enlargement does not exist, and we must seek for another cause of the symptoms complained of. But if the catheter has passed easily, say for nine or ten inches, which is at once known if the instrument is graduated (as all such ought to be) and still no urine flows; and if, in addition, while following its course, the handle has become more than usually depressed, approaching almost to the horizontal line (the patient being recumbent), there will be little doubt in respect of the existence of prostatic enlargement. The ordinary catheter being inadequate to reach the bladder, or doing so only when it has passed further than usual, and in the position described, another instrument may be employed. This is generally one which measures from two to four inches longer, and possesses a larger curve than the ordinary catheter; while some instruments describe also a larger arc, a third, for example, instead of a fourth, of the circle. If such pass readily, the increased length of the urethra is easily ascertained, and the direction of the prostatic canal is calculated from the position of the shaft noted at the moment that the point enters the bladder. A medium prostate

catheter (see fig. 15, p. 169) has its beak at right angles to the shaft, the recollection of which makes the direction and even the exact position of the beak obvious at once to the mind's eye, the axis of the shaft being, as it always is, in view. When the curve of the instrument is prolonged beyond this, the degree of incurvation being known may be allowed for, and its position is then ascertained without difficulty. In some few cases, while the beak passes through the prostatic part of the urethra, the handle will be distinctly deflected to the right or left, from which fact, if verified by two or three trials, a greater degree of enlarge ment may be suspected to exist on the side towards which the handle turns.

In this manner, we may obtain approximatively correct

H

views of the size and mode of development of the prostatic enlargement. The progress of the complaint may be noted. from time to time, but I am not aware that any very considerable advantages can be obtained by the possession of more exact knowledge respecting the tumor, attainable, perhaps, at the expense of reiterated and more painful applications of the instrument than those at present alluded to; unless, indeed, there is any ground for advocating the adoption of some operative proceedings, such as the division of an obstructing bar or the like: a subject which is discussed at length in the twelfth chapter. In view of any such undertaking, it is necessary to make an accurate diagnosis of the nature and size of the tumor; and this it is, within certain limits, in our power to accomplish, if ordinary care and the proper method be employed. But although we may not entertain any such intention, it is not the less desirable to be able to familiarize ourselves with the manner of accurately determining the condition of the prostate, of the bladder and its contents, especially in relation to the question of calculus or tumor, and for such a purpose the instruments with a large curve, already described, are wholly useless. Hence it is necessary to resort to one of different form, and that now usually adopted in sounding the bladder, is well adapted for the purpose; viz. a sound with a very short curve at its extremity, or possessing a beak rather than a curve, which is much shorter and more angular than that of the ordinary catheter. Instruments somewhat resembling this description have long been employed, but their use for sounding the bladder, and more especially for examining the condition of the prostate, has, during the last thirty years, been more particularly advocated by those among the French surgeons, who have bestowed special attention on maladies of the urinary organs, as Civiale, Leroy D'Etiolles, and Aug. Mercier. The two latter have represented the

FIG. 11. FIG. 12.

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forms which they employ; see the adjoining figures (figs. 11 and 12). It will be seen that they differ but little from the sound which is now generally used, and scarcely, if at all, from the form of the common lithotrite. The short beak is of course for the purpose of being carried into the bladder, in which cavity it can with care be turned freely in any direction, provided a sufficient quantity of urine or other fluid is retained. In this manner not only can every part of the bladder be searched for calculus, but information respecting the form and degree of obstruction at its neck can also be acquired. After the bladder has thus been

traversed, the instrument should be gently withdrawn until the beak lies just within the urethro-vesical orifice,

FIG. 13.

when by turning it round to the right and left, the natural condition, if it exist, of that part can be ascertained; or, on the other hand, the presence of tumor, or of stone, the

depth of the fossa behind the prostate (fig. 13), and other relative points, can be determined. Without giving my complete adhesion to a practice which requires the performance of the extremely numerous and varied manœuvres for the purpose of arriving at a diagnosis respecting the precise terms of a prostatic enlargement, which our French brethren habitually resort to, it may not be altogether unprofitable briefly to notice the methods by which the attainment of exact information respecting it is sought. I say sought, for I have good reason for believing that such manoeuvres have sometimes failed of their object, even in the hands of the most expert disciples of the practice. And again, since I am compelled for the most part to express an objection to the practical end which these manœuvres have confessedly in view as employed in France, that is, the destruction by mechanical or chemical means of the obstructing portions of tissue, there is additional ground. for doubting whether the employment of many of them can conduce to any beneficial result. Nevertheless, as some very useful hints may be derived from an observation of the manipulations referred to, I shall describe only one or two of the simpler means in use, for diagnosticating tumors of the neck of the bladder, premising that the instrument employed is always one similar to either of the two delineated at figs. 11 and 12. For the more complicated proceedings of this kind, the reader is referred to the practice and writings of the authors themselves.

1st. Means of recognizing tumors which rise into the neck of the bladder.

The sound having been introduced, it is slowly and gently, but completely, rotated on its axis in the cavity of the bladder, and close to its neck. If the prostate is healthy, this is done without any elevation of the instrument, and the shaft retains an almost horizontal position (the patient of

course being recumbent). But supposing that there is a tumor at the neck of the bladder, the beak will be arrested. in the movement of rotation, and it will be necessary to elevate it proportionately to the height of the eminence, after which it will descend again, the movement of the handle indicating approximatively the size and form of it. If, in introducing the instrument through the prostatic part, the beak is found to rise gradually, the handle being depressed below the horizontal line, there is probably spheroidal enlargement of the middle portion. If, on the contrary, the beak abuts upon an obstacle there, and has to be lifted over it in a direction upwards, entering the bladder with somewhat of a jerk, there is probably an enlargement of the same portion, but affecting the form of a bar, with a deep sinus of the prostatic part of the urethra. In withdrawing the instrument from the bladder, the beak being turned downwards to the basfond, if the prostate is healthy, it will come back into the urethra easily, but if there is an enlargement there, it will hook against it, and not leave the bladder in that position.

2nd. In order to recognize an enlargement of the prostate projecting into the urethra, Mercier proceeds as follows: "After having explored the bladder, I draw the instrument gently back into the prostatic region of the urethra, pressing lightly upon it, at the root of the penis" (its upper aspect), just under the pubic symphisis, so as to press the angle of the sound or salient part of its curve against the posterior wall of the prostatic urethra; then I draw it forward without elevating its shaft towards the abdomen as in ordinary catheterism, and without making it deviate much from the axis of the patient's body (15° to 25°). When there is a simple enlargement of the prostate in the antero-posterior diameter, the beak traverses it easily, without inclining either to the right or left. If, on the con