end of the catheter should be kept strictly in this median line; any deviation of the instrument when held with its point in the direction of the bladder indicates a departure from the proper line of the urethra. A similar twist of the point of the instrument out of its course is shown by a want of level in the rings on each side of the open end of a silver catheter. During introduction it is better to stand on the left side of the patient. The penis should be held between the finger and thumb of the left hand and the meatus opened by pressure above and below it. If a bougie or straight catheter be used, a firm yet gentle traction upon the penis should be made, so as to bring the front and more movable curve of the urethra in a straight line.

In using the silver catheter while the patient is standing up, a dexterous manipulator will often employ the "tour de maître," which is thus performed. The instrument is held with its concavity directed down and backward, and the penis is left to hang in its normal curve. The end of the catheter being placed in the meatus, it is then made to slide gently along the lower wall of the curve until the point reaches the front layer of the triangular ligament at the sinus of the bulb. A half turn round to the patient's left groin is then given to the end of the instrument, with a sweeping and at the same time onward motion. This brings the point of the instrument into the upward curve of the vesical end of the urethra, pressing gently against the upper wall, and places it in the position for entering the bladder at right angles to the level of the perineum. The shaft being kept strictly in the median line, its own weight will then be sufficient to urge the end into the cavity of the bladder. The advantage of the "tour de maître," when cleverly performed, is a greater ease of the passage and much less pain to the patient.

In the healthy urethra there are several points which might form a difficulty by obstructing the point of the catheter or bougie. Normally, the narrowest parts of the urethra, and pathologically, the most common strictures, are at the external orifice, and at the anterior layer of the triangular ligament— where the inner or upper curve of the ƒ meets the outer or lower

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bend; any instrument which passes these easily should pass through the whole canal. Below the size of No. 4, the point may become entangled in the "lacuna magna," a "cul de sac,' or follicle which is placed in the upper wall of the urethra about 11⁄2 inches from the meatus. Next it may be arrested in the sinus of the bulb by pressing against the triangular ligament below and behind the orifice of the membranous portion. It is here that the major part of false passages are made, by urging the catheter too much backward toward the rectum instead of upward into the bladder. Next the point of a small catheter may be entangled in the "sinus pocularis" of the "veru montanum" or in one of the prostatic sinuses on each side. All these are to be avoided by keeping the point of the catheter against the upper or front wall of the urethra in the median line. But even this direction must not be carried to excess. In cases of difficulty from stricture in the membranous portion of the urethra, a false passage is sometimes made through the upper or anterior wall, bringing the point of the catheter either between or behind the layers of the triangular ligament, and in front of or into the anterior part of the prostate. When false passages have been made there is great danger of urinary infiltration into the pelvic fascia, and of subsequent peritonitis, which is frequently fatal.

It cannot be too strongly impressed upon the mind of the operator that forcible catheterism is, under almost any circumstances of difficulty, a very dangerous proceeding. A great many cases of death resulting from the shock following careless and violent operations have happened, both in healthy and debilitated constitutions. It is much better to try again and again, with patience and gentleness, than to endanger the patient's life by injuring the passage.

If retention of urine be pressing and the bladder much distended, the comparatively safe operation of tapping the bladder from the rectum should be performed in case of failing to pass the catheter. Afterwards, when the congestion and spasm of the urethra have subsided and the abnormal traction upon the urethra by a distended bladder has been removed, persevering

efforts to pass a catheter, and subsequent slow dilatation, can in a great majority of cases be safely accomplished.

On Washing out the Bladder.-There are many conditions in which great benefit results from washing out the bladder. Sometimes pure water is required, but sometimes a very dilute solution of an acid or alkali is preferable, according to the character of the deposit or the condition of the mucous membrane. Weak solutions of antiseptics (1 of carbolic acid to 500 of water, or 10 drops of Condy's fluid to a pint of water, or a I per cent. solution of tincture of perchloride of iron) are often useful. In some cases the bladder does not empty itself, and the urine which always remains behind in small quantity may become decomposed, and set up decomposition in the fresh urine as it flows from the ureters and mixes with the fluid in the bladder. This state of things, which may have continued for many months and already occasioned damage to the mucous membrane, may sometimes be permanently altered by washing out the bladder occasionally with pure tepid water, introducing small quantities (an ounce or two) at a time, through a catheter, and then drawing off the contaminated water and throwing up another ounce or two of fresh, and so on until the water returns clear and free from smell. This washing out of the bladder and the surface of the mucous membrane is sometimes required to be performed very frequently if the mucous membrane is to be kept in a fairly healthy state. Many patients easily learn to perform the operation for themselves, and become adepts in passing the flexible catheter. To wash out the bladder, the nozzle of a small India-rubber ball syringe, holding not more than two ounces, is made to fit into the opening. After being filled with tepid water the ball is gently compressed with the hand, and the water slowly injected. After waiting a few minutes the water may be allowed to pass off in the usual way through the catheter after removing the ball syringe, or the contaminated water may be drawn into the syringe and removed; and the operation can be repeated if the quantity of decomposing urine be considerable. The patient, if skillful, may wash out his bladder twice or three times daily without risk.

In order to facilitate this operation, many ingenious contrivances have been introduced. The catheter has been divided, so that a continuous stream of water in and out could be obtained, but it is doubtful whether in ordinary cases any advantage is gained by this method, and in inexperienced hands harm might result.

In February, 1884, Dr. Wm. Job Collins described a two-way tap, which could be introduced easily enough by the least experienced into the catheter, the tube of an ordinary Higginson's enema syringe being connected with the flow tube, the tap of the outflow is closed while the water is being injected. When two ounces or less had been introduced, the latter was turned on and the water and urine allowed to flow out. A great improvement upon this nozzle was suggested by Mr. Buckston Browne, in which taps are quite done away with. This much simplified apparatus leaves little to be desired, and it can be carried into use by any one without the slightest difficulty, and without disturbing the catheter in the least degree. The new tube is fully described by Mr. Buckston Browne in the "Lancet" of October 18th, 1884. It is made by Messrs. Weiss & Son, Strand.

Patients who perform the operation for themselves should in all cases be carefully taught by the practitioner in the first instance, and the great importance of care and gentleness, and of introducing only a small quantity of water at a time and at the proper temperature, should be fully explained to them.

Lithotomy. This part of the subject I am not competent to discuss, but there are one or two recent modifications to which I may be very briefly permitted to advert. The operation of lithotomy which is performed by most surgeons in the present day is the lateral one. For a discussion of the various important points connected with this operation, I may refer to Bryant's "Practice of Surgery," and Erichsen's, and other treatises on surgery.

Some time since, the median operation was performed with considerable success by Mr. Allarton. Its principal advantage seems to be, that the levator ani and prostatic capsule and plexus escape injury, while the course into the bladder is most direct.

There is also the advantage that the knife is not used either to notch the prostate or to open the bladder. On the other hand, there seems to be considerable chance of injuring the ejaculatory ducts, and a surgical friend tells me that there is a want of space in manipulating with the forceps, and in seizing and extracting the stone, and that there is also some risk, especially in children, of injuring the bulb of the urethra or the rectum. The operation is described in the "Lancet," 1859, Vol. I, p. 122. (See also Mr. Allarton's work on "Lithotomy Simplified." London: Ash & Flint. 1854.)

In connection with the subject of lithotomy, I may remark that, by an improvement in the manner of carrying out the operation adopted by Mr. Wood, the injurious effects which sometimes result from a free division of the prostate, pelvic fascia and levator ani with the knife are altogether avoided. Mr. Wood employs a staff composed of two blades, which can be separated from each other while the instrument is held in position. Dilatation of the urethra is readily effected by allowing the finger to slide in between the blades. In the single case in which this operation has been performed in the living subject, it certainly succeeded admirably. ("Medical Times and Gazette," December 22d, 1860.) The principal advantages of this over the ordinary lateral and median operations respectively are that, as the knife does not enter the bladder at all, neither the prostatic veins nor the fascial capsule are injured, nor can the ejaculatory ducts be cut. .The levator ani cannot be divided, and all chance of the extravasation of urine into the pelvic areolar tissue is avoided. The form of the external incision is such that more room is given than in the ordinary operation, while injury to all important vessels and other structures is avoided. By this proceeding the dilatation necessary for the extraction of the stone is much more easily effected than in the median operation.

In some cases a stone becomes encysted or impacted in some part of the bladder. This may occur in two ways. First, by the previous formation of sacculi of the mucous membrane, protruding between the separated meshes of the dilated muscular

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