This paper then contains not only the discussion of the treatment of tumors of the bladder but a plea for the free use of the cystoscope, and a careful study of the urinary organs when the slightest symptoms appear. The later and more definite symptoms of tumor of the bladder are not necessary for us to discuss before this audience. We only desire to impress upon you the fact of the necessity of early diagnosis.

The successful management of bladder tumors, like the successful management of all such growths in the human anatomy, depends on an early diagnosis, at which time proper treatment and proper management may continue the life of the patient to an ordinary expectancy.

Treatment in general may be divided into palliative and

curative.

By palliative treatment we mean treatment for symptoms the result of tumors, such as hemorrhage, pain, tenesmus and retention, without any endeavor being made to remove the growth. The treatment of such conditions varies from the simple introduction of the sound to cystotomy for drainage. The various methods between these two extremes are, electrolization, fulguration, cauterization, use of astringents, dilation, etc.

Our attention is directed toward the problem of radical removal of the tumors. Many methods have been devised and used. We may mention the following:

First, removal of the tumor through the dilated urethra in the female; removal of the tumor by vesico-vaginal incision; perineal cystotomy; operative cystoscope of Nitze; destruction by fulguration of Beer; removal by suprapubic cystotomy; removal by partial cystectomy; removal by complete cystectomy and nephrostomy.

The removal of the tumor through the dilated urethra of the female is obsolete, unless the tumor extends pretty far down in the urethra, in which case such a removal might be justifiable.

The vesico-vaginal incison is very rarely used, and is, in our judgment, practically never justifiable and may be discarded; as may also the perineal removal of tumors.

Nitze is the first who devised a method of operating by means of a wire running through the cystoscope, making a loop within and attached to a screw on the cystoscope from without. Nitze was able to grasp a large number of small tumors within this loop and clip them off, or

slowly pull them out by the roots, and either remove them by another hold with the loop or allow them to pass at urination. Nitze claims that of 104 cases, 84 per cent remained entirely well after such manipulations. This method of treatment, however, can only be applied to that pedunculated vairety which would allow themselves to be grasped by the wire loop. Sessile varieties would under no conditions be subject for such treatment.

The fifth method of our number is that of fulguration. The principle of fulguration as described by DeKeating-Harte consists in an electric current with an exceedingly high voltage of twenty to thirty thousand with a very low amperage about 300 to 400 and an interruption of about one million times a minute. Such a current applied to a growth by means of a spark from four to five centimeters in length does not char or burn the growth, but shrivels it without any carbonization.

Beer of Mount Sinai hospital in New York was the first to call attention to such treatment in tumors of the bladder. He applied it to various kinds of tumors, claiming that such a current was a valuable treatment for carcinoma. However, in his last paper read before the Section of Urology in the American Medical Association, he receded somewhat from this position, but still claimed it to be the best method of handling small nonmalignant tumors of the bladder. We believe it to be very valuable as a curative measure in the very small tumors under certain conditions, and it may possibly inhibit the growth of carcinoma and extend the life of the sufferer several years. It is a simple method; easy to use, has very little pain, and no mortality.

The removal of the tumors by suprapubic cystotomy is at the present time the most general operation done, and indeed, it seems to the writer that it is one of the most difficult operations in surgery, because no two tumors are exactly alike, and no operation exactly duplicates another.

Certain principles may be laid down:

First, regarding the approach to the bladder: Many writers in the last few years have called attention to the fact that in operating upon tumors of the bladder one must use as large an incision as is possible. It is not necessary or advisable to keep within the space of Retzius in front of the peritoneum but to extend the incision so that we may approach the bladder from all sides. There is no great danger in this and often great good may be done.

The Germans recommend the cross suprapubic incision, i. e., the incision parallel with the symphysis, and we may say that in one of our own cases this proved very satisfactory. One can keep outside the peritoneum and at the same time have a good view of the bladder. Tuffier makes a "T" shaped incision extending the length of the "T" upward between the recti muscles. The location of the incision and the extent of the incision must depend upon the location of the tumor and what the operator intends to do.

If the tumor is a small one in the vertex of the bladder, an ordinary suprapubic incision in the space of Retzius is the only one necessary and a portion of the bladder wall may be removed. The peritoneum may be easily dissected back from the fundus of the bladder nearly to its base. It is only necessary to open the abdominal cavity when the base of the bladder is affected. By the use of the cystoscope in the bladder when the incision is completed down to the bladder and with an assistant looking into same, the relations of the tumor may be located from without by making a dimple in the external surface of the bladder and observing where it strikes the tumor from within and when a correct point is located on one edge of the growth this point is marked by a stitch, and two or three other such points are located and the tumor thus defined on the outer surface of the exposed bladder after Hagner's method.

When the tumor is single and confined to any free portion of the bladder partial resection of the bladder may be done with perfect freedom.

When small sessile tumors are dotted over different parts of the interior surface of the bladder the mucous membrane may be dissected off over very large areas of the bladder and it will soon return.

Pilcher reports one case in which he dissected nearly the entire mucous membrane.

Some tumors arise from the prostate. When such is the case removal of the prostate is indicated.

Tumors which begin at the junction of the ureter with the bladder often require section of a portion of the bladder at this point. In such cases the ureter may be transplanted into the bladder sometimes with good results, but if not a nephrostomy may be done, or the kidney removed on that side.

The total removal of the bladder is in itself not an extremely difficult procedure. But the disposal of the ureters after this is

yet quite another problem. If the ureteral openings are not affected, a triangular portion of the bladder may be transplated into the rectum. When, however, the ureter is affected it will have to be cut a few centimeters above the bladder and then the problem becomes very much more complexed.

Various methods have been devised under these conditions, such as implanting into the larger bowel; into the sigmoid; into the groin; and into the back. Watson recommends double nephrostomy before removal of the bladder is begun where portions of the ureters must be taken. Any method of procedure must depend upon the careful diagnosis of the character, extention, location and best method of approach to the tumor. The cystoscope is the most valuable aid in this condition. Any other method which may throw light upon problems to be met before operation is begun must be grasped, such as X-ray, rectal examination, etc.

Each tumor of the bladder is a law unto itself and can only be met as an individual case, and treated as the pathology, anatomy and physiology of this particular neoplasm indicates.

Dr. B. B. Davis, Omaha:

DISCUSSION.

I am glad to have had the privilege of listening to this paper. One reason is that it was a good paper and another is that it seems to me that in the progress of surgery the surgery of the bladder has not made quite as much advance as the improvement in treatment of other parts. It seems one of the things now to which all ought to devote a good deal of attention. Now, the main thing in the questions brought up by Dr. Stokes, it seems to me, is the question of the malignant tumors. The simpler tumors can be dealt with very satisfactorily if they are removed before they have undergone any malignant change. All benign tumors should be treated as if they were sometime to become malignant.

In the past there have been two extremely important things that have interfered with any satisfactory removal of malignant tumors of the bladder. The first is that, unfortunately, as Dr. Stokes has said, nearly all of those tumors occur down around the trigone. So that the location of these tumors is exceedingly important. Second, the diagnosis, as a general rule, has not been made sufficiently early. It seems to me that in this particular we have been extremely slow in reaching what it seems to me is the only rational thing to do. Every time we have a bladder case where we cannot explain the symptoms, we should clear them up at the earliest possible moment,and if we will do that we will discoved a great many of these malignant cases very early in their formation. Then, it seems to me, there is an opportunity to do something that might result in some permanent relief. Now, as it is, nine-tenths of the cases of tumors of the bladder have gone so far that it is out of the question to do a radical operation unless you remove the entire bladder and those cases as a general rule have not proven very satisfactory and it is an awful operation to do. If there is any lesson to be drawn from this, it is the careful, early exploration of the bladder by means of the cystoscope, the making of the diagnosis early, and if there is anything to be done, doing it before the disease has progressed.

Dr. Quigley, North Platte, Neb.:

Just one thing more. There is no other malignant tumor anywhere in the body that so readily lends itself to treatment by fulguration as the malignant neoplasm of the bladder. You will find in operating on these cases that where this results we get metastases. Assuming that it has come down to a question of operation or treatment by fulguration, I mention this because while the treatment by fulguration is satisfactory, the treatmen by operation is likely to result in a dangerous condition and I believe that treatment by fulguration is preferable.

Dr. Stokes, Concluding:

I have only one thing so say, that a recent article has shown us how to inject bismuth into the bladder and take an X-ray picture of it and locate the tumor in that way.

Very much obliged to the gentlemen for their discussion.

Foreign Bodies in the Air Passages, With Report of Cases and Treatment

*By O. GROTHAN, M. D., St. Paul, Neb.

It was with a degree of hesitancy, for fear of invading the sacred domains of specialism, that I chose this subject, but the importance of discussing this dangerous and most distressing accident should make it justifiable. If the lodgment of foreign matter in the nose is considered, this class of cases would be one of the most frequent emergencies met with. However, as the latter is not, as a rule, very dangerous to life, this part of the subject will be passed.

The symptoms of foreign bodies in the respiratory tract vary so very widely according to size, shape, consistency, and as to the site of lodgment, that for a full discussion we must refer to the text books. Nearly every case, though, presents the symptoms of dyspnea, strangulating cough and more or less marked signs of non-aeration of the blood. When the foreign body is lodged in the larynx, spasm of the glottis is the most marked sign. Should the larynx or trachea be nearly occluded, tearing at the neck and throat with signs of suffocation is one of the most distressing occurrences it is a doctor's misfortune to meet. If a larger or smaller bronchus is occluded symptoms of collapse of that part of the lung may be found. A small body in the lungs gives rise to signs similar to irritation and increased secretion and later to septic pneumonia.

A diagnosis must be based upon knowledge of the symptoms and especially will the history of the case be of assistance. Laryngoscopy and tracheoscopy may be, and very often are,

*Read before the Nebraska State Medical Association, at Omaha, Eay 13-15, 1913.