The patient's condition remained-unaltered until the summer of 1873, when I first saw her. She was a woman of medium size, with grayish hair, and features white and seamed by suffering. She was fairly fat, and her abdomen was tense: hence it was difficult to detect a tumor. Touch ing the urethra or the vagina was so very painful that she begged for chloroform, which was given her. I could then feel at the right pelvic entrance and near the uterus a projecting, tense, elastic, non-movable tumor, which appeared to spring from the right ovary. Urine was clear and contained no foreign bodies. The patient showed me a mass of nearly hazel-nut-sized warty bodies, sufficient to fill a, medium-sized goblet, which she said had in the course of time passed through her urethra,. My diag nosis, therefore, agreed with that of Dr. de Moor; a papillary cystoma of the ovary had pierced the bladder, and the bunches were being cast off in this way. No tumor was perceptible to the catheter in the bladder, and there was nothing in the urine; therefore there were no indications for operative interference.
In the next eight months there again began to be fragments passed from the bladder, on one occasion enough to fill a three-ounce vial. There was hemorrhage and pain, and the patient decided to undergo any operation to obtain relief. In order to keep her under close observation, I had her admitted into my clinic June 10th, 1874. There was no fever, appetite was good; costiveness was remedied by injections. Nights were bad, and were helped by small doses of tinctum thebaica. Drinking abundant hot drink, the patient passed June llth 32 ounces, J.une 12th 34 ounces, and June 13th 50 ounces of urine with some pus and blood, but no solid masses.
On July 17th she was chloroformed, the urine evacuated with a cathe ter, and the left finger intrcxluced cautiously into the dilated urethra, into which it passed freely without violence after 2 to 3 minutes. I could then feel on the posterior bladder-wall, at about the place where the right ureter opens, a large, movable, fringed, soft tumor. This I t,ore into fragments with the finger, and then injected with the syringe about eight ounces of warm water. I then introduced into the bladder a Carus's dilator uteri, and the detached masses passed out in large quantities. I
then attempted to remove the rest of the tumor in the same way; but the pediele eluded my finger, nor could I grasp it with a small pair of forceps, which I introduced along the digit. After three or four at tempts, all the prominent parts that I could feel were detached, and were removed in the way described. There was but little hemorrhage; the sphincter closed after withdrawal of the finger, so that no fluid escaped, and after the operation was done, there was only a small fissure in the upper part of the urethral mucous membrane.
The patient finally vomited once while narcotized, and this happened again several times during the next forty-eight honrs. But that was the sole reaction that she showed. Pulse remained 72 to 80, there was no fever, and hardly any burning when she passed water. The urine at first contained blood and clots, but gradually cleared. Warm baths were very refreshing to her.
The uterus I found entirely healthy, normal in size, position, and movability. I found no trace of the foriner tumor upon the right side.
The masses we removed were similar in nature to those the patient for nterly passed. They are papillary tumors, each being about the size of a grain of corn. Their surface is covered with hypertrophous pavement epithelium; their mass is composed of a delicate connective-tissue ground work, with large blood-vessels, which sent delicate vessels up into the papillm. If there had been a cystoma of the ovary, it would after cica trization of the pedicle, which connected the part which had penetrated the blaAlder to the rest, have grown in other directions. This occurs when such growths penetrate the rectum or the umbilical opening. That did not occur. Two years after the operation there was neither any trace of an ovarian tumor, nor any return of the vesical papilloma. In July, 1882, eight years after the first operation, she returned to me, in trouble again. I found the entire posterior vesical wall diffusely infiltrated with a new growth, extirpated a part, and found that there was carcinomatous degeneration. She moved away soon afterwards, and I do not know whether she is still alive.