CARCINOMATOUS PAPILLOMA OF BLADDER. 
OCCLUSION OF ORIFICES OF URETERS. 
DEATH BY UR/EMIC COMA 
BY 
SAMUEL B. WARD, A.B., A.M., M.D. 
PROF. SORG. PATHOLOGY, ALBANY MED. COLL. ; VISITING SURG. TO ALBANY HOSp’l ; 
CONSULTING SURG. TO ST. PETER’S HOSp’l, ETC., ETC. 
Reprinted from the Archives of Medicine, February, 1882] 
G. P. PUTNAM’S SONS 
27 & 29 West 23D Street 
1S81 CARCINOMATOUS PAPILLOMA OF BLADDER. 
OCCLUSION OF ORIFICES OF URETERS. 
DEATH BY UR.LMI# COMA. 
By SAMUEL B. WARD, M.D., 
ALBANY, N. Y. 
Col. J., American, married, 55 years of age, of healthy parentage 
and relations on both sides, has never had any serious illness, nor 
met with any injury ; has always been of perfectly correct habits 
in every respect; smokes moderately and drinks an occasional 
glass of wine. 
Eighteen years ago he had an attack of severe pain in the left 
side of the abdomen, the paroxysm lasting about six hours, and 
attributed by his attending physician to the passage of a renal 
calculus. With this exception, he does not remember to have had 
a pain or an ache in his life until his present illness. 
About ten years ago he began to have hemorrhoids, which, 
about six years ago, commenced to bleed and annoy him ; but he 
could, and always did, return them when they protruded. This 
summer (1880) they had to be returned a dozen times a day, and 
he then placed himself under the care of a physician in Bridge- 
port, Conn., and in the course of five or six weeks was cured by 
what he calls a “ process of absorption.” He has since been en- 
tirely free from all annoyance from this source. 
In Sept., 187$, when in Geneva, Switzerland, he passed, at one 
single urination, dark-colored urine which he considered to be 
bloody. The urine was clear the next time he emptied his blad- 
der, and so remained until the second week in November, when, 
at Nice, he passed a larger amount of blood than at Geneva. The 
next urination was again clear, and nothing further was noticed 
until, in going through the Pitti Palace, in Florence, in December, 
he experienced a sharp, burning pain in the end of the penis, 
Reprinted from the Archives of Medicine, Vol. vi, No. 4, February, 1882. 2 
SAMUEL B. WARD. 
which persisted for a day or two. He consulted Dr. Young, 
who said that the difficulty was due to the passage of uric acid 
crystals, and gave him alkaline treatment with the result above 
stated. 
In Feb., 1879, at Rome, the urine remained dark for about a 
week, and deposited a mahogany-colored sediment. He was re- 
lieved by capsules of copaiba. In Leipzig, the first week in 
April of the same year, after a long carriage-ride over the pave- 
ments, he passed a larger amount of blood than ever before, but 
at no time suffered any pain while passing the blood. In Paris, 
the second week in April, the urine again became bloody, and so 
continued for about three weeks. 
On April 28, 1879, he was carefully examined by Dr. Reliquet, 
who made the following diagnosis :—“ Hemorrhoides. Congestion 
prostatique consecutive. De D le sang evacu6 spontanement avec 
burine.” Dr. R., after careful examination, definitely excluded 
stone. On the theory of the diagnosis he was ordered to take 
Hunyadi Janos water every morning before breakfast, and a large 
rectal injection soon afterward, and sulphate and bicarbonate of 
soda three times daily. Thus the bowels were kept quite free 
and the urine alkaline ; but on June 3d the urine again became 
bloody, and so continued at pretty short intervals until Sept. 15th. 
Then it gradually diminished and the urine was only bloody for a 
day or two at a time at intervals of about a month, and has so 
continued ever since. A long railroad ride would always bring it 
on. 
Up to July 10, 1880, he had never had any pain or soreness 
connected with urination, except as above stated at Florence. At 
this time he began to have, at intervals, scalding pain the whole 
length of the urethra, accompanied by a desire to pass urine, and 
more or less straining. Urination was followed by an uncom- 
fortable aching, which lasted five to ten minutes. Belladonna 
suppositories afforded great relief. This condition of pain and 
aching persisted and increased in severity up to the time that I 
first saw him, Oct. 7, 1880, when he was suffering severely and 
almost constantly. 
In December, 1879, he first noticed an increased frequency in 
urination, and this became more and more of an annoyance until 
the latter part of August, 1880, he was passing water about every 
fifteen minutes during the day, and was obliged to get up at about 
the same intervals during the night, though toward morning he 
might sleep an hour and a half or two hours. About the middle CARCINOMATOUS PAPILLOMA OF BLADDER. 
3 
of September he began to pass urine involuntarily and during sleep 
unconsciously. 
Oct. 7, 1880.—Saw him late in the evening for the first time 
professionally, and found him looking haggard and worn-out from 
loss of sleep and constant suffering. Urine dribbling constantly 
and tenesmus well marked. As he thought that morphine affected 
him unpleasantly we gave him codeia for the night. 
Oct. 8th.—Had a much more comfortable night than usual, as far 
as the amount of sleep was concerned, but dribbled constantly and 
is still suffering as before. Put him upon half-drachm doses of 
lactic acid and washed out his bladder with a five-graj,n solution 
of the same. 
The urine examined this morning contained quantities of pus ; 
no considerable amount of blood ; no casts ; many crystals of 
triple phosphates ; sp. gr. 1,008 ; reaction neutral; no sugar ; a 
great deal of mucus ; considerable epithelium ; and after boiling, 
the addition of nitric acid, and standing six hours, the precipitated 
albumen occupied one third of the bulk of the urine used. 
Oct. nth.—The pus in the urine has largely decreased in quan- 
tity, and there is notably less mucus and epithelium, while its 
reaction is markedly alkaline. 
Up to yesterday the patient kept passing gravel in small masses 
every hour or two, which on examination proved to be triple 
phosphates. The bladder has been washed out every day, though 
the process is more painful than with most patients. He says that 
his suffering is entirely changed in character and very much di- 
minished, and the improved appearance of his face certainly cor- 
roborates his statement. 
Oct. 12th.—Sounded him for stone with an entirely negative re- 
sult. The passage of the steel instrument was effected without 
the least difficulty, and caused him very little pain ; but on its 
withdrawal about an ounce of clear blood ran from the urethra 
and formed a firm clot on a cloth which received it. 
Oct. 15th.—The constantly wet cloths in which the dribbling 
urine has been caught have made the head of the penis and the 
prepuce very sore, and the patient has therefore occupied the re- 
cumbent posture for the past twenty-four hours, and the urine has 
all been caught in a paper basin. We have thus been able for the 
first time to measure it accurately, and find that it amounts to 157 
ounces, a larger quantity than we had supposed. There is very 
little pus now, but considerable ropy mucus the passing of which 
causes almost as much pain as did that of the gravel. No great 4 
change in the urine except that to the naked eye the pus has al- 
most disappeared, while the microscope still shows a few cells and 
some blood. 
Oct. 16th.—In washing out the bladder to-day my attention was 
attracted by some small masses of tissue (apparently) floating in 
the fluid which now runs almost clear. These masses were exam- 
ined by myself, and also submitted to Dr. Wm. Hailes, Prof, of 
Histology and Pathology in the Albany Medical College, who re- 
ports that “ they are composed of papillae, consisting simply of 
connective tissue, forming a support for capillary vessels which 
have their embryonic walls and terminate in loops in the ends of 
the papillae.” Neither he nor I could find any thing which was 
characteristic or even suspicious of malignity. Fig. i is a very 
accurate reproduction of the appearance of one of the portions 
examined, and all the rest were entirely similar. 
SAMUEL B. WARD. 
FIG. I. 
Several detached papillomatous growths found floating in specimens of urine. They 
consist principally of connective tissue, forming a support for capillary vessels traversing 
the papillae, and resemble benign papillomatous growths. 
Rectal examination shows the mass to lie above the prostate, to 
be of considerable size and occupy a portion at least of the sides 
as well as the posterior wall of the bladder. 
Oct. 18th.—The quantity of fluid passed from the bladder has 
diminished to 113 ounces in the past day, having been yesterday 
125, and the day before 130. On the 16th the patient suffered so 
severely that he was obliged during the day and night to take 
three quarters of a grain of morphine. His stomach was disor- 
dered thereby, and his tongue, which has been thickly covered 
with a brownish fur all the time, was worse than ever. Pulse, 
which has ranged from ico to 120, is to-day 105. The temper- 
ature has been at all times from 98° to 990. 
Careful physical examination of the thoracic and abdominal CARCINOMATOUS PAPILLOMA OF BLADDER. 
5 
cavities reveals nothing. To-day he has taken no morphine ; has 
been more comfortable than usual ; has suffered no pain except 
when passing the little masses of tissue above referred to, or the 
ropy mucus, and the latter has still further diminished. 
Repeated examinations of the fragments of tissue passed show 
no change in their character, and the diagnosis, therefore, seems 
justified of simple papilloma of the bladder. 
Oct. 21st.—Mr. J. has gradually and steadily improved ; eats 
and sleeps better ; has much less pain ; and the amount passed 
from his bladder has diminished to 87 ounces. The amount of 
albumen varies from one fourth to one third, and no casts can be 
found at any time. The lactic acid has been increased to drachm 
doses three times daily, and the washing out of the bladder has 
been discontinued, because the operation causes him so much dis- 
tress at the time and for an hour or two afterward, while the dis- 
appearance of pus from the urine has done away with the neces- 
sity. 
To-day Prof. Wm. H. Van Buren saw the case with me in con- 
sultation, verified the diagnosis of vesical tumor, advised against 
an operation, but recommended the use of thuya occidentalis, 
from which he had derived much benefit in similar cases. He 
also agreed with me that notwithstanding the presence of large 
quantities of albumen in the urine there was no good reason to 
suspect any disease of the kidneys. 
Nov. 5th.—Since last date the patient has eaten and slept well, 
is cheerful and bright, and but for his local trouble would feel as 
well as ever. 
The amount of fluid passed from his bladder has varied from 
106 to 76 ounces ; the proportion of albumen from one to two 
fifths ; no casts at any time ; occasionally a little blood ; some- 
times a few pus corpuscles, sometimes almost none ; there is al- 
ways considerable ropy mucus entangling quantities of crystals 
of triple phosphates. The urea has been frequently estimated by 
the hypobromite method, and has varied from .50 to .59 of one 
per cent. No more villi have been found though they have been 
carefully searched for. The incontinence of urine is a great an- 
noyance to him. 
A faithful trial was given to the thuya but without any im- 
provement in the condition of the urine, or any relief to the 
patient. In fact he suffered so much more than when taking the 
lactic acid that he asked to go back to the latter, and did so with 
decided relief. 6 
SAMUEL B. WARD. 
He has now almost no vesical tenesmus, but suffers pretty 
sharply when passing the masses of semi-coagulated mucus with 
the crystals entangled in them, which seem to scrape and irritate 
the mucous membrane of the urethra. 
Dec. 19th.—There has been little change in the patient’s general 
condition since last date, but he is somewhat better. For a few 
days he has sat up in a chair, partially dressed, for about half an 
hour at a time, and eats very well. The constant dribbling of 
urine is a great annoyance to him whatever position he may as- 
sume. He has lost some flesh, but has gained in strength. 
No change worth noting in the condition of the urine. Though 
the specific gravity remains low and the proportion of albumen 
very considerable, there are no casts at any time. The daily 
amount has averaged 85 ounces, with a minimum of 50 and a 
maximum of 108. Another trial has been made of the thuya 
with the same result as before, and the remedy which gives him 
the most comfort is, without doubt, the lactic acid. He suffers 
most when passing only a small amount of fluid ; and at such 
times digitalis and acetate of potassa or other diuretics always 
afford relief. The infusion of digitalis-was the most reliable, 
but could not be long employed at a time on account of its in- 
terference with the action of the stomach. 
Jan. 28, 1881.—No change in the urine worth noting. Patient 
has had three hemorrhages from the bladder, one of which was 
quite copious. The blood coagulated in considerable amounts in 
the bladder, and the passing of the clots was the occasion of par- 
oxysms of pain so severe as to demand the hypodermic injection 
of morphine, in half-grain doses at night, to procure any rest. 
The family are exceedingly desirous that an operation should 
be done to remove the tumor, if not accompanied by too great 
risk. They are driven to this by the agony which the patient 
suffers, and are encouraged by reports which they have heard of 
success in cases which are narrated as being of a similar charac- 
ter. 1 therefore yesterday consulted Dr. Van Buren again as to 
the propriety of trying it. The arguments in its favor are that 
the patient has an excellent constitution and is in very fair gen- 
eral condition ; the only fragments of the growth which we have 
been able to obtain have proved to be simple papillomatous villi, 
without any evidence of malignity ; and the statistics of the re- 
moval of such growths are somewhat encouraging. Dr. Van 
Buren was opposed to the operation on the grounds that the 
growth was too large to be entirely removed, and that he was sat- CARCINOMATOUS PAPILLOMA OF BLADDER. 
7 
isfied from the history of the case that the base of the growth 
was malignant. He thought it possible that at some future time 
the vesical orifice of the urethra might become occluded, and he 
would then advise the opening of the bladder, by the usual peri- 
neal operation, for the purpose of giving exit to the urine through 
a permanent fistula. If this had to be done he would then ad- 
vise the removal, by tearing and scraping, of as much of the 
tumor as possible. Dr. Van Buren’s advice was followed and no 
operation was attempted. 
Feb. 24th.—The patient’s sufferings have been relieved by mor- 
phine as demanded. He is worse in every way ; the morphine 
interferes with his appetite and digestion and causes nausea and 
vomiting, though not as much as opiates given in any other way. 
Codeia and other drugs which do not interfere with the diges- 
tive apparatus exert no controlling influence over the pain. The 
morphine has been so objectionable that I gave to-night in its 
place fifteen grains of chloral hydrate with twenty of bromide of 
potassium. 
Feb. 26th.—Mr. J. rested very well after taking the chloral night 
before last. Yesterday he sulfered less pain than usual, and was 
notably dull and sleepy, though he could at all times be aroused 
and would then talk rationally and cheerfully. The drowsy con- 
dition was attributed to the chloral. 
Last night, without chloral or any anodyne, he rested well, 
but this morning the drowsiness, which has considerably deep- 
ened, can not be attributed to any drug. An examination of the 
account kept of the amount of fluid passed from his bladder 
showed that it had diminished to an average of less than 55 
oz. per day, and though there is no oedema of any portion of 
the body, there seems little doubt that the condition approach- 
ing coma in which he has lain for the past two days is due to 
uraemia. The administration of diuretics and sudorifics was 
therefore begun and a brisk cathartic given. 
March 1st.—In consequence of the treatment the flow of urine 
has increased to an average of over 60 oz., and the bowels 
have moved freely. Of course the patient’s condition is corre- 
spondingly better. 
There seems no satisfactory way of accounting for the uraemia 
except on the supposition that the growth has occluded the ori- 
fices of the ureters and thus made pressure backward through 
them on the kidneys, impeding their action. 
March 8th.—Up to the 5th inst. Mr. J. remained in very fair con- 8 
SAMUEL B. WARD. 
dition, but suffering intense pain from the passage, at short in- 
tervals, of masses of coagulated mucus entangling large numbers 
of crystals. For the past few days the amounts passed have 
been as follows : March 2d, 47 oz. ; March 3d, 30 ; March 4th, 32 ; 
March 5th, 33 ; March 6th, 24 ; March 7th, 14 ; and to-day scarcely 
any all this in spite of every effort made to effect an increase. 
Since the 5th he has been semi-comatose nearly all the time, 
aroused only when spoken to or by the paroxysms of pain. The 
suffering was so great that death, which came at 11 p.m., was al- 
most a relief. 
Gross appearance of bladder laid open by incision in anterior median line. Drawn by 
Dr. Lewis Balch. 
FIG. 2. 
Autopsy.—4 p.m., March 9th, 17 hours after death. Present, Drs. 
Vanderpoel, Sr. and Jr., Dr. A. Van Derveer, and Dr. J. S. 
Mosher. 
General appearance, well-nourished. Rigor mortis, well-marked. CARCINOMATOUS PAPILLOMA OF BLADDER. 
9 
By request of the family the head and thorax were not opened. 
Abdominal cavity opened by crucial incision. Omentum healthy 
and contained a fair amount of fat. Intestines healthy. 
Bladder removed and opened by anterior vertical incision. 
Walls thickened ; interlacing columns, formed by hypertrophied 
muscular bands, well marked ; mucous membrane at the base 
covered with a soft cauliflower growth, extending all around the 
neck and up on each side—rather more on the left than on the 
right—so that one half, or perhaps a little more, of the internal 
surface of the bladder was covered with it. Orifices of the ureters 
entirely concealed by the growth and their lumen obscured by the 
neoplasm. 
Both ureters were filled their whole length with urine and 
dilated to about half an inch in diameter, so as to easily admit the 
end of the little finger. 
Left kidney : pelvis very much dilated, connective-tissue cap- 
sule quite adherent, cortical substance and pyramids apparently 
free from disease. Right kidney : apparently healthy, capsule not 
adherent, pelvis greatly dilated. 
Not the least trace of disease was found in any of the other ab- 
dominal organs. 
The heart was examined through an opening in the diaphragm 
and found normal. 
Fig. ii, for the drawing of which I am indebted to my friend, 
Dr. Lewis Balch, gives a very correct idea of the appearance of 
the bladder and extent of the disease. 
Remarks.—The most important point to determine in this 
case, in relation to advising an operation, was the exact 
character of the growth. There was no history of malig- 
nant disease in any individual of any branch of the family. 
The patient himself was entirely free from any cachexia ; 
had, as far as careful examination could detect, no disease 
of any other organ ; had always been perfectly healthy, 
with the exception of the supposed passage of a renal calcu- 
lus eighteen years ago, which had never been repeated, and 
the hemori'hoids of which he had been entirely relieved 
when I first saw him. His bladder trouble dated back just 
two years to a passage of bloody urine, and that had been 10 
SAMUEL B. WARD. 
repeated on numerous occasions. There had been entire 
absence of the pains said to be characteristic of malignant 
disease, indeed there had been no pain worth mentioning 
until the attack of acute cystitis during which I first saw 
him. Then portions of the mass obtained in washing out 
the bladder and subsequently in the urine proved, on care- 
ful microscopical examination, to consist of simple papillo- 
matous villi, without a trace of any thing malignant. All 
this pointed to the existence of a benign growth which was 
the source of the hemorrhages, but which, could it be safely 
removed, would not, in all probability, return. The large 
size of the growth and its soft character as determined by 
rectal examination appeared to be the only sign pointing to 
any thing else. Yielding to Dr. Van Buren’s clinical ex- 
perience and declining an operation was proved by the 
autopsy to have been eminently judicious. Fig. i shows 
the exact appearance of three of the fragments obtained 
during life, and none of the others differed essentially 
from these. After the autopsy a portion of the tumor was 
sent to Dr. Hailes, who, with the aid of his freezing micro- 
tome, got sections through the whole length of these pa- 
pillae and the wall of the bladder from which they sprang, 
shown in fig. iii, and which could probably scarcely have 
been obtained in any other way. It is easily seen that the 
infiltration of malignant elements extends only a short 
distance up into the papillae, and explains how the por- 
tions we obtained during life gave false evidence of the 
character of the growth as a whole. Fig. iv shows a por- 
tion of the infiltration still more highly magnified. 
Another study of great interest in connection with this 
case was that of the urine. During the last fopr months 
and a half of Mr. J.’s life the average amount of fluid 
passed from his bladder each day was in round numbers 
90 oz., the specific gravity of which stood very steadily at CARCINOMATOUS PAPILLOMA OF BLADDER. 
11 
Is a section through the mucous membrane of the bladder, showing two large dendritic 
papillary vegetations implanted upon a carcinomatous base, and resemble benign papillo- 
mata, except near the base. 
FIG. 3. 
Encephaloid carcinoma, showing well-marked alveoli, with the large epithelial cells ot 
encephaloid disease. This field was taken from near the base of one of the papillx shown 
in fig. iii. 
FIG. 4. 12 
SAMUEL B. WARD. 
ioio. After boiling, and the addition of nitric acid, the 
precipitated albumen occupied, after standing four hours, 
from one-third to three-fifths of the bulk of fluid used. 
Repeated and careful examination failed to show a single 
cast at any time. The urea varied from one-half to six- 
tenths of one per cent., which, considering the amount of 
fluid passed, was just about normal. There was not a 
single rational sign of any form of Bright’s disease, and 
Dr. Van Buren’s reply, when questioned on this point, 
was: “I will stake my professional reputation that the 
patient has no organic disease of the kidney.” 
I have no doubt that a large part of the fluid passed 
from the bladder was albuminous liquid exuded through 
the thin walls of the infinite number of villi constituting 
the exposed portion of this growth. The examination of a 
small portion of the fluid taken from the distended ureters 
at the autopsy supported this view, for it contained only a 
distinct trace of albumen and no more—less, in fact, than 
might have been expected considering the mode of death. 
An interesting point in connection with the mechanical 
distention of the ureters and pelves of both kidneys, was 
that the same condition was found, on microscopical ex- 
amination of the kidneys, to exist in the tubuli uriniferi, 
though the organs appeared to the naked eye to be 
healthy. 
The persistent existence, then, of a large amount of al- 
bumen in the urine, without casts, without diminution of 
the total arpount of urea excreted, and without rational 
signs of Bright’s disease, might in other cases prove a 
valuable early diagnostic sign. 
In the treatment of the cystitis, which was at first a 
very painful complication in this case, lactic acid gave more 
relief than any other drug, and its value has been attested 
in many other cases in my experience. For the suggestion CARC1N0MAT0US PAPILLOMA OF BLADDER. 
13 
as to its use I am indebted to an article in the Buffalo 
Medical and Surgical Journal, for Feb., 1879, by Mr. Theo- 
dore Deecke. 
The entire freedom from disease on the part of all the 
other organs of the body, and the fact that the recto-vesical 
septum was not invaded, were noteworthy. 
I imagine that the mode of death by occlusion of the 
orifices of the ureters and the production of uraemic coma 
must be rare, for I do not find it recorded in the history of 
any case that has come under my notice. The probability 
of its having occurred was, in this instance, foreseen about 
a week before death. 
The diagnosis from the post-mortem examination of the 
bladder, ureters, and kidneys would be carcinomatous papil- 
loma of the mucous membrane and walls of the bladder, 
with hydronephrosis of both ureters and kidneys. There 
was also a marked dilatation of the straight and convoluted 
tubules in the medullary and cortical portions of the 
kidneys. 
The soft papillomatous growth resembled cauliflower ex- 
crescences, and involved fully one half of the internal sur- 
face of the bladder, extending from the neck to the bas fond 
and sides. 
This report, the micsoscopical examinations, and draw- 
ings were all kindly made by Dr. William Hailes, Jr. 
Literature.—The treatises on general surgery all devote a 
few pages, more or less, to the consideration of tumors of 
the bladder. They all agree in dividing them into benign 
and malignant. 
The names bestowed upon the varieties of the former 
class differ very considerably, and are founded rather on 
the results of microscopical examination after death, or in 
a few cases after removal, than on any possible clinical 
diagnosis. It is admitted on all hands that the growth 14 
SAMUEL B. WARD. 
variously known as papilloma, villous papilloma, villous 
tumor, and vascular tumor, is the most common, and that 
simple fibroids, mucous polypi, and fibro-myomata occa- 
sionally occur. 
Of the malignant growths encephaloid, scirrhus, and 
epithelioma are found, though authors do not agree as to 
their relative frequency. 
As to the value of microscopical examination of portions 
of a tumor of the bladder obtained in the urine during life 
authors differ. Sir Henry Thompson, in his Clinical Lec- 
tures,1 is cautious, basing his lack of confidence on the fact 
that there is no characteristic “ cancer-cell,” so-called. He 
speaks, however, of having “detected under the microscope 
the peculiar structure which the processes of the villous 
tumor present to the eye.” 
Harrison2 says “the microscope is most valuable in de- 
tecting small portions of genuine villous growth,” and the 
majority of authors speak as if finding such villi, free from 
any evidence of malignancy, would settle the diagnosis. In 
the case now reported a number of such villi were found, 
and yet the autopsy showed that any effort to remove the 
tumor by operation could have resulted in no good, in con- 
sequence of its nature. 
Harrison says, at p. 361, that “ tumors presenting some 
of the appearances of these villous growths, but of a malig- 
nant nature, are occasionally met with.” But the distin- 
guishing points which he mentions, such as induration, ten- 
dency to involve neighboring organs, implication of glands, 
and cachexia, were all absent in this case. 
Gross3 says that papillary fibroma is frequently con- 
founded with villous carcinoma, but we do not find that he 
1 London, A. & A. Churchill, 1876, pp. 351. 
3 Surgical Disorders of the Urinary Organs, Wood & Co., 1881, p. 358. 
3 Diseases, Injuries, and Malformations of the Urinary Bladder, Henry C. 
Lea, 1876, p. 136. CARCINOMATOUS PAPILLOMA OF BLADDER. 
15 
any where mentions the possibility of what occurred in this 
case—that the base of the tumor proved to be a carcinoma- 
tous mass, originating in the bladder, not extending to 
any other organ, and covered all over with a growth of be- 
nign villi. 
Gant1 says nothing on this point. 
Mr. Coulson/ in his admirably complete book, says “ there 
can be no doubt that malignant growths occur, springing 
from mucous membranes, and having their surface covered 
with shaggy projections.” Mr. T. Holmes3 says, in two 
lines, “a cancerous tumor may also sometimes be covered 
by villous processes of mucous membrane.” 
The lesson to be learned from this is that Sir Henry 
Thompson’s caution to his students is eminently sound : 
“ Most valuable as is the microscope in this great class of 
maladies, ranking next and very near to the sound itself, 
never let it obscure for you those broad features of the case 
which are to be determined by the unassisted eye and 
touch.” 
On the subject of the persistent albuminuria which was 
present in this case the general feeling of the profession is 
well laid down by Dickinson.4 He says that albuminuria 
may be artificially produced by the ingestion of a large 
quantity of highly albuminous food ; perhaps by a rapid 
absorption of a large amount of serous fluid from the pleura, 
and some exceptional forms of hepatic disease. “With this 
exception, it may be stated, as a rule, that when the urine 
contains albumen the kidneys are abnormal either in circu- 
lation or in structure.” 
Yet here is a case in which we think that a great and per- 
1 Frederick James Gant, Diseases of the Bladder, Lindsay & Blakiston, 
1876. 
2 Walter J. Coulson, Diseases of the Bladder and Prostate Gland, Wood & 
Co., 1881, p. 116. 
3 Treatise on Surgery, Henry C. Lea, 1876, p. 770. 
4 Treatise on Albuminuria, Wood & Co., 1881, p. 11. 16 
SAMUEL B. WARD. 
sistent albuminuria did not depend upon any form of kid- 
ney trouble. 
The only reference we have been able to find to this point is 
in Mr. Coulson’s book.1 He quotes Dr. Ultzmann as pointing 
out in an article, Ueber Hcematurie, in the Wiener Klinik, 
May, 1878, the fact that “in cases of villous tumor the 
urine always contains more albumen than corresponds to 
the blood or pus in the sediment.” He accounts for it in 
the same way that we have in this case, though Mr. Coul- 
son’s book and this reference came under our notice long 
after the first part of this article was written. Dr. Ultz- 
mann further points out the fact that fibrine sometimes ap- 
pears in the urine under the same circumstances and from 
the same cause. 
Gross mentions the possibility of death from uraemia from 
occlusion of the orifices of the ureters in the pelvis of the 
kidney. But we have not happened to notice the occlusion 
of the ureters at their entrance into the bladder. 
The following histories of cases, more or less similar, re- 
lated in medical journals, have come under my notice: 
1. American Journal Med. Sci., vol. 16, 1835, page 522. 
2. “ “ “ 7, 1844, “ 122. 
3- “ “ Oct., 1874, “ 561. 
4. “ “ Oct., 1879, “ 579. 
5. “ “ Juiy> 1880, “ 233. 
6. Dublin Journal Med. Sci., vol. 16, “ 333. 
7. Medico-Chir. Review, “ 19, 1831, “ 453. 
8. London Lancet “ i, 1849, “ 43. 
9. “ “ I, 1850, “ 188. 
10. *♦ “ I, 1854, " 212. 
11. “ “ 2, 1880, “ 978. 
12. British Med. Journal, “ 1, 1879, “ 854. 
13. Med. Times and Gazette, “ 1, 1879, “ 710, 
14. N. Y. Med. Record, “ 8, 1873, “ 342. 
15. “ “ 14. 1878, “ 395. 
16. “ “ 16, 1879, “ 82. 
17. N. V. Med. Journal, “ 20, 1874, “ 62. 
18. “ “ 21, 1875, “ 503. 
1 Op. cit., p. 188. CARCINOMA TOUS PAPILLOMA OF BLADDER. 
17 
lg. N. Y. Med. Journal, vol. 23, 1876, page 299. 
20. “ “ 27, 1878, “ 166. 
21. “ “ 28, 1878, “ 629. 
22. Archives Generates de Med., “ 1, 1876, “ 489. 
23. “ “ “ 1, 1877. “ 233. 
24. Medical News and Abstract, 1881, “ 854. ARCHIVES OF MEDICINE FOR 1881, 
A BI-MONTHLY JOURNAL, 
Edited by Dr. E. C. Seguin, with the assistance of many prominent physicians in this 
country and abroad, enters upon the third year of its existence. 
The Archives of Medicine will continue to be published every two months. 
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104 to 112 pages. The articles are illustrated’by means of lithographs or wood-cuts wherever 
necessary. 
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The following Editorial Articles have appeared during the year 1880 : Mr. Lister’s Antiseptic 
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