MULTIPLE PAPILLOMATA OF THE BLADDER; TIRPATION BY TRANSVERSE INCISION THROUGH THE SYMPHYSIS PUBIS.
DR. LANGE presented a man, fifty-one years old, on whom this operation was done on the 9th of March.
Commenting upon the he said that the removal of growths from the cavity of the bladder in stout and fleshy men offers a great deal of difficulty. Through the usual longitudinal incision such operation is hardly feasible in an exact manner.
The incision must be very long; and even then the thick abdom inal walls cannot be pulled sideways sufficiently to give easy access to the deep-seated field of operation. It becomes neces sary to sever the insertion of the recti, and this again has the disadvantage of a wider scar, predisposing to the formation of hernia. The same objection must be made to Trendelenburg's transverse incision above the pubes. It is hardly possible, in stout men at least, to unite again the recti muscles with such certainty that union is to be expected, since sutures, even thick ones, will cut through the cut edge of the retracted muscle and its fascial sheath, either right away under the heavy traction that is necessary to pull the powerful retracted muscle down, or as the result of vomiting or restlessness of the patient later on. Dr. Lange has therefore resorted to a modification of the Tren delenburg incision after his experience with the analogous modi fication of Bardenheuer's transverse incision for the removal of large tumors with broad attachment in the depth of the pelvis. This modification consists in chiselling a thin shell of bone with the attachment of the recti. It must be remembered that the insertion of the recti is not only the crest of the pubic bones, but also a portion of their anterior surface. The broad chisel to be used is to be directed accordingly. The bony substance thus left with the recti will stand any amount of traction by suture, and allow of a very solid union with the body of the pubic bone. The bladder is to be opened likewise by a transverse incision, and if drainage of the bladder should be desirable, the same must be done through the right or left or both angles of the wound.
For the removal of large pelvic tumors this incision must be carried sideways as far as necessary to give easy access. Dr. Lange has in this way successfully dealt with cases which had been regarded as inoperable by others. One gets comparatively easily and soon to the large vessels of the uterine plexus, and though the ventral incision may take more time and be more bloody, this disadvantage is made up by the safety of the work in the deep regions and the possibility of seeing better what one does. An additional longitudinal median incision may be of ser vice. One will also be able to avoid with more certainty the ureters and remain outside of the peritoneal cavity for the greater part of the operation in those cases where large tumors with broad insertion have lifted the peritoneum off from the anterior abdominal wall. The bladder must be cautiously dealt with in such cases. It may occasionally remain as a bag, freely detached. except in the region of the fundus and internal orifice.
The patient presented was unusually stout and fat, his weight being about 240 pounds. An unforeseen occurrence during the operation was the tearing off of the periosteum in a fit of cough ing, after the insertion of the recti had been severed to a small part only.
A large villous growth occupied the floor of the bladder to the left, not far from the ureter, backward of it. Several smaller ones were removed from the neighborhood of the orificium in ternum, and besides that a large number of small grain-like pro tuberances were burned by the actual cautery. The larger masses were removed by the galvanocaustic snare. Several larger ves sels had to be tied, not without difficulty.
It may be of interest that during the after-treatment regular injections of nitrate of silver were kept up according to the propo sition of Herring. Dr. Lange had expected from the macro scopical appearance of the bladder at the operation a speedy recurrence. A cystoscopical examination six days ago revealed, however, a very satisfactory state of affairs. The bladder shows everywhere a smooth, whitish surface, except about the region of the prostate and internal orifice, where a certain degree of injection betrays some catarrh. The openings of the ureters are normal. The one on the left side decidedly smaller than the right one, perhaps in consequence of cicatricial contraction in its neighborhood. Here the large tumor had been removed. The bone scar is perfectly firm, as it had become in all the other cases he had operated after this method. In this case alone a small fistula exists which will discharge a drop of pus every few days. It leads down to one of the threads of silkworm gut, but does not give any annoyance. The injections of nitrate of silver are kept up once a week.
The union of the bony surfaces was usually effected by four silkworm threads, and the pubic bones have to be perforated, of course, by drilling for said purpose.
Dr. Lange, in reply to a question, said that the pathologist to whom the tissue removed from the bladder was submitted for examination reported that it contained carcinomatous elements.
Thus far, however, there are no signs of a recurrence. From a clinical stand-point, Dr. Lange said, he was inclined to doubt the malignant nature of the growth. There is a kind of papilloma tous growth of the bladder which after its removal is strongly suspicious of a malignant growth.
DR. WILLY MEYER referred to a case in which he was called upon to remove a papilloma of the bladder of ample size, and resect with it a portion of the vesical end of the ureter. Patient made a good recovery, and did not develop kidney complications. The microscope showed carcinoma at the point of insertion of the tumor. There was a recurrence after two years, when the blad der was found to contain numerous growths (from sixteen to twenty), which the pathologist pronounced to be truly cancerous. There was another period of comparative immunity lasting eigh teen months, when a stone had to be crushed in the bladder. In the mean time, the man's wife had contracted cancer of the uterus and died. Five and a half years after the first operation the bladder was opened for the third time. The case was then found to be inoperable. The patient died six months later.