to a third of a circle, which measures from 4 to 5 inches in diameter; the former of these being, perhaps, the most generally useful size. Three good forms are shown at fig. 16, 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 success (fig. 16, 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 prostatecatheters. 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 stronglycurved 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. 16, 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

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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 juxtaposition 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. Once preferring the former, I now, with a larger experience, have no hesitation in making choice of the latter, that is, the gum-elastic catheter. It must, however, be one which has been treated in the manner described, and it is to be used without the stilet. The ordinary English gum catheter possesses this great advantage also, viz., that the surgeon can give it any curve or form he pleases while immersing it in warm water, which curve is rendered nearly permanent, or at all events sufficiently so to be available for immediate use, by plunging it into cold water. It is by far the easier instrument, so far as the feelings of the patient are concerned, and it is also the safest to employ, provided that in using it the operator is careful so to pass it, that the curve is maintained, and exists unspoiled, when the point of the instrument reaches the posterior part of the urethra. This requires a little dexterity on his part, but this is easily acquired by proper practice. Supposing the patient to be in the standing position, the well-curved gum catheter, previously oiled, and warmed, is introduced with the penis directed rather downwards, but drawn over the curve of the instrument, the shaft of which is kept close to the patient's abdomen, or, if he is very stout, is pressed backwards into his left groin. Nearly two-thirds of the catheter

should be passed with the shaft in the direction described, so that the point passes well under the pubic arch, when if the shaft is brought downwards towards the operator, in the middle line, and gently pressed inwards at the same time, the point will rise over any obstructing prostatic eminence into the cavity of the bladder. If the patient be recumbent, the same principle of keeping the shaft close to the body must be adopted. If it fails, and the catheter is withdrawn, the curve and proper stiffness must be restored by the hand, and by plunging it into cold water before reapplying it to the patient.

FIG. 17.

If this catheter fails, the French bulbous-ended catheter (see fig 17) may be successful. This instrument, which is generally straight, although sometimes made with a curve, owes its utility to its extreme flexibility, having no curve or force of its own. It follows the sinuosity of the urethra, and so frequently finds a way which the stiffer instrument has failed to discover. The delicate soft end, surmounted by a bulbous swelling, which prevents its becoming engaged in a lacuna or other such obstacle in the urethra, insinuates itself, and the larger body of the instru ment follows. In employing it the penis should be held out horizontally, the patient standing, and the catheter pressed in the same direction from first to

last.

Of course this instrument has no stilet; it is never employed with one. Indeed, as Indeed, as a rule, all flexible instruments are intended to be used without any wire in the interior, since of course it destroys the very quality which is the source of their value. Nevertheless, there are some exceptions to this rule, and the stilet has sometimes a real value.

The use of the stilet is twofold. First, if the silver instruments are insufficiently curved, we possess the means of employing an inflexible instrument, although constructed of gum, of any curve

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we desire, by first communicating it to the stilet, which ought to be stouter and stronger than a mere wire. Secondly, it enables us to put in practice a manœuvre of considerable utility, well known as having been originated by the late William Hey, of Leeds. Many have derived an advantage from adopting it in circumstances of difficulty. It may be thus described; the catheter, mounted on its stilet, having been introduced as far as to the obstacle, the stilet is then withdrawn about an inch, which has the effect of increasing the curve and elevating the point of the catheter, so as often to carry it over the enlarged portion in a manner less easily accomplished in any other way.* The stilet should be so large that it cannot issue from the eye of the catheter in any backward or forward movement which may be communicated to it.

After all it may be necessary to resort to the silver catheter. I never do so now until after failing to pass with tolerable ease either of the two kinds just described. As it is desirable to follow a uniform manner in introducing it, and to adopt one of the best, I may describe in detail the various steps which should be followed in the endeavour to acquire facility in the practice. The surgeon, standing at the left side of his patient's bed, who should lie on his back in an easy position, takes the catheter lightly between the thumb and fore and middle finger of his right hand, which occupies the supine position, the former (the thumb) being, therefore, applied to the upper surface of the handle, close to the rings; the two latter supporting it below, and in a horizontal direction. The penis may be either held indifferently between the thumb and fingers of the left hand, or uniformly according to the following method, which is not without a certain convenience. The left hand is in this case applied, the palm being upwards, so that the middle and ring fingers hold the penis just behind the corona glandis; the index finger and thumb are then at liberty to be applied for the purpose of retracting the pre

* Pract. Obs. in Surgery. By Wm, Hey, F.R.S. Lond., 1814, 3rd ed. pp. 399, 400.