rubber were to give way and collapse, and the water escape from undue dilatation, no pain or harm of any kind would result. At the first sitting the third or the half of a syringe is as much as will probably be borne, and it should be a rule not to cause pain, or, at all events, more than a slight and very tolerable amount of uneasiness, which, by the way, I have rarely found produced even by considerable dilatation. Following this rule it is impossible to do mischief. Supposing it is desired, as it probably often will be, that the dilatation should be applied a little further back, that is, to the posterior half of the prostatic urethra, and to the neck of the bladder at the same time, we have only to push the instrument about half an inch further in than the point marked by the thread, and to dilate forthwith. The stopcock at the end of the catheter should immediately be turned to prevent any reflux or escape, when we cease to make pressure on the piston-rod. The instrument can then remain in situ for a few minutes. Before removing it the stopcock must be turned, so that the water escapes from the distended portion.

I have stated that it is necessary to draw off the urine from the bladder before employing the dilator. The object, as has been explained, is simply to determine the length of the urethra. It sometimes happens that the dilatation is best effected when some urine is left in the bladder, indeed generally it seems to answer better when this is not quite empty. Consequently, we may either attain our purpose without removing the whole vesical contents, or, if we have done so, we may throw in a syringe-full of water through the catheter before withdrawing it. It is scarcely necessary to add that this, as well as that used for injecting the dilating instrument, should have a temperature of about 99° or 100°. Regarding the length of time during which dilatation should be maintained, the operator must be guided by the

feelings of his patient. At first from one or two to five minutes is sufficient. As he proceeds this term may be extended until it reaches fifteen or even twenty minutes. Longer than this I have not employed, nor would advise it. Indeed I am not aware that anything is gained by extending the period beyond five minutes. The frequency of the application must also be determined in the same manner. I have never, in any of these cases, encountered difficulty by proceeding cautiously at first, and can only advise that a similar principle of action be always maintained. Every third or alternate day, at first, afterwards every day, but not more frequently than that, it may be used. After its first application the patient may be placed in a hot hip bath for a few minutes as a precautionary measure; one, however, that will probably not require to be repeated. After three or four applications the patient will probably observe a notable improvement in the stream of water, and if he has been habitually retaining it, will very likely find the residual urine diminishing.

The india-rubber tube described may be supplied to fit any catheter, and be employed without any difficulty, provided that the instrument is of the requisite length, and is properly fitted to a syringe.

Division of the obstructing portion at the neck of the bladder has been performed. Other operations have been also attempted for effecting a similar purpose, such as the excision or the crushing of a protruding portion; and even the ligaturing of a polypoid outgrowth. Respecting the division of an obstruction, bar-like in its form, elevated from the posterior border of the neck of the bladder, it is no doubt a proceeding to be accomplished without much difficulty, with the exercise of ordinary care. In most cases, although not invariably, the bar is a prostatic development, and when well marked may perhaps in some cases be incised

with advantage, and without danger to the parient. Such was the opinion of the late Mr. Guthrie. As, however, he introduced the consideration of this subject to the profession In connection with his views of another affection occasionally met with, altogether distinct from enlarged prostate, and to which he gave the name of "bar at the neck of the bladder," I shall defer any farther remarks respecting the operative proceedings which must be the same, or nearly so, whatever ne the constitution of the obstruction in question to the twelfth chapter, which is devoted to an examination of that subject. In that place the various cutting operations which have been applied to the prostate will be considered at length. A very few words will suffice for the notice of crushing and the ligature. Some of our French brethren have performed on the living body these procedures, the first named not unfrequently. A portion, supposed to be the protruding one, is seized between the blades of a lithotomy forceps, or an instrument very similar, and is torn away, if possible, or crushed, so as to ensure a state of sphacelus in the part attacked. Jacobson's lithotrite has been also used, and is preferred for the purpose. M. Leroy has also described an ingeniously-contrived apparatus for applying a ligature to the base of a polypoid tumor, springing from the posterior median portion of the prostate. It is engraved in a late work, where he states also that he has used it with success.† No details of the operation are given, although, it must be confessed, they would have been exceedingly interesting, both in respect to the difficulties overcome, and the subsequent effect of leaving a putrid slough in the bladder, as a result of the process. Very recently, the same surgeon has

• The mode in which M. Leroy adapts the instrument of Jacobson to the purpose is explained and illustrated by a drawing in the Gaz. des Hopitaux, January 27, 1849.

↑ Thérapeutique des Rétrécissements, des Engorgements de la Prostate, &c. Paris, 1849. pp. 75 and 77.

designed an ecraseur, contained in a canula of the form of a catheter, for the purpose of removing these outgrowths.

In estimating these proposals, I think most English surgeons will be content with awaiting further experiences in the hands of those who have hitherto seen fit to adopt them. For my own part, I have no expectation that any benefit will be conferred on the patient by such methods of accomplishing the ends proposed, even granting that no doubt existed as to the possibility of carrying them into execution. Mention is made of them here, solely because there exists no good reason for ignoring the practice which is followed. by well-known surgeons in the great continental capital. Let it, however, by no means be supposed that such mention implies approval.

Bull. de la Soc. Anat. Paris, 1856. p. 420.

CHAPTER VIII.

THE TREATMENT OF RETENTION OF URINE FROM ENLARGED

PROSTATE.

Urinary Retention from Enlarged Prostate, generally due to Congestion of the Organ; first indication, to relieve Congestion-Baths; second, to allay Pain and Spasm-Opium; third, instrumental relief-Catheters, various.-Comparative Advantages of.-Modes of passing solid, flexible, &c.—Mercier's Instrument; Mode of passing.-Should the Bladder be emptied at once?— Should the Catheter be retained?-Catheterism unsuccessful, what Means are to be employed?-Perforation of Prostate.-Puncture of Bladder above Pubes; by Rectum; through Symphisis Pubis.-Comparative Merits of.— Case.-Perforator.-Perineal Operation.-Conclusions.

IT has been already premised that the term complete retention of urine, here used, does not include or designate that chronic retention of urine so frequently present as a result of enlarged prostate, and so familiarly known; but is intended to apply alone to that urgent condition in which, from this cause, the patient is unable to pass any urine at all, or, at all events, only in quantity so small, as not to equal the amount of excretion naturally produced; a condition in which he is therefore in a state of hourly-increasing difficulty and danger, and from which it is not merely expedient, but necessary, in order to save his life, that he should be relieved.

Some external circumstances generally give rise to that exacerbation of the habitual symptoms which constitutes the state in question. In by far the greater number of cases, exposure of the surface of the body to cold or wet, or to both combined, is the agent, which, augmenting the distribution of blood to internal organs, produces congestion in the already-enlarged prostate, and an engorgement of its vessels, which temporarily increasing its volume, occludes the already narrowed urethro-vesical orifice. Whatever the