estimating the distance between the finger and the instrument. The ordinary procedure for prostatic examination through the rectum is to have the patient bend over a chair or a table; the examiner introduces the forefinger of the right hand, covered with a well-lubricated finger-tip, into the rectum, and searches for any enlargement of the prostate or of the seminal vesicles.

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Fig. 1.-Examination of the prostate by the rectum only. Also position for massage of the prostate.

Any difference between the two lobes can be ascertained at the same time, also any points of softening that might be indicative of a prostatic abscess. When the latter condition exists, a sort of dimple will probably be present in the prostate. When the abscess is extensive, slight massage of the side of this dimple may cause pus to exude from the meatus. Should the patient urinate after the massage, if abscess of the prostate is present, the urine

will usually contain large quantities of pus. When the seminal vesicles are enlarged, they will ordinarily be found to run off like cords, at an angle with the apex of the prostate, forming with it a triangle whose base is the base of the bladder and whose apex is the prostate. Massage may also be applied to the seminal vesicles and to the prostate for the purpose of obtaining their contents for microscopic examination and for the purpose of locating painful

areas.

In women a vaginal examination may give considerable information as to the condition at the base of the bladder, and when made bimanually, as to the condition of the ureters. With thin male subjects it is well, besides examining the prostate through the rectum by the method previously suggested, to place the patient on his back, and to introduce the forefinger of the one hand into the rectum and, with the other hand on the abdomen, to press down over the suprapubic region. Considerable experience is necessary to correctly diagnose diseased conditions of the prostate or seminal vesicles by means of rectal examination alone, no instrument at the time being present in the bladder, and we find that even intelligent members of house staffs in hospitals are repeatedly making mistakes as to the findings derived from that procedure and drawing false conclusions from it. The mistake most frequently made is that of supposing an enlargement of the prostate or seminal vesicles to exist when none is present. Information concerning a stone in the bladder can rarely be ascertained by rectal examination, and still more rarely is it possible to learn the condition of the ureters in the male by this method.

An examination of the secretions is the next step in order, and it is best that this be made, in part at least, at the patient's first visit. When tuberculosis is suspected, prolonged examination is necessary to detect the presence of the tubercle bacillus with absolute certainty, and some time must elapse before the diagnosis. can be arrived at. Other conditions, however, may be more summarily dealt with. In cases of acute urethritis the discharge may be washed out from the urethra as far as the bulb, and the urine may then be passed and collected for examination. After this process the bladder may be washed out, emptied, and, if thought advisable, the prostate massaged, and an attempt at urination made. A few drops of this urine should be preserved for a future

examination, in order to ascertain the condition of the prostate and seminal vesicles. In those individuals in whom no acute discharge is present, washing out of the anterior urethra will be unnecessary; the patient should, however, be requested to urinate, and the urine be set aside for examination or a simple examination immediately made.

We have found some of the glass tests advocated for the purpose of locating the seat of urethritis to be misleading. One of these fallacious tests is to have the patient pass half the urine into one glass and half into another. If the urine in the second glass is clear, whereas cloudiness or shreds are present in the other, this has often been thought to prove conclusively that the inflammation is confined to the anterior urethra. This test has been proved to be unreliable, since if but a slight amount of discharge were present, it could be washed out with the first half of the urine passed, even when the inflammation extended, as it usually does, throughout the entire urethral tract. The test may, however, have a relative value if made when a large amount of urine is in the bladder, as on the first urination after rising. If both glasses are then found to be cloudy, and the patient is asked to urinate in the same manner later in the day, when the bladder contains but a small amount, and all the cloudiness is found to be confined to the first glass, this would indicate the existence of a posterior urethritis; if, however, then neither glass is clear and the cloudiness is seen microscopically to be due to pus, or the shreds to be made up of pus-corpuscles, a cystitis or kidney involvement would be demonstrated. If the early morning urine is collected in three glasses and all are found to be cloudy and to contain pus or numerous shreds, it indicates, generally, that the inflammation is beyond the posterior urethra. These various glass tests will be referred to again under the Diagnosis of Urethritis (p. 375).

The chemic examination of the urine is dealt with in more detail elsewhere (p. 88), but there are several valuable simple tests for learning some of its possible constituents that may be made expeditiously at the time the patient is being examined. Cloudy urine is ordinarily due to the presence of mucus, pus, bacteria, urates, phosphates, carbonates, or albumin; a simple test for determining to which of these agents the cloudiness is due has been outlined by Ultzmann, of Vienna. A portion of the urine

is placed in a test-tube and the upper portion boiled. If it immediately becomes clear, the cloudiness is due to the presence of urates; if it becomes more cloudy, to phosphates, carbonates, or albumin; and if it remains unchanged, to pus or mucus. If, then, by adding a drop of dilute acetic acid to the urine it is immediately clarified, the cloudiness was due to an excess of phosphates; and if, in addition, it effervesces in clearing up, it was due to carbonates. If it becomes still more cloudy, albumin is present, and if it remains unchanged, pus, mucus, or bacteria may be said to be present.

A very popular test for mucus or pus is to add an equal amount of liquor potassæ to the urine in the tube; shake the tube well, and if the mixture shows considerable cloudiness, particularly if of a stringy character, the presence of pus or mucus may be said to be established.

It is hardly necessary to state that when the presence of any of the above-mentioned substances has been detected, these tests must be further confirmed by means of more accurate methods.

THE INSTRUMENTAL EXAMINATION

The verbal and physical examination of the patient having been completed and the urinary and other secretions of the body having also been examined, it is often necessary, in addition, as previously mentioned, to complete the examination by the introduction of some instruments, such as a catheter, bougie, sound, searcher, or possibly endoscope or cystoscope, into the urethra or bladder. A detailed description of all these instruments is unnecessary; the following are those that have given the most satisfaction in the writer's hands. For ordinary purposes of catheterization, the soft-rubber, velvet-eyed catheter is probably the form most generally used. The smaller catheters are to be preferred to the larger. No catheter should be used ordinarily that has any hole besides the eye, and care should be taken that there are no rough places on the instrument that might scratch the urethra particularly, that there is no roughness about the eye. Often, after very little use, the edges of the eye of the catheter become roughened. This should be particularly guarded against where the services of a physician or of a trained attendant cannot be procured, and where the patient must be taught to use the

instrument himself. The shafts of these catheters, as ordinarily made, are round. Soft-rubber catheters, somewhat flattened at the lower end, have recently been put on the market. They are said to be useful in cases of enlarged prostate; the urethra being stretched by the prostatic enlargement, is necessarily generally narrowed from side to side, and a catheter somewhat flattened on the side will thus more easily conform to the shape of the canal. They are also made flattened at the top and the bottom. Softrubber catheters have very little penetrating force, their introduction being easily hindered by stricture of the urethra; in cases of enlarged prostate, moreover, where the prostate alters the natural curve of the urethra, they are particularly likely to curl up at the bulbomembranous junction. They are also introduced with difficulty if a spasm of the urethral muscle-a so-called spasmodic stricture-exists.

Catheters of gummed linen or silk with flexible olive ends preceding the entrance of the eye are extremely useful, when properly constructed. They are of value not only for the ordinary purpose of a catheter to empty the bladder, but are useful for examining the urethra in both its anterior and its posterior portions, as the flexible bulbous point very easily detects any irregularity in the canal. Then, too, they are useful as a means of making applications to the posterior urethra and bladder. In choosing catheters of this description great care should be exercised. As ordinarily made in this country, the olive-pointed ends are too inflexible, and the catheters partake too much of the nature of an Indian arrow. Such instruments are likely to do more harm than good. When the ends are extremely flexible, however, they are useful in overcoming urethral obstacles, such as strictures of not too small caliber; they are more useful than soft catheters in overcoming spasms at the neck of the bladder, and if flexible enough and not too large, will not irritate the urethra. Ordinarily they can be introduced into the bladder with less pain to the patient than any other form of catheter. For emptying the bladder, where this must be done rapidly, they are not, as a rule, so serviceable as some others, and in old prostatics, with large quantities of residual urine, or in cases where a large amount of fluid is to be evacuated from the bladder, they may not be found so prac