely. 
 Of this remarkable history there are six examples in 
 the series : of which three. Cases 8, 14, and 35, per- 
 fectly recovered, besides three others in which great 
 improvement took place, but not complete recovery, 
 Cases 17, 23, and 41. The result of operation under- 
 taken in the circumstances described, as a last if not 
 almost hopeless resource, has been surprising, and 
 fraught with great interest. I am disposed to think 
 that there are some persons in whom an attack of 
 cystitis with extreme frequency of micturition having 
 been set up, the want to relieve the bladder every 
 half-hour or hour, at first natural and necessary, still 
 continues after the local disease has passed away, in 
 spite of their efforts to overcome it, as the result of 
 what may be regarded as persistency of a morbid 
 habit, in certain constitutions. I cannot further 
 elucidate the pathological condition in any one of 
 them, having discovered nothing by the investigation 
 to account for the symptoms. 
 
 Besides these, one case has been already referred 
 to, in which adhesions between the mucous lining of 
 the bladder were separated by the finger. Case 12 ; 
 there was one case of division of the neck of the 
 bladder which was extremely tight and rigid, Case 
 41 ; and one case of hagmaturia in which the surface 
 
DIGITAL EXPLORATION OF THE BLADDER 29 
 
 of the mucous membrane was studded with numerous 
 minute "villous papillae, removed by scraping, followed 
 by applications of caustic, Case 37. In each of these 
 cases considerable improvement resulted from the 
 proceeding ; the last being completely successful. 
 
 I cannot but hope that the results reported in 
 these histories may lead to a further employment of 
 this simple operation in cases of like obscurity, feel- 
 ing sure that much valuable relief to suffering, as well 
 as prolongation of life, may be attained by a judicious 
 application of the proceeding. 
 
 Forty-three Cases of Operation for Digital Exploration 
 OF the Bladder, 'performed by the author, and briefly 
 reported, but containing the chief points of the history, 
 progress, and results in each. In tiventy instances, 
 tumour of the bladder vjas met ivith ; in this series that 
 fact only is named ; the details tvill be found in a table 
 at the end of the fourth chapter. 
 
 Case \.—T. K., 29. Exploration: 1880, November 6. 
 Tumour removed. (See Table, No. 1.) 
 
 Case 2. — J. H., 48. For several years has passed blood 
 in the urine, and occasionally phosphatic deposits, with much 
 frequency of micturition, chronic cystitis, &c. 
 
 Exploration: 1881, June 27. Nothiug found ; tube re- 
 mained a week for drainage. 1884, June 7. Very decided 
 improvement has continued ever since. 
 
 Case 3. — C. J., 52. I performed lateral lithotomy in 
 1880, with Dr. Jas. W. J. Smith, of Belfast, for a large uric 
 
30 DETAILS OF CASES OF 
 
 acid calculus : the wound healed slowly ; subsequently passed, 
 phosphatic masses with bleeding. 
 
 Exploration: 1881, June 17. Found phosphatic deposit 
 adhering to the walls of the bladder, and removed it with 
 my finger ; then drained the bladder for a week ; some relief 
 followed, but it was not considerable. 
 
 Case 4. — T. H., 68. A year ago a calculus removed from 
 the bladder by lithotomy. Soon after recovery he had hsema- 
 turia, continuing some months in spite of treatment. He 
 also experienced great pain, irritation, and extreme weakness, 
 his condition occasioning great anxiety. 
 
 Exploration: 1882, Feb. 10. Nothing found except a 
 scale of phosphatic matter, adherent to the bladder, and I 
 removed it with my finger. He soon recovered, and never 
 saw blood again. Was seen with me by Sir W. Jenner. 
 June, 1884. He called on me three months ago, stating that 
 he was enjoying better health and activity than for years past. 
 
 Case 5. — T. H., 60. Passes all urine by catheter, many 
 times in the day ; much phosphatic deposit and great suffer- 
 ing. 
 
 Exploration : 1882, March 20. Nothing whatever found 
 in the bladder. I therefore introduced a tube, which re- 
 mained there eleven days, thoroughly resting and draining 
 the bladder. The relief was great ; he resumed active habits, 
 and he has been better ever since. Drs. Chepmell and Barton 
 Smith present. 
 
 Case 6.— Mrs. F., 30. Exploration: 1882, May 9. 
 Tumour removed. (See Table, No. 2.) 
 
 Case 7. — A. S., 72. Passes all urine by catheter, with 
 great pain and extreme frequency ; very feeble ; seen in con- 
 sultation with Sir W. Jenner. 
 
 Exploration: 1882, June 21. I found a small impacted 
 calculus, and removed it with finger ; bladder drained through 
 tube ; great relief to pain, but died in a few days from ex- 
 
DIGITAL EXPLORATION OF THE BLADDER 31 
 
 haustion. The operation was undertaken to relieve pain, 
 and not with any view of saving life, as he was obviously 
 near his end. 
 
 Case 8. — C. C, 83. Micturition extremely frequent and 
 very painful, but requires the catheter only once daily, very 
 little urine being retained, the instrument withdrawing only 
 one ounce and that is clear. 
 
 Exploration: 1882, June 30. Nothing found; tube re- 
 tained for twelve days, after which the relief was remarkable 
 and permanent. I have recently seen him, and he is abso- 
 lutely free from symptoms. 
 
 Case 9. — B. Gr., 46. Exploration: 1882, November 3. 
 Tumour removed. (See Table, No. 3.) 
 
 Case 10.— M. C, 52. Exploration: 1882, Nov. 20. 
 Tumour removed. (See Table, No. 4.) 
 
 Case 11. — F. I., 24. History of severe heemorrhage and 
 very painful frequent micturition. Sent to me by Dr. lies, of 
 Fairford, Grloucestershire. 
 
 Exploration : 1882, Dec. 15. Dr. George Johnson 
 present. Nothing felt, except that the whole cavity of the 
 bladder is irregular and the lining membrane thickened. 
 Tube retained five days ; on removing it, bleeding which had 
 ceased reappeared. The wound does not heal, some urine 
 passing by it, partially prevented by frequent catheterism. 
 
 Case 12. — Mrs. H., 23. From New Zealand, with very 
 severe symptoms of three years' standing ; said to be due to 
 ' polypus of bladder.' 
 
 Exploration : 1882, Dec. 19. Cavity of bladder extremely 
 small, apparently limited by adhesions, w^hich gave way easily 
 under pressure of the finger at some points ; a condition I 
 never observed before ; no tumour. She soon recovered, lost 
 all pain from that time, but was compelled to pass water 
 almost as frequently as before. Her health was much im- 
 proved, and she returned in the following month. 
 
32 DETAILS OF CASES OF 
 
 Case 13. — E. K., 67. Exploration: 1883, January 17. 
 Tumour removed. (See Table, No. 5.) 
 
 Case 14. — W. C, 52. Very frequent and painful mictu- 
 rition, without ascertainable cause, for a year past ; rarely 
 holds water more than half an hour. No haematuria. 
 
 Exploration: 1883, Jan. 22. Dr. Van Syckel, of New 
 York, and others present. No morbid sign discoverable. 
 Tube retained a week. Healed quickly ; being one month 
 afterwards absolutely free from symptoms ; says he was never 
 better in his life. He returned to the Cape of Grood Hope, 
 whence he had come purposely to consult me. 
 
 Co,se 15. — Miss G., 30. Severe symptoms, without as- 
 certainable cause. Long-standing haematuria, evidently from 
 bladder. Health very infirm ; all treatment hitherto em- 
 ployed has been fruitless. 
 
 Exploration : 1883, Jan .23. Nothing found, but thicken- 
 ing of mucous membrane of bladder, the result of chronic 
 cystitis. No relief except from some of her pain. She slowly 
 sank, and died within a month. Sent to me by Dr. Myrtle, 
 of Harrogate. 
 
 Case 16.— T. F., 67. Exploration: 1883, January 30. 
 Tumour removed. (See Table, No. 6.) 
 
 Case 17. — W. K., 44. Symptoms severe. Haematuria 
 during the last year and a half; no cause ascertainable. 
 
 Exploration : 1883, Feb. 2. Dr. George Johnson present. 
 Nothing whatever found ; tube retained four days. Wound 
 healed readily, and in the following month he left free from 
 symptoms. Sent to me by Dr. Appleyard, of Bradford. I 
 have recently learned that there is some return of symptoms, 
 although much less considerable than before the operation. 
 
 Case 18.— W. W., 63. Exploration: 1883, Februarys. 
 Tumour removed. (See Table, No. 7.) 
 
 Case 19.— J. M., 64. Exploration: 1883, Feb. 21. 
 Tumour removed. (See Table, No. 8.) 
 
DIGITAL EXPLORATION OF THE BLADDER 33 
 
 Case 20.— Mrs. R., Q6. Exploration: 1883, Feb. 27. 
 Tumour removed. (See Table, No. 9.) 
 
 Case 21.— J. S., 53. Exploration: 1883, March 3. 
 Tumour removed. (See Table, No. 10.) 
 
 Case 22. — J. F., 27. Very severe symptoms for four 
 years without known cause. 
 
 Exploration : 1883, March 12. I found the upper part 
 of bladder coated with thin phosphatic deposit ; and detached 
 a quantity which proved to be thin flocculent membrane 
 with adhering phosphates, and was scraped off with my finger 
 nail, when it became free in the bladder, and was removed 
 with the forceps. I at first supposed it to be a slender 
 villous growth. It was examined by Mr. Eve, who described 
 it as above. Tube was retained one day ; the wound did not 
 heal ; he had orchitis, and suffered much for a long time ; 
 ultimately there was some improvement. 
 
 Case 23. — R. B., 50. Severely painful and frequent 
 micturition during last two and a half years ; passes urine 
 every hour, day and night ; occasionally blood, worse for 
 movements. No cause being discovered, exploration was 
 made 1883, March 15, with his medical attendant, Mr. J. 
 Hartley, Malton, Yorkshire. Nothing was found but rough- 
 ness of the mucous membrane, not considerable in places. 
 No fever, not much bleeding; tube taken out on third 
 day, gradual improvement, left in the middle of April much 
 relieved. June 1884. Continues to be troubled with undue 
 frequency, and a little pain, but much less than formerly. 
 Health good, and habits active. 
 
 Case 24.— C. L., 62. In 1880, October. Lithotrity for 
 small uric acid calculus, single sitting; a brief operation, 
 without any difficulty, but followed by severe cystitis ; 
 becoming chronic, and attended with much phosphatic 
 deposit; this condition continued in spite of treatment 
 during 1881 and 1882, phosphatic concretions being occa- 
 
 D 
 
34 DETAILS OF CASES OF 
 
 sionally removed by lithotrite. In the beginning of 1883 
 the symptoms were more severe than ever ; urine muco- 
 purulent and bloody, and no cause ascertained. 
 
 Exploration : 1883, March 21, with Sir A. Clark. On 
 the right side of the prostate a firm growth, size of a chest- 
 nut with broad base, protrudes into the bladder. Decided 
 not to touch it, but drained the bladder for some days. In 
 the middle of April the wound healed, and a little improve- 
 ment, certainly not much, has been experienced since. 
 
 Case 25.— W. D., Q5. Exploration: 1883, March 30. 
 Tumour. (See Table, No. 11.) 
 
 Case 26. — J. C. D., 43. Pain, frequency and repeated 
 attacks of hsematuria, more or less during five years ; symp- 
 toms now severe, without ascertainable cause. 
 
 Exploration : 1883, April 4. Dr. Stockton, of New York, 
 present. Found nothing but very notable roughness at 
 the top of the bladder, like phosphatic incrustation, but on 
 attempting to remove it with finger nail, found it was an 
 altered condition of mucous membrane, as if a congeries of 
 varicose vessels with thickened walls ; placed a tube in the 
 wound. On the fifth day signs of pyaemia appeared, and he 
 died on the 16th ; no autopsy permitted. 
 
 Case 27.— C. C. S., 56. Exploration: 1883, May 4. 
 Tumour removed. (See Table, No. 12.) 
 
 Case 28.— T. Q., 52. Exploration: 1883, May 9. 
 Tumour removed. (See Table, No. 13.) 
 
 Case 29.— A. Gr. S. C, 57. Exploration: 1883, June 27. 
 Tumour removed. (See Table, No. 14.) 
 
 Case 30. — H. B., 23. During last two years, subject 
 to pain, frequency and slight hsematuria, little influenced 
 by treatment, and associated with other symptoms of an 
 anomalous kind ; much care was bestowed on the case, and 
 no explanation of it was discovered. 
 
DIGITAL EXPLORATION OF THE BLADDER 35 
 
 Exploration: 1883, June 28, with Dr. Walker, of Lowes- 
 toft. Nothing whatever found ; tube retained eight days. 
 The wound healed, and he left in a month with less fre- 
 quency of micturition, but with constant pain in the penis, 
 and apparently little benefited by the operation. 
 
 Case 31. — E. W. C, 52. Had been cut for a large stone 
 in May 1882 by Dr. Greo. Buchanan, of Glasgow. Wound 
 healed rapidly. After this, great pain and frequency of 
 micturition, not relieved by treatment. 
 
 1883, June 23. Passes water every twenty minutes, night 
 and day ; worse for movement ; phosphatic deposits and 
 blood in the urine ; nothing discovered by sounding ; empties 
 his bladder perfectly. I thought it not unlikely that some 
 calculus might be impacted or sacculated, and decided to 
 explore. 
 
 Exploration : June 29 ; Dr. Walker, of Lowestoft, present. 
 Nothing found. Ketained tube eight days. He had much 
 subsequent treatment for the bladder, and he left in about 
 six weeks, retaining urine about an hour, instead of twenty 
 minutes, a very slight improvement. 
 
 Case 32.— J. H. B., 40. Exploration 1883, July 7. 
 Tumour removed. (See Table, No. 15.) 
 
 Case 33.— T. S., 42. Exploration 1883, November 16. 
 Tumour removed. (See Table, No. 16.) 
 
 Case 34.— H. N., 68; October, 1882. Last four years 
 much difficulty and pain in passing water ; of late increasing. 
 Now passes water about every hour, day and night. Catheter 
 passed, forty ounces of retained urine ; learned to use the 
 catheter. Seen with Dr. Barker, of Finsbury Park. 
 
 1883, November, greatly relieved by catheterism for 
 several months, but soon felt pain when the bladder was 
 empty. Sounded ; phosphatic calculus found, and removed 
 at one sitting. Relief at first ; subsequently increased pain 
 and frequency ; all urine passes by catheter. Decided to 
 
 D 2 
 
36 DETAILS OF CASES OF 
 
 explore the bladder, and did so December 11. Nothing was 
 found, but the bladder very rugose, and the walls thickened 
 by disease ; it was drained for ten days, with relief. Wound 
 soon healed, and he left on the 28th, not much benefited. 
 Not long afterwards he died, worn out by suffering. 
 
 Case 35.— C. H. C, 25. In 1881, Feb., he first con- 
 sulted me for attacks of ha3maturia, commencing two years 
 ago after severe exercise. Blood appears chiefly at the end 
 of micturition ; always after exercise or standing. Nothing 
 found by sounding : the symptoms strongly indicate tumour, 
 although no debris is found after repeated examinations of 
 the urine. 
 
 During 1883 lived chiefly on board his yacht, and then 
 rarely saw blood ; but this still appears freely after exertion. 
 
 1884, Jan. 23. Exploration of the bladder: Dr. Greo. 
 Johnson and Mr. Bryant present. No tumour found ; no 
 organic change detected ; retained tube nine days. There 
 was no fever ; health excellent ; wound healed by February 
 6. In the middle of the month he began to walk, and did 
 so for two hours a day during the third week, without any 
 bleeding. May, 1884. He is now perfectly well ; free from all 
 symptoms. 
 
 Case 36. — Mrs. W., 44. 1884, Jan. For a year and a 
 quarter micturition has been very frequent and painful, 
 becoming worse of late. Has had much treatment, but the 
 cause of her symptoms is obscure. Jan. 26, 1884. Explored 
 the bladder, after dilating the urethra, with Dr. John Smith, 
 of Dumfries, who brought the patient up. Found springing 
 from the centre of the trigone a firm prominence, externally 
 consisting of some soft structure, and almost polypoid in 
 form, but on drawing it forwards in the attempt to ligature 
 its base, this outer layer was first scratched through, when 
 a hard calculus about the size of an acorn was disclosed and 
 enucleated ; the prominence disappearing. 
 
DIGITAL EXPLORATION OF THE BLADDER 37 
 
 She had long-continued fever with much exhaustion 
 during almost a month ; but gradually recovered, and re- 
 turned completely relieved from her urinary troubles, and is 
 now quite well ; June, 1884. 
 
 Case 37.— H. F., 58. He first consulted me in 1879 for 
 recurring hsematuria, to which he had already been subject 
 three years. I saw him from time to time, and, finding no clue 
 to the cause, explored the bladder, 1884, Jan. 30. Mr. Henry 
 Morris was present. Extremely good examples of villous 
 growth had been found in the urine when examined under 
 microscope. 
 
 At the operation no tumour was found, but numerous 
 small papillae were felt affecting the upper surface and sides 
 of the bladder. These were dealt with by scraping with the 
 finger nail, and by subsequent injections of caustic. He 
 made a good recovery, and, on Feb. 20, the wound was quite 
 healed ; he was walking out ; no frequency, pain, nor bleed- 
 ing present. I have just seen him, June 5 ; he was walking 
 four miles daily without any of his former symptoms. 
 
 Case 38.— B., aged 50. Exploration: 1884, Feb. 5. 
 Tumour partially removed. (See Table, No. 17.) 
 
 Case 39.— W. Gr., aged 69. Exploration : 1884, Mar. 12. 
 Tumour found. (See Table, No. 18.) 
 
 Case 40. — F. J. 0., aged 58. Exploration: 1884, April 
 4. Tumour found. (See Table, No. 19.) 
 
 Case 41. — M. W. B., aged 45. Many years painful symp- 
 toms, and treatment for alleged stricture, which does not 
 exist. During last twelve months great frequency of mic- 
 turition : now, every half-hour, night and day. Instruments 
 have been passed by himself and others up to the neck of 
 the bladder, and then fail to enter. Examination shows 
 that the neck of the bladder is distinctly tense, rigid on the 
 lower aspect, but the short-beaked sound passes over it 
 
38 DIGITAL EXPLOEATION OF THE BLADDER 
 
 readily into the bladder ; nevertheless, there is no stricture, 
 for No. 15 (English) will enter. 
 
 1884, April 14. Exploration. The finger on entering the 
 bladder encountered rugae and a roughened surface of mucous 
 membrane, especially at upper part of bladder. The neck 
 of the bladder was exceedingly tight, grasping the end of 
 the finger like a ring; I divided this at the lower border so. 
 that the tension ceased. Free bleeding followed. A tube 
 was tied in four or five days. He recovered slowly, and 
 gradually regained power to retain his urine ; the intervals 
 being from two to three hours in the middle of May — a 
 condition for which he was extremely grateful. He takes 
 out- door exercise, and is in no degree worse for it. 
 
 Case 42.— R. S. R., aged 63. Exploration: 1884, 
 May 30. Tumour found and removed. (See Table, 
 No. 20.) 
 
 Case 43. — W. K. E., aged QQ. Severe symptoms for 
 some time ; prostate very large and irregular. I found 
 a phosphatic calculus, and removed it May 19, 1884, but 
 very little relief followed, in spite of daily injections, and 
 much treatment of various kinds. He requires frequent 
 catheter] sm, but the intervals are very short, and his suffer- 
 ing increased during the first week in June, and I decided 
 to explore the bladder, and did so on June 12. No frag- 
 ments of calculus had been left, but I found prostatic out- 
 growth forming a salient ridge, broad, and overlapping 
 the base and sides of the internal meatus ; tied in a tube, 
 and exchanged it for a soft catheter next day. Great relief 
 followed ; he retained the tube eleven days, and after its 
 withdrawal held his water two to three hours. June 28 : 
 he has not had such rest at night for several months, and 
 the urine, which was highly offensive, and loaded with 
 muco-pus, is now comparatively clear. July 10 : he returns 
 to the country almost well — better than I ever expected to 
 see him. Sent to me by Dr. Sawyer, of Birmingham. 
 
39 
 
 CHAPTER III. 
 
 TUMOURS OF THE BLADDER, THEIR PHYSICAL CHA- 
 RACTERS AND INTIMATE STRUCTURE — SYMPTOMS 
 AND SIGNS OF THEIR PRESENCE. 
 
 History of operations for vesical tumour in the male — Examples in the 
 metropolitan museums — The author's cases — Intimate structure — • 
 Varieties— Symptoms — Physical signs — Examination of the urine. 
 
 The literary history of vesical tumours is scanty ; and 
 inasmucli as, with few exceptions, its earlier records 
 treat the familiar outgrowths from the prostate, and 
 the rarer neoplasms which arise from the bladder, 
 without distinguishing between them, not much is 
 available for our purpose. 
 
 More than one attempt has been made of late to 
 cpllect all the cases which may be hunted up among 
 old authors, with the laudable view of collecting in- 
 formation on a subject so lately fraught with new 
 interest, but the result is not successful. The material 
 which has thus been apparently gained as regards 
 quantity by somewhat indiscriminately sweeping the 
 dusty pages of old surgical writers, in the keen 
 search for any semblance of a vesical tumour, is found 
 
40 ON TUMOURS OF THE BLADDER 
 
 to possess little value, from the uncertain quality of 
 the produce so gathered. The only object worth 
 attaining by antiquarian research is the discovery of 
 undoubted examples of true vesical growths, and of 
 some important facts respecting them, and not the 
 production of a list, the extent of which suggests 
 erudition, but is due to a miscellaneous collection of 
 records embracing mere prostatic outgrowths on the 
 one hand, and cancerous formations on the other, 
 indiscriminately mixed with all the varied products 
 which lie between them. 
 
 Carefully eliminating obviously useless matter, I 
 will give a brief historical epitome of the few unques- 
 tionable operations made for the purpose of removing 
 recognised tumours of the bladder, with a view of 
 showing what surgery has hitherto done in the way 
 of removing them. 
 
 History. — There is no doubt that Covillard, of 
 Lyons, performed the lateral operation for a vesical 
 tumour proper, in the year 1639, having previously 
 diagnosed, by sounding, the presence of ' un corps dur 
 et solide,' not a stone. He describes how he crushed 
 it with the forceps, destroying and removing it, and 
 records that the patient recovered.^ 
 
 The occurrence of flocculent, sprouting grovfths, 
 as well as of more solid growths from the neck 
 
 ^ Le Cliirnrgien operateur : avec des observ. iatrochirurgiqties, par 
 Joseph Covillard. 8vo. Lyons, 1640. 
 
HISTORY OF OPERATIONS FOR 41 
 
 of the bladder (prostatic) was well known to 
 the older surgeons. Le Cat refers to them, and 
 to some observations made respecting them by 
 Ruysch, Houstet, Le Dran, and others.^ In the 
 end of the last century, Deschamps, Boyer, Gruerin 
 (pere), and Desault, besides others, refer to vesical 
 outgrowths, but Ghopart offers the best descrip- 
 tion of them under the head of ' Fungus of the 
 Bladder' in his classical work, and here vascular 
 papilloma is distinctly described as differing from the 
 malignant and other forms. ^ Furthermore, he re- 
 lates the case in which Desault, towards the close of 
 the last century, recognised a pedunculated growth of 
 considerable size in the bladder of a patient, as he 
 was cutting for the stone in Hotel Dieu ; and relates 
 that, after removmg it, he twisted off the tumour with 
 the lithotomy forceps, and that the patient made a 
 good recovery.^ Then, very early in the present 
 century, A. Petit, of Lyons, operating on a man aged 
 28, supposed to have the stone, found a large tumour, 
 which, after consultation, was left untouched. The 
 patient recovered from the operation, but returned to 
 the hospital after a year to die, and at the autopsy 
 the tumour was found to be of the size of a fist, and 
 
 ^ Parallele de la taille laterale. Amsterdam, 1766, pp. 244-61. 
 
 ^ Traits des maladies des voies urinaires, par Chopart. A post- 
 humous edition, edited by Felix Pascal. Paris, 1830 ; vol. ii. pp. 
 74-79. Chopart and Desault both died in 1795. 
 
 ^ Idem, vol. ii. p. 97. 
 
42 ON TUMOURS OF THE BLADDEE 
 
 attached by a small pedicle which might have been 
 easily divided/ 
 
 The next definite record is by Civiale, who 
 refers to three instances in which, subsequently to 
 1827, he removed small growths from the bladder 
 evidently unimportant in size, with his original ' tri- 
 labe,' when crushing the stone, without any bad 
 results. He also describes a similar operation on a 
 fourth, much larger, the result of which was unsuc- 
 cessful, and another case in H6pital Neckar, treated 
 in the same manner, in 1834, with good result, add- 
 ing that he has crushed other small ones with the 
 lithotrite.^ The nature of these operations necessarily 
 precluded intelligent observation, or the acquisition 
 of information respecting the growths themselves ; 
 and very little, if anything, is known of the ultimate 
 history of the patients. 
 
 In 1834 Crosse, of Norwich, operated on a boy 
 with severe symptoms of calculus, by the lateral 
 operation, although on sounding he could find none, 
 but several small tumours protruded from the wound, 
 some of which he removed. The boy died in forty- 
 eight hours, and a number of these growths was found 
 in the bladder. The preparation is No. 2000 in the 
 Hunterian Museum here.^ 
 
 ^ Diet, des Sciences Medicales, vol, xliv. pp. 232-33. Paris, 1820. 
 Article ' Polype,' by Vaidy. 
 
 ^ Traite pratique, vol. iii. pp. 152-61. Paris, 1860. 
 
 ^ Treatise on Calculus, by J. G. Crosse, surgeon to the Norfolk and 
 Norwich Hospital ; plate xx. fig. 2, p. 124. London, 1835. 
 
HISTORY or OPERATIONS FOR 43 
 
 In 1874, Billroth, of Vienna, did the lateral opera- 
 tion on a boy of twelve to remove a tumour, a ' myo- 
 sarcoma ' of large size ; findmg the opening insuffi- 
 cient, he performed the suprapubic operation, and 
 extracted it there. The boy made a good recovery/ 
 
 In the same year Volkmann, of Halle, did the 
 suprapubic operation for a man aged 54, removing a 
 large myomatous growth, with a small pedicle only 
 half an inch long, the patient dying of infiltration 
 and peritonitis on the third day.^ 
 
 Professor Kocher, of Berne, performed Nelaton's 
 pre-rectal lithotomy, December 31, 1874, for a man 
 aged 38, for the removal of a papilloma. The man 
 was reported well one and a quarter year afterwards.^ 
 
 At Addenbrooke's Hospital, Cambridge, Professor 
 Murray Humphry did lateral lithotomy, October 17, 
 1877, for a man aged 21, removing a large tumour 
 completely, the man recovering.* 
 
 Suprapubic lithotomy was done by Marcacci on 
 a man aged 54 for vesical tumour in 1880. It was 
 villous on the surface, but it was stated to be a 
 ' spindle -celled sarcoma ' throughout. He lived two 
 months, dying of extravasation and peritonitis.^ 
 
 Berkeley Hill performed lateral lithotomy at 
 
 ^ Archiv fiir hlinische CJiirurgie, band xviii., 1875. 
 
 ^ Ihid., band xix. p. 682, 1876. 
 
 ^ Centralblatt fur Chirurgie, April 1, 1876. 
 
 * Medico-Chirurg. Trans., vol. Ixii. pp. 421-27. 1879. 
 
 ^ Lo Sperimentale, Oct. 1880 ; London Medical Record, Dec. 1880. 
 
44 ON TUMOURS OF THE BLADDER 
 
 University College Hospital in 1880, removing a 
 portion of an epithelioma, in a man aged 63, who died 
 two days after. ^ 
 
 Davies Colley, of Guy's Hospital, performed lateral 
 lithotomy in April 1880, for a man aged 32, drawing 
 out a long villous growth, and cutting it off with a 
 pair of scissors close to the wall of the bladder.^ Mr. 
 Colley has just written me (May 1, 1884) that the 
 man is at this time perfectly well, and has followed 
 his occupation — that of a shipwright — ever since. 
 
 The first case in which I myself removed a 
 tumour by operation was that of a man aged 29, on 
 whom I did the median operation, November 6, 1880. 
 I found a polypoid growth and removed the whole of 
 it with a pair of forceps, twisting it oiF at the base of 
 the pedicle. He made a rapid recovery, and is living 
 and well at the present time.^ 
 
 My subsequent cases — 19 in number, 17 in males, 
 as well as 2 in females, all the former having been 
 discovered by digital exploration of the bladder, and 
 treated by the limited perineal incision employed for 
 that purpose — will be furnished in a table to be con- 
 sidered presently. 
 
 Mr. Whitehead, of Manchester, has adopted this 
 method of treatment, and employed it with consider- 
 
 ^ Report of Surgical Registrar, Mr. Stanley Boyd, 1880. London : 
 Harrison, 1881, p. 33. 
 
 2 Clin. Soc. Trans., vol. xiv. p. 104. 1881. 
 
 3 Trans. Med. Ghir., vol. Ixv. 1822. 
 
HISTOEY OF OPERATIONS FOR 45 
 
 able success. He has recently, in conjunction with 
 Dr. Pollard, published six cases of operation for 
 vesical tumoar, four in the uiale, and two in the 
 female. In two of the former a very favourable con- 
 dition of the patient is reported nearly twelve months 
 after operation, and the female cases, more recent, 
 were well at the date of the report.^ 
 
 Certain other cases found recorded in the j ournals 
 have been quoted by recent writers as examples of 
 operation for vesical tumour, but are intentionally 
 omitted here, since the operations in question have 
 either failed entirely or partially to remove the 
 tumour, or no such body has been present.^ 
 
 It is also unnecessary to refer further to the 
 history of operations for vesical growths in the 
 female, since they have been long recognised as ac- 
 cessible to examination and amenable to surgical treat- 
 ment without much difficulty. The well-known 
 case by Surgeon Warner, of Guy's Hospital, in the 
 former half of last century, occurred in a woman 
 aged 24. He divided the neck of the bladder and 
 
 ^ The Surgical Treatment of Tumours, d;c. , by W. Whitehead and 
 Dr. B. Pollard (London : Churchill, 1883) ; containing much inter- 
 esting matter, and valuable information on the subject. 
 
 ^ Thus Gersuny, Billroth's assistant at Vienna, performed the 
 median operation in the winter of 1870-1, to remove a broken piece 
 of catheter, and discovered a tumour, which could not be removed, 
 and no attempt was therefore made. The patient died six days after, 
 and the tumour was found at the autopsy in a recess at the back of the 
 bladder. But clearly this is not an operation for tumour. — Aixhiv 
 fur klinische Chirurgie, band xiii. p. 131. 1871. 
 
46 ON TUMOURS OE THE BLADDER 
 
 ligatured a large polypoid tumour with a successful 
 result.^ 
 
 From the numerous well-known facts of a similar 
 kind, and from the short list of operations on the 
 male above recorded, it is quite certain that a consider- 
 able proportion of vesical tumours are removable, and 
 that when completely or almost completely removed 
 they often do not reappear. That is all which we 
 gain from the study of the slender experience of the 
 past, and, so far as it goes, it is not without value. 
 
 Examples in Museums. — But there is another 
 mode of studying the subject which has not been 
 pursued to any great extent, and which nevertheless 
 is fraught with greater promise ; a mode, indeed, 
 which it is only possible to pursue on an extensive 
 scale in this country, since here only the requisite 
 materials are to be found — I mean the study of the 
 vesical tumours themselves, with their physical charac- 
 ters exposed to view, as found in the various museums 
 of our metropolis, together with, in many instances, 
 a few important facts relating to the character and 
 history of those who were the subjects of the disease. 
 It is among these important collections that we find 
 the originals of those drawings which have served to 
 familiarise the student, both here and abroad, with 
 delineations of disease which they are rarely able to 
 
 ^ Cases in Surgery, by Joseph Warner, F.R.S., Surgeon to Guy's 
 Hospital (London, 1750) ; and Philosoph. Trans., vol. xliv. 
 
EXAMPLES OE, IN MUSEUMS 47 
 
 see or dissect, Here are the very organs which were 
 engraved for the works of Baillie, Hunter, Bell, 
 Home, Crosse, and others and from which Civiale 
 selected his subjects to illustrate the ' Traite pratique ' 
 in connection with this topic. ^ 
 
 Of growths or tumours arising from the inner 
 surface of the bladder and pursuing an independent 
 development within the cavity, there were in the 
 metropolitan museums, prior to 1882, about fifty 
 examples preserved in spirit. 
 
 Forty- three of these were from adults of various 
 ages ; eight had occurred m young children. A 
 large majority of the former or adult series had arisen 
 in male patients ; but as in a few preparations the 
 sex is uncertain, no exact statement can be made. 
 Of the eight children, six were female. In addition 
 to these fifty cases there is about an equal number 
 of growths and infiltrations preserved in the same 
 museums, which are probably cancerous, and respect- 
 ins* which there is little more to be said. Returning; 
 to the non-cancerous growths it may be stated that; 
 in respect of physical conformation, a considerable 
 proportion of them consist of a single growth from 
 the walls of the bladder, more or less pedunculated ; 
 and might obviously have been removed by operation 
 without difiiculty. Others are broad and sessile, 
 developed into two or more lobes ; and much more 
 
 ^ Traite pratique, vol. iii. pp. 107 et seq., figs. 9-13. Paris, 1860. 
 
48 
 
 ON TUMOURS OF THE BLADDER 
 
 rarely tbere are two or more independent growths 
 in the same bladder. Then some are delicate, soft, 
 
 Fig. 4. — Two growths, probably fibro-papilloma. From preparation 
 No. 2006, Royal College of Surgeons. 
 
 Fig. 5. — From a man aged 59. The tumour, which was of rapid 
 growth, springs from a narrow base. As here seen, it iills the 
 bladder, is chiefly solid, but covered with fimbriated papilloma. 
 From prep. No. 200i, Museum, Royal College of Surgeons. 
 A very similar preparation may be seen at University College 
 Museum, No. 1475. 
 
TYPICAL EXAMPLES OE 
 
 49 
 
 filamentous or fimbriated in structure ; while others 
 are firm and solid ; much variety of density is to be 
 
 Fig. 6. — Firm polypeid growths, each with very narrow peduncle. 
 Bladder everted to show them ; no papillte present. From 
 Museum of Guy's Hospital, No. 2104^8. 
 
 Fig. 7. — Small, firm, almost polypoid growth. 
 
 met with among different specimens in the fi:'esh 
 state, as my own cases have led me to observe. 
 
 E 
 
50 ON TUMOUES OE THE BLADDER 
 
 In relation to the question of situation, it does 
 not appear that any part of the bladder can be 
 regarded as a particularly favourite spot for their 
 origin ; the orifices of the ureters, for example, as is 
 stated by some. The lower half of the bladder is 
 more frequently affected than the upper ; and I think 
 that is the only distinct statement relating to locality 
 which can be made. 
 
 I have selected several of the most typical varieties 
 and have made drawings from them which have been 
 engraved in order to illustrate the subject of size, 
 contour, and number, so important in relation to 
 questions of surgical treatment, hereafter to be con- 
 sidered (see figs. 4, 5, 6, 7 ; also 1, 9, and 10). 
 
 The Author's Cases. — Next to the preserved 
 examples may be considered the result of my own 
 experience, derived from exploring the bladder, in 
 the manner described in the preceding chapter. By 
 means of this operation I have already encountered 
 no less than twenty cases of vesical tumour. At the 
 end of the volume will be found an account of them 
 in a tabular form, which shows at a glance the fol- 
 lowing particulars : the age of the patient, the date 
 of operation, the duration of symptoms up to that 
 period, what was the earliest symptom observed, the 
 result of examination of the urine before operation, 
 the nature of the operation itself, the form and 
 situation of the tumour, its structural elements after 
 
THE author's cases 51 
 
 examination, and the after results to tlie present 
 time. 
 
 In some cases I have, as far as the sense of touch 
 has enabled me to judge, removed the entire growth, 
 and when unable to do so have taken away as 
 much of it as possible ; pruning, so to speak, the 
 most salient portions, when the growth was insepa- 
 rable from the walls of the bladder, a condition, met 
 with in several cases. In all instances, however, I 
 have been very careful to examine the growth so 
 minutely with the finger before operating, as to be 
 able to offer a diagrammatic representation of its size 
 and form. In each one of these cases I made a 
 sketch at the time, representing to the best of my 
 ability the impression thus obtained of the contour 
 and situation of the growth iia relation to the vesical 
 cavity. These are reproduced here in order to illus- 
 trate each case when referred to ; and thus fresh 
 information in regard of the conditions likely to be 
 met with in such cases has been obtained. I think 
 in general terms it may be affirmed that a single 
 tumour attached by a narrow pedicle to the wall of 
 the bladder, and therefore resembling more or less 
 the outline of a fig, is not very common, and to say 
 that it may occur once in six or seven cases of 
 non-malignant tumour probably approaches a cor- 
 rect numerical estimate. On the other hand, sessile 
 growths, of which the base is perhaps the widest 
 
 E 2 
 
52 ON TUMOURS OE THE BLADDER 
 
 part, are met with, perhaps quite as frequently as the 
 pedunculated form just described : and then there 
 are intermediate forms of every grade between the 
 two ; the preponderance in number perhaps being 
 among the non-pedunculated class. 
 
 Structure. — We now come to structural charac- 
 ters. Hitherto most of the statements relative to vesi- 
 cal growths have been somewhat vague, since mate- 
 rials for observation have not been attainable. Thus 
 it has been customary to regard ' villous ' growths as 
 a class ; and these were at no very remote period 
 termed ' villous cancer.' The existence of papilloma 
 has been generally recognised ; occasionally sarco- 
 matous growths have been spoken of, although 
 probably without intention to convey the meaning 
 which modern pathology attaches to the term. After 
 that, follow epithelioma and cancer. Then occa- 
 sionally, but rarely, an isolated specimen has appeared 
 at the Pathological Society of London, and has been 
 subjected to a minute examination, but the total of 
 these specimens has not afforded data for making any 
 classification. Neither at present is it possible to 
 form a complete generalisation, but valuable indica- 
 tions have been attained from the twenty cases now 
 brought before you, which indicate a sufficient number 
 of important facts to commence with. Every one of 
 the tumours I have dealt with, including the few which 
 have not been removed (since I have invariably taken 
 
THEIR NATURE AND INTIMATE STRUCTURE 53 
 
 away a portion sufficiently large for complete histo- 
 logical examination), has been carefully treated by a 
 competent observer, at first by Mr. Stanley Boyd, 
 with one or two by Mr. Eve, and others by Mr. 
 Shattock, while all the later ones (fourteen in number) 
 have been laboriously investigated for me by Dr. 
 Heneage Gibbes, from whom I have received in every 
 instance a full written report on intimate struc- 
 ture and several microscopic preparations, some of 
 which furnished the originals of some very accurate 
 and beautiful drawings, made and engraved by Mr. 
 T. P. CoUings, and presented here. 
 
 After a survey of the museum specimens on the 
 one hand, and a consideration of the facts determined 
 by histological analysis of my own cases on the 
 other, with Dr. Heneage Gibbes, I have made the 
 following attempt at classifying these products, and 
 I think it will be regarded as warranted by the 
 evidence. 
 
 First, there is the simple mucous polypus which I 
 have at present only found in the bladder of children, 
 and in their cases only among the preparations in the 
 museums referred to — some of which appear to be 
 analogous in structure to the soft nasal polypus, a 
 form of myxoma, while other specimens appear to 
 contain, in addition, more of the deeper normal fibres 
 of the structures from which the growth arises. In 
 the specimens referred to, of which one was engraved 
 
54 ON TUMOUES OF THE BLADDER 
 
 in Crosse's work, and another is presented here (fig. 
 8) ; the growths are numerous, evidently rapidly 
 
 Fig. 8. — Poljpoid growths (myxoma), from a child 1^ year old, 
 under Mr. Marshall at University College Hospital. From. 
 Museum, No. 1471 E. 
 
 formed, soon fill the bladder, and in the case of 
 female children sometimes issue by the external 
 meatus, and present in the vagina.^ 
 
 The operators have described the first-named 
 
 ^ One example of polypoid growths in a child is given in Dr. M. 
 Baillie's series of engravings illustrating the morbid anatomy of the 
 human body, &c. (London, 1799, fasc. vii. vol. iv. fig. 2, p. 151). 
 This is now Prep. No. 1999 R.C.S. Museum. Crosse's example is 
 shown at pi. xx. fig. 2 of the Treatise on Calculus (London, 1835), and 
 is Prep. No. 2000 in the same museum. Three other specimens are 
 in Guy's Hospital Museum : one, a girl aged five years — No. 2104 ^° — 
 described by Mr. Birkett in Trans. Med. Chir. Soc, vol. xli. p. 311 ; 
 another, 2104 ^2 ; and a boy, No. 2104 ^\ 
 
 One is in St. Bartholomew's Museum, 2419, described in Fath. Soc. 
 Trans., vol. iii. p. 127 ; one in St. Thomas's, B B 28 ; and one in 
 University College, 1471 e, carefully described in Path. Trans., vol. 
 xxxiv. pp. 150-1 — by Mr. S. Gr. Shattock. An interesting case is 
 reported by Mr. Howard Marsh in the Path. Soc. Trans., vol. xxv. 
 pp. 178-80, carefully examined by Mr. Butlin and by Mr. M. Beck. 
 
AS APPEARING IN CHILDEEN 55 
 
 kind when fresh as soft, gelatinous, and translucent ; 
 conditions which are lost in the preparation by 
 immersion in spirit. 
 
 In all but one of the eight cases in the museums 
 the age was two years or less, and in the exception 
 was five years only. It is not unlikely that some of 
 these may be congenital, while the structure shows 
 them to be composed of embryonic elements. I have 
 never met with anything of this kind in the adult 
 bladder. 
 
 Two of the more recent specimens have been 
 carefully examined and reported on at the Patholo- 
 gical Society, and are referred to m the note below, 
 forming in fact the two specimens last on the list 
 there given. One, examined by Mr. Butlin and Mr. 
 Beck, was ' found to be composed almost entirely of 
 small round cells of a lymphoid type embedded in a 
 basis, homogeneous or nearly so on the surface, but 
 becoming more and more fibrous towards the pedicle, 
 until at the base the fibrous tissue forms the bulk of 
 the growth, the cells being only scattered here and 
 there, either singly or in groups.' The other, exa- 
 mined by Mr. Shattock, is described as displaying 
 ' oval and more elongated cells lying in an abundant 
 intercellular substance, either albuminous or mucous, 
 and scantily traversed by fibres ; no stellate cells are 
 present.' 
 
 In regard to the cases of vesical tumour in which 
 
56 ON TUMOURS OF THE BLADDEE 
 
 I have myself operated, tliey fall naturally, as do 
 those of other regions, into two distinct categories : 
 namely, those which consist only of elements iden- 
 tical with the normal tissues of the bladder, ' homoeo- 
 plastic ' ; and those which consist, more or less, of 
 other elements never found in the tissues of the 
 healthy bladder, or ' heteroplastic' 
 
 The first category offers at least three forms of 
 growth, but passing insensibly from one to the other, 
 being apparently diverse developments of the same 
 structural change. Two of them may be spoken of 
 as papilloma, which appears in two typical forms. 
 Before describing them I shall give a representation of 
 healthy vesical mucous membrane for the purpose of 
 comparing the epithelium and its underlying tissues 
 in the bladder with the analogous tissues in papil- 
 loma. It is a drawing from a very successful section 
 made immediately after death from the emptied 
 bladder of an ape by Dr. Gibbes (Plate I.). It shows 
 a minute fold of the mucous membrane, resulting 
 from that duplicature of it which takes place when 
 the bladder is contracted. And thus it has, in this 
 temporary condition, a strong resemblance to the 
 permanent form which a single papilla exhibits when 
 papillomatous growth is present in the bladder. 
 
 1. Fimbriated Papilloma. — I employ this term 
 to designate that product which has been familiarly 
 known as the ' villous ' growth, which is admitted 
 
PLATE ]. 
 
 C"} 
 
 \ 
 
 Section of Healthy Mucous Membeiake, jiade dib,ectly afu'er Death, 
 FROM THE Ape : showing Natural Poldisg of the Membraxe in thk 
 emptied Condition op the Bladder, and the resemblance the Fold 
 bears to a Papilla: x IGO. 
 
FIMBKIATED PAPILLOMA 57 
 
 to be objectionable on several grounds. The most 
 obvious character of the growth is a structure in 
 which the vesical mucous membrane is developed 
 into fine papillas, which consist of long fimbriated 
 processes of extreme tenuity, and usually form a 
 group arising from a small circumscribed base. 
 This last-named part contains other and more solid 
 structure than that which enters into the papillas 
 themselves. Sometimes the processes are almost 
 single thread-like forms, arranged side by side, and 
 undivided for a considerable distance ; others are 
 bifid, generally more compound still ; some may be 
 described as digitate, and occasionally the processes 
 radiate and suggest forms resembling those of leaves. 
 Immersed in fluid, the long fimbriated growths float 
 out like slender-leaved aquatic plants in deep water ; 
 and when removed to air, collapse and form a soft 
 mass resembling a small strawberry. Usually one 
 only is found in a bladder ; sometimes there are two 
 or three, and sometimes minute growths of the same 
 kind may be found affecting, more or less, the 
 lining membrane of the cavity (see figs. 9 and 10 ; 
 also fig. 1 at p. 11). The microscopic structure, 
 which has been often well described,^ may be given 
 
 ^ Examples of these have been presented to the Pathological Society 
 of London by several observers ; among them by myself as early as 
 1856. Vide vol. v. p. 200, and vol. vi. pp. 213-4, both relating to the 
 same case. Another, vol. vii. pp. 256-7. Also vol. viii. pp. 262-4 ; 
 vol. xi. pp. 153-5 ; vol. xviii. pp. 176-8 ; vol. xxi. pp. 239-44 and 
 265-6 ; vol. xxxiii. p. 220 ; vol. xxxiv. pp. 157-60. 
 
58 ON TUMOUES OE THE BLADDEK 
 
 Fig. 9. — Fimbriated papilloma (' villous '), arising from a single 
 peduncle. From Museum of University College, No. 1471 A. 
 
 Fig. 10.— Fimbriated papilloma ('villous')- From Museum of 
 Eoyal College of Surgeons, No. 2005. 
 
 briefly as follows : ' Each of these delicate papilla3 
 or " villi " consists of a connective-tissue ground- 
 
PLATE II. 
 
 
 
 
 
 :.#f^ ^m^ 
 
 
 / 
 
 ^'r^ 
 
 o; 
 
 /^ -> 
 
 ^O- 
 
 7 ff^ 
 
 m 
 
 
 ^^, 
 
 ^^/€^~3,-'^,cCl'tf /'- 
 
 )i'^y 
 
 
 FlMBRIAXKP rAFILLOMA, PHOIVING TWO 07 THE SLEXDER PAriLLOMATOT'S 
 PTiOCKSSKS OB, lSO CALMP, ' ViLLI ' ; X 160 (FJROM CAi^K 15 OF TMF. TABLE.") 
 
FIBRO-PAPILLOMA 59. 
 
 work, covered by layers of columnar cells, resting 
 on a fine basilar membrane, and exactly resembling 
 those of the normal bladder. In the deeper part 
 there are bands of non-striped muscle. These 
 bands do not run into the papillte, only two or 
 three isolated fibres enter their bases. The growth 
 is well supplied with blood-vessels ; capillaries 
 running up and into the villi, and branching 
 directly under the basement membrane. They are 
 large, and have very delicate walls.' (Dr. H. Gibbes.) 
 The case of T. H. B., aged 40, case No. 15, is 
 the best example of this in the series : see Plate II., 
 in which drawing, as in those which follow, the 
 structures have been faithfully and very admirably 
 represented. 
 
 2. Fihro- Papilloma. — I prefer this term to that 
 of ' Ordinary papilloma ' as first suggested, because 
 it more correctly indicates the difference between 
 the structure now in question and that described as 
 ' fimbriated.' Thus in ' fibro-papilloma,' the papillary 
 processes, although present in more or less abundance, 
 do not constitute the chief part of the structure, which 
 is accordingly more solid, consisting of the consti- 
 tuents, unstriped muscle, and connective-tissue fibres 
 of the submucous tissues of the vesical coats. The 
 papillae are sometimes shorter, less developed than the 
 ' fimbriated ' processes of the previous division. The 
 microscopical report of the solid part or groundwork 
 
60 ON TUMOURS OF THE BLADDER 
 
 of the tumour in a typical case is as follows : ' Here 
 there is a distinct outgrowth from the wall of the 
 bladder, of trabeculse composed for the most part 
 of non- striped muscle- tissue. From these trabeculas 
 arise secondary trabeculse, into which the non- striped 
 muscle-tissue is continued in varying amount, accord- 
 ing to their size. The growth is covered with layers 
 of columnar epithelial cells, exactly similar to those 
 of the normal bladder.' Of this class the case of Dr. 
 MacC, No. 4, is one of the best examples. See Plates 
 III and lY. 
 
 It may be remarked here that the mere presence 
 of papillee on a tumour, whether met with in the 
 simple form which has been just referred to, or when 
 assuming the long fimbriated form previously de- 
 scribed, does not serve in any way to identify or 
 characterise a growth, since such papillae may be met 
 with springing from the surface of heteroplastic 
 growths, as epithelioma and cancer. 
 
 3. Tumours of a Transitional Type, — The third 
 type above referred to, although related with the 
 preceding, inasmuch as the basic structures are 
 still homologous with those of the bladder, appears 
 to be best indicated by using the term ' transitional ' 
 to describe it, as perhaps occupying a place be- 
 tween papilloma and a formation of malignant type, 
 sarcoma. Thus there is not only a peculiarity in the 
 arrangement of the basic fibres, but the presence of 
 
PLATE III. 
 
 
 K. 
 
 
 I'MlKll-rAriLLO.MA : UNDEU A LoW PoWEll (X 80) TO SHOW GEXEiiAL ^r.\^..\\• 
 MEXT 01'' STUUCTUJiE. (1?E0M CASE NO. i OF THE TABLIS.') 
 
PLATE TY. 
 
 ■>isf»(' J* 
 
 
 
 V&f 
 
 %K. 
 
 -i "^^jrVi^tj 
 
 FiBEo-PAriLLOJiA : rxnEK Hien Powek (x340) showing a Capillary 
 Vessel axd a tew No'-stkiped Muscle-Fibres. (Fbom Case No. 4 of 
 THE Table.) 
 
PLATE Y. 
 
 iS^. 
 
 ii^-j 
 
 
 ■-Ci_::s 
 
 .jr-S -<, 
 
 
 
 //• 
 
 
 
 .-■^ 
 
 ExiMPLi: OP THE ' Traxsitioxal ' Type of Tu.moue : showing the Grouxd- 
 
 SUBSTANCE INFILTRATED WITH VABIOUSLY-SHAPED CELLS.; AND NUMEROUS 
 BLOOD-VESSELS RUXXIN(J to THE SURFACE : OXE HAS GIVEN WAY, AND EFFUSED 
 
 Blood is well shown at the highest point : x ICO. (From Cask Ko. 1-' 
 ov THE Table.) 
 
OF A TRANSITIONAL TYPE 61 
 
 certain cells foreign to the structure itself is observed 
 — a fact of importance. 
 
 Dr. Heneage Gibbes describes these tumours as 
 ' characterised by a dense fibrous groundwork of very 
 irregular growth ; and by the presence in this ground- 
 work of variously shaped cells, generally arranged in 
 definite groups. In some they are small round cells, 
 in others large irregularly shaped cells with nuclei. 
 In some of these tumours there are in parts short, 
 thick papilla : in other places there are no papilla3, 
 but in all cases the surface is covered by colum- 
 nar epithelial cells, resembling those of the normal 
 bladder. The one feature which differentiates them 
 from the two preceding forms is the arrangement of 
 the ground substance, and the presence in it of the 
 irregularly shaped cells, which do not belong to 
 normal tissue on the one hand, or to distinct new 
 growth on the other.' These characters excite sus- 
 picion as to the issue of the growth. The cases of 
 C. C. S., No. 12, and T. S., No. 16, are examples of 
 this group : see Plate Y., which is faithfully drawn 
 from Case 12. 
 
 The second category of growths, the characteristic 
 of which is heteroplastic structure, is illustrated in 
 the bladder by epithelioma, and perhaps, but if so, 
 certainly in rare instances, by the sarcomata : between 
 which latter and the papillomata a relation has been 
 suggested in the last-noticed growth of the previous 
 
62 ON TUMOURS OF THE BLADDER 
 
 category, through the presence of certain cells above 
 described. 
 
 One example of epithelioma was met with in my 
 series, namely Case 6. It will be unnecessary to enter 
 on any description of this familiar product, but a 
 microscopic section of that tumour is seen, Plate YI. 
 The existence of true sarcoma of the bladder has been 
 affirmed,^ but not on the observation of fresh speci- 
 mens. The presence of leucocytes, or of other cells, 
 both round and spindleshaped, liable to be found in 
 abundance after inflammatory action in the growth, 
 or as seen in the transitional form described, has 
 perhaps led some observers to pronounce such struc- 
 tures to be sarcoma. Before long it is not improbable 
 that some unquestionable example will be met with 
 and identified. 
 
 Scirrhus undoubtedly occurs as a deposit in the 
 walls of the bladder, and usually affects the base and 
 sides sufficiently to admit of identification by rectal 
 examination. The hard, unyielding, irregular, knotty 
 outline presented there to the finger is so charac- 
 teristic as to make its presence easily recognised. 
 
 Cancer of an encephaloid type is sometimes met 
 with, but it is difficult at present to say how often it 
 affects the adult bladder ; it is probably not common 
 in that situation. It is interesting to observe that 
 there is one preserved example of melanotic growth, 
 
 1 Path, Trans., vol. xxxiv. p. 157. 
 
PLATE Yi. 
 
 / 
 
 '# 
 
 m 
 
 \ 
 
 1 V 
 
 
 
 ,1 
 
 \? 
 
 
 « • . ' .liifs 
 
 m^' 
 
 :3 
 
 Epithelioma : showixg Ingrowth of Epithelium axd a ' Nest ' ix 'i'hk Cextiik 
 OF the Section- : x 160. ("From Case No. 6 op the Table.) 
 
OE A CANCEROUS NATURE 
 
 G3 
 
 a very small one, affecting the bladder. It is in the 
 Museum of Guy's Hospital, and was found at the 
 autopsy of a man aged thirty-two, who had been a 
 patient with melanotic disease of the eyeball, and 
 with similar deposits in various other parts of the 
 body. It is represented at fig. 11. 
 
 Fig. 11. — Small melanotic tumour of the bladder. Guy's Museum, 
 No. 210^2°. 
 
 Finally, that rare product, dermoid tumour, is 
 occasionally found in the bladder. The contents of 
 dermoid cysts, it is well known, are sometimes ex- 
 pelled, probably from an ovarian source, through the 
 urinary passages. But in one case, which occurred 
 in the practice of my friend Mr. T. Bryant, and 
 which I had the pleasure of seeing with him, the 
 locality of a dermoid tumour was undoubtedly vesical. 
 It occurred in a married lady, aged 30, whose first 
 symptoms were those of cystitis, with the appearance 
 in the urine of long hairs coated with phosphates, 
 considerable quantities of which were from time to 
 
64 
 
 ON TUMOUES OF THE BLADDEE 
 
 time removed from tlie bladder. Subsequently digital 
 exploration was made, a pedunculated tumour dis- 
 covered, and completely removed in two operations. 
 It was composed of a tbick layer of true skin, witb 
 mucb fibrous matter, interspersed witb sebaceous 
 glands and bair follicles. Altogetber it much re- 
 sembled in form and size an ordinary, ratber large 
 button musbroom. Tbe patient is now absolutely 
 free from all symptoms. I am indebted to Mr. 
 Bryant for tbe accompanying drawings illustrating 
 tbe nature of this formation (figs. 12 and 13). 
 
 ■o.y^ 
 
 Fig. 12. — Dermoid growth removed from the bladder, with hairs 
 (A) covered with phosphatic concretion. B. First part re- 
 moved. C. Pedicle with ligature. D. Growth and pedicle 
 finally removed. 
 
 It may be now fairly inferred tbat tbe common- 
 est species of tumour affecting tbe adult bladder are 
 
DERMOID TUMOUKS 
 
 65 
 
 papilloma, occurring in two forms — the fimbriated in 
 tufts of elongated papillas, and the fibro-papilloma, 
 
 Section 
 
 -J Muscular O^^^^^^fc 
 
 Fig. 13. — Microscopical appearance of a section of the skin 
 covering the dermoid tumour. 
 
 more solid, largely composed of the ordinary sub- 
 mucous tissues forming the vesical coats — all homoeo- 
 plastic in character. A third product, more or less 
 resembling the latter in its fibrous constituents, but 
 exhibiting the presence of cells, doubtful in character, 
 sometimes perhaps due merely to inflammatory action^ 
 while it excites suspicion as to its tendency, cannot 
 be altogether removed from the homoeoplastic group, 
 and, as before said, is provisionally termed ' transi- 
 tional.' The papillomata have certainly no malignant 
 
66 ON TUMOURS OE THE BLADDER 
 
 tendencies, but their disposition to increase and fill 
 the cavity of the bladder, and thus to disintegrate at 
 their periphery, together with their vascularity and 
 consequent strong disposition to bleed largely, render 
 them sooner or later invariably fatal. 
 
 About ten or eleven cases of my own series 
 are certainly papillomatous. Collating the accounts 
 given, and the phenomena manifested by these 
 patients, the general symptoms may be described as 
 follows : — 
 
 Symptoms. — The earliest symptom is mostly 
 haimorrhage. It is observed before unduly frequent 
 micturition is complained of and before it is painful. 
 On the other hand, in most of the cases in which 
 the tumour was of the malignant type or approached 
 thereto, pain and frequency of passing water gener- 
 ally preceded the appearance of blood, sometimes for 
 a considerable period of time. In almost. all cases 
 symptoms had been noted during at least three years 
 before the patient applied to me ; in some as much 
 as six or seven years. When the growth consists 
 chiefly of delicate filiform papillse, the bleeding is 
 more continuous and free than in ' fibro-papilloma,' 
 or in the ' transitional ' forms, where the structure 
 is more solid, and where the fimbriated processes may 
 be altogether absent, or but little developed. There 
 appears to be nothing particularly characteristic in 
 the nature of the , haemorrhage, excepting the one 
 
SYMPTOMS AND PHYSICAL SIGNS 67 
 
 important circumstance, always to be inquired for, and 
 which ought, if possible, to be observed by the sur- 
 geon himself; namely, that in the act of micturition 
 the stream may sometimes commence without any 
 blood stain, or with only a slight admixture, and end 
 of a bright red colour from the presence of much fresh 
 blood. With such an occurrence, and no recent 
 urethral lesion having been made, the source of 
 hsemorrhage must always be vesical. Supposing in 
 such circumstances that the absence of stricture, ordi- 
 nary diseases of the prostate, calculus of the bladder, 
 and cancer, have .been ascertained by sounding and 
 by rectal examination, it remains only to observe 
 certain products which the urine itself may contain. 
 
 Physical Signs. — I should first say, that little 
 positive evidence is obtained by the rectal and vesical 
 examinations just referred to, in relation to any other 
 growth than the hard, cancerous deposits, which are 
 usually easy enough to identify. The result is 
 generally negative, or nearly so, when a growth of 
 the papillomatous or of the allied variety is present. 
 The only positive physical sign thus attainable which 
 I have met with, and this in a few cases only, has been 
 the sense of slight obstruction to the free movement 
 of the sound on one or the other side of the bladder, 
 in others merely ' a soft feel,' as I have termed it 
 in my notes, as if one were moving the sound in a 
 thicker medium than urine, and without so defined a 
 
 F 2 
 
68 ON TUMOURS OF THE BLADDER 
 
 limit as is presented by the healthy vesical walls. 
 Then, when examining by rectum, a soft rounded 
 fulness is sometimes to be felt when the finger can be 
 passed beyond the prostate to the base of the bladder, 
 but nothing that is in the least degree definite or dis- 
 tinct. 
 
 I have made a practice of fully examining the 
 bladder with a sound, and the rectum by means of 
 the finger while the patient is under the influence of 
 ether on the operating table, prior to performing 
 digital exploration ; nevertheless, such are the con- 
 clusions I am compelled to come to in relation to 
 sounding for tumour. 
 
 Examination of the Urine. — This process is 
 highly important, and is often very significant. Its 
 object is to obtain disintegrated portions of the tumour 
 if present, and to identify their structure under the 
 microscope. It may be necessary to examine several 
 specimens in order to obtain indubitable evidence on 
 this point. An excellent way of obtaining such 
 specimens is to wash out the bladder freely with 
 warm water. It rarely happens that this process fails 
 to detach fragments sufiicient for our purpose if there 
 is a fimbriated growth in the interior. But I have 
 recently adopted, after failure by simple washing, the 
 use of an evacuating catheter of small size, connected 
 with the aspirator employed in lithotrity, and by this 
 means have easily obtained specimens which were 
 
EXAMINATION OF THE URINE FOR 69 
 
 complete evidence of the presence of a growth. This 
 occurred in my last case, No. 20. 
 
 There is still another method which, when a fim- 
 briated growth is present, will secure a specimen, and 
 will, moreover, sometimes identify the presence of a 
 salient tumour. It consists in carefully exploring 
 the bladder with a small flat-bladed lithotrite. I dis- 
 covered my first tumour thus ; it was coated with 
 phosphates, and I thought it might be a partially 
 sacculated calculus, as I could seize but could not 
 move it. I have been able to detach small portions 
 of a growth thus, a little haemorrhage necessarily 
 resulting. 
 
 Supposing, however, that some fragments have 
 been washed out, these should be placed under a 
 :|-inch object-glass, when the following elements 
 may be sought. First, a portion of a slender papilla, 
 or so-called ' villus,' sufiiciently complete for identi- 
 fication, may be met with ; the arrangement of colum- 
 nar epithelium, at right angles to a central axis, and 
 radiating round the terminal point, and presenting a 
 structure which is unquestionable proof of the exist- 
 ence of such a growth in the bladder. On two occa- 
 sions I have decided to operate on the strength of this 
 evidence. 
 
 Secondly, the appearance to the naked eye of small, 
 slightly translucent, semigelatinous fragments in the 
 urine are, of course, very significant. Under the power 
 
70 ON TUMOURS OF THE BLADDER 
 
 named, these mostly appear to be made up of spindle- 
 shaped nucleated cells, some comparatively short and 
 broad, others elongated, and some nearly acquiring the 
 character of a short fibre. These fragments have been 
 present in several cases in which tumour has been 
 subsequently found ; a fact which, in each instance, is 
 noted in the Table of Cases. In two or three instances 
 I have examined the urine day after day, and found 
 no characteristic structure, but this was before I 
 sought, as I now invariably do, by purposely washing 
 out the bladder. In one or two others I have found 
 great numbers of cells like young pavement epithe- 
 lium, but these are not sufficiently characteristic to 
 offer any indication available for diagnosis. 
 
71 
 
 CHAPTER IV. 
 
 OPERATIONS FOR THE REMOVAL OF TUMOUR AND 
 THEIR RESULTS — CASES AND TABLE. 
 
 Treatment — Styptics — Injections — Operation for their removal — 
 Results — Cases. 
 
 Treatment. — Supposing we have arrived at the con- 
 clusion that the bleeding is certainly vesical, and that 
 in all probability it arises from the presence of an 
 intravesical growth respecting which there is no evi- 
 dence that it is cancerous in its nature : — are there 
 any means to be employed for checking the growth, 
 or even for destroying it, without having recourse to 
 a surgical operation involving the use of the knife? 
 Are there any means by which haemorrhage may be 
 subdued or restrained in cases considered temporarily 
 unfit for operation through exhaustion, &c., or for 
 cases in which operation is only partially successful in 
 removing the tumour, and a portion is inevitably left 
 behind ; or for those cases of malignant tumour which 
 are not amenable to any attempt to remove them, and 
 are therefore only susceptible of palliative treatment? 
 I would reply that, in my experience, I do not 
 know one of the so-called internal styptic remedies 
 
72 ON TUMOURS OF THE BLADDEE 
 
 which is of any service in vesical haemorrhage from 
 any form of tumour. It is exceedingly difficult to 
 prove a favourable result on the trial of any one 
 of these agents. An attack of vesical ha3morrhage 
 naturally runs a short course provided the patient 
 ceases his usual active habits. It is in connection 
 with this influential treatment — viz. rest and the 
 recumbent position — that styptics are given ; and 
 when the haemorrhage stops, as it has a natural 
 tendency to do, the drug swallowed at the time 
 obtains the credit of a power which almost certainly 
 does not belong to it. 
 
 I have much more confidence in astringent injec- 
 tions thrown into the bladder with great gentleness, 
 and through a small soft catheter. The two which 
 I have used, and with some frequency, for cases in 
 which operation is not at present decided on, and 
 especially for those in which the tumour has been 
 only partially removed, are perchloride of iron and 
 nitrate of silver. These latter cases have been far 
 more improved after incomplete operative procedure 
 than I could have anticipated, and their recurring 
 haemorrhages have been readily controlled by these 
 agents, the iron being, perhaps — certainly in two 
 of these cases — more efficient than the other. The 
 strength employed has been from 20 to 60 minims of 
 the tincture of the perchloride of iron in 4 ounces of 
 cold water ; to be used daily once or twice, accord- 
 
TREATMENT BY INJECTIONS 73 
 
 ing to circumstances. Of the nitrate of silver, from 
 gr. i. to gr. vi. in 4 omices of water ; the stronger 
 solutions being rarely tolerated or necessary. 
 
 In regard of malignant disease above alluded to, I 
 may in this place briefly but emphatically state that 
 if the physical characters and symptoms, especially 
 the former, indicate the presence of a growth of this 
 nature, any operative proceedings for its removal 
 must be not merely futile and imperfect, but ex- 
 tremely dangerous, and ought not to be undertaken. 
 It does not follow, however, that in such, cases the 
 draining of the bladder by a perineal opening may 
 not, in certain circumstances, be a useful proceeding 
 to relieve suffering or prolong life, &c. 
 
 Lastly, I do not propose to do more than name 
 here the great importance of careful attention to the 
 digestion and state of the bowels, in all cases of 
 haemorrhage from intrapelvic sources, but shall re- 
 turn at once to consider the only means of affording 
 permanent relief to the subject of vesical tumour, 
 namely, the operation for its removal. 
 
 Operation. — We now suppose that digital ex- 
 ploration has been made by external urethrotomy, 
 and that the steps of the proceeding have been 
 followed, as described in the second chapter, and 
 further, that the operator, on introducing his left 
 index finger, at once encountered a growth of some 
 kind. He should first deliberately spend some two, 
 
74 ON TUMOURS or THE BLADDER 
 
 three, or four minuteSj if necessary, in ascertaining 
 its size, situation, and general outline. 
 
 Pressing the abdomen firmly with his right hand 
 into the pelvic basin, he soon ascertains whether the 
 tumour be attached to the wall of the bladder by a 
 narrowish pedicle, or whether it is rather an out- 
 growth which springs from a considerable area of the 
 coats, and is inseparable from them. He traces the 
 surface, which may be broadly mamillated, one or 
 many lobed, or simply polypoid, firm in contour, or 
 soft and fleecy. Lastly he observes whether the 
 whole is dense, compact, and immovable, or soft, 
 more or less floating, and perhaps fragile. It is im- 
 portant to have a distinct idea of the situation of the 
 tumour, as to whether it lies more to the operator's 
 right or left, which is at once apparent in most 
 instances ; then, whether it belongs more to the side 
 or to the floor of the bladder, or whether it springs 
 from the opposite surface farthest from the meatus, 
 or from the upper aspect of the cavity. The mind 
 soon forms a distinct image of the body to be dealt 
 with, and simultaneously arrives at a judgment as 
 to whether it be possible to remove it entirely or 
 partially, and if the latter, whether a sufficient portion 
 can be safely taken away to warrant further surgical 
 interference. If the tumour be polypoid in form, 
 with a distinct pedicle, narrow, or even wide, there 
 can be no doubt as to the propriety of operating. 
 
THE OPERATION BY EXTERNAL URETHROTOMY 75 
 
 But if the growth admits of considerable portions 
 being removed without injuring the substance of the 
 vesical coats, which -should be approached with great 
 caution, then, also, my opinion is that such portions 
 should be attacked, under the conditions hereafter to 
 be named. When, on the other hand, the substance 
 is hard, and exhibits no marked prominence of con- 
 tour, characters usually found to be associated, no 
 such attempt should be made ; a small portion may 
 be easily removed for microscopic examination, and 
 that should be done. 
 
 But now comes an important consideration which 
 should be carefully disposed of before any interference 
 with the tumour takes place from the perineal opening. 
 
 When the survey of the vesical cavity has been 
 completed, the operator has to determine the follow- 
 ing question : Am I capable of completing my design 
 of removing the tumour before me wholly or parti- 
 ally, as the case may be, through the incision made, 
 or should I do so more efficiently through a supra- 
 pubic opening ? For it may be taken for granted 
 that a case may occasionally present itself in which 
 the latter course may appear to be preferable, and 
 if so there is no reason whatever for not selecting 
 it. The perineal incision made will not add to 
 the risks of the case, and it has afforded that most 
 important element, the means of obtaining an exact 
 diagnosis. 
 
76 ON TUMOURS OF THE BLADDER 
 
 Now I may here say that my proposal to remove 
 vesical tumours by perineal urethrotomy has met with 
 a direct challenge in Paris from my friend Professor 
 Guyon and his school, who say that the suprapubic 
 operation should be invariably employed for the pur- 
 pose, and the perineal operation never. I cannot 
 refrain from suggesting that the emphasis with which 
 this doctrine is just now enunciated by some, would 
 be more authoritative had the writers ever tested the 
 method I have now so often practised. There can, I 
 suppose, be no hesitation in anyone's mind that the 
 high operation is a much more formidable and 
 hazardous proceeding than the simple boutonniere. 
 Why, then, should the former be practised in any 
 case until absolute certainty is attained, not only 
 that tumour is present, but also that it is remov- 
 able by operation ? No doubt that in a consider- 
 able proportion of suspected cases, the presence of 
 tumour may be regarded as strongly probable ; but 
 in very few can it be stated with certainty until 
 the finger has entered the bladder. In no single 
 case can the surgeon ascertain whether or no the 
 tumour in question is separable from the bladder 
 until the cavity has been opened and the physical 
 conditions examined. Well, all these facts— first, 
 the fact of the presence of tumour; secondly, its 
 form and size ; thirdly, the nature of its connections 
 with the vesical structures— all the data necessary 
 
PERINEAL PREFERABLE TO HIGH OPERATION 77 
 
 for determining the question of operation can be 
 attained by a slight urethral incision which involves 
 no risk. What imprudence, then, can be greater than 
 that of performing the high operation with all its 
 admitted risks while the operator does not know for 
 certain that a tumour is present ; and while he knows 
 that if he does find one the numerical chances are even 
 that the tumour, although thus completely approached 
 and laid bare, cannot be entirely removed without 
 inflicting fatal injury on the patient ; since one-half 
 the cases are not completely removable. 
 
 Further, I declare that while the boutonniere 
 enables the surgeon to ascertain all the facts which it 
 is so necessary to obtain before operating, it also 
 enables him to remove the tumour without difficulty, 
 when it is polypoid in form, and therefore capable of 
 being removed with a fair amount of ease and safety. 
 If however he believes — and he is then in a position 
 to determine the question — that he can attain a better 
 result in any particular case by the high operation, 
 there is nothing whatever to prevent his performing 
 it. In one, or at most two, of my twenty cases, 
 in two of the early ones perhaps I might have so 
 operated with advantage. I should probably do so 
 now on again encountering similar conditions, but in 
 all the remaining cases the risk to the jDatient would 
 have been greatly increased by performing the high 
 operation, and I should have acquired no facility for 
 
78 ON TUMOURS OF THE BLADDER 
 
 removing his tumour beyond that which external 
 urethrotomy afforded me. On the other hand, when a 
 tumour is discovered which it is impossible to remove, 
 I have the satisfaction of knowing that, at all events, 
 nothing has been done to endanger the patient's life 
 by the simple operation which has been performed. 
 
 We shall now consider the means which it is 
 desirable to employ m order to remove the tumour, 
 when, having examined it fully, we have decided 
 to make an attempt through the perineal opening. 
 First, if we have the good fortune to encounter a 
 single growth, polypoid in form (see diagrams, in 
 the Table of Cases, Nos. 1 and also 13 and 15), and 
 therefore with a pedicle of no great width, there 
 need be no hesitation whatever in introducing a 
 pair of forceps into the cavity of the bladder, and 
 employing them there without any aid from the 
 operator's finger. The forceps to be used for this 
 purpose are to have rather wide and serrated margins 
 where the blades meet, so as to crush, but without 
 any power to cut the tissues seized. These forceps 
 should be provided in different forms. The first, 
 or simplest pattern, should be straight, resembling 
 an ordinary lithotomy forceps (fig. 14). Others 
 should be curved for seizing tumours which are 
 situated laterally and near to the neck of the bladder, 
 in which last-named position the straight forceps 
 are powerless to grasp the tumour (figs. 15 and 17). 
 
FORCEPS USED FOR REMOVING TUMOURS 79 
 
 Fig. 14. —Straight forceps. 
 
 Fig. 15. — Slender, laterally curved forceps, for removing a growth 
 close to the neck of the bladder 
 
 Fig. 16. — The same forceps looked at from the front, so as not to 
 show the curve. 
 
 Fig. 17. — Curved forceps for tumours occupying the sides of the 
 bladder. 
 
 Fig. 18. — The same forceps looked at from the front. 
 
80 ON TUMOURS or THE BLADDER 
 
 A pair of each pattern should have cutting edges 
 for exceptional cases, when, for example, the growth 
 is more firm and solid than usual. When the 
 blades are free in the cavity they have merely to be 
 opened easily and widely, and on closing them it is 
 almost certain that they will grasp the polypus more 
 or less completely. The proceeding thus advised is 
 more likely to prove successful in accomplishing its 
 object, than is the attempt to seize a stone in the 
 bladder. But here let it be observed that no supra- 
 pubic pressure should be made during this act ; 
 nothing should be done to interfere with the natural 
 contour of the bladder. The operator, by light and 
 easy movements of the forceps in varied directions, 
 ascertains that he has the growth within their grasp. 
 My advice is that, above all things, he is not now to 
 pull forcibly, but that he is to press firmly the blades 
 together, biting or chewing a little, if I may use the 
 terms, with the extremities of the blades, without 
 changing the original situation of the bite or grasp. 
 Then a little twisting movement may help to dis- 
 engage the mass, which if accomplished, the forceps 
 will be felt free, and may be withdrawn with their 
 contents ; after which the finger enters to feel what 
 remains, and what more must be done in order to 
 complete the removal. Let me remark, whenever the 
 forceps has removed a portion, however small, the in- 
 strument should never be re-introduced until the finger 
 
OTHER INSTRUMENTS TO REMOVE TUMOUR 
 
 81 
 
 has again examined the interior, and enabled the ope- 
 rator to form a fresh estimate of the portion remain- 
 ing, if any, to be removed. But, supposing that the 
 tumour has not been separated by the moderate 
 amount of forceps action described, the operator may 
 disengage and remove them ; when on introducing 
 the finger he will probably find the part so nearly 
 
 Fig-. 19. — Instrument with serrated end for separating by rotatory- 
 movement a portion of tumour fixed by the index finger. 
 Seen in profile, one-third natural size. The end is shown in 
 two positions of the natural size. 
 
 Fig. 20. — Another serrated instrument, curved in form. 
 
 severed that the actual division may be completed 
 with the finger nail ; or with one of the little serrated 
 instruments which I have designed for the purpose, 
 and for the employment of which there is ample room 
 through the urethral wound, by the side of the index 
 finger (see figs. 19, 20). There is really no difficulty, 
 nor is there any risk, with ordinary care, in removing 
 
 G 
 
82 ON TUMOURS OF THE BLADDER 
 
 a growth or two of pedunculated form, sufficiently 
 near to the walls of the bladder to render the opera- 
 tion a permanently successful one. I suppose that 
 the ultimate result of dividiiig the pedicle of a tumour 
 in the manner described is such a cicatrisation of 
 the wound as to prevent the recurrence of outgrowth 
 from that spot hereafter. 
 
 But other means may be used according to the 
 judgment of the surgeon. A very small ecraseur, 
 with violin-string ligature, may be manipulated by 
 the side of the index finger, and used in polypoid 
 forms of tumour. In the cases of women, such a 
 tumour may sometimes be slowly and carefully 
 brought into view by traction on the forceps, and 
 then the pedicle may be ligatured. I have succeeded 
 in doing this is one case ; so has Mr. Bryant. In 
 another I drew a polypoid mass within view, and 
 found it was a completely encysted calculus ; I then 
 opened the mass, when the calculus escaped. 
 
 But in the male it has occasionally happened that 
 the tumour can be drawn through the wound, as 
 happened with Mr. Davies Colley, and also with Mr. 
 Morris, in whose case the growth seemed to have 
 been extruded by natural vesical efforts on the day 
 after operation (having been left untouched on the 
 first), and was then removed, the patient making a 
 good recovery. 
 
 But when the growth takes a more complex form 
 
PARTIAL REMOVAL IN SOME CASES 83 
 
 — as when several lobes spring from a wider base, 
 for examples see diagrams Nos. 4, 7, 13, 16, in 
 Table of Cases, pp. 97-111 — the forceps must be de- 
 pended upon for removing them by repetitions of the 
 same process which is employed for the single growth. 
 But when the base is wider still and the growth is 
 less prominent, as that represented in diagrams Nos. 
 5, 12, 17, 18, 19, it is doubtful whether complete 
 extirpation is possible by any proceeding, either 
 through a perineal or through a suprapubic opening. 
 The wide base involves such intimate continuity 
 of tissue between the coats of the bladder and the 
 structures of the growth, that I believe separation 
 to be mostly impossible ; and that ablation of the 
 promment portions of the growth, when feasible, 
 should be undertaken only with the view of retard- 
 ing its progress, but with no prospect of effecting 
 complete separation of the disease from the body. 
 
 These portions are to be seized and destroyed, 
 partly by removal on the plan just described, and 
 partly by crushing, and thus inducing sphacelus and 
 sloughing of the growth. The question of applying 
 some chemical astringent arises in such cases, and 
 its utility may be regarded, perhaps, as twofold. A 
 solution of the perchloride of iron may tend to check 
 the haemorrhage, which is almost invariably very 
 free for a few hours after the removal of wide -based 
 growths, and it may partially destroy the portion 
 
 G 2 
 
84 ON TUMOURS OF THE BLADDER 
 
 which remains after the forceps have done their work. 
 For this purpose I have contrived a straight and also 
 a curved glass syringe containing a small sponge, 
 saturated with solution ; the sponge being pressed 
 by the piston permits the escape through small 
 perforations at the extremity of from 30 to 60 
 minims of the solution, at the precise spot where it 
 is desired to make the application. 
 
 There is one circumstance important to be noted, 
 especially in dealing with the less prominent growths ; 
 and that is, the effect of strong suprapubic pressure 
 made by an assistant in relation to their apparent 
 situation, and their mode of presentation to the finger 
 of the operator engaged in exploring the bladder, and 
 in estimating their size and form. If that pressure is 
 considerable it forces the upper wall of the bladder 
 into its own cavity, and thus gives to the growths 
 a larger contour than they possess, and makes them 
 apparently salient to a much greater extent than they 
 really are. Thus an eager or inexperienced oper- 
 ator, unaware of the effect of strong suprapubic 
 pressure, might be led to seize the mass offered to 
 the forceps, through the influence of this pressure, 
 and under the belief that it was a large growth, he 
 might inflict a fatal wound by crushing a double fold 
 of the coats of the bladder, and so making an opening 
 in the peritoneum. To avoid such a catastrophe it 
 is only necessary, first, to decline the attempt to 
 
RESULTS OF OPERATION FOR 85 
 
 destroy any growth which is clearly not sufficiently 
 salient to admit of complete or nearly complete re- 
 moval ; and, secondly, never to employ the forceps 
 while forcible suprapubic pressure is made ; at least, 
 no more pressure than is desirable just to steady and 
 support the bladder and the parts adjacent. 
 
 Results. — We have now, finally, only to consider 
 what are the results which have been attained by 
 the perineal operation in relation to vesical tumours. 
 
 Of the twenty cases of tumour, two were in 
 women : one of these died in three days of total sup- 
 pression of urine ; autopsy showing advanced disease 
 of kidneys (one contained a large calculus), and that 
 no injury was inflicted upon the bladder. The other 
 is now in excellent health, having entirely lost her 
 painful symptoms ; observing a few drops of blood, 
 occasionally, after more exercise than usual : more 
 than two years have elapsed since the operation. 
 
 Of the eighteen male cases, five died within three 
 weeks after the operation ; three others died at periods 
 of some months after, two of them from malignant 
 disease developed elsewhere. The other nine are 
 living ; one of these, from whom I removed a tumour 
 in the autumn of 1882, 1 operated on again, removing 
 a larger growth than the original one last February, 
 and he has again recovered. In four cases no attempt 
 was made to remove the tumour, it being manifestly 
 impossible to do so, but only to diminish it as far as 
 
86 ON TUMOUES or THE BLADDER 
 
 practicable with safety ; all these recovered well, and 
 are rather better than before. Of the remaining four, 
 one has had no return whatever, four years having 
 elapsed since the operation ; a second has slight signs 
 of a return, one year and a quarter since operation, 
 but works hard for his living at 64 years of age ; a 
 third, who, like the last, was at death's door from loss 
 of blood when I operated, has greatly improved, and 
 is actively employed ; but has recently shown some 
 disposition to bleed after exercise, nearly a year 
 since operation. The fourth was greatly improved, 
 and returned to the active life for which he was 
 before disqualified. The others have too recently 
 been operated on, to furnish any material fact to 
 be reported. More ample details are furnished in 
 the Table of Cases drawn up and accompanying 
 this. 
 
 1 may thus briefly sum up the record of the nu- 
 merous facts related. For every one of these patients 
 with tumour, in the natural order of events, one result 
 only was possible. Left without surgical aid, death 
 inevitably awaited each : a fate not merely certain, 
 but necessarily involving protracted suffering. 
 
 Whatever surgery can accomplish m the way of 
 saving life for several of these patients is obviously so 
 much clear gain. I am therefore satisfied with what 
 has been achieved for the first twenty cases ; having 
 naturally desired greater success ; but I have reason 
 
RESULTS OF OPERATION FOR 87 
 
 to expect that it will be greater in the next twenty 
 cases, through having acquired some valuable expe- 
 rience which I have thus attempted, so far as this is 
 possible, to make useful to others. 
 
 We may certainly reckon on ability to save life in 
 a few instances, such as are recorded here ; we may 
 also often prolong valuable life, a fact illustrated by 
 several of the cases recorded both by myself and by 
 other operators. 
 
 There is still another result which ought not to 
 be overlooked. Whatever value may have accrued 
 to a few patients in the matter of saving or pro- 
 longing life, a matter which is wholly incalculable, 
 there has been an opportunity afforded, on a scale 
 never before met with, for careful inquiry into the 
 external physical characters and histological elements 
 of vesical growths. This research has been system- 
 atically pursued ; and with the aid of valuable co- 
 operation already referred to, I have been able to 
 present a scheme for classifying the facts obtained, 
 which I trust may prove to be a contribution, how- 
 ever humble, to an improved acquaintance with this 
 important subject. 
 
 I append five of the cases which are most worthy 
 to be reported at length, partly because each more or 
 less illustrates a particular type of growth, together 
 with its history and progress, and the symptoms 
 
88 ON TUMOURS OF THE BLADDER 
 
 associated with it, and partly because the kind of 
 after-treatment and subsequent history are to some 
 extent indicated also. The number to each case 
 corresponds with that which marks its place in the 
 table of twenty cases which follows after. 
 
 Case 1. — T. R., set. 29. Fibro - papilloma, or transi- 
 tional (?). 
 
 1880, July 26. He first consulted me. I learned that 
 eight years previously he had passed ' a piece of gravel the 
 size of a pea.' After this he felt nothing unusual until three 
 years ago, when his micturition became more frequent, and 
 was followed by pain in the end of the penis, also occasion- 
 ally blood appeared in the urine, especially after exercise. 
 
 With these symptoms, I sounded the patient, and I 
 found a small calculus, which on August 5 was easily 
 crushed and removed. It was composed of oxalate of lime. 
 
 Very little improvement followed the operation : the 
 bladder was not quite emptied by the natural efforts ; the 
 gum catheter was used daily, and on two occasions gave 
 signs of the presence of something in the bladder, which a 
 subsequent exploration of the lithotrite did not discover. 
 Such results were unusual and somewhat puzzling. Being 
 relieved, he resumed his employment, and was occasionally 
 seen relative to the still existing slight symptoms, which, 
 however, gradually increased. 
 
 On October 5 I examined the bladder, and removed a 
 quantity of phosphatic deposit with the lithotrite. I then 
 seized what at first felt like calculus, and partially crushed 
 under pressure ; but it was evidently fixed, giving me the 
 impression that I was dealing with a portion of stone par- 
 tially impacted, and that the remainder would be beyond 
 my reach. 
 
 1880, Nov. 6. I made exploration after median incision 
 
SOME CASES OP OPERATION IN DETAIL 89 
 
 into the urethra in presence of Dr. Seegen of Carlsbad, Dr. 
 Paggi of Florence, and Mr. Ceeley of Aylesbinry. Having 
 introduced my finger well into the bladder, and pressure 
 being made above the pubes, I soon recognised a tumour, 
 about the size of a chestnut, growing apparently from the 
 opposite wall or fundus, and somewhat to the patient's left, 
 coated with phosphatic matter, and evidently the fixed body 
 I had formerly seized with the lithotrite and denuded of its 
 sabulous covering. Taking a pair of small forceps, I ad- 
 justed them to a full and firm hold, and then twisted off the 
 mass without difficulty ; a small piece or two were subse- 
 quently withdrawn, but the tumour appeared to be entirely 
 removed, and very Kttle bleeding followed. He had no bad 
 symptoms, made a rapid recovery, speedily regained good 
 health, never having had any return of symptoms since the 
 operation, now nearly four years ago. He is now in perfect 
 health, June, 1884. 
 
 Mr. Stanley Boyd, formerly Surgical Registrar of Uni- 
 versity College Hospital, examined a portion of the tumour 
 from this case, and his report thereon is as follows : — 
 
 ' A small piece, taken from the surface of the tumour, 
 was handed to me for examination. It was thickly encrusted 
 with phosphates, and beneath these the surface was finely 
 irregular. On section, the growth was firm and of uniform 
 consistence ; but its structure could only be guessed at as 
 fibrous. 
 
 ' Microscopically, it consisted of fine bundles of fibrous 
 tissue, having a general direction vertical to the surface. 
 Small round cells were scattered pretty copiously at parts, 
 especially towards the free surface, but there was no regu- 
 larity in their distribution.' 
 
 It might perhaps now be classed as an example of ' fibro- 
 papilloma.' 
 
 Case 2. — Mrs. F., aet. 30. Fibro-papilloma. 
 
 1882, May 5. I first saw her with Dr. Philson of Chel- 
 
90 ON TUMOURS OF THE BLADDER 
 
 tenham, and learned that in 187*7 she first observed blood 
 in the urine, but had no pain. 
 
 In June, 1879, severe cystitis, which became chronic. 
 Throughout 1880-81 much frequency of micturition, but no 
 severe attacks ; occasionally blood in the urine. 
 
 1882, February. Much bleeding. In March, severe 
 cystitis, and confined to her room since. 
 
 May 9. Dilated the urethra under ether, detecting a 
 growth (represented by the diagram in the Table) at the 
 centre of opposite aspect of bladder behind and above the 
 trigone ; and removed three chief portions with the forceps. 
 Bleeding free at first, subsiding during the day. A catheter 
 was tied in, and remained forty-eight hours, She made a 
 rapid recovery, and left town holding water five hours at the 
 end of three weeks. 
 
 The tumour was examined by Mr. Stanley Boyd. See 
 report below. 
 
 1883, February. There has been slight bleeding lately, 
 and she has come up to town at my desire. Dr. Philson 
 was present. I found a growth near the neck of the bladder 
 about the size of a cherry, which I removed with a pair 
 of laterally curved forceps. At the first operation I had 
 only forceps of the ordinary form used in lithotomy, and 
 could not command any outgrowth thus placed, and only 
 constructed other forceps as fresh circumstances demanded. 
 She soon returned quite well. 
 
 1884, J-pHi 17. I heard there was no frequency of 
 micturition, and that there was no pain. Occasionally, after 
 exercise, sees a few drops of blood. 
 
 Mr. Stanley Boyd examined the parts removed, and 
 reported as follows : — ' The growth consisted of three chief 
 masses of roughly spherical form, one-half to three-quarters 
 of an inch in diameter, and having short, narrow pedicles, 
 and of two or three small sessile masses of similar shape. 
 All the nodules were velvety on account of the projection 
 
SOME CASES OF OPERATION IN DETAIL 91 
 
 everywhere from their surfaces of thin folds, and embranched, 
 somewhat club-shaped processes, one-sixteenth of an inch 
 or less in length. Under the microscope these processes 
 consisted almost entirely of one or two very thin-walled 
 vascular loops of wide calibre, but some showed a good deal 
 of round-celled infiltration. They were covered by a thick 
 layer of epithelium, the component cells of which were 
 columnar, very long, and narrow ; the epithelium stripped 
 off with the greatest ease. The mass of the tumour con- 
 sisted of rather loose connective tissue, containing here and 
 there small collections of round cells. No glandular struc- 
 ture was seen. Vessels very large, numerous, and provided 
 with stout coats in the body of the growth, but towards 
 the surface large numbers of the same wide, thin-walled 
 vessels were seen, as were noticed in the processes on the 
 surface. They had no muscular fibres in their walls. The 
 surface of the growth between the processes is covered by 
 epithelium similar to that on the villi. At the base of the 
 nodule examined some bundles of the involuntary muscular 
 layer of the bladder were seen, but no such tissue existed in 
 the growth.' 
 
 Case 7. — W. W., set. 63. Fimbriated papilloma. 
 
 1883, Jan. 24. I first saw him. Occupied on the 
 Thames as a bargeman. Seven years ago, the first attack 
 of hsematuria occurred : severe ; the clots causing retention 
 of urine. Several attacks, with rather long intervals, during 
 the succeeding five or six years. 
 
 During last year more bleeding ; during last month 
 almost continuously seen. All this time he has worked 
 hard at the oar ; he bleeds less when resting, but has little 
 pain ; holds water two hours or more, night and day. Passes 
 it sometimes quite clear at beginning of stream, ending 
 deep red. 
 
 He is very weak, and obviously anaemic from loss of blood. 
 
92 ON TUMOURS OF THE BLADDER 
 
 At this visit he passed in his urine a shred, which, under 
 the microscope, proved to be a perfect specimen of fimbriated 
 papilloma. Hence I decided at once to operate. 
 
 Feb. 8. Dr. Gfeorge Johnson and others present. Found 
 tumour : rather wide base, but prominent ; springing from 
 the back of the bladder a little on his right side. I nipped 
 off all the salient portions, leaving a slightly projecting, 
 ragged base. The tube was introduced; it remained five 
 days. 
 
 Feb. 20. All urine still by wound; generally a little 
 blood in the urine, which seemed to be checked by mild 
 daily injections of perchloride of iron. 
 
 March 2. Up and going about. Very little bloodstain ; 
 urine partly passing by urethra. 
 
 March 12. No blood for a week ; holds urine three 
 hours. Walked an hour yesterday. All the urine by 
 urethra. 
 
 April 3. Stronger than for months ; has returned to his 
 work. 
 
 November 1. Has been working hard all summer and 
 autumn, and occasionally sees a little blood when work is 
 severe. 
 
 1884, April 16. Called on me. Continues his work. 
 No frequency of micturition ; no pain ; passed a little urine 
 with faint blood tint. 
 
 Dr. Gribbes examined this tumour, and reported upon it 
 as follows :- — ' This growth consists of a number of delicate 
 filiform processes : each of these consists of a central stalk 
 from which branch several secondary processes. They are 
 formed of a very delicate connective tissue in the centre, 
 which is infiltrated with small round cells ; and they are 
 covered with a stratified layer of columnar epithelium, which 
 resembles that of the normal bladder. This epithelium is 
 set on a nucleated basement membrane; a large blood-vessel 
 enters at the base of each villus and branches as it goes on. 
 
SOME CASES OF OPERATION IN DETAIL 93 
 
 until it finally breaks up into a network of capillaries, which 
 lie directly under the basement membrane. In some places 
 these capillaries may be seen to have ruptured on to the 
 external surface. The whole growth is very vascular. 
 Many of the columnar epithelial cells are distended with 
 mucus. In some of the processes there are crypts lined 
 with columnar epithelium similar to that on the surface.' 
 
 Case 10. — J. S., set. 53. Fibro -sarcoma, or transitional (?). 
 
 1881, August 24. I first saw him. Leading an active 
 life ; from Wales. Sent to me by Dr. Maguire, of Holyhead. 
 Last six months, micturition frequent, little painful before 
 and after, occasionally slight hsematuria. Urine healthy, 
 no organic deposit seen ; under microscope a few blood 
 corpuscles. 
 
 1882, May 8. He came up again. Slight advance in 
 symptoms. Sounded : nothing felt worth recording ; pro- 
 state rather full ; blood little increased. 
 
 August, Pain increased slightly ; a little florid blood 
 lately seen at the close of micturition. 
 
 November. Pain increases; rarely three days without 
 marked appearance of florid blood ; appetite good ; walks 
 three miles, and thinks exercise makes little or no difference. 
 Nothing characteristic in urine. 
 
 1883, March 2. The last two months blood has appeared 
 every day, and passes water every hour day and night, with 
 much local pain ; none in legs or back. 
 
 March 3. Digital exploration. Mr. Coward and others 
 present. Felt a large mass more than half tilling the blad- 
 der, and much harder than growths usually met with. Was 
 compelled to use the forceps with cutting edges, removing 
 great part of it, bit by bit, with great care, examining afresh 
 with the finger after every portion. Very free bleeding for 
 twenty-four hours. 
 
94 ON TUMOUES OF THE BLADDER 
 
 March 5. Blood diminishing. Weak. Abdominal ten- 
 derness. 
 
 March 6. Urine passes by tube freely ; still bloody. 
 
 March 7. Died at noon. 
 
 March 8. Autopsy showed a portion of tumour about 
 base remaining ; of very firm consistence, and apparently con- 
 tinuous with the coats of the bladder. Both kidneys small 
 and pale, the right showing marks of pyelitis. 
 
 Mr. Shattock carefully examined the bladder with a view 
 to determine the connection of the growth with the organ, 
 and reports as follows : — ' A vertical section carried through 
 the middle of the tumour and the wall of the bladder shows 
 the morbid growth to be throughout solid, white, of soft 
 consistence, and very evidently constructed of an alveolar 
 stroma, from which the contained elements can be expressed. 
 The growth nowhere extends through the wall of the blad- 
 der ; the longitudinal muscle-bundles are traceable without 
 interruption beneath its base, though the transverse are 
 unrecognisable in the situation, a result due apparently to a 
 displacement rather than to any proper disappearance from 
 infiltration of the transverse bundles by the tumour. 
 
 ' The deep limit of the growth is clearly defined, convex, 
 undulatory or lobular in character ; the tumour substance 
 has nowhere extended laterally, its deep limit being in fact 
 its narrowest part. The wall of the bladder beneath the 
 tumour is folded inwards for a depth of nearly half an inch, 
 a condition due, doubtless, to the enforced dragging of the 
 growth upon the subjacent part of the bladder, as the con- 
 nective tissue and fat lying over this spot are quite lax, and 
 present no induration or cicatricial-like shrinking. 
 
 ' A microscopic section shows throughout an alveolar 
 stroma of connective tissue, the wide meshes of which are 
 filled with multiform epithelial cells, many of an elongated 
 form, columnar, pyriform, some with bifid tails, and arranged 
 with the long axis at right angles to the wall of the space 
 which holds them. 
 
SOME CASES OF OPERATION IN DETAIL 95 
 
 ' Taking all the facts together, there is no evidence that 
 the tumour is malignant.' 
 
 Case 12.— C. C. S., ^t. 5Q. 'Transitional.' 
 
 1883, January 11. I first saw him. Habits sedentary. 
 About a year and a half ago severe attack of painful mictu- 
 rition, followed by more or less irritation ever since. 
 
 Three months ago, first saw blood in the urine, after a 
 long walk. Has recurred frequently since. 
 
 Now, there is considerable frequency of micturition, pain, 
 and often blood. Sounded : nothing found ; the bladder 
 empties itself by its own efforts. Kectal examination reveals 
 nothing ; in the urine, no signs of tumour debris. 
 
 He returned to the country to carry out some treatment 
 advised ; but his symptoms becoming more severe, he came 
 to town again. 
 
 April 3. Sounded and otherwise examined under 
 ether : nothing discovered ; a ' softish ' feel in rotating the 
 sound. Tried mild injections of perchloride of iron. He 
 passed some small phosphatic concretions a week or two 
 later. As he made no progress, I decided to explore with the 
 finger. 
 
 May 4. The brother Dr. S., and others present. I found 
 a broad sessile tumour occupying (his) right side of bladder ; 
 one which it was clearly impossible to remove, since its 
 incorporation with the walls of the bladder was manifest. I 
 nipped off two of the most salient portions of the mass, 
 diminishing it considerably, and put in the tube. It re- 
 mained two days, when all bleeding ceased. He left for the 
 country, the wound being healed and symptoms relieved, on 
 May 24. 
 
 1884, May 10. Came up again to see me, with much 
 frequency and pain, but with little bleeding ; troubles 
 mainly due to some phosphatic deposits, which were re- 
 moved by lithotrite and aspirator under ether ; and he left 
 again, relieved, but suffering much at times, on May 20. 
 
96 ON TUMOURS or THE BLADDER 
 
 Dr. Gibbes examined this tumour, and reported upon it 
 as follows : — ' This tumour appears to be an hypertrophy of 
 the submucous coat of the bladder. The muscle appears 
 normal, but the tissue inside it is composed of dense 
 bands of fibrous tissue, which are irregular in direction, and 
 which have here a macerated or sodden appearance, as if 
 there had been great oedema into them. Nearer to the 
 epithelium the fibrous tissue is much finer, and directly 
 under the epithelium it has a reticulated appearance, 
 exactly resembling granulation-tissue in the bottom of a 
 healing wound. The epithelium on the surface resembles 
 that of the normal bladder in every respect. The blood- 
 vessels in the depths have very thick walls, and are sur- 
 rounded with round cells in some places. The capillaries 
 run directly to the surface, generally without branching, and 
 are there ruptured in many places. They are also ruptured 
 in some parts of the deeper tissue, and there are many spots 
 of extravasated blood. There are collections of round cells, 
 and numerous irregularly shaped large cells, in some places 
 resembling " lymphoid " tissue, and these are arranged in 
 round or oval masses. 
 
 ' There are no papillomatous or " villous " growths in that 
 portion of the tumour examined.' 
 
 The microscopic drawing, Plate V., was taken from the 
 above described tumour. 
 
TABLE OF CASES OF OPERATION FOR 
 VESICAL TUMOUR. 
 
 II 
 
98 
 
 TABLE OF CASES. 
 
 TABLE OF TWENTY GASES OF OPERATION FO 
 
 Date of 
 operation 
 
 1880, 
 Nov. 6 
 
 T.K. 
 
 29 
 
 1882, 
 May 9 
 
 Mrs. F. 
 
 30 
 
 Nov. 3 
 
 B. G. 
 
 Turation of 
 symptoms 
 
 Earliest sign 
 observed 
 
 Besult of urine 
 examination 
 
 3^years 
 
 Blood in the urine 
 
 46 1 year 
 
 Not examined, no 
 growth being ex- 
 pected; the opera- 
 tion was made for 
 a supposed encysted 
 calculus 
 
 Ditto 
 
 Frequent micturi- 
 tion; blood much 
 later 
 
 Much large cell- 
 growth ; various 
 forms 
 
 Complicatioi 
 with calculu 
 
 A small oxf 
 late of lim 
 and pho; 
 phatic ca 
 cuius 
 crushed 
 
 1 
 
TABLE OF CASES. 
 
 99 
 
 ^SIGAL TUMOUR BY SIR HENRY THOMPSON. 
 
 Nature of tumour 
 
 |bro-papilloma 
 
 ibro - papilloma : 
 with ' club-shap- 
 ed processes,' not 
 slender papillae 
 or 'villi' (Mr. S. 
 Boyd) 
 
 Perhaps interme- 
 diate between 
 papilloma and 
 sarcoma.' Proba- 
 bly belonging to 
 the group termed 
 below ' transi- 
 tional' (Mr. S. 
 Boyd) 
 
 Operation and result 
 
 Single polypoid growth; removed at 
 base by forceps. Dr. Paggi, of Flo- 
 rence, Dr. Seegen, of Carlsbad, and 
 Mr. Ceeley, of Aylesbury, present. 
 Rapid recovery. Living and well, spring 
 1884 
 
 Polypoid growths ; removed by forceps ; 
 recovery rapid. Seen with Dr. Philson, 
 of Cheltenham. February, 1883. Re- 
 moved a small growth which I had 
 been unable to grasp at first opera- 
 tion for want of forceps acting late- 
 rally ; she was well in a few days 
 and returned. 1884, April 17 : heard 
 that she is quite well ; there is no 
 frequeocy of passing water ; no pain ; 
 after exercise a i race of blood is some- 
 times seen 
 
 Very large ; almost entirely removed by 
 forceps ; great hsemorrhage ; died few 
 days after operation ; no autopsy per 
 mitted ; probably some giving way of 
 bladder at base of tumour 
 
 H -2 
 
100 TABLE or CASES. 
 
 TABLE OF TWENTY GASES OF OPERATION FO 
 
 Date of 
 operation 
 
 1882, 
 Nov. 20 
 
 No. 
 
 Case 
 
 Dr. M. 
 
 52 
 
 1883, 
 Jan. 17 
 
 E. K. G. 
 
 67 
 
 30 
 
 T. F. 
 
 67 
 
 Duration of 
 symptoms 
 
 5 years 
 
 Ear'iiest sign 
 observed 
 
 Blood in the urine 
 
 Eesult of urine 
 examination 
 
 Shreds formed of fusi- 
 form cells 
 
 Ditto 
 
 Nuroei*ous fusiform 
 cells and fibres 
 
 Complication 
 with calculus 
 
 A small uri( 
 acid calcu 
 lus crushec 
 
TABLE OF CASES. 
 
 101 
 
 \ESIGAL TUMOUR BY SIR HENRY THOMPSON (continued). 
 
 Nature of tumour 
 
 Operation and result 
 
 ■ Diagram of 
 form and situation of tumour 
 
 he base of the 
 growth contains 
 unstriped muscu- 
 lar fibres not con- 
 tinued into the 
 filiform processes, 
 which arise in 
 great number, 
 and form long 
 villi. Normal 
 
 bladder tissue 
 with fimbriated 
 papillae (Dr. H. 
 Gibbes) 
 
 apilloma ; resem- 
 bling structure of 
 ' soft warts ' (Mr. 
 Shattock) 
 
 Spithelioma 
 H. Gibbes) 
 
 (Dr. 
 
 Rather broad-based growth, springing 
 from side of the bladder. Seen with 
 Dr. Geo. Johnson. The patient was 
 free from bleeding for nearly six 
 months after operation ; then little 
 blood seen after a seven miles' walk, 
 and continued. In June, 1883, 1 made 
 a slight exploration and removal, fol- 
 lowed by relief. On February 10, 1884, 
 I again explored, and removed a 
 larger quantity than on either pre- 
 vious occasion ; the bleeding had 
 been very severe during the preceding 
 two months. He made a slow recovery, 
 being much exhausted prior to the 
 last operation 
 
 Sessile, and partially removed. Returned 
 to Cape ; probable reappearance of the 
 tumour. Heard of his death there 
 subsequently 
 
 Broad and sessile ; removed much of 
 it. Signs of reappearance of tumour 
 in the spring ; and in the summer he 
 died 
 
102 TABLE OF CASES, 
 
 TABLE OF TWENTY GASES OF OPERATION FOl\ 
 
 No. 
 
 Age 
 
 Duration of 
 symptoms 
 
 w. w. 
 
 63 
 
 J. M. 
 
 64 
 
 Mrs. O'E. 
 
 65 
 
 7 years 
 
 1 year 
 
 7 years 
 
 Earliest sign 
 observed 
 
 Blood in the urine 
 
 Eesult of urine 
 examination 
 
 Well-marked villous 
 growth 
 
 Complication 
 with calculus 
 
 Never found any cha- 
 racteristic debris in 
 uiine 
 
 Large spindle-shaped 
 cells ' 
 
 Calculus in 
 left kidney, 
 large ; both 
 kidnej's dis- 
 eased ; pye- 
 litis 
 
TABLE OF CASES. 103 
 
 VESICAL TUMOUR BY SIR HENRY THOMPSON {continued). 
 
 Nature of tumour 
 
 Operation and result 
 
 Diagram of 
 form and situation of tumour 
 
 'imbriated papil- 
 loma chiefly ; 
 very vascular (Dr. 
 H. Gibbes) 
 
 Composed of nor- 
 mal bladder tissue; 
 fimbriated pa- 
 pilla (' villi ') 
 abundant : no 
 structure resem- 
 bling malignant 
 growth was found 
 (Dr. H. Gibbes) 
 
 Papilloma 
 Eve) 
 
 (Mr. 
 
 Rather broad-based polypoid growth ; 
 freely removed. He was so weak with 
 long-continued haemorrhage, I almost 
 feared to operate. Living and well 
 in the spring of 1884, working as a 
 bargeman on the Thames. Seen with 
 Dr. Geo. Johnson 
 
 Broad and sessile ; removed rather 
 freely. Died two months after with 
 secondary malignant growth in thigh. 
 Seen with Dr. Harvey, of Bayswater 
 
 Large tumour, freely removed, leaving 
 the base, which was broad. Died 
 three days after with suppression of 
 urine. Seen with Mr. Thurland, of Wil- 
 mington Square, with whom autopsy 
 was made. Kidneys much diseased; 
 large calculus in the left 
 
104 
 
 TABLE OF CASES. 
 
 
 
 TABLE OF 
 
 TWENTY CASES OF 0PEEA2 
 
 'ION FO 
 
 Date of 
 
 No. 
 
 Case 
 
 
 Duration of 
 
 Earliest sign 
 
 Result of urine 
 
 Complication 
 
 operation 
 
 Age 
 
 ■ symptoms 
 
 observed 
 
 examination 
 
 with calculus 
 
 1883, 
 
 10 
 
 J. H. 
 
 53 
 
 2^ years 
 
 Frequent and pain- 
 
 No characteristic de- 
 
 
 
 Mar. 3 
 
 
 
 
 
 ful micturition. 
 
 bris found 
 
 
 
 
 
 
 Blood at later 
 
 " 
 
 
 
 
 
 
 
 stage 
 
 
 
 „30 
 
 11 
 
 W. D. 
 
 65 
 
 1 year 
 
 Blood later 
 
 Numerous long cells 
 and fibres 
 
 ■— - 
 
 May 4 
 
 12 
 
 c. c. s. 
 
 56 
 
 2 years 
 
 Pain first ; blood 
 later 
 
 Nothing found 
 
 — 
 
TABLE OF CASES. 
 
 105 
 
 VESICAL TUMOUR BY SIR HENRY THOMPSON {continued). 
 
 Nature of tumour 
 
 Operation and result 
 
 Diagram of 
 form and situation of tumour 
 
 Tissues like those 
 forming the wall 
 of the bladder, 
 with fimbriated 
 papillae (Mr. 
 
 Shattock) 
 
 Tissues like those 
 of the walls of 
 the bladder, and 
 some papilliform 
 growth in small 
 quantity on sur- 
 face (Dr. H. 
 Gibbes) 
 Fibro-papilloma 
 
 Example of growth 
 termed ' transi- 
 tional.' The 
 structure resem- 
 bles a ' hyper- 
 trophy of the sub- 
 mucous coat of 
 the bladder ; col- 
 lections of round 
 cells in some 
 places resembling 
 lymphoid tissue ; 
 no papillomatous 
 growth present ' 
 (Dr. H. Gibbes) 
 
 Large hard tumour partially removed ; 
 largely involving the coats of the 
 bladder. Died few days after operation. 
 Sent to me by Dr. Maguire, of Holyhead 
 
 Sessile ; firm ; removed salient por- 
 tions. Died fourteen days after opera- 
 tion, of exhaustion. Seen with Mr. 
 T. W. Mason, of Regent's Park 
 
 Tumour firm, sessile ; inseparable from 
 walls of bladder; removed salient 
 portions only. Living ; symptoms re- 
 lieved at present ; probably from 
 drainage of bladder. 1884, May 10: 
 came to see me ; washed out many small 
 phosphatic concretions wiih great 
 relief. Tumour not much increased ; 
 occasiorally some blood in urine ; on 
 the whole the symptoms not worse 
 
106 
 
 TABLE OF CASES. 
 
 
 
 TABLE OF 
 
 TWENTY CASES OF OPERATION FO.^ 
 
 Date of 
 operation 
 
 No. 
 13 
 
 Case 
 
 Age 
 
 Duration of 
 symptoms 
 
 Earliest sign 
 observed 
 
 Besult of urine 
 examination 
 
 Complication 
 with calculuB 
 
 1883, 
 May 9 
 
 T. Q. 
 
 52 
 
 4 years 
 
 Frequent micturi- 
 tion and pain. 
 Blood seen two 
 
 Passed mass, the size 
 of large pea, of soft 
 fleshy material in 
 
 None 
 
 
 
 
 
 
 years ago 
 
 urine ; when exa- 
 mined by Dr. II. 
 Gibbes appeared to 
 be portion of growth, 
 composed of normal 
 vesical elements 
 
 
 June 27 
 
 14 
 
 A.G.S.C. 
 
 57 
 
 )> »» 
 
 Frequent micturi- 
 tion : soon after an 
 attack of bleeding 
 
 No cells of suspicious 
 appearance found in 
 the urine 
 
 — 
 
 July 7 
 
 15 
 
 J. H. B. 
 
 40 
 
 3 „ 
 
 Blood seen at the 
 first ; now daily 
 and profuse bleed- 
 ing. Micturition 
 never very fre- 
 quent 
 
 No Evidence obtained 
 from the urine 
 
 - — 
 
TABLE OF CASES. 
 
 107 
 
 VESICAL TUMOUR B SfE HENRY THOMPSON {contvnued). 
 
 Nature of tumour 
 
 Made up of un- 
 striped muscular 
 fibres, with nume- 
 rous tubes and 
 crypts lined with 
 columnar epithe- 
 lium ; probably 
 malignant (Dr. H. 
 Gibbes) 
 
 Made up of un» 
 striped muscular 
 fibres ; numerous 
 small cells inter- 
 spersed; nume- 
 rous fimbriated 
 papillfB (Dr, H. 
 Gibbes) 
 
 The body of the 
 tumour made up 
 of normal ele- 
 ments of the vesi- 
 cal walls with 
 here and there in- 
 filtration of small 
 round cells. Abun- 
 dant fimbriated 
 processes, 'vil- 
 lous ' from every 
 part 
 
 Operation and result 
 
 A soft growth, removed to the base. 
 Much bleeding up to second day ; be- 
 came feverish, indisposed to take 
 food, and gradually sank on the twelfth 
 day. Mr. W. Adams, of Regent's Park, 
 was present at the operation 
 
 Diagram of 
 form and situation of tumour 
 
 Sessile growth, implicating the walls of 
 the bladder, and could only be par- 
 tially removed. Rapid recover^'. Dr. 
 Weir, of New York, was present. Had 
 no bleeding for two months after 
 operation. April 17 : micturition fre- 
 quent and painful ; much blood at 
 times ; the growth evidently increasing 
 
 A rather large polypoid growth removed 
 entire at once. Recovery rapid. An 
 assistant to Dr. Bell, of Rochester. 
 Professor Holmer, of Copenhagen, pre- 
 sent. He was so reduced by persistent 
 hemorrhage, that I operated with 
 great reluctance. 1 884, April 20 : he 
 writes that he is actively employed, 
 but has seen after exercise ' occa- 
 sionally a few drops of blood, just as 
 he did three or four years ago ; ' 
 ' health good ' 
 
108 
 
 TABLE OF CASES. 
 
 TABLE OF TWENTY GASES OF OPERATION FOR 
 
 Date of 
 operation 
 
 1883, 
 Nov. 16 
 
 Case 
 
 Age 
 
 16 
 
 T. S. 
 
 42 
 
 1884, 
 Feb. 5 
 
 17 
 
 D. of B. 
 
 50 
 
 Mar. 12 
 
 18 
 
 W. G. 
 
 69 
 
 Duration of 
 symptoms 
 
 Earliest sign 
 
 8 years 
 
 nearly 4 
 years 
 
 Attacks of has mat- 
 uria; of late mic- 
 turition frequent 
 
 Attacks of frequent 
 and painful mic- 
 turition,with little 
 blood 
 
 Blood occasionally 
 seen eight or ten 
 years ago ; last 
 four years very 
 often ; frequent 
 micturition only 
 recently 
 
 Besult of urine 
 examination 
 
 Shreds of tissue 
 passed, made up of 
 spindle-shaped cells 
 and fibres with nu- 
 clei on them 
 
 Shreds of tissue 
 washed out show 
 villous structure 
 
 Shreds of tissue 
 washed out show 
 numerous large nu- 
 cleated spindle- 
 shaped cells 
 
 Complication 
 with calculus 
 
TABLE or CASES. 
 
 109 
 
 VESICAL TUMOUR BY SIR HENRY THOMPSON (continued). 
 
 Nature of tumour 
 
 Operation and result 
 
 Diagram of 
 form and situation of tnmour 
 
 Normal structure 
 of bladder co- 
 vered with fim- 
 briated papillee ; 
 but groups of 
 small cells are 
 seen in places in 
 the substance of 
 the papillae (Dr. 
 H. Gibbes) 
 
 Growth like a cauliflower, from rather i 
 wide base ; removed all but the latter ; I 
 A good recovery. Seen with Mr. "Wood- j 
 cock, of Knutsford, Cheshire, who was 
 present at the operation. 1 884, ilav 
 10 : called on me. He attends to the 
 active duties of his profession as land- , 
 surveyor, but after more exercise than 
 usual sees a little hgemorrhage. Has 
 been busily occupied some days in \ 
 London and seen no blood : no fre- ! 
 quency or pain in micturition [ 
 
 Normal structure A firm broad-based growth from the 
 
 of bladder, with back of the bladder : from which I 
 
 numerous large removed the salient portions ; and it 
 
 papillae, from ; appeared to me that a suprapubic 
 
 which spring the | operation would not enable me to 
 
 long fimbriated : remove the tumour entire. June 3 : 
 
 processes in ' symptoms now very slight ; no pain : 
 
 abundance ; a few walks three miles without seeing 
 
 leucocytes seen blood 
 (Dr. H. Gibbes) ; 
 
 Normal structure 
 of bladderchiefly ; 
 no long papillae 
 or ' villi,' but 
 broad papUls co- 
 vered with strati- 
 fied columnar epi 
 thelium (Dr. H. 
 Gibbes) 
 Fibro -papilloma 
 
 A broad-based sessile mass, of firm con- [ 
 sistence, involving the coats of the 
 bladder ; it would be useless, there- 1 
 
 ; fore, to propose suprapubic operation. 
 
 , Eemoved two or three salient portions. | 
 He gradually sank, about three weeks i 
 afterwards. Seen with Dr. Geo. .John- 
 son, who was present at the operation 
 
110 
 
 TABLE OF CASES. 
 
 TABLE OF TWENTY CASES OF OPERATION FOl 
 
 Date of 
 operation 
 
 1884, 
 April 4 
 
 No. 
 
 19 
 
 Age 
 
 F. J. 0. 
 
 58 
 
 May 30 
 
 20 
 
 R. S. R. 
 
 63 
 
 Duration of 
 symptoms 
 
 9 months 
 
 15 
 
 Earliest sign 
 observed 
 
 Severe 
 first 
 
 bleeding 
 
 Result of urine 
 examination 
 
 Complication 
 •n-ith calculus 
 
 Nothing found in the 
 
 Bleeding after ex- 
 ercise was the first 
 
 / 
 
 Fragments removed 
 from the bladder bj^ 
 the aspirator, no- 
 thing being found 
 in the urinary de- 
 posit by simply 
 washing out 
 
TABLE or CASES. 
 
 Ill 
 
 VESICAL TUMOUR BY SIR HENRY THOMPSON (continued). 
 
 Nature of tumour 
 
 Operation and result 
 
 Diagram of 
 form and situation of tumour 
 
 Normal structure 
 of bladder chiefly; 
 groups of small 
 round cells ; some 
 like inflammatory 
 cells : resembling 
 Cases 12, li, and 
 16 : and regarded 
 as ' transitional.' 
 No long papillae 
 (Dr. H. Gibbes) 
 
 Normal structure of 
 bladder, covered 
 with columnar 
 epithelium ; un- 
 der latter, round 
 cells Uke ' lym- 
 phoid tissue ; ' 
 somewhat uncer- 
 tain (Dr. H. 
 Gibbes) 
 
 A firm broad sessile tumour, with very 
 slight lobulation ; could not be 
 separated from walls of the bladder. 
 Removed a small portion for examina- 
 tion. Wound soon healed. Seen 
 with Dr. Dove, of Pinner 
 
 A firm multilobular tumour, with broad 
 peduncle, which was removed almost 
 level with the walls of the bladder. 
 Dr. Shippen, of New York, and Dr. 
 Charamis, from Paris, present. Re- 
 covering rapidly. June 7, 1 88-i 
 
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