THE LIFE HISTORY OF HEMORRHAGE FROM BENIGN GROWTHS WHICH ARE SITUATED AWAY FROM THE ORIFICE OF THE BLADDER.
The history is often of long duration—a matter of years, not months. Usually the bleeding commences insidiously ; perhaps it ap pears in the form of darkish clots like flies, only to disappear in a few clays, or the urine may be merely discolored, or a little blood may be passed at the end of clear micturition, or the whole secretion may be of a dark coffee-color. The patient may connect the onset with over-fatigue, but I believe this is uncommon. It is also rare, as far as my experience goes, for a profuse arterial-colored hemorrhage to form the onset attack. The hematuria ceases as spontaneously as it commenced, but it recurs unexpectedly, causelessly, at longer or shorter intervals. As the tumor increases in size, the length of the periods of rest appears to decrease and the loss to be more profuse. The bleeding is unaccompanied by any other symptom; neither fre quency of micturition, pain, nor stoppage of the stream is noticed.
The larger the tumor is, or the wider the area which is occupied by the base, the greater is the tendency for the bleeding to recur after exercise or over-fatigue. In the male, coition will sometimes induce an attack or increase the bleeding. It is usually more under the control of rest than hemorrhage from a malignant surface. Probably it will be, now and again in the course of the case, of a dis tinct vesical type, i.e., bright blood will appear at the finish of a
stream of clear urine.
The hemorrhage is rarely of the violent arterial type, though I have known one or two patients blanched with the loss; usually it is less furious and darker. If the deeper layers of the growths become carcinomatous I believe the hemorrhage becomes more profuse and more persistent. As the neoplasm approaches the urethral orifice, either by the lengthening of its stalk or by overgrowth, it is exposed to greater damage, the bleeding is more severe, and other symptoms, such as irritability of the bladder, and stoppage of the stream, also appear. Sessile, closely-felted villous growths bleed less often and less profusely, and attain a greater age than other forms.
The hematuria may be checked for a time by intercurrent disease, e.g., carcinoma of the breast, acute rheumatism, or some fever, but recurs after the interloper has been removed or subsides.
Lastly, when the period of cystitis is ushered in (either from change in the character of the base of the growth, or from the tumor having begun to necrose, or from injudicious exploration on the part of the surgeon), the appearance of the blood changes, pus becomes mixed with it, and the hemorrhage may be permanently arrested by the inflammatory plugging of the vascular supply of the surface of the tumor which takes place on the establishmant of severe cystitis.