consistency; the absence of fluid; the tolerance of pressure upon the tumor on the part of the child; its situation to the right of the median line; its mobility; and its uniform color with the surrounding skin, excluded the probability of its being a Spina Bifida; for it is hardly necessary to here state that a spina bifida presents almost just the opposite features.

In all recorded cases the presence of fluid is easily recognized through the thin walls of the sac; the tumor is always in the median line; its color is darker than the surrounding skin; and its size can be considerably reduced by continued and firm pressure, a proceeding which is generally accompanied by more or less tetanic symptoms on the part of the child.

None of these features presenting themselves, and there being not the slightest evidence that the tumor was of a fibrous character, Prof. Jacobi felt justified in pronouncing it a lipoma, and recommended the usual treatment, excision. The parents being desir ous of its immediate removal, requested me to operate, which I consented to do. Accordingly, on the day appointed, with the assistance of Drs. C. S. Ward and Grunhut, and ether having been administered, I proceeded to operate by making an eliptical incision with the intention of enucleating the mass. After careful and deep dissection through an abundance of adipose tissue without finding any sac, the former in reality composing the tumor, I proceeded to remove the same by separating the mass from the subjacent tissues, which was nearly completed when a spirt of fluid revealed the presence of a cyst. A digital examination discovered a bifidous condition of

the two lower lumbar vertebræ, over which were superimposed the still undetached portion of the tumor. Drs. Ward and Grunhut concurring, it was ligated and removed. The edges of the wound were then approximated with sutures and adhesive straps, and a firm compress applied.

For thirty-six hours not the slightest symptoms of constitutional disturbance from the loss of the spinal fluid occurred, giving some hope of a possible recovery, which was also brightened by the fact that the wound united by first intention throughout its entire course.

At the thirty-seventh hour after the operation, however, the child was seized with a slight convulsion, which was repeated at short intervals, coma supervened, and death occurred six hours after the first convulsion.

No post mortem was allowed by its parents.

Examination of the removed mass showed that the supposed lipoma was nothing more than a remarkable development of adipose tissue over a small spina-bifida sac. The thickness of the mass after removal was one and three-quarter inch, at which measurement from the top the membranes of the spinal cord constituting the sac of the spina bifida cut into, was reached. The size of this sac was exactly that of a small sewing thimble, just admitting the little finger to the depth of three-fourths of an inch.

The great point of interest in this case was the absence of the recognized features of a spina-bifida, and the presence of those characteristic of a lipoma.

In all the works that I have so far consulted, no mention is made of such a case, or of the excessive development of adipose tissue over the sac, but on the

contrary, the walls are described as thin, and the presence of fluid therefore easily recognized. Such was the condition in three other cases seen by myself.

The tolerance of pressure on the part of the child in the case reported, can be explained by the very small size of the sac, which at its fullest distention, I estimate, could not have contained more than half an ounce of fluid; this fact also explains why its size was not in the slightest degree diminished by firm pressure.

In regard to the operation, it may be said that the previous use of an exploring needle or trochar would have revealed the true character of the tumor. To this I can reply that, even had there existed any doubt as to the character of the mass, such a precautionary measure would undoubtedly have given no result, as the excessive thickness of the adipose tissue and the small size of the sac would have undoubtedly prevented its being reached by the instrument.

It must be allowed, on the whole, that this was a rare and unique case, and the operation and its result one of those much to be regretted occurrences which is experienced by almost every surgeon. The removal of the spina bifida sac was not necessarily fatal, for a few cases are on record where the operation has been followed by recovery, though it is certainly not advised.

The instruction to be derived from this case is val uable, and although such another one may not be found again in many hundred cases, yet it will not be unadvisable to recommend before operating, thorough explorative punctures in all apparently solid tumors in infants, situated more or less directly on the spinal column.

This case was reported and discussed at the meeting of Jan. 3d, 1871, of the New York Obstetrical Society, and was generally pronounced an unusual and interesting one.

URETHROCELE, CATARRH AND ULCERATION OF THE BLADDER IN FEMALES.

By NATHAN BOZEMAN, M.D., New York.

(Read at the Annual Meeting of the New York State Medical Society, February 7, 1871.)

THESE three local lesions are intimately related in one morbid state or malady. By insensible degrees urethrocele occasions vesical catarrh, and this ter minates in ulceration: thus we find them associated in the same subject. The insidious progress of the malady often baffles the physician's acumen in seizing its distinctive phases, or in assigning to each a beginning and an end. Its cause or causes may escape our ken, and the disease be quite advanced before it is suspected. Urethrocele, its primitive lesion or first manifestation, may have occasioned but little inconvenience for years before surgical aid was sought, and this neglect may have entailed catarrh and ulceration in that pathologic order for which continuity or contiguity of tissues is responsible. At this late period, it is often impossible to trace the relations of cause and effect. Urethral stricture, so formidable to the male bladder, rarely exists in the female, and the absence of the prostate gland might seem to afford an immunity from vesical inflammations; but experience belies this. If the male urethra, by its greater length

and lesser calibre, is more exposed to blennorrhagia and its consequences, the female is subjected to the still graver perils of child-birth. In both sexes the morbid results are much the same, but as their causes differ widely by anatomical and physiological peculiarities in each sex, so the treatment must also differ.

An English physician, Sir Charles Mansfield Clarke,* called attention to an affection of the female urethra, which he designated as "a thickening of the cellular membrane surrounding the urethra throughout its whole extent, accompanied by a varicose state of the vessels of the part." "If," he continues, "the parts are exposed and the patient presses down, the diseased part will be boht into view, putting on the appearance of a tumor, but which is nothing else than a thickening of the urinary passage. On the surface of this thickened part blood-vessels ramify, of a size large enough to admit of being opened by the point of a lancet. *** If pressure is made is made upon the part, the swelling and redness subside for a time, but both return directly upon the pressure being discontinued.

"Sometimes a pouch forms in the posterior part of the urethra in which a few drops of urine lodge, and from which situation it may be pressed out by the finger applied to the part. If a catheter is introduced into the urethra, it may be carried backwards to the part where the lodgment of urine is found. Upon this cause depends, perhaps, one of the most troublesome symptoms of the disease, a frequent desire to make water, both in the night and during the day, so as to interfere with the patient's rest."

* On Diseases of Females, vol. 1, p. 295, 1814.