at once examined the penis, hoping to find a case of phimosis, and sure enough I did; I had the family physician called as soon as possible, and before leaving the house that night I introduced a small grooved director into the prepuce and laid it open with a bistoury. This exposed the glans penis inclosed in a sheath of mucous membrane; the latter adhered to the glans so tightly that I had to use a sharp instrument to get under it, and even after I got a place started I could hardly separate the two; I persevered, and finally exposed behind the corona glandis a roll of sebaceous matter of a cheesy consistence, and about the size of a cotton shoe string, extending almost around the penis. I removed this, and, after making a free incision of the mucous membrane, I washed away the remaining debris and applied water dressing, and in a few minutes left the child almost asleep, not near so nervous, and seemingly in a condition of well feeling. I used no internal remedies, and now, three days later, the child has made marked improvement and bids fair to make a rapid and complete recovery. The gland, while in the grasp of the mucous membrane, was about one-third its natural size, and I think the contracted scar tissue. the result of inflammation, was the cause of the whole trouble. If you desire it, I will report the progress of the case.

Very truly yours,

T. F. LEECH, M.D.

My Dear Doctor: Of a number of cases of reflex paralysis upon which I have performed circumcision, I desire to send you the account of one demonstrating remarkably the rapid curative effect of the operation. Some time in April last, a boy fourteen years of age was brought to me, supposed by his friends to be suffering from chorea. There was intense hyperesthesia of the skin over the whole body, very marked want of co-ordination of motion in the arms and hands, and great difficulty in walking. The youth. was so uncertain in his gait and had fallen so frequently that he was afraid to attempt to act alone. He had been suffering in this way for three years, becoming gradually worse, and was mentally below the average of boys of his age. Having taken medicine in large quantities and sugar of milk adulterated infinitesimally, for a long while, his attendants were surprised, after I examined his penis, with my opinion that circumcision would cure him.

The operation was performed that afternoon; the next morning

the boy was relieved of his hyperæsthesia, and in forty-eight hours had recovered entirely the use of his limbs. He is now at school, which he had not been able to attend in three years, and was so altered in appearance, when I met him on the street last week, that I scarcely knew him. I have the notes of a number of other cases, less striking in their features and rapidity of cure, but all demonstrating the correctness of the views you hold of the pathology of the disease.

Very truly yours,

JAS. S. GREEN, M.D.,
Elizabeth, N. J.

To LEWIS A. SAYRE, M.D.,

285 5th Ave., New York.

EXSTROPHY OF THE BLADDER.

BY C. B. KING, M.D.,

OF PENNSYLVANIA.

WM. J. KILPATRICK, aged 13, was admitted to the Western Pennsylvania Hospital, at Pittsburgh, April 10, 1874, for congenital deficiency of anterior wall of abdomen and bladder.

The posterior wall of the bladder projects forward, and forms a tumor about the size of a goose's egg, oval in shape, measuring 2† inches across from side to side, and 24 inches from above downwards. In the erect position the tumor protrudes 1 inches, and measures around the oval from side to side 4 inches. No hernia. Pubes wanting 2 inches. Penis epispadic, about the size of an almond, and covered with an imperfect prepuce. Scrotum quite small, and contains two well-developed testicles.

For some time previous to the operation, the patient was put upon tonics and nourishing diet with gentle out-door exercise.

May 3. He took an ounce of castor oil which operated freely. The following morning the lower bowel was washed out by enema, and the patient being put under the influence of ether, a horseshoeshaped incision was made; beginning about one and a half inches to the left, and a little above the penis. This incision was carried down close to the left thigh, then across the perineum to the opposite thigh just in front of the anus, and then upward to a corresponding point on the right side. The flap was dissected up, laying bare the testicles. An oval incision was made in the flap to allow the penis to drop through. Another incision, beginning about three-quarters of an inch above the starting-point of the first incision, was made through the skin of the abdomen and extending around and about one-half inch above the upper edge of the bladder to a corresponding point on the opposite side. The skin was dissected up about three-quarters of an inch. The first flap was then turned up over the bladder, and its edges placed beneath

the last flap, and held in position by eight silver wire sutures secured by perforated shot.

As the walls of the abdomen were found to be very thin, the sutures were only passed through the two flaps, and thus differed from Prof. Pancoast's "tongue and groove suture," in having but two raw surfaces together instead of four. The urine flowed freely over the raw surface under the upper flap, but I did not fear urinary infiltration, as the opening made in the lower flap for the penis was large enough to allow free escape for the urine.

The skin remaining between the ends of the first and last incisions was now pared, and the raw surfaces united by two interrupted wire sutures on each side. The testicles being exposed, I attempted to close the large wound in the perineum by drawing the edges of the skin together, but the testicles still remained uncovered. The raw surfaces were dressed with lint spread in carbolized cerate. The knees were crossed and bandaged together, and the thighs flexed upon the abdomen, by placing him in a half sitting position in bed with a pillow under his knees to relieve the flaps of tension. As soon as he recovered from the effects of the anaesthetic, he was given an eighth of a grain of morphia, which was repeated at three and six P. M.

At 7 P. M. (six hours after the operation), pulse, 112; temp. 101° F.; suffers but little pain.

5th. 8 A. M., pulse, 122; temp. 101°. Slept well during the night. Feels comfortable. 8 P. M. An erythematous blush has made its appearance, extending toward the left groin. Is very sensitive to the touch, and has the appearance of urinary infiltration. Pulse, 128; temp. 102°.

6th. 8 A. M., rested well all night; blush not extending. Pulse, 132; temp. 101°.

7th. 8 A. M., blush has disappeared. Rested well during night. Takes nourishment well. Pulse, 130; temp. 1010.

8th. 8 A. M., pulse, 130; temp. 1003°. Dressings removed, and union found to be complete throughout. The bladder is very much protruded from accumulation of gas in the bowels. He was given f3vj ol. ricini, followed by enema, which acted well, and relieved distension.

9th. 8 A. M., pulse, 124; temp. 10030. Rests well, and feels. hungry. All the stitches but three were removed. The swelling, being much greater than was expected, caused three of the stitches to cut through, allowing the urine to escape through the openings.