duty at St. Luke's Hospital, my House Surgeons understood it perfectly and always tried it before passing a catheter. That is, the patient being in bed, with the pelvis elevated, a high enema should be given and then the urethra irrigated, by way of the meatus, with hot boric acid solution and this repeated in an hour or two. Sometimes, in some of these individuals, you will see a fine spurt of urine follow the irrigation, with evidence of relief on the part of the patient. This does not succeed in all cases, but should be tried first; subsequently, the catheter may be used and regular systematic catheter life be entered upon, if necessary.

It may be well to say a word or two in regard to emptying the bladder at the first sitting. Although so high an authority as Dr. Keyes of New York, does this with an antiseptic procedure of his own, I am inclined to agree with those who object, and recommend a gradual, systematic emptying of the bladder by taking a few more ounces from the bladder at each succeeding sitting. I believe that this is less than liable to produce a condition of shock, that the relief to the pressure upon the bladder wall is gradual and not sudden, and that the back-pressure upon the kidneys (which are doing their work under tension) is also relieved gradually and not suddenly. In these elderly men, trifling things are apt to produce acute congestion or attacks of prostatitis in this chronically enlarged state. These conditions may be treated as I have indicated to you when speaking of acute or subacute prostatitis.

Now, when we come to the question of operative or radical treatment, I am obliged to premise that there should be a discrimination made between the men who belong to the higher classes, and those of the lowly and poor and uneducated. If you look through your experience with prostatic

cases you will find that a large proportion of those who have been forced upon catheter life and get along comfortably, have that comfort because of their comfortable surroundings, because of their training and education, which has given them intelligence and a certain amount of tactile skill. They are able to pass the catheter and to[understand your minute directions as to asepsis and the care of the bladder, and as long as these conditions can be maintained, any operative procedure is contraindicated. But, even among the intelligent and well-to-do, cases will arise which demand some operative relief. It is very different with the men who have no education, no continued home, who rely upon a day's labor or who are the parasites upon the community, and who resort from one hospital or dispensary to another. These individuals are of no use to themselves or to society; they are unable to care for themselves, and upon them we must attempt radical relief by operative procedure. This, I think, is the experience of all men who do hospital work.

In

Heretofore, the choice was generally between drainage, either temporary or prolonged, and some form of prostatectomy. Drainage certainly presents a means of easy and speedy relief to present suffering. The individual has no violent or dangerous attack made upon his pelvic organs, the shock is not very serious, and in some cases,—after prolonged drainage, there is a certain amount of spontaneous urination. those acute, serious cases, which are showing symptoms of uraemia because of the back hydrostatic pressure upon the kidneys, I would commend it to you rather than repeated aspiration of foul, purulent, infectious urine. It can be done with local anaesthesia, and on several occasions, in extremis, I have simply made use of a long trocar introduced quickly and easily behind the pubes, left it in place, and run a

bistuory down by the side of it until an opening was made through which a drainage tube could be inserted, from which purulent urine flowed quickly, and the use of an antiseptic solution followed at once.

PROSTATECTOMY, or the operation of cutting out the whole of, or portions of the gland, needs but brief mention. The subject has been ably presented from time to time, and the cases in which it shall be selected will have to be decided by the good sense, skill and experience of the surgeon.

My earlier operations were done by means of scissors and prostatic rongeurs, but of late the operation has been modified, and I think greatly improved by Dr. Nicoll of Glasgow, and by Dr. Samuel Alexander and Dr. Eugene Fuller of New York. I have not yet had an opportunity to do this modified operation, but I have witnessed it and seen its results, and it seems to me in every way commendable. Although a number of operators have had a few successive cases of prostatectomy, which resulted successfully, when the cases of all operators are put together, the death-rate is still very high,-from 20 to 25 per cent.

We have now another operation of choice, and to an American surgeon, Dr. J. William White, of Philadelphia, Pa., we are indebted for its suggestion and its organization. His experimental and clinical work have been recently laid before the profession, and although its results are not yet positive, I think it is but fair to say that enough testimony has been advanced for me to believe that there are many cases which will be benefited by the operation of double castration. Being one of those who have taken a conservative and critical position in regard to it, I take this opportunity to pay a tribute to my friend, Dr. White, and of saying to you that at the last meeting

of the American Association of Genito Urinary Surgeons, over which I had the honor to preside, he presented the whole subject so thoroughly and in such a candid manner, that I believe it entitled to the most care fnl and discriminating consideration. He reports an amelioration of symptoms in 83 per cent. of the cases operated on; but, the deathrate which he gives, namely, of 7 per cent., I confess surprised me. No doubt this will be reduced as experience is gained. But the question which will be presented to us as practical men, and which we will have to consider with great care, is his Which will be the cases to be benefitted by the operation of double castration? And before deciding in a given case, it is well to bear in mind that there are still some doubtful points in regard to the relation between the testes and the prostate, some of which were brought out in the discussion upon Dr. White's paper. I agree with Dr. Cabot, of Boston, that the operation is so easy and the relief following it has been so enthusiastically stated, that it becomes very seductive, and we are liable to be placed in the same position as the profession was during the early days when ovariotomy was too frequently resorted to, as we all know.

In conclusion, let me again call your attention to the statements which I have made, that enlargement of the prostate begins earlier than we have supposed. That in many men it bears a distinct relation to sexual hyperaemia, and although I can only suggest this method of observation to you, I believe that if the profession will carefully accurate record of each

observe their cases, obtaining an man's sexual history from boyhood up, we will be able to arrive at a prophylactic treatment of Enlargement of the Prostate which will settle the question of future generations of men.

Antitoxin Treatment of Diphtheria.

By Edward R. Campbell, M. D., Bellows Falls.

Perhaps it is safe to say that during the past year no subject has received more attention from the medical profession than serum therapy, especially in relation to its value in the treatment of diphtheria. While it is true that we who practice in the country have not individually the large number of cases to report that our city friends see in their great hospitals, I believe that collectively this society can, if each member will report his carefully watched cases, collect statistics at least equal in value to those given us by our hospitals. The loss of a little patient nearly a year ago of membranous croup under the old methods of treatment, and noticing some reported cases shortly after where treatment with the antitoxin had apparently saved life, led me to investigate. I first wrote Dr. Caverly, the efficient president of our State Board of Health, who replied that owing to the fact that Rutland had been quite free from diphtheria for some time, he had had no personal experience with the remedy. Having met Dr. Durgin, President of Boston Board of Health, at