gently, curved, is found to be more easily introduced, than when it is very much bent. The female catheter is straight, excepting a slight curvature towards its point, and it is about six inches in length. The ordinary flexible catheter is nothing more, than a hollow bougie; and the elastic one, which was invented by M. Bernard, contains in its composition elastic gum. The two last descriptions of catheters have the advantage of being less irritating to the urethra, and less apt to become covered with calculus incrustations, than silver tubes. They can also be introduced, in cases of obstructions in the urethra, when an inflexible silver catheter cannot be passed. Sometimes, the instrument is difficult of introduction, owing to a spasmodic affection of the urethra, and neck of the bladder. In this case, a dose of opium should be administered, before a second attempt is made. When inflammation is present, the introduction may often be facilitated by a previous bleeding. The operation of introducing the catheter may be performed, when the patient is either standing up, sitting, or lying down; but that posture, in which the patient reclines back on a couch or bed, is reckoned the most advantageous. In performing it, one of the most important maxims is never to force forward the instrument, when it is stopped by any obstacle. If there are no strictures, the stoppage of the catheter is always owing to one of the following circumstances. Its beak may be pushed against the os pubis. This chiefly occurs, when the handle of the instrument is prematurely depressed. Here the employment of force can obviously do no good, and may be the cause of serious mischief. The beak of the catheter may take a wrong direction, and push against the side of the urethra, especially at its membranous part, which it may dilate into a kind of pouch. In this circumstance, if force were exerted, it would certainly lacerate the urethra, and occasion a false passage. The end of the catheter may be entangled in a fold of the lining of the urethra; and here force would be equally wrong. Lastly, the point of the instrument may be stopped by the prostate gland, in which event force can be of no service, and may be productive of great harm. Hence, it is always proper to withdraw the instrument a little, and to push it gently onward in a different position. As Richter states,* the operation may be divided into three stages in the first, the catheter passes, in the male subject, * Richter's Anfansgr. der Wundarzneykunst, band 6, p. 232, 233, edit, 1802. that portion of the urethra, which is surrounded by the corpus spongiosum; in the second, it passes the membranous part the canal, situated between the bulb, and the prostate gland; in the third, it enters this gland, and the neck of the bladder. In the first stage, little trouble is usually experienced; for, the canal is here so supported by the surrounding corpus spongiosum, that it cannot easily be pushed into the form of a pouch, in which the end of the instrument can be entangled. The operator need only observe the following circumstance. The penis should be held, by placing the corona glandis between the thumb and the index finger of the left hand in this way, the entrance of the urethra will not be at all compressed. The penis is then to be drawn upward, with moderate force. The catheter, being well oiled, is now to be introduced, with its concavity towards the abdomen, into the urethra, directly downward, until its point reaches the bulb. As soon as this occurs, and the beak of the instrument has passed under the arch of the pubes, the surgeon must very slowly bring the handle of the catheter forwards, between the patient's thighs, and in proportion as this is accomplished, the beak of the instrument becomes elevated, and glides into the bladder. In this stage of the operation, the penis must be allowed to sink down, and not be kept tense, as this would only drag the membranous part of the urethra against the os pubis, and render the passage of the instrument more difficult. The operation, however, is not always successfully accomplished in this manner. The beak of the catheter may be stopped by the os pubis; it may take a wrong direction, so as to push the membranous part of the urethra to one side or the other; or it may be stopped by a fold of the lining of the passage. The first kind of impediment is best avoided by not depressing the handle of the catheter too soon; that is, before the point has passed beyond the arch of the pubes. When the membranous part of the urethra is pushed to one side, or the other, the instrument ought to be withdrawn a little, and then pushed gently on in a different direction. When this expedient is unavailing, the index finger of the left hand may be introduced into the rectum, for the purpose of supporting the membranous part of the urethra, and guiding the extremity of the catheter. When the prostate gland is enlarged, the diameter of the urethra does not undergo any diminution; but, it turns upward very suddenly, just before its approach to the bladder. In such cases, the end of the catheter should be more bent upward, than the rest of its curvature. Mr. Hey has found, that, in withdrawing the stilet of an elastic gum catheter, the instrument becomes more curved; and he has availed himself of this infor mation, by withdrawing the stilet, as he is introducing the catheter beyond the arch of the pubes, by which artifice, the point of the instrument is elevated in the due direction. This gentleman is in the habit of employing stilets made of brass wire, about one tenth of an inch in thickness.* When such experiments fail, the surgeon should try catheters of various sizes, and curvatures. In the third stage of the operation, the beak of the instrument has to pass the prostate gland, and neck of the bladder. The chief impediments to its passage in this situation arise from a spasmodic contraction of the neck of the bladder, and from the instrument being pushed against the prostate gland. The first obstacle may be generally obviated by waiting a few moments, and gently rubbing the perineum, before pushing onward the catheter. The impediment, caused by the prostate, is best eluded, by using an instrument, the point of which is more curved, than its other part. Sometimes the surgeon himself presses the prostate towards the os pubis, by means of the finger in the rectum, and thus prevents the passage of the catheter, by increasing the sudden curvature at this part of the urethra. Hence, as Richter observes, it is a very important maxim, never to introduce the finger so far into the rectum, as to press on the prostate gland itself.† Many eminent surgeons prefer introducing the catheter, as far as the perineum, with its convexity towards the abdomen; then keeping the point stationary, they make the handle describe a semicircular movement downwards, so as to bring the concavity of the instrument towards the pubes, as it is situated in the above method. This is the plan, which the French surgeons call "le tour de mâitre." Flexible and elastic catheters may be introduced, either with, or without, a stilet. These have the same curvature as the silver catheter. When there is difficulty in introducing an elastic catheter with a stilet, the latter may be withdrawn, about an inch, in order to allow the end of the instrument to become more curved. INFLAMMATORY AND SPASMODIC RETENTION OF URINE. Inflammation, occasioning this complaint, is frequently situated in the neck of the bladder, urethra, or adjacent parts. The difficulty of voiding the urine is rather to be attributed to the spas * Practical Observations in Surgery, p. 397, 398, edit. 2. modic affection of the urinary passage, than to the swelling produced by the inflammation. The complaint must obviously originate in this way, when the inflammation is not situated in the urethra, and neck of the bladder, but in some neighbouring part. Hence, the antiphlogistic treatment, and antispasmodic remedies, are both indicated. It is commonly believed, that a mere inflammation of the neck of the bladder may occasion retention of urine; but, as Desault and Richter have remarked, the complaint is, most probably, generally owing to inflammation in the vicinity; for, inflamed muscles are not prone to contract. In examining the bodies of those subjects, who die of enteritis, we find the intestines preternaturally distended, not contracted.* The inflammation, causing retention of urine, may arise from various circumstances. Violent fits of the stone; very bad piles; the use of stimulating diuretic medicines, especially the tinct. canth.; the absorption of cantharides from blisters; bruises of the perineum; fistulæ in ano, &c. may be productive of such irritation in the urinary passages, as shall occasion them to become spasmodically affected. But, the most frequent exciting cause of the spasmodic, or inflammatory, retention of urine, is the irritation produced by strictures, and virulent gonorrhoeas. From this account, it is manifest, that besides taking care to employ antiphlogistic and antispasmodic remedies, it is also necessary to pay attention to cach particular cause of the irritation. The most potent means for relieving the retention of urine, now under consideration, are, copious venesections; the application of leeches to the perineum, or vicinity of the os pubis; the exhibition of opium by the mouth, and in clysters; the warm bath; and fomentations to the hypogastric region, and perineum. Some also recommend rubbing the latter part with an embrocation, composed of hartshorn, camphor, and tinct. opii. When these measures have been fairly tried, without success, the catheter is to be used without delay. The continued lodgment of the urine, and the distention, arising from its quantity, may soon cause the paralytic affection of the bladder, already noticed, and even occasion, in the course of three or four days, * "On ne voit jamais un muscle inflammé se contracter, et si on le force d'agir, il ne peut exécuter que de foibles mouvemens. Nous avons aussi remarqué constamment avec ceux, qui ont cuvert des cadavres, que dans les inflammations de bas-ventre, les intestins phlogosés étoient distendus, au lieu d'être rétrécis et resserrés sur eux-mêmes." Œuvres Chirurg. de Desault, par Bichat, tom. 3, p. 147, 148. . sloughing, and a fatal extravasation of the urine. When no kind of catheter can be introduced, not even a small one made of elastic gum, and the other remedies are unavailing, it becomes necessary to puncture the bladder, in the way, which we shall next describe.. THIS operation ought not to be considered a very dangerous one. It is probable, that, when death follows, it is generally owing to the puncture not having been made sufficiently soon. We can hardly suppose, that a small wound, made in such parts, as are divided in the operation, can often occasion the fatal terHence, I think, there can exist no mination of these cases. rational doubt, that, when such means, as seem best calculated for promoting the discharge of urine, haye failed, after having had a fair trial, the operation of puncturing the bladder becomes immediately as much indicated, as the division of the stricture in cases of strangulated hernia, when other means have not been productive of the object in view. Mr. Charles Bell states, that the fifth, sixth, and seventh days, from the commencement of the total obstruction, are those, on which the urine may escape from the bladder into the abdomen; and, consequently, he recommends the operation to be performed on the fourth day.* However, although I am an advocate for not delaying the puncture, after milder methods have decidedly failed, I believe that these methods will almost always prove successful under skilful hands, and that the operation may generally be avoided. In the opinion of Desault, there are very few instances, in which a surgeon, expert at introducing the catheter, cannot introduce the instrument into the bladder, and, consequently, the cases, in which paracentesis is absolutely necessary, must be exceedingly unfrequent. This assertion, says Bichat, might be confirmed by a multitude of cases. During ten years, while De |