the laryngoscope and the ophthalmoscope, is limited in its utility, (1) by the conditions present which facilitate or prevent thorough examination; (2) by the skill of the individual observer, who must be able to interpret correctly what he sees. In the adult with normal patency of the urethra, there is no difficulty in introducing the cystoscope into the bladder, even when there is considerable enlargement of the prostate. When an examination is attempted, the fluid in the bladder must be free from blood and pus, either of which even in small quantities obscures the field, and nothing is learned. It is hardly necessary to say that before the cystoscope is introduced care should be taken to see that the battery is working efficiently, that the lamp is secure, and that all the connections are perfect. All the above conditions being complied with, we may learn first of all that a tumor is present, perhaps how it is attached, whether by a pedicle or otherwise, the exact site of the attachment, whether the growth is ulcerated or not, and, with some degree of probability, whether it is innocent or malignant. The more distinctly pedunculated a tumor is, the more likely it is to be innocent; the more delicate its papillæ, and the more they are localized to one part of the bladder, the greater is the presumption of innocency. When the tumor is sessile, when instead of delicate papillæ we have raised bossy masses giving the appearance of a solid oedema, and especially if there is ulceration, the indications point to malignant growth. Summing up the value of the cystoscope, under suitable conditions it is impossible to overrate it. Its great virtue is that it tells almost with absolute certainty whether a tumor is or is not present. I said that the value of this instrument, when it is really available, cannot be overrated, and I emphasize this by pointing out to you five conditions which are most likely to be confounded with tumors of the bladder, and in which exclusion of tumor is of the utmost importance: these are sarcoma of the kidney, stone in the kidney, granular kidney with severe hemorrhage, tuberculosis of the kidneys commencing, as it occasionally does, with severe bleeding, and hæmaturia in a hæmophilic subject.

Treatment. Whether this is to be operative or not will depend upon the opinion formed as to the nature of the tumor. If it is believed to be innocent, it should be removed if the patient's general condition permits. If the characters are distinctly those of a malignant growth, as a rule operation is not called for; the exceptions to this rule will be dealt with later.

As a very large proportion of tumors of the bladder are located on the floor and parts adjacent, it seems at first sight reasonable to

approach them by a perineal opening; but this method is deservedly falling into disuse. In elderly men with deep perineums, the finger introduced by a median opening may fail to recognize the presence of a growth, because the tip of the finger only just reaches into the bladder. Even when the finger can fully explore the viscus, the repeated introduction of fingers and instruments through the perineal opening, with the unavoidable bruising and laceration of the parts, renders the operation, in my opinion, more serious than suprapubic section, which should be the routine method adopted. This, when the patient is in the Trendelenburg position, gives free access to the bladdercavity for the manipulation of instruments, and especially so if the attachments of the recti are divided, and by the introduction of retractors or of a large Fergusson's speculum, and the aid of electric light, the tumor may be exposed to direct observation. It is not necessary for me to dwell upon the details of the suprapubic section, with which you no doubt are all familiar from seeing it done so often here.

The bladder being opened, various instruments may be used to remove the growth. If it has a slight pedicle, it may be snipped off with scissors curved on the flat, or it may be evulsed with nasal polypus forceps. If its base be more solid, but still pedunculated, it may be snared with wire, and this may be more effectually done if a perineal opening be made through which the snare can be introduced, the fingers above the pubes manipulating it round the base of the growth. For tumors such as the fibro-papilloma of Case III., Thompson's forceps for evulsing the tumor in fragments are useful.

If the tumor has been diagnosed as malignant, an operation is called for under two conditions: the first is when the growth is so limited in extent, and located in such a part of the bladder, as to justify the belief that it can be extirpated completely. The other condition is when a tumor too extensive to be completely removed is yet causing the patient so much distress, from pain, frequent micturition, and bleeding, that some relief has to be given to make life bearable.

I have now only to say a few words as to the prognosis of bladder tumors. Complete and permanent cure by the excision of a malignant growth is so rare that it need scarcely enter into our calculations. At the same time it is necessary to remark that the progress of many malignant growths is slow, the mean duration being about three years, and the tendency to secondary infection of the viscera and glands is slight. The prognosis in papilloma is better than in any other form of tumor, but cases accurately recorded show that occasionally a papilloma becomes carcinomatous, as, for instance, one published by Mr. Alexan

VOL. I. Ser. 4.-16

der in the Lancet, vol. xvii. p. 8, 1878. More important than this rare occurrence is the tendency of the firmer papillomas to recur. This will, I expect, be the case with the female patient whom I have shown you to-day, and in such it not infrequently happens that two or three recurrences take place which can be removed, and then at last a recurrence so extensive is produced as to be beyond relief by operation. In a case such as the second I related to you the prognosis is extremely good. Cases are occasionally recorded of papilloma of the bladder and of some of the other innocent forms going on for many years; for instance, in the first case I described to you, symptoms had existed for ten years. It may not unreasonably be asked, why interfere with tumors which seem to have the capacity of doing so little harm? The answer is, that almost invariably secondary dilative and inflammatory changes are set up in the ureters and kidneys, producing hydronephrosis and pyonephrosis, which will eventually kill the patient, or will militate against a successful operation if the growth be left until a long time has elapsed.

THE RESULT OF A PRETENDED OPERATION UPON A PATIENT SUFFERING FROM A DELUSION OF A SEXUAL CHARACTER; OPERATION FOR THE CURE OF EPISPADIAS; CASE OF PERINEAL SECTION FOR TRAUMATIC STRICTURE, WITH A DESCRIPTION OF A NEW FORM OF PERINEAL STAFF; NEW METHOD OF TREATING A RESILIENT AND NODULAR STRICTURE OF THE PENILE PORTION OF THE URETHRA.

CLINICAL LECTURE DELIVERED AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL.

BY ORVILLE HORWITZ, B.S., M.D.,

Clinical Professor of Genito-Urinary Diseases in Jefferson Medical College; Surgeon to the Philadelphia Hospital, etc.

GENTLEMEN,-The first case that I bring before the class to-day is that of an individual who applied for relief at this institution five years ago. At that time he was suffering with spermatorrhoea dormientium, or nocturnal pollution, accompanied by well-marked neurasthenia. I call your attention to the case not only because it is one of great interest from a psychological point of view, but also because it illustrates what I have so frequently insisted upon when lecturing upon the treatment of individuals whose condition was similar to that of this person now before you; that is, that in order to benefit these cases every effort should be made to gain the confidence of the patient, and all your tact must be employed to allay his fears until the disordered nervous system regains its tone. You must ever be ready to meet all complications which from time to time will arise.

This individual is twenty-eight years old. He is a carpenter. When he applied to the surgical department of this hospital he asked to have his testicles removed, believing that it was the only way whereby the seminal discharges might be stopped, and saying that their continual recurrence was undermining his health, and that his reason would be

destroyed unless he was relieved. He stated that the various methods of treatment resorted to by numerous practitioners had all failed to benefit him. His condition had preyed upon his mind to such an extent that he declared that unless he could find some one who would be willing to castrate him, he would himself perform the operation. Six months previously he had attempted excision of the scrotum, but after making an incision his courage failed him. You may readily observe the scar resulting from this attempt at emasculation. The scars that you see on the body of the penis are the results of ulcerations produced by acids employed to render the organ sore, so as to make masturbation impossible. At the age of sixteen he had contracted the habit of self-pollution, which he had continued until the time of his application for treatment. He attributed his condition to this unfortunate practice.

His nocturnal emissions occurred as often as three times weekly; he occasionally experienced pain along the course of the urethra, extending into the spermatic cords and testicles. He urinated with abnormal frequency.

He stated that his appetite was poor; that he had a feeling of gastric depression; that his sleep was neither sound nor refreshing. He was oppressed by heavy pains in the groin, lumbar region, and back of the head; there was great mental hebetude; he was easily fatigued; his hand was unsteady; he had an anxious look; was markedly anæmic. When a seminal discharge took place it was

followed by unusual depression and lassitude, with increased pains.

The urethra was intensely hyperæsthetic, especially the prostatic portion. The meatus was contracted; there was no stricture. The prepuce was elongated.

The individual was placed upon full doses of bromide of potassium and fluid extract of ergot, atropine being given at bedtime; hot douches were applied to the spine, and a bougie was passed every third day.

Under this treatment the emissions lessened in frequency, and, in fact, became normal; that is, they occurred about once in two weeks.

The patient's mental condition remained unimproved, and whenever a seminal discharge took place he was plunged into the depths of despondency.

Observing that he was not improving mentally, and fearing that, unless some means was resorted to that would make a strong impression upon him, he would either become insane or do himself bodily injury, I resolved to perform upon him a pretended or bogus operation. Both