When we have recognized the existence of a new growth upon the bladder-wall, and the possibility of removing it, the patient should be deeply narcotized and put in the lithotomy position. The left index fin ger is then passed into the bladder to fix the tumor, and Simon's forceps (Pig. 61) passed in. It is then to be seized and twisted off. If too great hemorrhage is feared, the loop of a wire 6craseur (Braxton-Hicks's case) or a galvanocaustic wire may be passed over the forceps to the base of the tumor. If the tumor is too large for this, it may be divided int,o smaller portions by Simon's forceps or sharp spoons, and extirpated piecemeal, 'or portions may be removed through the speculum.
Schatz in his case incised the right side of the urethra, and, after pass ing several threads from vagina through bladder and urethra, inverted through the urethra that part of the bladder containing the base of the tumor. He then removed it in two parts, and united the edges of the wound with ten silk sutures. Then the patient was dismissed. These sutures, slightly encrusted with salts, were still in situ.
In flat diffuse growths, especially in carcinomata, where radical extir pation is out of the question, scraping must be done with one of Simon's spoons, and all loose portions of tissue removed. If there is much bleed ing, cold lavements, or ice water, or direct application of liquor ferri see quichlorati (Braxton-Hicks) may be tried. The bladder should be re peatedly washed out; and if the bleeding persists the vagina should be tamponed with cotton and an ice-bag laid upon the vesical region. We can then certainly control the hemorrhage.
Finally, in those cases where the tumors and excrescences are situated so high up upon the walls of the bladder, or are so large that they cannot be well extracted even through the dilated urethra, a T-shaped vagino vesical incision may be made, as Simon has proposed. (Comp. page 15.) The bladder can then be inverted, and scissors, knife and actual cautery be used. Then the vesico-vaginal incision is to be treated as a fistula. Simon removed the above-mentioned papilloma from the vertex of the bliwider with the scissors, returned the bladder after cie,atrization had occurred, and then performed the regular fistula operation. Kaltenbach made a single incision upon a catheter in the bladder, drew out the growth, tied its base in several places, removed it with knife, scissors and paquelin, and closed the fistula with eight wire sutures. After four teen days a filbert-sized portion of tissue with the silk threads passed by the urethra. The fistula healed by first intention.
\Vhen operative help is out of the question, we can use narcotic irrigations (hyoscyamus), or astringent and styptic ones (liq. ferri sesquichlorati, lec. quercus) or antiseptic ones (Sol. ac. salicyl. 1:500) with Hegar's funnel. Thus we can relieve pain, prevent odor, lessen hemorrhage, and, with warmth externally, and narcotics inwardly, render the dreadful lot of these sufferers more bearable.
Mrs. M. S., :39 ye :rs old, from New York, had a very itchy eruption in childhood, probably urticaria. At 4 years eat a quantity of unripe plums, in consequence of which she had dysuria; relieved by medicine. At 15 there began regularly returning monthly febrile attacks. Men struated first at beginning of 16th year, and has had courses regularly every 26 days. Cholera in 1866. 1868 married. Shortly before this she had fallen with the whole weight of her body upon her abdomen against a sharp corner. She feared that she bad sustained an internal injury. But the pain, severe at first, gradually disappeared. May Oth, 1869, 7 months aft,er marriage, bore a living girl naturally, after 11 hours of labor. Since then abdomen large. In 1869, child having died, she first felt a paralyzing kind of weakness in the left side of her abdomen, low down. While it lasted she could neither walk nor speak. These attacks began to come frequently, and soon were accompanied by general convulsions. A few weeks later she first found pinhead-sized little masses of pus and blood in her urine. A year later the least motion caused neuralgic and violent urethral pains. The alxIomen swelled and became painful, espec ially in vesical and urethral regions. Appetite enormous; sleep deep. In the beginning of 1872 first noticed movable masses which attempted t,o flow out of the bladder with the stream of urine. Sometimes they suddenly and completely plugged the passage, and when this happened, there occurred a sudden spasmodic contraction of the muscles, which pre vented her from emptying her bladder until she had taken abundant draughts of hot water, and had made local applications of a sponge dipped in hot camomile tea. Soon there appeared a new trouble. Every morning, when the bowels began to act, and wind to pass out, instead of going the natural way, the flatus passed from the right side above into the bladder, feeling, as she says, like a stream of molten lava. Amid the most terrible pain she felt it pass like the smoke from a locomotive among the trees; she felt the presence of a branched growth, but was only laughed at when she told of it. About this time she discovered at the entrance of the urethra a sniall inflamed tumor, which she touched with nitrate of silver. 3 or 4 weeks later, after passing much blood and pus, there passed from the urethra, with great pains, the 3 first bean-sized growths. A few more followed next day. For a while she felt better; but in a month the pains returned. On October 23d, 1872, Dr. de Moor of New York, after an exact examination declared her trouble to be due to an outgrowth from the right ovary, which had entirely penetrated the bladder. She was painted with tincture of iodine, and in a month the matutinal troubles disappeared, and have not since returned.