cause, however, by which prostatic congestion is thus suddenly favoured, this is, in almost all instances, the essential nature of the obstruction. Hence may be inferred the first indication by which to direct our treatment, viz. to overcome or dissipate as much as possible internal congestion. The second is to allay pain, and quiet those involuntary but unavailing efforts to pass water, which the patient almost invariably suffers from to a distressing extent; and thirdly, and mainly, to give exit to the urine, and unless in very exceptional cases, by the natural passage of the urethra.

We shall fulfil the first indication in the most efficient manner, by employing the hot bath for the whole body. This may always be ordered with advantage, unless the presence of the surgeon is required at a very late period in the course of affairs. It sometimes is alone successful, and if so, ensures the desired end with the smallest amount of suffering or risk. If not, it at least places the parts in a better condition for the subsequent use of the catheter. The temperature should be high, from 100° to 104°. Patients who have resorted to it frequently require a much higher degree of heat than those who are not so accustomed; and the duration of the bath may be about fifteen or twenty minutes, the heat being rather increased than diminished during that time. Before the first-named period has elapsed, it is more than probable that a full effect will have been produced on the skin, that its vessels are filled, and a considerable derivation from the internal viscera must have been accomplished. Supposing, then, that the patient has not been able to relieve himself freely by this time, and is not unduly faint, an attempt may be made at once, while he is still in the bath, to introduce a catheter. If, on the other hand, he is becoming faint, and this is more likely than otherwise to happen in patients more or less advanced in years, as the subjects of these attacks always are, it will be

better to wrap him in warm blankets and move him at once to bed, before taking the next step to give effectual relief to the bladder. Meantime, however, if there be signs of much suffering, and it is almost certain that such will be the case, and particularly if involuntary paroxysms of straining to pass urine are present and uncontrollable; some sedative should be freely administered. Opium is one of the best; and no better form need be desired for the purpose, than the "liquor opii sedativus," of which thirty to fifty minims may be given, according to the judgment of the medical attendant.

With the third and last indication comes the question of the catheter; not a question as to the propriety of using it forthwith, or of delaying; for of the former course there can be no question, but that of the kind of instrument to be employed, and of the best manner of overcoming the varied difficulties which may present. Let me premise, then, that with the exercise of great care, and of ordinary skill and judgment, there should rarely, very rarely indeed, be failure in the attempt to reach the bladder and remove its contents, by introducing an instrument safely through the track of the urethral canal. There are certain circumstances under which this accomplishment would be impossible, but such are fortunately of very unfrequent occurrence. The surgeon should be provided with silver and gum elastic catheters of the ordinary prostatic length and curves. First,

EXPLANATION OF FIG. 15.

a Prostatic Catheter, No. 1, adapted for most ordinary cases.

Prostatic Catheter, No. 2, the curve and size usually sold by instrument makers as that of Sir B. Brodie.

c Prostatic Catheter, No. 3, the largest size, the curve commonly called "Liston's."

d A Prostatic Catheter strongly recommended by the late Mr. Guthrie. "This particular curvature I obtained after many trials with a flexible metallic instrument, and I believe it to be the best."-Anat. and Dis. of Urinary Organs. 3rd ed. p. 34.

e The Prostatic Catheter of Mercier-" sonde coudée."

f Another, recommended in some cases of difficulty-" sonde bicoudée.”

g An Elastic Gum Catheter, mounted on an over-curved iron stilet, for the purpose of ensuring a suitable curve in the instrument after the stilet is withdrawn.

respecting silver instruments, a prostate-catheter should not be less in size than No. 9 or 10; it should be from 12 to 14 inches long from the rings on the handle to the end of its beak or point; and the curved portion should comprise about a fourth to a third of a circle, which measures from 4 to 5 inches in diameter; the mean of these being, perhaps, the most generally useful size. Three good forms are shown at fig. 15, a, b, and c. The first is sufficient for most cases, the second and third are necessary only for those in which the organ is very considerably enlarged. Besides these there is another instrument, a useful one in some cases, if properly managed. It was first suggested by Mercier of Paris, and described by him in his work many years ago. I have employed it in exceptional cases for a considerable period, and with advantage (fig. 15, e). The total length of this instrument should be about twelve inches, of which the small beak, or upturned portion at the end, is only seven-eighths of an inch in length; this takes a direction which makes, with that of the handle or shaft, an angle not exceeding 100° or 110°—a matter of importance, as will hereafter appear.

With respect to gum elastic instruments, almost any of those made for ordinary purposes are sufficiently long for prostate-catheters. The size should be about that named for the silver instruments. It is advantageous, indeed it is more, it is almost necessary, in order to render them efficient, to keep a few of these in preparation; that is to say, the catheter should be maintained constantly, during a considerable period of time, on a strongly-curved stilet, describing almost two-thirds of a small circle, a curve, it is almost unnecessary to add, in which it would be impossible to employ it; but on removing the stilet from one which has been so treated for a few months, we possess an instrument which may be found in some circumstances to possess

qualifications of extreme utility (fig. 15, g). The value of this method arises, in great measure, from its ensuring that the beak, or last inch or two of the catheter, is sufficiently curved. However well curved the rest of the instrument may be, if the last inch be straight, it will, almost to a certainty, become engaged in the prostate, and will not pass over an enlarged median portion. This should never be forgotten in giving the intended curve to the iron stilet, which cannot be done with the fingers; the last inch can be well curved only with a pair of pliers. A gum catheter also may be used, either with or without a stilet; in one case being a flexible, in the other an inflexible instrument; so that it possesses sometimes an advantage over metallic instruments in its capability of being adapted in form to any curve which the peculiarity of the case may appear to demand.

It will, I think, answer no practical end to refer to the usage and recommendations of acknowledged authorities on the debatable point as to whether the flexible or the metallic instrument is to be preferred in catheterism for retention from enlarged prostate. We should, by doing so, but place in juxta-position the most opposite opinions and practice, and that from men of large experience and sound judgment. By some the silver catheter is exclusively used; others believe the elastic instrument infinitely superior. Now, although for cases of stricture of the urethra I advocate the use of inflexible instruments as the rule beyond all question, and one which admits of very few exceptions (a subject fully discussed in my work on that subject), I have as little hesitation in regarding the two varieties as possessed of almost equal utility in cases of prostatic disease. And there is nothing paradoxical in this. The object in stricture is to introduce an instrument of small size into a narrow opening, situated usually in the straight part of the canal, or, more accurately speaking, in that part of the canal which