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and abdominal walls. Urinary extravasation due to injury of the prostate, as just stated, is rare, and, when it does occur, is a most danger- ous and insidious complication. The point of injury is, as a rule, some portion of an enlarged middle lobe, and the gland is tunneled backward into the prostatic or superior chamber of Tillaux, giving the extravasated fluids access to the anal portion of the perinieum and sub-peritoneal cellu- lar spaces, and ischio-rectal fossae. Of Levitra Canada Pharmacy Online course in these cases the genital organs are absolutely uninvolved, and, unless one is on the watch for every new symptom which may follow the infliction of an injury during catheterization, rapid in- flammatory and destructive changes occur before the sur- geon's attention is called to the accident Levitra Canada Pharmacy Online by any outward phenomena. These changes are much more serious than those which follow traumatisms in healthy urethrae, from the fact that the urine extravasated is, as a rule, highly amraoniacal and irritating, and the shock proportionately greater than in simpler cases. Desperate as the circumstances are, patients can occa- sionally be snatched from impending death by the prompt performance of an external urethrotomy, or the lateral in- cision as for stone, and treatment appropriate to rupture of the bladder. In approaching the treatment, however, of any given case, should false passages exist, they can in most instances be avoided by carefully studying their position and passing them by keeping the point of the instrument used constant- ly in contact with the opposite wall of the urethra or by employing Mereier's ingenious instrument which I now show you. The outer catheter of silver is deliberately en- gaged in the false passage, and then held in position, while through its eye a long soft-rubber catheter, or whalebone guide, is pushed on into the bladder. With patience and care, one of the instruments just shown can be passed in the great majority of cases. And now the query arises as to how much of the retained urine should be evacuated. The answer varies with the conditions found in any given case. If the retention occurs in an old man, whose symptoms are of recent date and whose bladder is only moderately dis- tended, and especially if the stream flows from the catheter in Levitra Canada Pharmacy Online full force as the bladder diminishes in size, thus showing that its muscular walls are in good condition, do not hesi- tate to empty it. If, however, the distension is great, the bladder reaching, as is not so very Levitra Canada Pharmacy Online uncommon, up to or above the umbilicus, and especially if chronic retention pre- cede, all authorities agree as to the extreme peril of such a course. Fatal syncope or haemorrhage Levitra Canada Pharmacy Online is a classic sequel to the procedure, especially if the urine is drawn with the Levitra Canada Pharmacy Online patient in a standing or sitting posture. In all such cases the rule should be to evacuate perhaps a quarter of the bladder's eon- tents, or less ; in a few hours, removal of another portion may be attempted, and by a succession of such removals the viscus emptied, and its walls, with their dilated and weakened vessels, returned to their natural state of contrac- tion. It is in this class of cases that the retention of a cathe- ter is justifiable, especially if its introduction has been ac- companied with unusual difiiculty, or false passages exist. It should be an elastic instrument (these being tolerated by an irritable bladder much better than metallic ones), its vesical end withdrawn until its eye lies Levitra Canada Pharmacy Online just within the bladder, and its outer end plugged. It may be fastened by tying it to the hair of the pubes, or to loops of rubber ad- hesive plaster fastened to the skin of the penis. If, in spite of careful and skillful attempts at catheterization, the blad- der is not reached, the only resources left are to be found in the difEerent methods of tapping or puncturing the blad- der. Of these the aspirator should be first employed, though its use should I)e confined entirely to the relief of acute retention. An objection Levitra Canada Pharmacy Online frequently raised to its use — that, on withdrawal of the needle, urine is allowed to escape into the surrounding tissues — need never occur if the simple precaution of keeping up the exhaustion during the with- Levitra Canada Pharmacy Online drawal be adopted. I have had many opportunities of Levitra Canada Pharmacy Online studying post mortem the appearance of the punctures made by this instrument in different viscera, and within a very few hours of its use, but have Levitra Canada Pharmacy Online never seen any evidence of its injury to tissues. In fact, it has always been a diflS- cult matter to identify the site of puncture, so Levitra Canada Pharmacy Online rapidly is- repair effected. Having bv its means gained a little time, other measures may be adopted which are calculated to give more permanent relief, such as puncture by supra-pubic or rectal methods, which should be considered in the order named (though neither finds much favor among American surgeons), or perineal cystotomy. The latter operation, which consists in opening into the prostatic urethra from the perina'um, and then either dilating or incising the neck of bladder, seems, to my own mind, to be the coming operation, both for per- manent relief for those rare cases not amenable to less radi- cal treatment, and, in cases of obscure disease, tumors, etc., for purposes of diagnosis. A paper upon this subject appeared a few yeiirs ago in the " Lancet," in which Sir Henry Thompson stated that, out of many operations for opening the urethra from the periuieum, excluding stone cases, he had ne^-er known a fatal result. The operation has now been extensively used for July 10, l«86.j BE LA SOTA Y LASTRA: THE STUDY OF LUPUS OF THE THROAT. 35 mere diagnostic purposes, as a direct result of Levitra Canada Pharmacy Online the paper just mentioned, and has within the last two years Levitra Canada Pharmacy Online been practiced and advocated by Harrison as a legitimate method of treat- ment for prostatic obstruction where catheterism has failed to relieve. Its author urges the importance of resort to the opera- tion before the tonicity of the bladder-walls shall have been impaired, or aggravated and incurable cystitis renders its success more than problematical. His first case occurred in the person of an old man who, at eighty-two, underwent the operation, the result being rapid atrophy of the pros- tate and restoration of the power of micturition. Other cases have since been markedly relieved, but without the resulting atrophy gained in the first. A modification of the operation is now advocated by Mr. Harrison, which con- sists in doing a median cystotomy and, through the open- ing thus gained, divulsing or incising and removing the obstructing tissues, whether enlarged median portion, intra- urethral bar, or fibrous outgrowth, and then leaving in the