one occasion he passed by the urethra a small substance which looked like a black grape. Sounding detected no stone, and from the passing of some foreign body it was surmised that there might be a tumor in the bladder. The wretched condition of the child forbade any exploratory operation, and he died in a few days. The post-mortem examination revealed a patch of polypoid growth attached over a surface two and a half inches square, spread over the posterior and inferior walls of the bladder. Some of the growths had narrow pedicles and were as large as the end of the finger, others were much smaller and sessile, the mucous membrane around being like thick wash-leather. To the naked eye the tumors looked when fresh like nasal polypi, and it could be seen that they were connected only with the mucous membrane, which could be stripped off, leaving the other coats healthy. The specimen shows the general appearance of the tumor. There are a few other tumors, fibromas, myomas, and dermoids, which have a history similar to this.

Let me now relate a case to illustrate another clinical variety of bladder tumor, a malignant form.

A male, aged fifty-one, was admitted to the hospital on May 16, 1892, complaining of difficulty in passing water and of pain under his penis after he had passed it, and of clots of blood in his urine. His history showed that he had passed blood for the first time three years before, and at intervals of varying length ever since. Some time later he had pain and frequent micturition, but he was quite certain that the hæmaturia preceded the other symptoms. The pain now is at the end of the penis when he passes water; he also has pain in the loins. The frequency of micturition is both by day and by night. Examination with the cystoscope showed a wide-based growth attached to the floor and posterior wall of the bladder; this was ulcerated in the centre. The finger detected thickening and infiltration in the floor of the bladder. The growth being diagnosed as malignant, the patient was advised not to have an operation done unless his symptoms of pain and frequency of micturition became more severe. In about a month he returned begging for relief from his pain and frequency: so on July 4 a suprapubic cystotomy was done, and the growth scraped away down to its base with a sharp spoon. In three weeks all the urine was passing by the urethra, the patient was free from pain, and the frequency of micturition was much less marked than before the operation. On July 31 the wound, which had quite healed, broke open again, and from this time on there was a steady increase of pain, frequency, and loss of condition. The first week in September there were rigors and

vomiting, and masses of growth began to project through the suprapubic opening the patient died at the end of September. The post-mortem showed that the whole cavity of the bladder was filled with a growth which had involved the tissues of the wound. Both ureters and kidney pelves were dilated, and both kidneys were in a state of pyelo-nephritis. Microscopically the growth was an alveolar carcinoma. The photograph (Fig. 5) of an epithelioma shows the flat, thick-edged, sessile tumor which is characteristic of malignancy.

These cases illustrate, then, the three chief groups of bladder growths, -the innocent group, which chiefly gives rise to hemorrhage; the second

FIG. 5.

innocent group, in which hæmaturia is slight or passing, and pain and frequent micturition are the chief features; and the third group, the malignant, in which painless hemorrhage is nearly always the first symptom, though it is speedily followed by painful and frequent micturition.

When a patient presents himself or herself with symptoms suggestive of bladder tumor, we have by careful investigation to determine the presence of a growth, and, if possible (and it generally is possible), whether that growth is innocent or malignant, and how it is to be dealt with. In arriving at a diagnosis we weigh the signs and symptoms presented, and we resort to physical examination. I

propose to consider the various points which present themselves for investigation, and the first I shall deal with is hæmaturia. You will appreciate the importance of this symptom when I tell you that in seventy-five per cent. of all cases of tumors of the bladder hæmaturia is the first symptom. Other symptoms may arise later on, but in many papillomata there is no other indication of the presence of a tumor. The hæmaturia may be slight, or severe, so much so as to make the patient quite faint if he gets out of bed, as in the first case I related to you, but the amount of bleeding is no criterion as to the size of the tumor. In one patient, between sixty and seventy years of age, upon whom I operated, there was a severe attack of hæmaturia lasting nearly eighteen days, and yet

the papilloma which gave rise to it did not weigh altogether a drachm. One feature, which in a certain number of cases differentiates the hæmaturia of tumors of the bladder from that caused by other conditions, is that the bleeding may take place only towards the end of the act of micturition, or at all events the amount of bleeding is much increased then, owing to the obstruction of the venous return from the growth, or else to the actual involvement of the growth in the urethral orifice. In a certain number of cases of papilloma the intermittent hemorrhage unaccompanied by other symptoms (unless there be slight increase in frequency and some pain due to the passage of clots) is most characteristic, and is paralleled only by the bleeding which occurs in some few cases of malignant growth of the kidneys. Besides being intermittent and symptomless, the hemorrhage in the cases I have just alluded to is capricious: it comes without apparent cause and disappears in the same way; it is practically uninfluenced by drugs; it may last an hour, a day, or a week, and the intervals between the various attacks are just as uncertain. Such hemorrhage as I have been speaking of may be present in any malignant growth of the bladder, but at the end of a few months pain and frequent micturition, often due to cystitis, arrive, and trouble the patient much more than the bleeding. This is not always so in malignant growths, and depends to some extent upon the nature and situation of such growths; for instance, I operated upon a patient in pre-cystoscopic days, in whom for two years intermittent symptomless hemorrhage had occurred suggesting papilloma, but on opening the bladder I found at its vertex an ulcerating growth of limited extent, which proved to be a typical scirrhous carcinoma, a growth very rarely seen in the bladder. The absence of pain and the frequency of the hemorrhage were doubtless due to the growth being situated in a locality distant from the usual one-the floor of the bladder.

Pain and frequent micturition are often merely the indications of cystitis, which comes on early in malignant growths and in the firm innocent growths, such as the myxoma I mentioned to you. Cystitis is not common in connection with papilloma, though it may arise when the growth has existed for some time, perhaps not till the end of years. Patients with the more solid forms of papilloma, however, as, for example, the case of fibro-papilloma I related to you, may early suffer from cystitis and its results, pain and frequency. When pain is present it is most often associated with the act of micturition, and is especially felt towards the end of the penis. It may, however, trouble the patient at other times, and may be felt in the perineum, in the rectum,

and down the thighs, or it may be experienced as a dull ache above the pubes. It is always necessary to ascertain whether the pain is due simply to the passage of clots along the urethra; otherwise a wrong conclusion may be drawn from it. The frequency of micturition is very variable, sometimes only a moderate increase on the normal state, at others so frequent that the patient's rest is constantly broken by it, and at last life may become unbearable from the incessant demands to empty the bladder. With regard to frequency it must be borne in mind that the presence of blood from an innocent tumor may cause some increased frequency, which passes off as the hemorrhage subsides, and must not be misinterpreted as meaning that a more formidable growth exists. Pain and frequent micturition, usually secondary to hemorrhage in their appearance, may be the earliest symptoms, and if so they suggest an innocent tumor of solid formation, or a malignant growth.

Retention of urine may occur from a portion of growth becoming impacted in the internal orifice of the urethra, as happened in the first case I related to you. In the same way the patient may suffer from a sudden interruption of the flow of urine when he is micturating, as does a patient with stone, owing to the foreign body corking the urethra and then being displaced, when the urine again flows. Sometimes dribbling of urine may occur, either an overflow or a true incontinence. The first is due to an over-distended bladder with growths in its orifice, by the side of which a little urine manages to escape; the second may be due to absolute inexpansibility of the bladder from infiltration of the growth in its walls, or in the female to a massive tumor, such as a fibroma, being gradually forced through the urethra, sometimes until it appears externally.

When a tumor is suspected, the urine should be constantly examined for the presence of fragments which may be passed, as occurred in two of the cases I have mentioned to you: this accident is most likely to occur in papilloma, but it may occur in any kind of tumor. To detect fragments, all the urine the patient passes, especially when an attack of bleeding is on, should be carefully collected every day, and the surgeon himself should pour it from one vessel into another, looking carefully in any sediment which may remain, and, if necessary, breaking up any clots of blood which may hide what he is seeking for. It is, of course, impossible to overrate the value of the evidence which a fragment gives as to the presence of a growth, provided it is examined by a person competent to give an opinion upon it under the microscope,-to show, in fact, that it is not an accidental foreign body. When it comes to the nature of the growth, however,

it must not be concluded that the tumor in the bladder is of the same nature as the fragment which has been shed. The fragment is no doubt most commonly of the same nature as the bulk of the tumor, but to this there are many exceptions, and from the surface of malignant growths fragments may be separated which, examined microscopically, are nothing more than simple papilloma. Again, do not commit yourselves to a diagnosis of malignant growth because of certain irregular shaped and sized epithelial cells in the urine, which occasionally betray the inexperienced into speaking of them as "cancer-cells." From the urinary passages generally very various epithelia may be shed, and the knowledge of this should put us on our guard.

Thus far I have been speaking of the information to be obtained by interrogating the patient and by examining the urine. I now come to what may be learned by physical examination. The first method resorted to generally is the use of the sound. The evidence obtained by this instrument is usually negative,—that is, we learn that there is no stone present to cause the symptoms, and we may learn nothing more than this; on the contrary, though no stone may be found, irregular solid projections may be recognized, and subsequently sharp hæmaturia may follow, showing that some growth has been abraded by the sound. When the instrument is in the bladder, the finger introduced into the rectum may recognize thickening and infiltration about the base of the organ. Objection has been taken to the use of the sound in the diagnosis of tumor of the bladder. When the chief symptom is hemorrhage, such as suggests papilloma, I never trust to sounding to tell me anything, but resort to the use of the cystoscope forthwith. When the symptoms are mainly pain and frequent micturition, the exclusion of stone is the first business, and then the sound must be employed, and this, of course, is especially true where cystoscopic examination cannot be provided. Bimanual examination should also be instituted, to tell the physical character of the growth if it may be learned in this way. With one hand above the pubes, and the fingers of the other in the rectum or the vagina, according to the sex of the patient, a tumor of any consistency and size may be recognized if the patient is under an anesthetic. This method of examination will also tell whether a tumor infiltrates the floor of the bladder, giving a dense leathery nodulated feeling, and whether it fixes the lateral walls of the bladder to adjacent parts, either of these conditions, of course, indicating malignancy.

And now I must point out the value of our modern instrument the electric cystoscope. This, like other instruments of precision, as