know but little of the causes of vascular new growths. Carcinoma is generally secondary, and is more common in women than in men. Heilborn found it 37 times in 4778 necropses, in 33 women and 4 men; it being primary in 4 women and 3 men. And since of these 4778 subjects 3043 were males and 1734 females, carcinoma of the bladder is 15 times as common in men as it is in women. In the Dresden hospital it was found more frequently. Among 2505 women it was found 73 times, almost 30 per cent. as against 20 per cent. in Berlin.
As the cause for other neoplasmata is mentioned irritation by foreign bodies, especially fragments of calculi (Hutchinson, Civiale, Birkett), although decomposition of the urine and deposition of calcareous matter occurs in consequence of and secondary to the existence of many vesical tumors.
It is probable that various lesions, contusions, permanent displace ments, etc., may be of influence in causing local irritation and determin ing the formation of tumors in the female bladder; but they appear too rarely for us to admit either these or the puerperal processes as fmpecially active agents in their formation. The number of recorded non-carcino matous vesical tumors in females increases froni day to day, as dilatation of the urethra is more frequently practised. Sutton once extirpated a papilloma of the anterior vesical wall, which was inverted through a vesico vaginal fistula caused by confinement.
Hutchinson's case is of interest. A woman twenty-three years old over-exerted herself in lifting, and thereupon began at once to stiffer from pain in the back, retention of urine, until she finally had all the symptoms of papilloma vesicEe. And in my own case the patient fell with her entire weight against a projecting corner and struck the right side of the abdo men; and a year later only she began to notice little clumps of pus and blood in her urine. A hemorrhage of the walls of the bladder was prob ably the starting-point of the tumors in these cases.
New growths of the bladder oe,cur at every age. We have already men tioned two that were congenital. Plieninger's patient was 2f years old; Perri ice's 3 years, Birkett's 5 years,Hewett's 9 years, Hutchinson's 39 years, ours the same age, Albers' 44 years, Heim-Viigtlin's 54 and 64, Clarke's and Coulson's 63 and 64 years.
Prognosis.—This may be called good, nowadays, for benignant circum scribed neoplasmata of the bladder. They can be removed and the patient cured, always with certainty, and often with ease. The necessary opera tive procedure is not severe; and even when the tumor is large, a perma nent incontinence need not be feared. Warner's patient was cured after three years, Hutchinson's after one year; G. Simon has one who has remained well for five and a half years, though in some of his cases there were relapses within a few months. In my case (see below) there was no return in eight years. One of Braxton-Hicks relapsed in six months.
Carcinoma vesicm rarely lasts over one year. The secondary form leads to vosico-vaginal fistula in 50 per cent. of the cases, and thus hastens the end. Some few authorities, as Lambl, have held that cancer is less in fectious in the bladder than it is in other localities. Probably they con founded it with benign vesical growths; for Heilborn's investigations prove the contrary-. Metastases do rarely occur but this may be due to its rapid course, or to its occasional development from a non-malignant papilloma. The prognosis in every respect is very bad. Death does not usually occur from hemorrhage, but from unemia secondary to hydronephrosis, or sep tictemia with peri- or pylonephritis, or septic peritonitis after perforation of the bladder, or numerous metastases.
Therapy.—Warner was first to recognize a neoplasm of the bladder, and at once inaugurated a rational mode of treatment. He removed. it as soon as possible, splitting the anterior half of the urethra upon the right side. He then drew out the egg-sized tumor and tied its pedicle. It fell off on the sixth day, and the cure was complete. (1747.) Civiale fol lowed, who used a lithotriptor to crush vascular growths. Hutchinson 1857 in one case dilated the urethra with Weiss's dilators, in another incised the left side of the urethra, and then tied the-tumors. He cured the second patient. The rest, like Clarke, Plieninger, Blich-Winge, con fined themselves for the most part to internal treatment, recommending creosote internally for the hemorrhages, morphine hypodermically and by the mouth, and lukewarm baths.