soft-rubber catheter, an attempt should be made to pass either a coudé catheter or one of the flexible olive-pointed French silk catheters. Occasionally, any difficulty that may be experienced in passing a catheter or sound with the patient in the prone position may be overcome by having him assume the erect posture. This latter position may be preferable in two classes of patients-those in whom a spasm of the compressor urethræ muscle exists, and those in whom a pocket at the bulbomembranous junction occurs. Some patients, especially neurotics, are more successful in passing the sound or catheter themselves than is the attendant, and accomplish it with less distress. In those individuals who have a pocket at the bulbomembranous junction, the instrument, when its handle is depressed, seems to engage in the pocket instead of entering the fixed portion of the curved urethra; if, while the handle is depressed, the instrument is pulled very gently slightly outward for about a quarter of an inch, so that the beak is pulled up a little more on the roof of the urethra, and the handle is again depressed, the beak will not infrequently find its way into the curved canal. Pressure with the fingers of the left hand on the perineum over the beak of the instrument aids in such conditions. These are often found in old men in whom the urethra exhibits a tendency to sag down at the bulb. For descriptive purposes, the methods of passing the catheter or sound may be divided into three stages: To recapitulate, in the first stage the instrument is introduced as far as the bulbomembranous junction and is placed with its shaft parallel to the abdomen and its upper extremity below the umbilicus; in the second stage it is brought over in a curve, so that its upper extremity points toward the feet of the patient; the third stage represents its progress through the prostatic urethra into the bladder. When the instrument has been brought into such position that its shaft is parallel with the abdomen, care should be taken to see that, by stretching the penis, the urethra is well pulled up on the instrument. This is particularly necessary with those inclined to corpulency. Time and gentleness are the two important factors in passing. an instrument through the urethra, either for purposes of examination or to empty the bladder. Patients who are obliged to catheterize themselves will, after a time, generally find the catheter that is best adapted to their needs. We have previously stated that, in these cases, the soft-rubber catheter, of as small a caliber as seems practicable, or the silk coudé catheter, will be found most suitable. The English silk catheters with stylets, so popular in the past, have proved dangerous in both the patient's and the practitioner's hands, and have fallen into disuse. They possess all the disadvantages of the steel instrument, and, besides, being made of silk, are likely to be handled carelessly. CHAPTER II ENDOSCOPY.-CYSTOSCOPY. CATHETERIZATION OF THE URETERS ENDOSCOPY With the invention, within recent years, of a small electric light that does not give off heat and that can be placed at the end of a tube introduced into the urethra, this method of making urethral examinations has come largely into favor. The tubes used for making endoscopic or urethroscopic examinations are procurable in a variety of lengths, and the various manufacturers have projected numerous modifications of the original. The principle of most of them, however, is the same. The endoscope in general use is a metal tube fitted with a mandarin for introduction; the tube being inserted into the urethra to the desired point, the mandarin is removed, and a tiny electric light is introduced on its groove to the distal extremity of the tube. In order properly to examine the urethra by means of the endoscope the patient should lie on a high table, in a semirecumbent position, his legs, from the knees down, hanging below the table, and rest on two supports or chairs. The examiner should sit on a stool at his feet. The bladder should be emptied previous to examination, and about one dram of a 2 per cent. cocain solution be injected into the deep urethra. If the size of the meatus will admit, the endoscopic tube is easily passed as far as the bulbomembranous junction. If, when a more extensive examination is demanded, it is desired to introduce the tube beyond the bulbomembranous junction, it is necessary to depress the outer end of the endoscope to a very marked degree. This is best done in all cases, especially when the instrument is used for diagnostic purposes, for it is only by allowing the end of the tube to pass a little beyond the bulbomembranous junction that the colliculus can. well be made out and a fair conception be had of the appearance of the deep urethra. For these purposes, and more especially for that first mentioned, a tube somewhat smaller than that required for examining the pendulous urethra alone should be selected. Curved endoscopic tubes, though easier to introduce into the posterior urethra, have not, as a rule, been found to be of much practical value. A straight tube, by being well depressed, can be introduced with comparative ease so far into the posterior urethra that the colliculus, especially if enlarged, can be seen at the distal end of the tube. When this is seen, the tube is slowly withdrawn, and various portions of the urethra from the colliculus out can be examined as the tube is removed. Pledgets of cotton wound on the end of long slender applicators should be frequently Fig. 23.-F. C. Valentine's electric endo- introduced through the tube in order to remove the constantly accumulating mucus, which would otherwise obstruct the view. It is only after considerable practice in the examination of healthy urethras by the endoscopic method that one becomes thoroughly familiar with the normal urethral picture. An endoscopic examination will reveal to the surgeon the conditions that exist from the colliculus outward, and it should always be made in those cases in which the ordinary treatment for chronic inflammatory conditions of the urethra fails to give good results. The presence of vegetations or of internal chancre may be ascertained through an endoscopic examination. The effect of treatment may, if desired, likewise occasionally be observed. A persistent localized lesion also may be treated by means of the endoscope in a satisfactory manner. This is particularly true of those cases in which infection of the follicles exists, pus being easily seen exuding from them. For the treatment of such conditions as infected follicles, a fine-pointed galvanocautery probe can be introduced through the endoscope in a line vertical to the base of the follicle, which is then destroyed by means of the current. Not more than two or three follicles should be destroyed at one sitting, and the operation should not be repeated oftener than once Fig. 24. Galvanocautery point. a week. Small knives devised for the purpose may be used to open up infected glands and for other purposes, such as the removal of vegetations. Applications made through the endoscope seem to be of practical use in reducing hypertrophy of the colliculus. This hypertrophy is frequently accompanied by loss of sexual vigor. Once seen through the endoscope, the colliculus is easily recognized Fig. 24 a.-Kollmann's probe. subsequently. It projects, as a small pillar, from the bottom of the urethra into the endoscopic field, and in color and appearance somewhat resembles a small preserved mushroom. When hypertrophied, the mound appears much higher. This hypertrophy may be reduced and the sexual tone restored by applying a strong solution of silver nitrate (from 30 to 60 grains to the ounce) for a moment on a pledget of cotton to the colliculus. This method of treatment has also been recommended by some German writers as an excellent one for the relief of neurasthenia of urethral origin. Most of the endoscopes for sale in this country have a tube that is cut off straight at its lower end. A much better field for observation is obtained through an endoscope having the tube |