DRAINAGE OF THE BLADDER. Drainage of the Bladder.—Following upon the consideration of in flammation and suppuration within the bladder, it will be convenient to consider certain methods of drainage which are advantageously adopted in connection with the more chronic forms of these disorders. There are some bladders so shaped as to require treatment on precisely the same principles as are adopted in connection with the management of chronic abscesses. Bladder drainage may be effected by an open ing above the pubes or through the periumum. The former will be referred to when describing the operation of supra-pubic cystotomy. Perineal puncture of the membranous urethra for this purpose is most conveniently effected in the following manner : The patient being placed in the lithotomy position, when under an anesthetic, a centrally grooved staff is passed into the bladder. The correctness of the position of the instrument being verified by the finger in the rectum, the perineum is punctured by a long finger knife entering in the median line one inch in front of the anus. The cutting side of the blade is directed toward the operator, while the point is made to penetrate the perinmum so as to enter the groove in the staff immediately in front of the apex of the prostate. The inci sion thus made is somewhat enlarged in a direction toward the scro tum, so as to admit with ease the index finger of the other hand. The latter is then introduced into the wound, and the staff felt for. If this has not been sufficiently bared as to be readily distinguishable to the touch, I clear the way by the use of a blunt knife made for this purpose; then a Wheelhouse's probe-pointed cone-shaped gorget is run along the groove in the staff so as to prepare the way for the fin ger which subsequently follows. The staff being withdrawn, a pas sage is now made into the bladder for the introduction of the drain ing-tube. Thus a tube exactly fitting the wound can be inserted without incurring risk of bleeding.
I will now notice some different kinds of drainage-tubes and the manner of their employment. Among the various means that are used in connection with the operative treatment of diseases of the urinary organs, the drainage-tube, in relation to the urine, probably occupies the most prominent position. It is, in fact, now identified with almost every procedure of importance. We see its use in con nection with injuries of the urinary apparatus, more particularly in cases of rupture of the urethra, where the condition of the scar that follows is largely influenced by the kind of provision made for the disposal of the urine while repair is proceeding; iu the treatment of several plastic operations on thd urethra as well as the bladder; in the cure of chronic suppurative affections of the several parts consti tuting the urinary apparatus; in pouching and sacculation of the bladder both with and without stone; and particularly in the preven tion of some distinctive forms of fever originating in this system. In these as well as in other directions its use is now well recognized.
For introduction into the bladder through the perineal puncture, and retention in this position for the first forty-eight hours or so, I usually select a gum-elastic tube with a metal mount, having an opening on either side for the retaining tapes . In calibre they are about as thick as my index finger, that is to say, they fit with some accuracy the opening they are intended for, though I generally have some of different sizes by me in case the wound may for any reason be somewhat larger than usual. Sometimes a suture is put into the perineal opening either above or below the tube, so as to make it fit accurately and prevent bleeding or oozing by the side. I use them in the same way after median cystotomy. They are not necessary after the lateral operation, except sometimes temporarily, to restrain hemorrhage by fitting the wound, as this incision into the bladder entails a condition of urinary incontinence for some days.
These tubes are not to be passed too far into the bladder, hence we should have at hand various lengths to suit different depths of peri neum. If the fit is accurate there is not likely to be trouble with bleed ing, or necessity for a ligature. A gum-elastic tube is preferable for the first forty-eight hours, as in case there should be any oozing we have something solid to plug upon. At the expiration of this period, a soft rubber one with a velvet or depressed eye, and open at the end is substituted, such as are made for me in different lengths and cali bres by Messrs. Tiemann & Co., of New York (Fig. 43). The rubber drainage-tubes, with the punched-out eyes, are most objectionable. as the mucous membrane of the bladder is liable to be sucked into them, and then, when they are withdrawn, pain and perhaps a little bleeding are occasioned by the sharp edge of the opening. This re mark also applies to rubber catheters of all kinds. The soft tubes are easily retained in position by a perineal band, to which they can be attached either by a safety-pin or tape. In some cases of extremely pouched or sacculated bladders, where the urine drained with some difficulty, I have used the two varieties in combination with advan tage—that is to say, a soft rubber tube has been passed through a gum-elastic one, on the principle of the double tracheotomy tube. Where it has also been found necessary to wash out pockets in the bladder this has proved more, effectual than the single tube. After the first forty-eight hours, whatever tube is used for drainage, the bladder should be washed out through it, and then the tube removed and changed. Care should always be taken, on replacing the tube finally, to test it with a syringe, and to see that it works accurately. For douching the bladder in connection with drainage-tubes nothing is better than a hydrostatic tank and a vulcanite tap at the end of the tubing, by which means the supply and force of whatever lotion is used can be regulated without producing any jar or sudden concus sion. During the first forty-eight hours I usually let the urine drain into a pad of wood-wool or some antiseptic absorbent material which can be frequently changed. After this, when the flow is established, the patient may be kept quite dry by attaching a piece of rubber tub ing to the metal nozzle of the drainage-tube, by which the urine is conveyed into some suitable receptacle between the patient's legs, or even outside the bed. No drainage can be perfect when the bed is of such a shape as to cause the patient to lie in a hole ; the buttocks should be slightly elevated, and drainage favored by raising the head of the bed. The latter can easily be done by a brick or a wooden block. A little experience soon shows how all these details may be attended to, as much importance is attached to them. The length of time drainage should be carried on depends on the nature of the case. Where the urine, to commence with, is alkaline and ammoniacal or offensive, it will at all events be required until the excretion is dis charged in a normal condition. I have tried other kinds of drainage tubes, including those made of glass or of metal, but I find nothing so efficient as those I have mentioned.
There is a vulcanite tube with a movable collar described by Dr. F. S. Watson, of Boston, U. S. A. (" The Operative Treatment of the Enlarged Prostate"), which will be found useful in some cases where. the bladder is much pouched behind a large prostate. The end of the instrument lies in this dip, and thus perfect drainage as well as provision for irrigation of this portion of the bladder are secured. By the movable collar the instrument can be at once adapted to any depth of perineum.