Should retention of urine come on in the course of the case, it should be relieved as quickly as possible, as typhoid symptoms are apt to supervene rapidly in these elderly and debilitated patients. Morphine in small doses and the general hot bath will facilitate sur gical measures for the relief of the retention. A soft catheter should be passed if possible, and failing in this, the ordinary gum catheter with a stylet may be used. The stylet should be curved to conform with the prostatic urethra, and care should be taken not to exert much force upon the catheter in its introduction, as the point will very often catch at the point of obstruction. Under such circum stances the instrument may often be successfully passed by pressing against it just below its point, with the index finger introduced into the rectum. The finger in this instance acts as a fulcrum, and the force employed in passing the catheter is expended against it instead of the prostatic obstruction or bar. This little manoeuvre will often succeed where the introduction of an instrument would be otherwise impossible. It will be found that with this semi-flexible instrument the pressure of the finger just in front of the anus will often answer the same purpose, the handle of the catheter being depressed, simul taneously with the application of pressure to the portion occupying the deep urethra. It will be seen that in manoeuvres of this kind an accurate knowledge of the conformation of the distorted urethra is necessary. There is no danger in employing tolerably firm pressure after the surgeon becomes moderately expert in this method of pro cedure, providing such pressure be received upon the finger applied to the bend of the catheter in the perineum.
Another little manoeuvre which will be found to be very efficacious is the following : The stylet having been given an exaggerated curve is passed into the catheter and the latter introduced into the urethra until it comes in contact with the obstruction; the point is now pressed with moderate firmness against the obstruction with the fin gers of the left hand upon the handle, and the stylet is withdrawn, while the catheter is pushed steadily forward, It will be found that, as a rule, the withdrawal of the stylet will curl the point of the cathe ter upward and forward, in such a manner that the point of the in strument readily glides snakewise up over the obstruction and into the bladder.
When it is found to be impossible to introduce a flexible or semi flexible instrument Thompson's silver or Gross' jointed metallic catheter may be used. In extreme cases it may be found necessary
to aspirate, or in lieu of an aspirator to use a small trocar. Dieula foy's aspirator is the best for the purpose. The operation of tap ping may be repeated a number of times if necessary while waiting for the acute congestion of the parts about the neck of the bladder to subside, after which the urine either flows readily or may be evacu ated by the catheter. Should a trocar be used in lieu of the aspira tor, it may be passed into the bladder above the pubes, or through the rectum. In the latter event a very small curved instrument should be used, the bladder being punctured in the trigonum vesicce just above the border of the prostate. Should median hypertrophy exist and fluctuation at this point be absent, rectal puncture will be impracticable. When the trocar is used, it is well to leave the can nula in situ until it becomes practicable to evacuate the bladder by means of the catheter.
If retention has existed for some little time, care should be taken not to evacuate the bladder completely, lest there be set up, as a con sequence of removal of pressure from the already weakened vesical walls, acute inflammation and sloughing with an inevitably fatal re sult. It has been shown experimentally that this is due to acute bacterial infection, the resistance of the tissues having been lessened by the circulatory disturbance. Such accidents are not so rare as might be supposed.
In a day or two, after the bladder has contracted down somewhat, it is advisable to evacuate it completely at each seance. The writer has in some instances emptied the bladder completely at once, but has followed its evacuation by irrigation with a warm, mild antiseptic solution, a sufficient quantity of the irrigating fluid being left in the bladder to moderately distend its walls.
It will be found that very few cases will require the aspirator if the catheter be intelligently used.
It should be remembered, in connection with the subject of reten tion, that after a time the urine is likely to dribble away as a conse quence of overflow. This may mislead the practitioner into the belief that there is no longer any necessity for the evacuation of the blad der. Many an old man has been allowed to die unrelieved because of the ignorance of the physician on this point.