bladder wall, but not from the base, as a rule. When somewhat old, and coming at the last of the act, it is more apt to have been a slow oozing from the base; old, black and well mixed, it is suspected to come from the kidneys. To all of these statements probability only can be assigned, not certainty. Continuous rapid hemorrhage from the kidney or ureter often occurs, and the blood is bright red when passed with the urine. The clots of wormlike shape that have been sometimes supposed to be casts of the ureters are just as often formed in the urethra. Large and breaking down clots are, as a rule, of bladder or prostatic origin.

Every case of hematuria demands. early and thorough examination to determine its source. Physical inspection of the external organs must be a part of this examination, as may be well illustrated by the following two brief histories.

A very old woman, who for years has suffered from incontinence of urine, suddenly began to pass blood, and thereafter retention ensued. A large suprapubic swelling appeared, which was thought at first to be retained blood clot in the bladder. Several attempts to catheterize were made, but without complete exposure and without success in drawing the water. When I had her placed upon the table I found the urethra surrounded by a dense mass of stony hardness, evidently a scirrhous cancer. Ulcerative changes had destroyed the meatus, so that attempts to pass the catheter without the aid of the eye were futile; the blood came from the eroded vessels of the urethra: the

suprapubic mass was simply the bladder distended with urine, which was

readily evacuated when a catheter was passed into the bladder through the ulcerated area.

The other case was that of a young man who entered hospital because of an obscure febrile movement that was suspected to be typhoid fever. He suddenly complained of passing blood with his urine, whereupon he was transferred to my service for investigation. I found him bleeding continuously from the orifice of a long, tight and greatly inflamed foreskin. This, upon incision and removal, was found to conceal a large eroding chancroidal ulcer that had opened the dorsal artery of the penis. The hemorrhage was therefore quite outside of the urinary canal, and

the admixture of blood with his urine a mere extraneous accident. It is of further interest to note that the discovery and treatment of his venereal lesion put an abrupt end to his obscure fever.

In cases where the blood is undoubtedly passed with the urine it is well for the surgeon to insist that if possible the urine should be passed in his presence, or he should withdraw it by catheterization. The urine thus passed or drawn should be noted in accordance with the observations already made as to time, quantity and quality of blood admix

It is possible in the female to secure the same information by the use of the Kelly tubes and air dilatation of the bladder, the hips being well raised for the purpose. When it is desirable to carry the exploration beyond the bladder itself, the ureteral catheters are the means employed.

By visual inspection through these short, broad urethral tubes by means of direct or reflected light, a reasonably satisfactory view of the bladder wall can often be obtained. In one instance I thus found the mucous membrane wholly anemic, and the bloody urine entering from the left side. It proved to be a case of renal calculus of that side. In another case I found an infiltrated area with lime scales upon it, which had hitherto given a fictitious impression of calculus. This deposit of calcareous scales is of somewhat frequent occurrence in connection with ammoniacal urine and new growths, especially should the new growth be of a cancerous nature. I have twice so observed their presence, and find that Fenwick attaches some importance to their discovery as an evidence of can

cer.

We naturally suspect new growth in every case of sudden urinary hemorrhage in the adult if stone can be excluded. But hemorrhage alone is altogether insufficient to base a diagnosis upon, nor should operation be under taken upon this unsupported suspicion, unless the case seems otherwise very grave. I have observed a case of fatal hemorrhage of the bladder, in which post-mortem examination revealed

nothing but an intensely engorged mucous membrane. Operation for such a condition would have been entirely fu

tile.

In a young man who last year had one free hemorrhage coincident with the appearance of a hematoma of the right spermatic cord, the urine contained debris, which I submitted to Dr. Mitchell for examination, and in which he found the eggs of the Hematobium. Bilharzia, a parasite very unusual in temperate climates and altogether inexplicable in this case, since my patient had never been out of the United States.

A deep urethral or prostatic hemorrhage sometimes reflows into the bladder and gives a mixed, bloody urine instead of coming, according to rule, at the beginning of the act. It is equally easy for a very free hemorrhage from kidney or ureter to partially fill the bladder so that all of the urine as passed will seem to contain fresh blood as if from the bladder wall. It cannot be too urgently repeated that the sum total only of signs, symptoms and lesions can be relied upon for decision in any given case. Diagnosis must always be guardedly expressed, since errors are by no means infrequent.

I remember one instance in which two eminent gynecologists concurred in the diagnosis of cystitis and bladder hemorrhage. I had an opportunity to see the patient, but failed to discover any reason for disagreeing with them. A post-mortem, however, at a later period, revealed the actual trouble as a branched calculus of the kidney. The frank rehearsal of such an error does not mean that errors are the rule.

bleeding from the growth blurs the field of vision and interferes with a prolonged observation. Cancerous growths of the bladder often have a papillomatous fringe develope upon their surface, and fragments of this fringe may give under the microscope no evidence of the underlying malignant tumor.

This was the case in one of my patients last year. I secured fragments which were typically papillomatous. The cystoscopic picture was of swinging polypoid masses only, but when I operated I found this papilloma springing from a hard base, portions of which were sloughy and which seemed to penetrate the surrounding tissues. The malignancy of this case thus established in my mind at the time of operation was confirmed by subsequent rapid recurrence and death. The growth was pronounced by Dr. Axtell to be a cancer. It has been my fortune to have charge of one other such patient, and of another in whom scirrhous cancer originating in the prostate invaded the bladder, penis and testes secondarily. Added to these cases and the one of epithelioma of urethra and bladder base already mentioned this evening are two others, one of cancer of the base in a female and one of primary adeno-carcinoma of the prostate invading the bladder, making six cases of cancer of the bladder (primary or secondary) that I have observed. In every instance the invasion began in one of the lower quadrants; in every instance the disease after recognition proved rapidly fatal.

The only hope of operation in such cases is to lessen the pain of frequent urinary acts by providing free drainage. It is fortunate that the disease is so rare, as it entails exquisite torture upon its unfortunate victim,

and is susceptible of but little palliation.

In the operative treatment of growths of the bladder my experience during the last two years has served to confirm me in the belief formerly expressed before this society that the perineal route should be when possible the one chosen. In any event it should always be made use of first, when, if exploration by means of finger and instruments serves to show that it is insufficient, the suprapubic opening may be readily made in addition. This combined method of operation has served me exceedingly well in four cases, and I believe is being advocated more and more by the best operators. For complete excision of the prostate the perineal section enables one to hook the index finger within the sphincter and thus drag down the gland within reach of knife, scissors or dissector, if the enlargement be not too great. great. If the gland is so large and the perineum so deep that the finger cannot reach within the prostatic collar, this object can be attained by means of a small supra-pubic opening just large enough to admit the finger of the other hand, which then presses down from above until the finger already in the wound of the perineum succeeds in hooking itself above the collar. It has been recently proposed to make this suprapubic opening into the peritoneum instead of into the bladder, as superior drainage is thus avoided and the pressure can be equally well applied. Some operators claim that in thin subjects they have been able to apply the necessary pressure through the abdominal wall without opening it.

The non-operative treatment of dis

ease of the bladder and its neighboring organs, the prostate and the vesicles, is just as important as is the operative. Similarly, it is as necessary to realize what not to do just as much as to know what to do.

Mechanical troubles due to enlarged prostate or to hypertrophy of the bladder walls should have as little instrumental interference as possible while the urine remains aseptic. The adminThe administration of urinary antiseptics, such as piperazin, urotropin, cystogen, salol or quinine, should if possible precede instrumentation for several days. Catheterization, when necessary, must be conducted with strict asepsis, and repeated as seldom as possible. Recurrence of complete retention from stricture or disease of the prostate should be made the excuse for early operation by perineal section before the patient becomes exhausted, unless there are

grave counter indications to any operative procedure. Long attempts at catheterization at such times not infrequently result in permanent damage to the deep urethra or in infection of the bladder, with more or less permanent invalidism. Prostatotomy and formation of a low level urethra at such a time is the operation of choice, and in my personal experience has given results that for permanence and satisfaction seem to equal those reported for the Bottini operation.

Bladder irrigation is a palliative measure deserving special consideration. The time for its employment, methods of use, solutions to be chosen and other practical points in connection therewith are deserving of extensive discussion. I therefore only mention it at this time in order that it may not seem to have been overlooked.

The subject I have chosen for presentation is one little discussed outside of text-books, and seldom fully treated there. The attention of the general practitioner, however, is liable to be suddenly called to this serious disease by a tragedy occurring in his practice. While it involves an organ the treatment of which has been specialized, the specialist is liable to be of little assistance when we meet it. The reason for

this is that it so frequently occurs as an emergency, and the object of this paper is to grope toward the possibility of an earlier apprehension of the threatened danger that we may be better prepared to meet the emergency. I wish to report a case and take it as the text for a few remarks.

B, a young man just a few days past his seventeenth birthday, called at my office on January 27th with follicular