TOILET OF THE BLADDER. Toilet of the Bladder.—After the general consideration of cystitis, I shall now refer to what may appropriately be called the toilet of the bladder. This will include, first, the mechanism, and then the ma terials appropriate to each class of case. In the first place, it is well to remember that the process of washing out some bladders is a very different thing to what it is in others. This will readily be under stood by comparing a pouched bladder with a tolerably normal one. In the former case, unless the siphon-action of the catheter is perfect, a considerable amount of urine, perhaps loaded with mucus or pus, may be left behind to decompose and become swarming with various kinds of bacteria. Hence the catheter should be gently moved about and partially withdrawn as the flow ceases, to see if another collection of urine can be tapped. As I have elsewhere stated, in some instances it is even well to let the patient lie over on his side, so as to render the abdomen somewhat dependent, before the catheter is finally with drawn. It can be understood how a metal catheter may positively shut down a sort of prostatic valve by its weight, and render, from the position of the exit aperture, the complete emptying of the bladder an impossibility.
For ordinary purposes, I usually employ a soft silk or rubber catheter with a bevelled eye, and a rubber bottle holding four or six ounces of fluid, with a brass nozzle and stopcock, which can easily be screwed on, or, what is better, be connected by means of a bayonet joint. The nozzle should taper to a fine point so that it may fit catheters of various sizes. I formerly used double-current metal catheters, but these I have discarded, for the reasons that an unyielding instrument is not so generally applicable as a flexible one, and because there is no object in having an arrangement for the synchronous flow of fluid into and out of the bladder at the expense of the calibre of the tube. The soft catheter having been introduced, and the rubber bottle filled and connected with it, the fluid is gently pressed by the hand on ward to the bladder. Two or three ounces usually suffice for a time, the tap is again turned and the fluid retained in the bladder for a few moments, and then allowed to escape. This process may be repeated two or three times until the return fluid indicates that the object in tended has been attained. The process should be a painless one, with
out provoking either bleeding or spasm. Mr. Buckston Browne " has described a tube which can be fitted to almost any catheter, by which a Higginson's syringe may be adapted for filling the bladder, while by raising the finger from over one of the openings, the current is re versed and the fluid ejected.
I used to wash out with a glass funnel to which about two feet of rubber tubing and a catheter were fitted. When the funnel is elevated and water poured into it, the latter, by hydrostatic pressure propor tionate to the calibre and length of the tubing, flows into the bladder, and, upon the funnel being depressed below the level of the patient's pelvis, escapes.
Where the bladder is much pouched or irregular in shape, it is better to employ hydrostatic pressure in the form of a reservoir or rubber bag (which is convenient for travelling), as shown in Fig. 41, representing an arrangement described by Dr. Keyes. By this plan the bladder can be very gradually filled, so as to float out of these various depressions and crevices pieces of tenacious mucus which otherwise would remain behind and keep up irritation and bacterial decomposition. From the sketch (Fig. 41) it will be seen that the apparatus consists of a rubber bottle (A) capable of holding a pint of fluid, which can be suspended to any convenient hook; a piece of tub ing (B), five feet in length, terminating in a stopcock (C), which per mits fluid to flow either through the catheter end (D) or the outlet pipe (E), according to the direction in which the tap is turned. A conical metallic catheter mouthpiece (F) completes the connection with the catheter (0). A soft-rubber catheter is generally preferred. The instrument is used in the following way : The bag or reservoir, being filled with the fluid to be injected, is hung up about six feet from the floor. The stopcock (C) is then turned until some of the fluid escapes, so that no air is allowed to enter the bladder. The patient, being in the erect position, then introduces the catheter and connects it with the tubing. By the alternate action of the tap (C) the fluid is made either to enter the bladder or to escape; if the lat ter, it passes into the receptacle (H). The instrument can be adapted to the recumbent position, and also ena bles patients to perform this operation readily without assistance.