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W. STEIN, M.D., SURGEON TO CHART HOSPITAL, GENITO-URINARY AND VENEREAL DIVISION. PROF. OF VISCERAL ANATOMY AND PHYSIOLOGY AT THE N. Y. COLLEGE OF DENTISTRY, ETC., ETC. K--: '<*■>%* '' &. 0~ ^cr: NEW YORK WILLIAM WOOD & COMPANY 27 Great Jones Street 1881 /i-w-^ex wr 5"oo S8l Clark, Lambl, Thompson). The long duration of some TUMORS OF THE BLADDER. 63 cases of vesical cancer can only be accounted for in the supposition that malignant tumors are sometimes develop- ed from long, pre-existing, benign growths which, having remained for a long time innocuous, or else, having already occasioned serious organic changes in the urinary tract, require but the cancerous development to run rapidly to a fatal termination. My case of medullary cancer above referred to, with a history of seventeen years, renders such a conclusion almost inevitable. Treatment. Tumors of the bladder have been so much looked upon as a nole me tangere, that it may be instructive to note what has been done and what may be done in this department of surgery. The following is a concise re'sume' of the operations that have been performed for the removal of tumors from the bladder, up to the present time. They are mentioned in a chronological order as regards females and males respectively, and will serve to show the various methods and manoeuvres that have been successfully em- ployed. Operations Performed on Females. 1750. The first operation we can find on record for the removal of a tumor from the bladder was performed by Warner in 1750. The subject was a woman aged twenty- three. On June 24th, after lifting a great weight, she was seized with pain in the back, and afterwards, retention of urine which lasted until the 29th, when she was relieved by catheterization. Nearly three years afterward she applied to Mr. Warner and stated that she had never been able, from the moment of the accident, to void a drop of urine without the assistance of a catheter, and she had often lost blood in considerable quantities. A polypus of some size projected into, and sometimes at the external orifice of the urethra. An incision was made in the left 64 TUMORS OF THE BLADDER. side of the urethra about half way to the bladder, the mass drawn forward by a thread previously passed through it, and a ligature applied to its base which was very broad. On the sixth day the tumor, which is given as the size of a turkey's egg, came away, and the patient recovered perfectly. 1823. In Howship's work on the urine, of this date, a case is related of a fungous tumor of the bladder which a French surgeon, M. Le Cat, attempted to remove. He cut into the bladder, and with his forceps pulled away and crushed several fungi at two different sittings. The wo- man died in two days after the second operation. 1834. Pleininger removed from a female, ast. two and three-fourth years, a strawberry-like mass, which projected into the urethra. The canal was dilated and the mass re- moved by ligature. Further examination by rectum and by sound revealed the presence of other tumors, but no further operative attempt was made. The child became emaciated and finally died of peritonitis. Autopsy re- vealed numerous flocculent excrescences over the base and posterior surface of the viscus and also others of a cartila- ginous consistence and of the size of an almond. 1844. Theinemann. Female, ast. forty-five, a tumor, the size of a hen's egg, with a pedicle one-third of an inch thick, was followed into the bladder by the urethra which had already been sufficiently dilated by the tumor, and a ligature was thrown around the pedicle by means of two elastic catheters and then, with a proper canuU, constricted it as far within the bladder as he could reach. On the third day, the ligature was tightened, and on the sixth day the polypus fell off and the patient recovered completely. 1846. Guillon is said to have removed from the bladder of a female a pediculated growth seated at the vesical neck, by carrying a silver wire around it by means of a slightly bent catheter. 1858. Birkett applied a strong silk ligature around the TUMORS OF THE BLADDER. 65 root of a polypus which protruded from the urethra of a child five years old. She was very weak, and a few days after the tumor sloughed, considerable pyrexia supervened, and she died. A number of polypi were found in the blad- der. 1859. Senftleben attempted the extirpation of a sarcoma through the urethra, which had already been dilated by the tumor large enough to admit the index finger. An attempt was made to seize the base of the tumor with for- ceps and draw it out; this, however, did not succeed, and because of the great friability of the tumor it had to be removed piecemeal; its broad base, however, could not be so removed. The hemorrhage was very insignificant. Patient died on the fourth day after the operation from purulent peritonitis. On examination there was found on the right side of the fundus a perforation large enough to admit the index finger; this was made during the at- tempt at extirpation. 1864. Bryant, in the British Medical Journal, May, 1879, says that, fifteen years before, he removed a growth from the bladder of a female with the 6craseur, and the patient was still quite well eight years afterwards. 1864. Morris, in the same journal, refers to a female, ast. fifty-six, from whom he took away a large growth with the ecraseur; all the immediate symptoms were relieved, though she died eventually of hydronephrosis. 1868. May. Braxton Hicks. Female, ast. sixty. The urethra was dilated; the finger passed, and a cauliflower- like mass, the size of a small orange, was found attached to the posterior wall of the bladder, as much of the mass as could with safety be removed was taken away by the for- ceps, and with the wire-rope ecraseur. This had the effect of restraining the bleeding and other symptoms. Six months afterwards, however, the bladder became more irritable and the urine bloody; the urethra was again dilated and 5 66 TUMORS OF THE BLADDER. the tumor found not to have recovered its original size ; a strong solution of tannin was applied with benefit. 1868. June. Guerssant. Female child, ast. twenty- two months. A small tumor, like a nut, projected from the urethra, it was seized, drawn forwards, and a metallic thread was passed as far as possible round the neck of it, after gaining access to it by dividing the urethra with the scissors. The thread was gradually and slowly tightened by a serre-nceud, but broke before the tumor was separated, so the operation had to be finished by the ecraseur. The child gradually lost strength, and though the bladder symptoms improved, the soft parts became inflamed and there was sloughing. Diarrhoea supervened, and she died exhausted on the eighth day. 1869. A. R. Jackson. Female, ast. forty. Fibrous po- lypus, December, 1869. A sponge-tent was introduced and left in four hours, after which, the finger being intro- duced, a tolerably dense mass with a smooth surface was felt occupying the lower part of the bladder and pressing against and somewhat into the vesical orifice of the ure- thra. A larger tent was introduced and the husband in- structed to remove it in four hours, and should tumor again appear to secure it against return. On withdrawal of the tent, the tumor appeared, it was seized with the forceps and fingers, but in making traction it broke off in the urethra. The portion removed was a fleshy-looking mass about the thickness and nearly the length of a finger. Two days after, the tent was again introduced, the tumor appeared at the urethral orifice, it was grasped and drawn out about two inches and by twisting it like a rope, a por- tion of growth eight inches long and of the thickness of the thumb was removed. Very little bleeding attended the operation. Several fragments came away during four or five days succeding. April 30th, 1870, patient fully regained general health and the incontinence from which she had been suffering since the operation was improving. (The TUMORS OF THE BLADDER. (^y incontinence was no doubt occasioned by the slow method which was adopted in dilating the urethra.) 1869. Simon. Female, ast. seventy; urethra dilated, finger discovered a pediculated villous growth behind the urethra, the most accessible portion of the tumor was seized and twisted off by forceps, \vhile its infiltrated base was scooped out with a sharp spoon. The reaction was insignificant, although the lesion to the vesical mucous membrane must have been considerable. Patient left the bed on the fourth day and remained perfectly well five years afterward. 1869. Winckel. Female, ast. thirty-nine. Urethra di- lated with index of left hand, near the orifice of right ureter was felt a large movable soft villous growth, small pieces of which were detached by the movements of the finger. After this, the bladder was injected with about one hundred and fifty grammes of warm water, and by means of the finger and forceps all appreciable prominences were removed from the posterior wall of the bladder. The sphincter contracted in such a manner that after withdrawal of the finger none of the injected fluid escaped. Patient made a complete recovery ; saw her two years after the operation and there was no sign of a re- lapse. 1872. C. S. Bishop (related by Gross, Surgery, second edition). Female, ast. fifty-six; removed a cylindrical vascular polyp nearly three inches long ; it had a globalar head eight lines in diameter, and was attached by a narrow pedicle to the bas fond of the bladder. Finding a portion of tumor projecting from meatus, he ligated it. The next day applied a silver wire around its neck, and at the expi- ration of forty-eight hours he rem oved the mass by rotat- ing a double canula upon its axis. 1874. Simon. Female, ast. 40; had urethra dilated sev- eral times, and small portions of tumor twisted off by for- ceps. Two years after first discovery of tumor, patient 68 TUMORS OF THE BLADDER. came to Simon, who, April 14th, dilated the urethra, and found that two-thirds of the bladder was occupied by a tumor. With a sharp spoon he scooped out and removed a large portion of the growth. In the course of about an hour and a half, the spoon was introduced into the bladder about twenty times, and the scraping made under the guidance of the finger. Patient had only a little pain after the operation and perfect continence of urine. The bladder was washed out with luke-warm water daily. The urine soon acquired an acid reaction, and in five days patient left the bed. On April 28th, the operation was repeated, and again considerable portion of tumor re- moved. Eight weeks after the first operation, when the patient left the hospital, there were no papillary promi- nences apparent to the touch, but at the place where the tumor had been, there was felt an uneven, rather hard sur- face, covered with mucous membrane. The urine was acid; the bladder pains had disappeared; could hold water five hours, and the general condition of the patient was excellent. This case is especially interesting as show- ing what can be done even with very large and sessile tumors of the bladder. 1874. Simon. Female, ast. 44. July ; urethra dilated ; all over the internal surface of bladder, as far as finger could reach, there were warty or papillary projections. A sharp spoon was introduced, and as much as possible of the new- formation removed. The patient was quite well after the operation, and in the middle of August the symptoms were much better. But, he adds, the next time she will have to submit to an operation through the vesico-vaginal septum. 1873 to 1876. Schatz. Female, ast. 18. The posterior three-fourths of the urethra was found dilated to the dia- meter of the finger, by the projection from the bladder of a tumor the size of a goose's egg. The tumor had its ori. gin by a pedicle of about four centimetres in thickness from the right antero-lateral wall, one to two centimetres TUMORS OF THE BLADDER. 69 above sphincter. So much of the tumor as could be reached was removed by the 6craseur, and the remainder ■separated in smaller portions by means of the finger. Patient recovered, and had no trouble for about a year. In August, 1874, she returned with about the same symp- toms as at first, and the operation with the ecraseur was repeated. She was up in a few days. December, 1875, gave birth to a child. January 10th, 1876, found that the tumor had not grown much beyond the size of a hazel-nut. January 20th, incised the right side of the urethra, and in- verted the posterior wall of the bladder with the tumor through the urethra by means of several threads previ- ously passed through the tumor from the vagina, and after cutting out the growth in two portions, united the edges of the wound with ten silk sutures. Although during the operation the urethra was dilated to the extent admitting two fingers, the patient retained her water one hour after the operation, and, afterwards, two and three hours ; from the seventh day she micturated once at night and twice during the day. There was pain only on the first day dur- ing micturition. The patient recovered rapidly. Micro- scopic examination found the tumor to be a benign myxo- ma. 1876 to 1878. Wm. Alexander. Female, ast. 44. The ure- thra was in such relaxed condition that the finger could be inserted into the bladder without the infliction of much pain. The floor of the viscus was extremely rough and irregular. These irregularities were of various heights; a few were as much as a quarter of an inch from base to apex, and one seemed to be nearly an inch in height. This large one, on the left side of the bladder, had a rounded, enlarged apex; the apices of the others were thin and pointed. July, 1876, the urethra was dilated with an anal speculum ; the wire of an ecraseur was passed around the base of the largest growth, and the same cut through ; in trying to get it out, others were displaced from their place yO TUMORS OF THE BLADDER. of growth by the movements of the finger, and all nodules that could be felt were scraped off with the finger-nail, and the bladder washed out with a weak solution of perchloride of iron. There was not an excessive amount of hemor- rhage during the operation, but the urine contained a good deal of blood for the first week. She had incontinence of urine for two days only, during which scraps of the tumor came away. There were about two dozen small growths removed, and five or six growths were lost. The patient soon resumed her work as cook in a very good condition. In October, 1877, she had a relapse. Numerous soft growths were felt upon and beyond the trigone; about a dozen small arborescent growths were easily removed by the finger-nail, and several small growths came away the same evening. October 19th, urine was perfectly clear; pain on micturition was almost gone ; health was good, and system well nourished. May, 1878, again removed a large mass of growths. Recovery was more rapid and more perfect than on either of the previous occasions, and the urine has continued clear ever since, August 17th, 1878. 1879. Christopher Heath. Female, ast. 39. Urethra was dilated with a four-bladed dilator and the finger. Right side of bladder was occupied by a villous growth, situated on a hardened base. Some of the growth was torn away (villous sarcoma). Patient died May 25th, from general exhaustion. 1879. Godson. Female, ast. sixty. A polypus the size of a walnut was found protruding from the urethra and connected with a narrow pedicle with the fundus of the bladder, which viscus was partially inverted. Catgut liga- ture was applied and the tumor separated with scissors. 1879. Incision Urethro-Vaginal Septum. A. T. Norton. Female, ast. thirty, January 3d, 1879. Dilated urethra with the finger and discovered a papilloma, in size about one square inch and coated with phosphates, not much raised above the mucous surface, but very hard, and situated on TUMORS OF THE BLADDER. yi the trigone about half an inch from the sphincter. It was impossible to remove the growth through the urethra. The spring scissors were inserted,one blade into the bladder nearly up to the tumor and the other into the vagina, and closed ; the front wall of the vagina was then incised cen- trally to within half an inch of the uterus. The vagina which was not incorporated in the growth was dissected from the bladder, the growth was seized with the vulsel- lum forceps, drawn forwards, and excised with the scissors. Bleeding was arrested by the actual cautery and the lateral flaps of the vagina were approximated by sutures. No hemorrhage of importance took place. The temperature remained below normal and the pulse rose to one hundred and twenty. Severe vomiting was persistent until the tenth day after the operation. After the tenth day, she was considered out of danger, was making good progress, took food well, and was cheerful. On the twelfth day, when apparently in health, she vomited, and shortly after- ward fell asleep, in which sleep she died from syncope at a time when she was recovering from the operation. 1879. Mr. Norton says that soon after the above experi- ence he had an opportunity of operating a second time, in a similar manner, without any untoward symptom. Tumor was situated on the front wall of the bladder; it was one inch long* one-half inch wide, and three-quarter inch above the level of the mucous membrane. It did not infiltrate the tissues of the bladder. Structure, fringed papilloma. The opening in the bladder was allowed to remain for a month and then it was closed by the ordinary method. Operations Performed on Males. 1827. Civiale, while manipulating with his trilabe with a view of removing a calculus from the bladder, acciden- tally tore away a soft, pedunculated mass about the size of a pea. This accident at first gave him some uneasiness as to the possible result; but no untoward symptom 72 TUMORS OF THE BLADDER. appearing, he conceived the idea of having recourse to this manoeuvre for the removal of small growths at the neck of the bladder, which he put into successful practice in several cases. In a man aged seventy, he used the trilabe three times, at intervals of some days, each time taking away a small portion until he had removed a mass the size of a large walnut. The man died three months afterward from typhoid fever. The method of operating, as recommended by Civiale, consists in opening the instru- ment in the bladder, drawing it forward as far as possible so that the blades of the same lie in contact with the vesi- cal neck, when by turning the instrument from side to side the excrescences fall between its blades and are crushed. In a few days the necrosed portion is carried off with the urine. Covillard (Obs. Iatro-chir. p. 93, mentioned by Crosse) performed cystotomy for a tumor in the bladder the size of a nut. " Je la mouchait avec les tenettes, ceque reussit de sorte qu'en moins de huit ou dix jours, la dite tumeur termina par suppuration," and in a month the patient was convalescent. 1830. Perineal Cystotomy. Dessault. Chopart mentions a man at the l'Hotel Dieu, from whom D. extracted a cal- culus, and afterwards finding a pediculated growth, he seized it and twisted it off. There was no hemorrhage, and the patient left the hospital perfectly cured. 1834. Crosse performed perineal cystotomy for the re- moval of a villous growth, upon a male child two years old. On removing the knife after the necessary incisions were made, a mass of tumors, connected together like a bunch of grapes, and resembling in appearance and struc- ture ordinary nasal polypi, protruded through the wound ; as many of these as were accessible were cut off, but upon introducing the finger into the bladder, it was found that much of the diseased mass remained attached by a broad base, and it was not deemed advisable to make any further TUMORS OF THE BLADDER. 73 attempt for its removal. After forty-four hours of inces- sant suffering, the child died. 1871. Gersuny attempted to remove a tumor from a man aged forty-nine, by perineal cystotomy, but the growth was beyond reach in a diverticulum, and the operation failed. The day following, the patient felt better than be- fore the operation, and afterward made no complaint of any kind, but refusing all nourishment, he gradually be- came exhausted, and died after the sixth day. 1874. Perineal and Supra-pubic Cystotomy. Billroth. Boy, ast. twelve. Lateral incision was made ; finger intro- duced into bladder, and a tumor found nearly the size of the fist, with an uneven surface projecting from the pos- terior wall and extending towards the top of the bladder. Owing to its size, it was impossible to extract tumor through the perinasum. A supra-pubic incision was made without injury to peritonaeum, and to give sufficient room both recti muscles were cut across at their insertion ; a transverse incision was also made into the bladder. Bill- roth found that the use of the ecraseur was not practica- ble, and decided to tear the tumor with his finger-nail near its base, and to cut out the remainder from the wall of the bladder, after passing a ligature around to check the bleeding. In dissecting out the pedicle, it was found that the tumor took its origin from the muscular coat. Two arteries were tied, and the ligatures brought out through the upper incision. The wound in the bladder was not closed, but a drainage tube was drawn through the bladder and brought out at the perineal incision. On the fifth day, the wound was granulating freely, and there being no more danger of infiltration, the drainage-tube was removed. In thirty-four days, the wound had closed, and the patient was discharged cured. Tumor is seen at Plate ix. 1874. Perineal and Epicystotomy. Volkmann. Male, ast. fifty-four. Membranous urethra was opened on the raphe 74 TUMORS OF THE BLADDER. of the perinasum, and the finger passed into the bladder. A tumor was found, of the consistence of a uterine polypus, and about the size of a lemon, attached by a pedicle to vertex of bladder. Epicystotomy was now made, the bladder being opened by incision one and one-quarter to one and one-half inches long, made on the finger, passed through the perineal wound. Peritonaeum not visible ; the tumor appeared at once, its surface covered with dilated veins, and on scratching through the pedicle, which was of the size of the little finger, the growth was removed by traction with forceps, assisted by pressure from the rectum. The wound in the bladder and abdominal walls, after washing with carbolized water, were closed with su- tures ; the whole abdomen enveloped in carbolized gauze, and a drainage-tube placed in the perineal wound. The following day, abdomen became tender; peritonitis devel- oped, and death ensued on the third day after operation. Autopsy revealed peritonitis, diffuse purulent infiltration of subserous areolar tissue of abdominal wall; muscular coat of bladder moderately hypertrophied ; mucous mem- brane swollen, showing a number of old and recent ecchy- moses, but otherwise healthy. At the situation of the pedicle, which is four lines long, the muscular coat is exposed on the posterior wall. Volkmann believes the extravasations of blood to have been caused by the rectal explorations. No sign of inflammation about the inci- sions. The size and form of the tumor is represented at Plate x. 1874. Kocher. Male, ast. thirty-four. Began to suffer in the spring of 1874, with a constant desire to micturate and incontinence. In June, these symptoms changed to a violent burning pain and increased desire to pass water. Urine of intolerable odor, and contains blood and pus. A piece of tumor which came out proved to be a papillary growth. December 31st, urethra was opened by a T- shaped incision. A vertical cut in the mesial line and a TUMORS OF THE BLADDER. 75 horizontal one, after Nelaton's pre-rectal method. The urethra was opened on a grooved staff and the finger introduced into the bladder. On its posterior wall was felt the soft, tufted, fungoid mass of the new-growth ; a large sharp scoop, bent at an angle, was introduced against the finger, whereby it was forcibly scraped off. The hemor- rhage was pre tty severe, but was arrested by cold water injections. No dressing was applied. The wound healed in six weeks, and in fifteen months the patient was consid ered as quite cured. 1877. Humphry. Male, ast. twenty-one. A mass could be felt in the bladder above and behind the pubes. Suf. fering being extreme, made an incision into the bladder as for lateral lithotomy, and found a firmish tumor, with a ragged surface, attached by a pedicle to near the orifice of right ureter. Partly by finger and partly by forceps, the .pedicle was torn through, and the tumor was extracted with lithotomy forceps. The root of the pedicle was scraped out with the finger-nail. After a day of compar- ative ease, the pain returned with great severity, requiring the subcutaneous injections of morphia, which had to be increased to large doses, and continued for more than two months. Then the pain diminished and gradually sub- sided. The wound healed, and the patient completely recovered, and was quite well eighteen months after the operation. 1880. Davies-Colley. Male, ast. thirty-two. Opened the bladder by the usual incision for lateral lithotomy. At first nothing could be felt. Then a slight projection was made out on the left side of the fundus, and a cord- like process running from it. In a short time the free end of this process, with a soft pinkish tuft of villi attached to it, was seen at the deeper part of the wound. This was seized with the forceps, drawn out, and the pedicle cut with a pair of scissors close to the wall of the bladder. No other growth could be felt. There was but little y6 TUMORS OF THE BLADDER. hemorrhage during the operation, and some which oc- curred in the evening was readily arrested by the injection of iced water into the bladder. He made a rapid recov- ery. In two weeks, the urine ceased to flow from the pe- rinasum, and soon afterwards the wound healed. When last seen, two months after the operation, there had been no return of the hemorrhage. The irritability of the blad- der had ceased, and he was in the enjoyment of perfect health. The tumor grew from the posterior wall of the bladder, at a point about three inches from its neck, and one inch to the left of the middle line. It consisted of a fibrous stalk, one-sixth of an inch thick and two inches long, and terminated by branching filaments from half an inch to three-quarters of an inch long. These filaments contained capillary loops, invested by many layers of epithelium of a cylindrical shape. 1880. Supra-pubic Cystotomy. Marcacci. Male, ast. fifty-four. An incision thirteen centimetres in length was made, commencing one centimetre above the upper mar- gin of the symphysis pubis, and extending through the linea alba. The bladder was found to be enormously dis- tended, its whole interior being filled with a large neoplas- tic mass; this was removed. The wound in the bladder was brought together with four catgut sutures; that in the abdomen with interrupted metallic sutures, and the whole dressed antiseptically. The patient progressed favorably during the first ten days, when, on the removal of the metallic sutures, the wound being apparently healed, a few drops of urine escaped from the openings where the sutures had been. All attempts to cure these urinary fis- tulas failed. Patient died within two months after the operation from extravasation of urine, pelvic abscess, and peritonitis. M. considers that the cause of death was due to the too early absorption and destruction of the catgut sutures, which probably lost their holding power before the wound in the bladder had become consolidated. TUMORS OF THE BLADDER. jj 1880. Berkeley Hill. Male, ast. sixty-three. Not with any expectation of effecting a cure, but of affording relief, the lateral incision as for stone was made, the finger introduced, and a soft mass, about as large as a marble, projecting from the floor of the bladder on the right side, was brought away in a lithotomy forceps. By free injec- tions of cold water, several such masses were washed out along with much stinking pus and mucus. The patient was but little relieved by the operation, and death oc- curred on the third day from exhaustion, consequent on the irritation of bladder and from cachexia of a malignant tumor, which was found in the bladder after death. Perhaps not altogether irrevelant to the operations above recorded is one performed by Liston (related by Robt. Knox, M.D., Lon. Med. Times and Gas., August 2d, 1862), for the removal of a cyst from the bladder of a man suffering with difficulty in discharging his urine. Liston passed a catheter and felt a soft, yielding but obstructing body in the prostatic portion of the urethra. This readily gave way before the catheter, which then passed into the bladder, but on being withdrawn it was followed by the foreign body, which immediately reoccupied its former position. Liston opened the bladder above the pubes, and as the incision was made, there escaped from the bladder a body resembling a cyst or false membrane of the shape of the interior of the bladder. The wound was closed, the patient recovered and lived for some time. From the foregoing we learn that thirty-four operations have been performed for the removal of tumors from the bladder: twenty-three upon females and eleven upon males. In seventeen of the former, the growths were removed through the urethra by previous bloodless dilatation of the canal, and in six by incision of the urethra or of the vesico-vaginal septum. The subjects varied in age from twenty-two months, two and three-quarter and five years 7% TUMORS OF THE BLADDER. to seventy years. The growths removed have included papillomata, myxomata, myomata, and sarcomata. The tumors have been removed by simple torsion and avulsion, by ligature, silk, and catgut, silver wire, by Ecraseur and by scooping out with a sharp spoon. Excepting the method of scooping, in which the hemorrhage is sometimes consid- erable, the loss of blood in the other operations was insigni- ficant. Of the seventeen patients from whom the growths were removed by urethral dilatation, ten recovered. In this number we include the cases of Guillon, Bishop, and Godson, in which, although the result is not absolutely stated, the phraseology is such that there can be little doubt as to their successful termination. Two cases are reported as much improved by the operation and five ter- minated fatally. After the six cutting operations, three re- covered and three died. We thus find, after both opera- tions, a total of thirteen recovered, two improved and eight died. Let us now examine to what degree, in the fatal cases, the operations may be regarded as having been the imme- diate cause of death. In the patient of Le Cat we have no data other than that she died in two days after the second operation. In Heath's case, a portion of sarcoma was torn away and the patient died a month after, from general ex- haustion. In the case of Morris, the patient improved by the operation, but died eventually, he does not say when, evidently at some remote period, from hydronephrosis. In Guerssant's child, aged twenty-two months, the bladder symptoms improved, but the child weakened, had diarrhoea, and died exhausted on the eighth day. Norton's patient died on the twelfth day when apparently in health; she vomited, and shortly afterwards fell asleep in which sleep she died from syncope at the time when she was recover- ing from the operation. In these four cases, certainly it cannot be said that the operation caused or precipitated the fatal termination. TUMORS OF THE BLADDER. yg Neither is this at all evident in the patients of Pleininger and Birkett; both of those were children, aged respectively two and three-quarters and five years. The first little suf- ferer remained unrelieved by the operation, because nu- merous growths were left behind. " She became emaciated and finally died of peritonitis." It does not appear how soon after the operation death ensued, but from the lan- guage we may reasonably infer that the peritonitis had no connection with the operation. The other patient was a very weakly child, and a few days after the tumor came away, considerable pyrexia supervened and she died. It may, therefore, be said that in but one of the eight fatal cases in the female can the operation be positively held as the immediate cause of death. In this case (Senftleben), the bladder was perforated during the attempted removal of a sarcoma, and the patient died on the fourth day from purulent peritonitis. With regard to the size and character of the growths that may be successfully removed through the urethra, some are given as the size of a goose's egg, turkey's egg, etc., which have been removed by ligature, ecraseur, etc. But the most noteworthy operation, as showing what can be done even in the least promising of cases, is that of Simon, who successfully scooped out from the walls of the bladder a sessile tumor that had occupied two-thirds of the cavity of that viscus. The male bladder has been opened for the removal of tumors eleven times : eight times through the perinasum, including in this enumeration Covillard's operation, about the precise nature of which, however, we have no data; twice jointly through the perinasum and above the pubes, and once above the pubes only (not including Liston's successful removal of a cyst). Of these eleven opera- tions, six proved successful and five fatal. Of the success- ful cases, five recovered after perineal cystotomy and one after both perineal and supra-pubic cystotomy. Of the 8q TUMORS OF THE BLADDER. deaths, three occurred after perineal cystotomy, one after both perineal and supra-pubic cystotomy, and one after supra-pubic cystotomy. The ages of the subjects operated upon varied from two to sixty-three years. These statistics would show apparently a mortality of nearly fifty per cent, but a more careful examination will show that such a percentage of deaths is probably much in excess of what may be expected. In the first place, the case of Hill cannot be included in the results, as militating against the operation, for this was not done with any idea of effecting a cure, but simply as a palliative measure, with the hope of affording temporary relief from intense suffering due to malignant disease in a subject sixty-three years old, already worn out and cachectic. The case of Gersuny was very exceptional in that the tumor was inclosed in a diverticulum of the bladder and was alto- gether beyond reach. Besides, the tumor had been of so long standing that it had given rise to other serious changes in the vesical walls, which, even in the event of the suc- cessful removal of the tumor, would have rendered recov- ery impossible (see Plate iv., Fig. i). In the child of Crosse, the growths were but partially removed, hence recovery could not have been expected. In the cases of Volkmann and Marcacci, the cause of death was the imperfect closure of the vesical wound. In both, the wound in the bladder and abdomen was closed with sutures. In the first case, death occurred on the third day from peritonitis and dif- fuse purulent infiltration of subserous areolar tissue. In the latter, the vesical wound was brought together with catgut ligatures, and the abdominal wound with metallic sutures. Patient did well at first, but died within two months from extravasation of urine, pelvic abscess and peritonitis, because, as Marcacci thinks, of the too early absorption and destruction of the catgut sutures, which probably lost their holding power before the union of the wound in the bladder had become firmly established. The • TUMORS OF THE BLADDER. 8l question might here be asked, if, when the imperfect closure of the bladder was first manifest by the appearance of the supra-pubic urinary fistulas, the fatal complications might not have been averted had the bladder been opened in perinasum. In this connection, it may also be noted that a number of post-mortem examinations indicate that the cases of successful removal of tumors from the bladder might have been multiplied by an early operation. In some cases, the bladder has been actually opened and yet no attempts were made for the removal of an existing tumor. Perhaps the earliest example of this is recorded of Petit, of whom it is said that, although he did not re. move the polypus, the operation of opening the bladder was not attended with any bad result, and a year after- wards, on post-mortem examination, it was discovered that there was a polypus the size of a fist in the bladder, of a pyramidal figure and attached by a very delicate pedicle. Although this man, aged twenty-eight, is said to have died of phthisis, there is probably little doubt that his life would have been prolonged by the removal of the growth which apparently could have been most easily accomplished. Gross alludes to two operations for stone, one Deschamp's, the other his own, in which the calculi were extracted, but the neoplasms which were afterwards found were not in- terfered with. He does not say why, but speaks of his1 own case as a tumor situated on the anterior wall of the bladder, lobulated and sessile. From a reference to the histories and drawings given of several of our cases, such^s those of Springall, Barton and Hudson, in which for some reasons no operation was attempted, it will be seen that the removal of the growths could have been most easily accomplished, and, as it would seem, with every prospect of success. The foregoing citation of the various methods adopted for the removal of tumors from the bladder leaves 6 f 82 TUMORS OF THE BLADDER. P* little more to be said in regard to treatment. The choice of an operation, however, will depend upon the seat, nature, and size of the growth. In the female, owing to the shortness and dilatability of the urethra, tumors may be removed by this channel with comparative ease and safety. The urethra being dilated in the manner already laid down, the left index introduced and the tumor recognized, a long, slender pair of forceps or scissors may be guided along the finger to the pedicle of the growth, and the same twisted off or cut away. Fig. i represents the forceps used by Simon for this purpose. They are very long, S-shaped (A), and their branches are scissors-like, either toothed (b), or with a smooth edge (c). If the tumor is not removed in this way, it may be treated by ecrasement, or ligature, as may be deemed most expedient. Sessile or flat growths may be extirpated by the knife, or by means of sharp spoons especially constructed for the pur- pose. The instrument so success- fully employed by Simon is de- picted at Fig. 2. It is long handled; A, the edge, is very sharp, and the spoon is bent at a right angle to the handle, b and c. The growth is scraped or cut away by pressing the part to be taken off against the edge of the spoon with the finger. This operation is always attended with pretty free hemorrhage; but this maybe kept under control by means of iced water, injected .Fig. i. Fig. 2. TUMORS OF THE BLADDER. 83 into the bladder, or the application of a pledget of lint soaked in perchloride of iron to the base of the tumor, and the bladder afterwards washed. If the tumor is not accessible, or is too large to admit of removal after bloodless dilatation of the urethra, the canal may be further enlarged and shortened by incision. This was done successfully, as we have seen, by Warner, who divided the left wall of the urethra half-way to the blad- der, and also by Schatz, who incised the right side of the urethra and inverted the posterior wall of the bladder with the tumor through the urethra by means of several threads previously passed through the tumor from the vagina. If lateral incision of the urethra is not made, the tumor may be reached by kolpo-cystotomy. In regard to this operation, Simon recommends that the incision through the vagino-vesical septum should be T-shaped. He says that by a long incision through the whole length of the urethra to the mouth of the uterus the bladder cannot at all, or but very little be introverted. The inversion of the vertex and the upper part of the fundus, however, is obtained after a transverse incision of three centimetres in length into the anterior wall of the vagina, one-quarter to one-half centimetres in front of the anterior lip of the os uteri; and, still better, when, besides the transverse incision, a second one is made at right angles directly toward the urethra, so that a T-shaped incision results. By the exercise of some traction in the direction of the vagina with a fine double hook inserted into the mucous lining of the bladder, and a simultaneous pressure over the hypogastrium, the interior of the bladder is made so completely accessible by inversion, that the most compli- cated and most difficult operation can be performed with the same facility as on the surface of the body. The tumors may be extirpated with scissors, knife, and even the galvano-cautery can be used. After the internal wound g. TUMORS OF THE BLADDER. has cicatrized, the vesico-vaginal incision may be closed by the usual method. In the male, the tumor may be reached either through the perinasum or from above the pubic symphysis. It would scarcely be to the purpose now to institute a close inquiry into the relative advantages and disadvantages respectively of suprapubic and perineal cystotomy. For the removal of tumors of the bladder, the selection of an operation can rarely be a matter of choice, but must depend upon the location, mode of attachment, and size of the growth. The perineal operation will, perhaps, be more frequently adopted; i, because of the usual seat of tu- mors in the lower portion of the bladder, which, in the absence of great hypertrophy of the prostate, are gen- erally sufficiently accessible from this point, and, espe- cially if pediculated, are easily enough removed ; 2, because the operation itself is considered less hazardous than is the opening of the bladder from above; 3, because, if after perineal cystotomy the tumor proves to be inaccessible or too large to be thus removed, and supra- pubic cystotomy is found necessary to reach it, the peri- neal incision will not diminish, but rather increase the chances of recovery, by affording free drainage for the urine in the most depending position. It is said of Frere Come (1758-1778), whose high operations for stone were so successful that, in order to prevent urinary infiltra- tion, he was in the habit, before performing epicystot- omy, of opening the urethra in perinasum. The value of perineal drainage was also appreciated by Civiale, who, according to Bransby Cooper (Coulson, p. 476), while engaged in the high operation for stone, accidentally wounded the peritonaeum, and fearing extravasation of urine into the peritoneal cavity, opened the bladder through the perinasum, and the patient recovered. In BiUroth's case, the preliminary perineal incision proved eminently satisfactory. TUMORS OF THE BLADDER. * 85 Sometimes, however, the most available method of reach- ing the tumor will be from above the pubes. In addition to the freedom from hemorrhage, absence of danger of wounding the rectum and ejaculatory ducts, etc., statistics show that for calculi above two ounces in weight the results after the high operation are more favorable than after lateral lithotomy—a fact which has an important practical bearing on the possibilities of success in the removal of tumors by the supra-pubic method. But without further dwelling upon the relative advantages of the two operations, the fact, that in the high operation the parts are freely exposed to view, is an advantage which must, in certain difficult cases, supersede every other con- sideration. Preparatory to the operation, the supra-pubic region is to be shaved, the bladder, after being evacuated of urine, is distended with, perhaps, a one-quarter per cent solution of carbolic acid, and if necessary or desirable, the bladder may be still further raised above the pubes by distending the rectum with a colpeurynter or a few sponges. The patient is placed in the recumbent posture, with the pelvis elevated above the level of the loins and shoulders, so that the abdominal viscera shall gravitate away from the bladder. The surgeon, standing to the left of the patient, makes an incision from three to four inches in length, com- mencing immediately over the pubes, upwards in the mesial line and down to the aponeurosis of the abdominal muscles. The linea alba being exposed, this structure is divided at the upper border of the pubes, sufficiently to admit a grooved director upon which the linea alba and fascia transversalis are slit up to the requisite extent, per- haps one and a half or two inches. The bladder will now be felt at the bottom of the wound as a soft fluctuating tumor, still covered, however, by areolar tissue, which may be divided with a few touches of the knife or separated with the handle of the scalpel; but the areolar tissue con- 86 TUMORS OF THE BLADDER. nection between the bladder and symphysis should be left as much as possible intact, because it forms the best barrier against the infiltration of urine or pus. The bladder being now fairly exposed, it should be secured by ligature or transfixed by a tenaculum before it is opened; otherwise, when the incision is made it will collapse out of sight and embarrass the surgeon in the succeeding steps of the operation. The bladder being held in position, a vertical incision is made, the margins of the vesical wound held apart while the tumor is drawn out if possible, and removed either by avulsion, ecraseur, knife, or galvano-cautery. The incision in the bladder should be as small as possible, but always clean cut and free enough for easy access to the growth, as stretching of the wound implies more or less bruising or laceration which, when the edges are brought together, will correspondingly interfere with the union by first intention. If the external longitudinal inci- sion affords too limited a field for operation, the wound may be enlarged by two small, transverse cuts immedi- ately above the pubes, without separating entirely the insertion of the recti muscles. Billroth, in order to obtain sufficient room, was obliged to divide both recti at their insertion. But this is to be avoided, if possible, because such wounds require a longer time to heal and are apt to lead to the formation of abdominal hernia. The dangers apprehended from supra-pubic cystotomy are, wounding the peritonasum, and urinary infiltration of < connective tissue. The danger of wounding the peritonas- um is not so great as is generally supposed. Out of 478 cases of supra-pubic lithotomy collected by Dr. Dulles {Amer. Jour. Med. Sc, July, 1875), in only 13 had this mem- brane been wounded and of these 3 cases were fatal. Even for the removal of large tumors, the bladder can be so dis- tended as to present above the pubes, and opened without endangering the peritonasum. Garson {Edin. Med. Journ., Oct., 1878) has shown that the bladder can be as easily raised TUMORS OF THE BLADDER. gy above the symphysis by distending the rectum as by in- jecting the bladder, and that, in case where it is not advis- able to distend the bladder to a large size, distention of the rectum by a colpeurynter is all that is required to make the parts suitable for the operation. Petersen, of Kiel, by numerous experiments, substantiates these ob- servations, and finds that, with the bladder and rectum moderately distended, the line of reduplication of the peritonasum, as'shown by measurements on the cadaver, is thus displaced upward to the distance of about five and one-half centimetres, and can thus be kept out of the way of injury. In children, it will be remembered the bladder is almost an abdominal viscus ; but if it is desirable to dis- tend the rectum, this can be done with one or two sponges, previously attached to a string, to prevent them from passing beyond reach. With reference to the question of urinary infiltration, this is a danger to be apprehended as well after perineal as after supra-pubic cystotomy ; but the danger of septic infection is, perhaps, less after epicystic infiltration, be- cause 'it is less confined and more accessible to our inter- ference than when the urine has infiltrated the peri-pro- static and cirumrectal areolar ^tissue. The prevention of urinary infiltration involves the con- sideration as to the best way of dealing with the vesical wound. Shall it be stitched or shall it be left open? Both methods have their strong advocates, and both have shown excellent results. If we turn to our present expe- rience in epicystotomy for the removal of tumors, we find, on the one hand, the success of Billroth, by the open method, and, on the other hand, the failures of Volkmann and Marcacci, by the closed method. Although Volk- mann operated in a manner similar to Billroth in making the preliminary perineal incision, in his case, as in Mar- cacci's, purulent infiltration and peritonitis occurred from, as it is said, imperfect closure of the vesical wound. 88 TUMORS OF THE BLADDER. Prof.Trendelenburg, Rostock {Berlin. Klin. Wochenschr., No. i, 81), reports four successful cases of supra-pubic lithotomy, which he treated by the open method with ab- dominal decubitus. At the completion of the operation, he washes out thoroughly the wound and the bladder with carbolic solution, and then relies altogether on the efficacy of drainage, which he secures by inserting through the wound and into the bladder a T-shaped drainage tube, its peculiar shape preventing its falling out, and employing the abdominal decubitus on air cushions. He considers infiltration of urine impossible under this management. On the other hand, excellent results have been attained after the high operation for stone with stitching of the vesical wound. Although we have been unable to obtain statistics, our German brethren, especially, appear just now to have a predilection for this particular procedure, and we have every reason to expect that with good depending drainage and thorough Listerism, rriany a good result will follow the same operation for the removal of tumors. The time, however, has not yet come when it would be judicious to express a positive opinion* as to the safest method of dealing with the vesical wound ; we must await further experience. .But it will, no doubt, be impracticable to adopt a uniform practice in all cases. Among other things, we shall have to be governed much by the condition of the vesical walls. In one of my own cases, for instance, the vertex of the bladder had become so attenuated by distention from blood-clots that, had the viscus been opened from above, a perfectly water-tight closure of the wound by sutures could not, I am convinced, have been accomplished. As an absolute water-tight closure of the vesical wound is a conditio sine qua non, to union by first intention, as soon as the sutures are applied, the bladder should be moderately distended with water to see that" this has been accomplished. '» TUMORS OF THE BLADDER. 89 With the view of preventing urinary infiltration, Vidal de Cassis suggested dividing the supra-pubic cystotomy into two separate operations: the first to consist in mak- ing the abdominal section down to the bladder, and some days after the establishment of surrounding adhesive in- flammation, to open the bladder. Nelaton is said to have once operated in this manner, but the patient, seventy- eight years old, had so much pain that the bladder had to be opened on the third day. I cannot find that this pecu- liar method has since been repeated. T. Gaillard Thomas has very recently made a success of clamping the lips of the vesical incision between those of the abdominal wound, and it may be that we have by this method the prospect of better results than those hitherto obtained by sewing up the opening and return- ing the repaired viscus to the pelvic cavity. This new procedure was effected on the occasion of a laparotomy, performed on a lady, aged thirty-eight, for the removal of a large multilocular ovarian cyst. The abdominal walls being laid open to the extent of about three and one-half inches in the median line, Thomas found the bladder greatly expanded over, and extensively attached to the anterior surface of the ovarian tumor. H e attempted to define this attachment by passing a long catheter into the bladder, but the tumor pressed so firmly against the pubes that it could not be introduced beyond that point. He now made an incision through the anterior wall of the bladder, and passing the index finger of the left hand, he was able for the first time to determine the upper limit of the adherent viscus, and succeeded in separating it from its extensive attachments. After this the tumor was re- moved in the usual way; its pedicle cut, ligated, and returned to the peritoneal cavity. With Peaslee's needle, he applied silver sutures to the abdominal wound, until the same was closed from above downwards to the open- ing in the bladder. He now passed the needle through 9o TUMORS OF THE BLADDER. the abdominal wall; then through one vesical wall, through the other, and, lastly, through the opposite abdominal wall, and so continued to do, until the whole opening in the bladder was traversed by sutures. The sutures were then twisted, care being taken to lift the bladder well up to the surface, and the operation was completed. A Sims' sigmoid catheter was kept in the bladder. The sutures ^vere removed on the tenth day, and the case progressed favorably until the fourteenth day, when a slight oozing of urine was discovered from an opening not larger than a cambric needle in the line of the incision ; but this minute opening was closed by the application of an additional su- ture, and at the end of three months, the patient went home entirely well. If after epicystotomy the drainage of the bladder is to be secured by the retention of a catheter per urethram, the method suggested by Chiene, of Edinburgh, for the cure of obstinate urinary fistulas—the value of which I have re- cently had opportunity to verify—commends itself for adoption also after supra-pubic cystotomy. It is as follows: A flexible, perfectly smooth-eyed catheter is introduced and fixed to the penis with sticking-plaster. Care is taken that the eye of the instrument is just within the neck of the bladder. To this catheter an India-rubber tube is fixed, of sufficient length to reach, without being strained, over the side of the bed to the floor. It then passes into a bottle. The bottle and tube are filled with carbolized water before attaching the apparatus to the catheter. Care is taken that no air can get in at any of the joints. It is well to introduce a piece of glass-tubing at a convenient part for observing the direction of the flow. In order to keep the India-rubber tube steady in the bottle, a piece of glass- tubing is attached to its extremity. If the glass tube ex- tends beyond the neck of the bottle, any folding of the India-rubber tube at this point will be prevented. A siphon action is in this way established, with a suction TUMORS OF THE BLADDER. 91 power, the strength of which depends on the height of the column of water, and which will draw the urine into the eye of the catheter as it passes drop by drop from the openings of the ureters into the bladder, and a constant slow current of water will pass along the tube into the bottle. The bottle is allowed to overflow into a basin, which as it fills can be emptied without displacing the apparatus. The bladder is kept constantly empty. Care must be taken not to have too great a fall, or the suction of a piece of mucous membrane into the eye of the cathe- ter will cause uneasiness and plug the catheter. The height of the hospital bed is generally sufficient, and in some cases even a less height is all that is required. Palliative Treatment. With regard to the treatment of malignant tumors, there is no reason why a timely operation may not, in certain cases, prolong life; but, as a rule, cancerous tumors will admit at most of but palliative treatment, such as alleviation of pain, controlling hemorrhage, and making life as endur- able as possible. Pain, irritation, and spasm should be allayed as completely as possible by the free administra- tion of anodynes, as by so doing we not only afford the necessary relief from suffering, but keeping both mind and body in a condition of quiet and rest, we diminish greatly the tendency to hemorrhage. Conditions that tend to the determination of blood to the pelvic organs should be avoided, the patient should lie with the pelvis somewhat elevated and the bowels must be kept free. As to the efficacy of ergot, gallic acid, turpentine, iron, sulphuric acid, matico, alum, etc., in restraining hemorrhage from tumors of the bladder, we are not enthusiastic; they seem to have occasionally served their purpose, but they must always be administered freely, and even then they will often disappoint. Local astringents and styptics are of much more value. Cold-water irrigation, ice-bags applied to g2 TUMORS OF THE BLADDER. the hypogastrium or perinasum, or ice introduced into the rectum or vagina is often of much service. The topical application of sol. zinci chloridi, argent, nitrate, iron, alum, etc., have proved of marked success in checking hemor- rhage. In injecting the bladder, it must always be re- membered that the greatest care is to be taken during catheterization to avoid touching or bruising the tumor with the instrument, which always provokes more or less hemor. rhage, and may thwart the very object it is sought to attain. In the introduction of the instrument, the eye of the catheter should reach just within the vesical orifice and no further. In some cases, the bladder may be more advantageously injected by means of a fountain syringe or rubber-bag syringe without the aid of a catheter, and simply by hy- drostatic pressure, as recommended by Zeissl. The pa- tient is placed in the recumbent posture, with nates raised; the penis is brought up against the abdominal wall without undue stretching; the nozzle of the irrigator is introduced into the urethra and there held in such a manner that re- gurgitation of fluid from the meatus cannot take place; the stopcock is opened and the urethra becomes distended; the sphincters yield, and the fluid enters the bladder. Hunter McGuire, Professor of Surgery in Virginia, mentions a case of malignant vascular tumor of the bladder, where the soft gum catheter gave rise to serious bleeding and to-severe urethral fever. Nothing gave the patient so much comfort as the use of this rubber-bag syringe. He not only em- ployed it morning and night to wash out the bladder of the blood, mucus and pus that collected there ; but sometimes an injection of simple warm water stopped the pain and vesical tenesmus better than anything else. Sev- eral times the bleeding was stopped by adding alum to the water. I have myself practised this method of injecting the bladder in many cases during the past few years, and often with much less pain and discomfort to the patient than when the catheter was used. TUMORS OF THE BLADDER. 93 Conclusions. From the foregoing observations and statistics 1 think we may formulate our conclusions as follows: • ist. In a few remarkable instances in the case of women, apparent recovery seems to have resulted from a sponta- neous expulsion of growths from the bladder. But in general it may be said that tumors of the bladder, if unin- terfered with, are inevitably fatal. And, although they may exist for several years without creating much distress, a fatal termination almost invariably ensues in a few weeks or months from the outbreak of active symptoms. 2d. Death results most frequently from hemorrhage, and from the effects of mechanical obstruction to the outflow of urine. Hence the indication would be to remove the growth while the general condition of the patient is yet favorable for an operation ; before the subject has become exhausted from loss of blood, or the kidneys and bladder have become so much diseased as to make recovery im- possible, even in the event of the successful extirpation of the growth. 3d. In women, because of the accessibility of the blad- der to direct exploration, there is no excuse for temporiz- ing, and the surgeon should lose no time in acquiring an exact knowledge as to the existence, nature, etc., of the tumor, and, if practicable, attempt its removal as early as possible. 4th. The results thus far attained by surgical interfer- ence, in the cases of women, could scarcely be more satis- factory, and excepting one instance in which the bladder was accidentally perforated, it does not appear that the fatal termination was precipitated by the operation in any of the cases. 5th. In the male, the propriety of operative interference must necessarily always be a more serious question; be- cause of the occasional uncertainty of diagnosis, and because 94 TUMORS OF THE BLADDER. of the gravity of the undertaking necessary for the remova of the growth. Nevertheless the results, thus far attained by operation, are most encouraging and in every way jus- tify a repetition of the same. 6th. From a number of autopsies made, we learn that the successful operations might have been multiplied first in those cases in which no operation was attempted, although the growths could have been easily removed and with ap- parently every prospect of success; and again in those in which the operation was too long deferred and which, it is reasonable to assume, would have terminated successfully, had the same been undertaken at an earlier period. 7th. Given a positive diagnosis of tumor, the absence of severe secondary symptoms should be no excuse for de- ferring the operation. On the contrary, the earlier the growth is removed the better the prospects of complete recovery. With a healthy bladder and kidney, cysto- tomy is not so dangerous an operation as to warrant any delay. 8th. Evidence strongly pointing to the existence of a tumor with severe catarrhal symptoms or with spasm of the bladder and much suffering, will often justify an oper- ation ; for, if a tumor is found, its extirpation will afford the only chance for life; and if no growth exists, or the bladder is occupied by an irremovable cancer, the cystot- omy may at least afford temporary relief from suffering. 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