THE SYMPTOMATIC STAGE - TUMORS OF THE BLADDER AND PROSTATE. The Symptomatic Stage.—The larger proportion of bladder tumors sooner or later pass out of the quiescent condition, and enter upon the second or more active stage of their existence. Whether this transition is slow or rapid, gradual or sudden, greatly depends on their kind as well as on the accidents and contingencies connected with their growth ; but whether innocent or malignant, primary or secondary, the majority of them sooner or later make it apparent that life will eventually be destroyed, either by persistent hemorrhage or ulceration, or by the degree of interference with micturition. Con tinuous or intermittent hemorrhage, evidence of ulceration, and inter ference with micturition are the symptoms of progressive tumor of the bladder which may be sufficient to indicate operative interference. In addition, valuable assistance in diagnosis can generally be obtained by examination of the bladder from the rectum and with the sound, and by the evidence that may be furnished by an inspection of the growth. By the rectum the finger will frequently prove that the pos terior wall of the bladder, as well as the contiguous portion of the bowel or prostate, is implicated in a growth of an irregular form and consistence, partaking of the characteristics usually associated with the physical signs of malignancy. Exploration with the sound will often also unmistakably indicate that the area of the bladder is more or less encroached upon by a new tissue formation, which as a rule readily bleeds, even under delicate manipulation. Direct evidence is sometimes afforded by the microscopical examination of portions of growth voluntarily discharged during micturitiou or removed in the eye of a catheter or by any other instrument. Too much importance must not be attached to this, in the absence of symptoms of a corrob orative nature.
In the present day the most reliable evidence of the presence and nature of a tumor within the bladder, including some varieties of prostatic outgrowths, is to be obtained by the illumination of the interior of the viscus by means of the electric light and the use of a suitable speculum in connection with it. The mode of doing this is shown in the following figures from ran (Figs. 46 and 47). Apart from the question of agnosis, it is upon an examination of this kind, taken in conjunction with the symptoms each case sents, that conclusions as to treatment, more particularly in reference to operative measures, are to be drawn and a course decided upon. Ocular inspection obtained in this way has now almost entirely seded the digital explorations which were practised before the intro duction and perfecting of this means of diagnosis. It is for these reasons that attention may here be drawn most conveniently to elec tric cystoscopy. For its general application to local states of uri nary disturbance reference should be made to special works upon this subject, among which I may mention those of my colleague, Mr. Hurry Fenwick," as containing the fullest information, and as fur nishing the most practical guide to all matters relating to it. I have
already indicated the symptoms which would suggest the presence of a growth within the bladder, and the necessity for proceeding to an examination of this kind.
For this purpose I have been in the habit of using Leiter's instru ments. As a rule it is best to have the patient placed under an amns thetic, and in the lithotomy position at the end of an operating table of a suitable height. A deep injection of a ten-per-cent solution of cocaine in some cases suffices to render the examination painless. The following requirements, as stated by Mr. Fenwick, are necessary for success : " (1) The urethral canal must have a calibre of twenty two French catheter gauge. (2) The bladder must have a capacity of at least four ounces. (3) The water in the bladder must be trans lucent, and ought to be perfectly transparent." The last condition is probably the most difficult to obtain in cases of growth, and requires some patience and aptitude in the preliminary irrigation of the blad der. Washing out with equal parts of extract of witch hazel and hot water will often render the urine clear of blood.
The kind of vesical growth and the possibility of its complete or partial removal may in this way be determined with much accuracy. In some forms of pendulous, grape-like, and simple papilloma removal may usually be undertaken with the prospect of permanent success, while in diffuse villous carcinomata of considerable extent, operative measures can do no more than palliate symptoms arising from con stant hemorrhage and obstruction to micturition, as well as from the tension produced by the pressure of the growth on the wall of the bladder. Hence the growths that are most accessible to operative treatment are those belonging to the former variety. Their diagnosis is tolerably easy; they are usually situated at the most accessible part of the bladder, namely, at the orifice of a ureter, and when removed, as I have had frequent occasion to note, they do not recur. On the other hand, the carcinomata and semi-malignant growths of the blad der, so far as their removal by operation is concerned, in no way dif fer from what is observed, in this respect, in connection with similar tumors situated in other parts of the body.
I have opened the bladder in some cases by the supra-pubic and in others by the perinea' method, though the former is to be pre ferred, on the same principle that the intestine is sometimes opened and an artificial anus formed to relieve the obstruction and distress which is occasioned by a cancer situated lower down the intestinal canal. On grounds such as these, a supra-pubic opening for drainage, and as a substitute for the long and narrow channel of the natural urethra, is to be recommended when the nature of the symptoms de mands it by reason of the bladder being obstructed by a more or less fungating cancer. In the following case the relief afforded by opera tion was marked and continuous as long as the patient lived :