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or peritonitis show when perforation has occurred, and in spite of attempts to drain the inflamed parts death is the common result.

Chronic spontaneous ulceration is uncommon. It takes the form of a solitary ulcer on the posterior wall of the bladder to the inner side of the ureters. At first it is little larger than a shilling, and appears as a cleanly cut ulcer surrounded by healthy mucous membrane; later on it spreads and becomes coated with phosphatic plaques, and finally it scars up, leaving a small bladder with dense, inelastic walls.

It occurs in young males with no venereal history. The onset is sudden, the symptoms being increased frequency of micturition by night as well as by day. Hæmaturia follows in a few hours and is often profuse, accompanied by a constant aching pain in the head of the penis or in the scrotal angle. The urine shows a few pus cells, but no specific bacteria in the early stages. Sooner or later the symptoms and signs of chronic cystitis become well established and last for a variable time. In the healing stage the only symptom that persists is increased frequency of micturition, caused by the decrease in the size of the bladder.

Diagnosis.

The diagnosis is made by cystoscopic examination after exclusion of (1) tuberculous disease by the inability to find tuberculous nodules elsewhere or tubercle bacilli in the urine; (2) mechanical causes by the history; (3) diabetes and disease of the nervous system by routine examination. The position and character of the ulcer, the age and sex of the patient, and the sudden onset with profuse hæmaturia are the characteristic features.

Treatment.

Ulcers consecutive to stone, instrumentation, etc., should be given a chance to heal, the ordinary treatment for chronic cystitis being employed (see Ch. III, Sect. III). The most important measures are to keep the whole body at rest with the pelvis elevated; to support the general healing powers by means of good food, tonics, and fresh air; and finally to keep the urine as clean and non-irritating as possible. Lavage with lactic acid (3 per cent.) or acetic acid (1 per cent.) may be employed to get rid of phosphatic crusts.

In cases of chronic spontaneous ulceration the same course should be adopted, and in addition rest is obtained for the

worried bladder, the frequency and pain being controlled by sandal-wood oil and small doses of opium.

OPERATIVE TREATMENT.

If the ulcers show no signs of healing under this régime as evidenced by cystoscopy at regular intervals, it becomes necessary to apply more radical measures.

The ulcers should be gently curetted and painted with silver nitrate (gr. xx ad 1 oz) through the endoscope or operating cystoscope, or failing this, perineal or supra-pubic cystotomy is performed, the ulcers thoroughly curetted, and the bladder rested by drainage for some weeks. The disease will usually yield to energetic treatment. If perforation should occur adequate drainage of the pelvic cellular tissue or peritoneum must be instituted.

CHAPTER VI.

TUMOURS OF THE BLADDER.

Ætiology.

THE true causes are unknown, though chronic irritation seems to play a minor rôle in aniline dye workers, amongst whom the disease is common (Leichtenstein), and oxaluria is sometimes held to predispose to papilloma.

Age.-Bladder tumours are uncommon before the age of thirty; between the ages of thirty and forty they are more often benign; after forty they are usually malignant. In children they are rare, but when they do occur they are usually sarcomata or myxomata, are of rapid growth, early fatal and quite inoperable.

Sex.-Men appear to be more often attacked than women in the proportion of 3 or 4 to 1.

Frequency.-1 -Published figures show that bladder tumours form 4 to 8 per cent. of all tumours.

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Papilloma and epithelioma are the only common tumours; the others are so rare as not to be worth considering in detail. For instance Albarran in a series of cases found 100 carcinomata, 21 papillomata, 2 fibromata, 3 myxomata, 2 sarcomata, 3 myomata, 1 angeioma.

Sarcomata are round-cell, spindle-cell, giant-cell or mixed. They, like myxomata, occur in children as smooth pedunculated or sessile tumours which grow rapidly, fungate early, and are quite inoperable.

Myomata and fibromata resemble those found elsewhere, originate in the walls of the bladder, and may grow outwards or inwards. They are of slow growth, and if removed tend only to recur locally.

EPITHELIAL TUMOURS.

These are benign or malignant, pedunculated, sessile, or infiltrating.

The papilloma is a pedunculated tumour projecting from the surface of the mucous membrane, and may present numerous delicate filamentous processes like an open sea anemone, or may be smooth and lobulated. The filamentous or villous variety may be benign or malignant, the smooth variety is always malignant. The growths are often multiple (30-40 per cent., Albarran), and may occur in any part of the bladder, but in the large majority of cases (80 per cent., Fenwick) they are found on the postero-lateral wall of the bladder above and to the outer side of the orifice of one ureter. The pedicle can be lengthened by traction, which pulls the loose mucous membrane of the bladder into the pedicle from off the surrounding muscular coat. A large papilloma tends to drag upon the mouth of the neighbouring ureter, and may partially obstruct it, giving rise to hydronephrosis and secondary infection of the corresponding kindey. Less commonly a long papilloma "corks" the urethra as the bladder empties itself, interrupting the stream or setting up retention.

The sessile tumour is an uncommon variety; it projects into the bladder, but has a short, stout pedicle as thick as a finger or even thicker, which consists of tumour-tissue. The surface may be villous or smooth. This variety is always malignant. Sections of the sessile base or pedicle show that it consists of firm bands of connective tissue surrounding islands of epithelial cells, which may be seen invading the submucous and muscular coat.

The infiltrating tumour is attached to the bladder by a wide base, and presents two varieties:

(1) A soft fungating mass of tumour-tissue is seen projecting into the bladder, which can be curetted away without causing much bleeding, a large raw ulcer being left, the floor of which is formed by tumour-tissue invading the walls of the bladder over a wide area. This type is very malignant, and consists of epithelial cells lying in a delicate connective-tissue stroma, which project into the cavity of the bladder, and also invade the connective-tissue spaces and lymphatics of its wall.

(2) An epitheliomatous ulcer which lies upon the wall of the bladder. The ulcer is small, shows a rolled, raised edge, surrounding a friable floor covered with phosphatic débris. The base is dense and hard. In 70 per cent. of the cases the ulcer involves the lower third of the bladder and early involves the bladder base.

HISTOLOGY.

A papilloma consists of a fine central core of delicate connective tissue containing large blood spaces, on the outer surface of which are arranged many layers of epithelial cells. A malignant papilloma, a sessile tumour, and an epithelioma show characteristic changes in their bases. The connective tissue of the submucous coat is increased in amount, and the tissue and lymphatic spaces are packed with epithelial cells isolated or lying in groups, of all shapes and sizes, many showing degeneration of their cytoplasm. Epithelial cells may be traced between the muscle-bundles and beneath the peritoneum in the pelvic cellular tissue. They can also be followed in the lymphatics to the regional lymph-nodes.

MODE OF SPREAD.

These are four in number: by contact; by continuity; by lymphatics; by blood-vessels.

(1) By contact ("Kiss-cancer"). There is abundant evidence to prove that fresh tumours may arise at spots on the healthy bladder-walls constantly being touched by the surface of a growth. In this way multiple tumours may appear on the anterior wall of the bladder, the primary source being a large tumour on the posterior wall.

(2) By continuity. The epithelial cells grow down along the connective-tissue spaces of the submucosa, pierce the muscular coat and spread along in the pelvic and subperi

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