In two-thirds of the cases of vesical cancer there are adhesions between the bladder and neighboring organs, especially the uterus and intestine. There are often thromboses of the larger veins, of the femoralis, renslis, cava, and a. pulmonalis. Purulent thrombi of the vesical neck may cause embolism and metastatic abscesses. Peritonitis is not uncommon. Finally the cancerous cachexia sometimes causes amyloid degeneration of the kidneys, spleen, liver and intestine. (Heilborn.) A most inter esting specimen of this kind in the Kiel collection, has been described by E. Muller. (See ante.) The lumen of the bladder was entirely filled by a fist-sized, round, pedicled tumor, which was attached to the upper inner vesical wall. Its color was grayish-yellow, its surface smooth though cleft in places. Its pedicle was an inch in breadth, .4 of an inch in thick ness, and .6 of an inch long. The bladder wall was Ith of an inch thick, and the muscle bundles were greatly hypertrophied. The tumor con sisted chiefly of a sparse oonnective tissue with spindle cells, and contain ing large bundles of smooth muscle: In many softer places were collec tions of epithelial cell-nests, diffuse cell infiltrations being present only to a small extent. Uterus, tubes and ovaries were normal. Of the history of the case we know nothing.
The cases of primary carcinoma which I have observed have been de scribed by Dr. Bode. (See ante.) The only case upon which I had to operate occurred in a woman fifty-six years old; and after a partial removal of the tumor, it grew very rapidly and extended into the urethra. The patient died seven weeks after the operation. The necropsy allowed an apple-sized spongy tumor, which included all the layers of the bladder. The urethra also was infiltrated. Another, still rarer, case is one of secon dary vesical carcinoma, after primary urethral cancer, I have shown in Fig. 15 of this book.
Adclendum.—Hair on the walls of the female bladder. Trichiasis, pilmictio vesiese, have so far been observed only in consequence of the perforation into that organ by an ovarian dermoid cyst. Blich-Winge's ease (page 168), though no tumor was demonstrated during life, was found after death t,o be due to this same e,ause.
In all these new growths the symptoms are of gradual appearance, and are in general alike. First there is felt oppression in the vesical region, then urinary troubles, sometimes simple dysuria, or strangury, or even early ischuria; in Schatz's case there was dribbling of urine. The pains are situated partly in the hypogastric region, and partly in the back, loins, and legs; in some cases, as in ours, they may run along the urethra. After the pains have lasted for some time, there is usually htematuria. This occurs with all the new growths, and is sometimes great enough to lead to exhaustion, even with benign tumors. The urine is now often decomposed; it smells ammoniacal and foul. There may occur a sudden stoppage in the flow of urine, while micturating, from the presence of the tumor, or of coagula at the internal opening of the urethra. In the cases of Hutchinson, Plieninger, Clarke, Birkett, and in my own, frag ments of the papilloma temporarily plugged the urethra. These loo,se portions of the tumor are very liable to become encrusted in decomposing urine, and calculous formations are common. This occurred in my cases, and in those of Coulson and Watson. The pain and hemorrhage due to the catarrhal condition of the bladder, together with the dilatation of the ureters and the secondary kidney affections, cause cachexia even in those suffering from benign forms of new growth, and cause death by anaemia, peritonitis, or even urtemia. The malady may last for many years. lit
our case it had existed 13 years, in one of Hutchinson's it lasted 6 years, and in Blich-Winge's 19 years. Appetite and digestion often remain unimpaired. In some patients there is an exacerbation in the symptoms at each menstrual epoch; and the pains are usually worst when the patient is in the recumbent position. Blich-Winge's patient had a cystitis in 1850, due to perforation of the bladder by a dermoid cyst; the tumor was intimately connected with the bladder, into whose cavity it projected as a walnut-sized tumor, and was united to the ovary only by a narrow band. Nevertheless the patient only died in 1859.
In cancer of the bladder the secondary nodules appear in kidneys, lungs, stomach, and liver.
The diagnosis of vesical tumors is not always easy. We should never neglect to dilate the urethra in cases of obstinate luematuria in women. An exact urinary analysis should of course be made in all c.ases. Frag ments of matter may be found in the sediment which can be recognized microscopically, as being papillomatous, or carcinomatous. Catheterization is as a rule excessively painful, and does not enlighten u.s much as to the condition of the vesical wall. It will inform us, however, if they bleed easily, whether they are very soft or not, and whether they are crumbly. Necrotic tissue spe,aks for cancer; and so does, according t,o Sperling, the finding of htematoidin crystals imbedded in the fragments. Small tumors cannot be exactly recognized from the vagina; and even with larger ones their sensitiveness, and sometimes their lateral and inaccessible situation, prevents our ascertaining whether the tumor spring's front the bladder wall or originates between the bladder and the uterus, or perhaps from the uterus or ovary itself. The presence of teeth, hair, and bones in the bladder show beyond doubt that tumors springing from these last-named organs can perforate the urinary receptacle. We are thus relegated to Simon's specula or Rutenberg's illuminating apparatus, for information as to the seat, size, consistency, moveability, and possibility of operative interference. The illuminating apparatus is especially necessary when we desire to examine new growths, situated upon the anterior vesical wall. We can positively say that many a patient who has perished miserably from hemorrhage, etc., c,aused by a benign neoplasm of the vesical wall, might have been saved bad we known Simon's method before. If after palpation and inspection the histological diagnosis is still not clear, we may scrape off portions of the tumor with the sharp spoon, and examine them microscopically. On the other hand, in no one of these cases is catheterization of the ureters allowable; for as we have just remarked, it is exactly around the ureters that the neoplasmata are most frequently seated. It would not only be difficult to find the displaced ureter, but it would be quite possible to bore through the softened tissues with the instrument. Nor can hydronephrosis, from extension of the growth, be prevented thereby, as Plieninger's case shows. The examination per rectum may be important when the vagina will not permit it in very young girls. But even in these cases the urethra nifty be dilated to the extent of ad mitting the little finger, as we shall see when considering the question of the extraction of calculi.