chronic inflammation of the seminal vesicles, with or without true spermatorrhoea), up to organic changes in the spinal cord and brain. The PROGNOSIS in neurotic states varies with the cause. are easily controlled; others absolutely defy all and every treatment of which I have any knowledge.

Some cases

The TREATMENT involves a removal, if possible, of the cause. Local measures which have been found most effective in subduing the deep urethral irritation are-(1) the gentle passage of a soft bougie or conical steel sound into the bladder at intervals of one to seven days. The instrument should be removed at once. Sometimes it is necessary to cut a narrow meatus or a stricture in the pendulous urethra in order that a sound of large-enough size may be employed to put the sensitive deep urethra sufficiently on the stretch. (2) The application to the deep urethra and prostatic sinus of pastes of tannin or iodoform with the cupped sound or other apparatus, or the injection of the deep urethra with strong solutions of tannin or mild solutions (gr. i-x to 3j) of nitrate of silver. (3) In the most extreme cases, those furnishing all the symptoms of stone, even cystotomy is justifiable. It nearly always furnishes a temporary, sometimes permanent, relief.

Medical measures include all the bland diluent mineral waters, alkaline and tonic remedies, already considered in discussing Irritability of the Bladder.

Atony and Paralysis.

Atony of the bladder is more or less lack of expulsive force, due to failure in power of the muscles of the bladder, the nerves remaining sound. Paralysis is the same condition perhaps more pronounced, but due to central origin. A patient may be unable to pass water in more than a dribbling stream, but if he has true organic stricture or spasm of the deep urethra, the muscular coat of his bladder may perhaps not be to blame for his imperfect urination. The question of atony may be decided in such a case by introducing a catheter of any size that will pass. If there is atony, the stream flows sluggishly from the mouth of the catheter, and toward the end is influenced by the breathing of the patient. If there is no atony, the stream rushes through the catheter, and maintains its force until the last drop flows away. In paralysis and extreme atony the influence of the descent of the diaphragm during inspiration is noticed during the whole course of the flow of the sluggish stream through the catheter.

The CAUSES of atony are over-distension of the bladder, voluntary (by persistently neglecting the call to urinate), involuntary retention (from fever, coma, stricture, large prostate), and a certain intrinsic, sometimes inherited, tendency to weakness on the part of the bladder, noticed by some people during their entire lives.

Atony is most common, often a part of their malady, in old men with enlarged prostate. Paralysis of the bladder accompanies certain organic changes due to injury or disease in the spinal cord or brain. Both in atony and in paralysis the bladder may be constantly distended to a certain extent, perhaps to its utmost limit, as a passive sac, and the excess of urine over this uniform residuum may dribble away involuntarily

(false incontinence), or may be expelled in small portions by repeated acts of urination performed in the ordinary way or by the aid of great straining and assistance from the voluntary contractions of the muscular walls of the abdomen. No condition of incontinence of urine can be considered proved until demonstrated by the passage of a catheter. Both atony and paralysis may get well under proper treatment in favorable cases. Many cases are incurable, but the discomfort they tend to cause may be almost entirely counteracted.

TREATMENT.-Under all circumstances where the bladder cannot empty itself, the catheter should be used, and the bladder should be washed out, kept clean, and disinfected. All the suggestions laid down for catheterization and vesical injection in the section on Chronic Cystitis are applicable here and need not be repeated. It is particularly necessary to disinfect the catheter on each occasion before it is introduced. This is best effected by washing the catheter outside and inside with a 5 per cent. solution of carbolic acid in water, and finally washing it outside with clean water, before its introduction. If the bladder is over-distended, it should not, as a rule, be entirely emptied at the first introduction of the catheter, for fear of possible collapse, or, what is more to be dreaded, setting up acute cystitis by suddenly taking off all the internal pressure from the vessels in the walls of the weakened bladder, to which pressure the circulation has become accustomed. If, therefore, the bladder is emptied inadvertently, it is better to inject a few ounces of warm water containing borax in solution (a teaspoonful to the pint), and leave it in until the next catheterization. The quantity left in may be reduced at each sitting. By careful attention to these means most cases of over-distension due to atony or paralysis may be relieved without the intervention of cystitis, or with so little that it does not become a serious factor in the case.

The medical treatment of these cases is less important than the mechanical. Under the latter alone and improvement in general health curable cases often get well. Milk diet is of service, and iron and tonics of considerable value in proper cases. Electricity has not yielded satisfactory results in my hands, and I have not derived the advantage from ergot which is often claimed for it. In cases of atony I think I have seen good results sometimes follow the use of strychnine internally in pretty full doses. The same remedy under the skin acts more promptly and more effectively if it is to do any good at all. In true paralysis of central origin the cure of the bladder depends upon relief of the original disease and local treatment to the bladder.

Hysterical women sometimes feign paralysis in order apparently to secure the sympathy and personal attention of the physician. The application of the actual cautery above the pubes, and entrusting a female nurse with the function of catheterization, is generally effective treatment in these cases.

Hemorrhage from the Bladder.

After all sorts of wounds and injuries to the bladder, and in cases of rupture of the viscus, blood is found in the urine. In certain medical

conditions, in scurvy, hemorrhagic eruptive diseases, cases of vicarious menstruation, it has been noticed. In strangury due to cantharides, or in any condition of acute or chronic cystitis with considerable spasm of the bladder, the urine contains more or less blood. Especially is this true if ulceration exist at or near the neck of the bladder, as in tubercular or cancerous cystitis.

In cases of stone in the bladder one of the cardinal symptoms is vesical hæmaturia, while in villous growth often the only symptom of the malady is repeated attacks of more or less profuse bleeding from the bladder coming on unexpectedly, without obvious exciting cause, and showing no regularity in the length of the intervals between the hemorrhages or the intensity or duration of the latter. Outbursts of unexpected hemorrhage are not uncommon in connection with some cases of enlarged prostate and chronic cystitis, while these outbursts are the rule, sooner or later, in most cases of true cancer of the bladder.

The DIAGNOSIS is often very important-that is, in a given case to decide whether the blood comes from the bladder or from the kidney. This may usually be ascertained by a very simple manœuvre, especially when the flow of blood is not excessive: a silver catheter of short curve is introduced and the urine drawn off, the bladder gently washed several times without moving the catheter, and the shade of red in the wash noted. Now, the bladder being slightly distended with warm water, the point of the catheter is moved somewhat roughly in all directions and made to touch different portions of the wall of the bladder. The water is now allowed to escape, and its deepened color will decide that the hemorrhage has a vesical origin, for manipulations of a silver catheter in a healthy bladder will not occasion a flow of blood. In doubtful cases on two occasions I succeeded in locating the point whence the blood escaped as follows: In one I passed a soft catheter, and washed the bladder until the wash escaped nearly clean; I then withdrew the catheter until the point reached the membranous urethra (the bladder having been left full of clean water), and immediately passed the instrument again and withdrew the contents of the bladder, which were now brilliantly colored, thus locating the bleeding point in the prostatic sinus. In the other case, that of a young man with moderate stricture, whose urine was nearly solid with blood, I noticed that no blood escaped by the meatus between the acts of urination; therefore the bleeding point was posterior to the membranous urethra. Was it in the prostate, the bladder, or the kidney? To decide this I passed a soft catheter and washed the bladder until the wash flowed clear. I then injected some warm water, withdrew the catheter, and caused the patient to empty the bladder. The flow was brilliant with blood. In both these cases I effected a cure by one application of solid nitrate of silver through the urethra to the prostatic sinus.

The TREATMENT of vesical hæmaturia is the treatment of the cause, which, if possible, must be ascertained. For the symptom itself the internal use of iron, turpentine, opium, gallic and tannic acids, are of service. I have not derived any advantage from ergot. Locally, rest in bed, ice over the region of the bladder, and avoidance of straining at urination are generally all that is necessary. I have had good results from injecting the bladder with a solution of alum, gr. i-ij to 3j of warm

water, and cures have been effected by injecting nitrate of silver in solution. It is not well to inject iron in solution, since this substance makes a hard clot, and a soft clot is preferable. When the bladder fills up with a solid clot of blood, the best treatment, according to my experience, is to administer opium freely and diluent drinks. The urine slowly dissolves the clot, which has already arrested the hemorrhage, in most cases by its pressure, and the blood flows away as a dark coffee-ground material, sometimes nearly black. If the catheter is used, the clot broken up or dissolved with pepsin or other substance, and washed or pumped out, a new clot is apt to form at once; and although this treatment is based on high authority, and is often practised successfully, it is a question whether the patient would not in many cases do as well, or better, by being let alone, soothed by opium, until the urine dissolves the clot and nature relieves him.

New Growths in the Bladder.

These belong strictly to the province of surgery, but they fall also under the notice of the physician. Tubercular disease may involve the whole mucous surface or only the neck of the bladder; cancer may infiltrate its walls or grow out as a solid tumor in the vesical cavity; fibrous, sarcomatous, and myomatous new formations, polypi, and cysts, simple and hydatid, have been encountered; villous growths, both benign and cancerous, may occur. These morbid deposits give rise either to recurrent hemorrhage or to varying grades of chronic cystitis. The diagnosis is often difficult, the treatment generally palliative. Much has been done of late in an operative way for the relief of tumors of the bladder, and some brilliant results have been secured by operations through the perineum as well as above the pubes. A tumor of moderate size may be detected by the searcher within the bladder, and often may be grasped in a lithotrite and measured. Such a tumor can generally be plainly felt by conjoined palpation in a thin subject, one hand pressed firmly down behind the pubes and two fingers of the other hand passed into the rectum. Recently, Sir Henry Thompson has advocated vesical exploration for purposes of diagnosis through a median incision in the perineum, as for median lithotomy, and has practised it a number of times with a large measure of success. I have made the same exploration several times, and have encountered and successfully removed one tumor. The expedient is worth bearing in mind for use in any obscure cases. It is probably less objectionable and more likely to yield valuable information than the exploration by introducing the whole hand into the rectum (Simon's method).

SEMINAL INCONTINENCE.

BY SAMUEL W. GROSS, A. M., M. D.

DEFINITION. By the term seminal incontinence, which is synonymous with involuntary or abnormal seminal emissions, pollutions, and spermatorrhoea, is meant the involuntary discharge of semen beyond the limits. of health. Although usually described as a distinct disease, it is symptomatic of, and, as a rule, primarily dependent upon, weakness or exhaustion, along with exaggerated irritability, excitability, impressibility, or mobility of the centres which preside over erection and ejaculation. Hence it should be regarded as a motor neurosis, and not as a functional disorder of the testes.

CLASSIFICATION.-Involuntary seminal losses embrace three conditions, which constitute as many varieties of the affection, and which may exist separately, or pass into one another, or be combined. These varieties are, first, nocturnal losses or pollutions, which occur during sleep, and are generally attended with an erection, erotic dream, and pleasurable sensation; secondly, diurnal pollutions, which take place when the patient is awake, are excited by trivial mechanical or psychical causes, and are associated with imperfect erection and diminished sensation; and, thirdly, spermorrhagia, or spermatorrhoea, in the strict acceptation of that term, which is characterized by a constant escape of a slight amount of seminal fluid, without the orgasm, pleasurable sensation, or impure thoughts, or during micturition and defecation.

1. Nocturnal Pollutions.-By far the most common of the varieties of seminal incontinence is the first, or that in which the emissions occur during sleep under the influence of an erotic dream, and which may, therefore, be regarded as an exaggeration of the normal or physiological endition. In health, provided the subject leads a continent life, the number of emissions varies greatly, and as they are merely reflex signs of distension of the seminal passages, they are not pathological nor are they attended with ill effects. The knowledge of this fact is of great practical importance, as it frequently enables the physician to assure his patient that the emissions are not abnormal, thereby relieving his mind of a great weight. It is, of course, to be remembered that the frequency of nocturnal pollutions depends upon age, climate, habits, temperament, Constitution, diet, and predisposition, and that young men who suffered during childhood from nocturnal incontinence of urine are particularly obnoxious to them. Their frequency also varies greatly in the same person, and it is scarcely possible to determine what constitutes the standard