CASE.-A male patient, aged 66, whom I saw toward the end of 1892, had been suffering from vesical hemorrhage for many months previously. The bleeding, retention of urine and clots, and the pain from tension had become so constant and unmanageable as to indicate the necessity for adopting other means, as all medicines as well as catheterism and irrigation of the bladder had proved useless. I ad vised a supra-pubic opening, which I made shortly after I first. saw the patient, and removed portions of a carcinomatous growth from a hard base immediately above the prostate. The relief was complete, the growth was checked, and the hemorrhage was only slight and oc casional. The interior of the bladder was rendered clean and aseptic by passing a soft catheter each day along the urethra and washing out through the wound. The urine was discharged by the opening, and the patient kept dry by means of wood-wool pads. He was enabled to get about again, and remained free from pain until a fortnight be fore his death, five months afterward.
When it is determined to operate for the removal of a tumor within the bladder, with the object of either cure or relief, supra-pubic totomy, as described later on, is on all grounds to be recommended.
If the connections of the tumor are extensive, and there is a doubt as to whether all can be got away without doing serious damage to the bladder itself, I feel sure that we had better content ourselves with the opening, which may under all circumstances be safely made, and the drainage with a suitable apparatus that this aperture will provide. The lesser proceeding has in many instances proved the means of arresting hemorrhage, and of adding materially to the com fort as well as to the life of the patient, even where it has been found impossible either to remove the tumor or with safety to reduce its size. And what relates to the male is equally applicable to the fe male, though with the latter, by reason of the anatomical differences in the parts, both exploration and removal can be more readily effected. It must not be overlooked that in some cases of malignant tumor of the bladder which have been operated upon, recurrence has taken place in the wound. Dr. J. H. Neale " records an instance of
adeno-encephaloid cancer of the bladder, operated on by Air. C. H.
Marriott, where the wound and the perinteurn adjoining were subse quently largely invaded by the growth. Mr. Marriott remarks : " This case alone appears to me to put a limit to the range of surgical treatment of vesical tumors. Where a polypoid or pedunculated growth is diagnosed, by all means remove it; but in the case of a sessile tumor, closely incorporated with the muscular walls of the blad der, the treatment best suited to the requirements of the case seems to me to be to establish and maintain free drainage and so relieve the strangru-y, leaving the tumor to take its own course." In this ex pression of opinion most surgeons of experience, I think, will agree.
Some cases of partial resection of the bladder wall containing a growth have been recorded by Albarrau and others, but this method of treatment has so far not proved to be practicable except to such a limited extent as hardly to require special notice.
In malignant growths involving the bladder, which are considered as being outside the pale of operative treatment, the question arises, can anything be clone either to check their progress or to avert the blood deterioration which becomes evident? For these purposes iodide of potassium and Chian turpentine have sometimes been used with apparent temporary advantage. The former certainly does oc casionally check the growth and extension of neoplasms, while the latter has been known to do more, as stated by the late Mr. Clay, when given in malignant growths involving more particularly the urinary passages. The therapeutic effects of Chian turpentine may possibly be due to some of the constituents of the drug being eliminated by the urine, and this may also explain its efficacy, undoubtedly observed in some instances, in controlling hemorrhage and rendering the ab sorption of cast-off products of inflammation less deleterious.