RETENTION OF URINE.
Before treatment can be undertaken the surgeon must differentiate carefully between suppression and retention, and he should endeavour to find out the cause of the retention, which is but a symptom or result of-several distinct diseased conditions, as of the bladder or more commonly obstruction in the urethra from spasm, stricture, enlarged prostate, calculi, inflammatory swelling or spinal disease.
There is perhaps no condition in which the novice is so liable to make a grave mistake—a mistake which is also not infrequently committed by the careless though experienced practitioner. This consists in over looking the serious condition, in which after a paralytic distension of the bladder from retention the dribbling overflow of the greatly distended organ is regarded as a simple incontinence of urine. The error is most likely to occur in the profound toxaemia of long-continued fevers. where it may be the cause of death.
The history of each case will almost always give the clue to the cause and nature of the retention. Thus in a patient in advanced life with a history of failing power in emptying the bladder, and in the absence of a history of stricture, enlargement of the prostate is almost certain. Here, as already mentioned under Prostate, Enlargement of (p. 7S7), the surgeon should attempt to pass a soft vulcanised rubber instrument of the size of about sz (English). The catheter should not be passed till the patient has been placed in a hot bath, and often micturition occurs in hospital cases especially after 20 or 3o minutes in the bath. When the rubber instrument fails, a rare event, the gum elastic or French coude may be tried. The writer, after failing with the rubber, generally finds that a large-curved silver instrument is the best in acute cases. With skill and confidence this will seldom fail in entering the bladder. The novice is almost certain to try the smaller sizes, but a No. so (English) long silver prostatic catheter with a wide curve is a good instrument.
The catheter must be rendered aseptic inside and out, and it should be well lubricated with sterile vaseline or K.Y. Jelly; the greatest patience and gentleness are essential, and sometimes the introduction of the left index-finger into the rectum will greatly assist, but force of any kind is never justified.
The silver instrument should be slowly introduced with its beak pressing against the floor of the urethra till the penile portion of the urethra is traversed in order to avoid catching the extremity of the instrument in the lacunw of the ceiling of the passage; the operator's hand being depressed as the prostatic urethra is reached, the openings in the floor of the passage are similarly avoided. In old prostatic cases the intro
duction of the metal catheter is usually facilitated by placing the patient in the upright position, but this should never be attempted after prolonged submersion in a hot bath owing to the danger of syncope. Where there has been much residual urine present before the retention has set in some warm saline or boric solution should be injected to avoid the danger of collapse, and the flow from the catheter should be rendered as slow as possible for the same reason, the urine being only partially removed at first by permitting so or 15 oz. to flow, when the catheter left in situ may be plugged for half an hour or more before removing the entire contents.
Where the difficulty of introducing an instrument is very great, especially when some previous operator has succeeded in making a number of false passages, it will be necessary after its introduction to tie in the instrument for a time (the tying in of a silver catheter is, when possible, to he avoided).
When the passage of an instrument is impossible after reasonable patience has been exercised, and where the patient urgently requires relief, his bladder may be tapped by the aspirator above the pubes—a simple :Ind safe operation, owing to the distension of the bladder—after which often a rubber catheter can be passed through the urethra and tied in for several days : or the bladder may be tapped above the pubes by a curved trochar and canula, the latter being left in situ; a. long rubber catheter or tube is passed through it, and the urine is continuously siphoned off into a vessel beneath the patient's bed. (See under Prostate, Enlargement of.) In retention from organic stricture or the urethra, it is necessary to keep in mind t he pathology of the affection. In this lies the secret of successful treatment. A few hours before the attack „of retention probably the patient passed his urine freely, though in a small stream. The element of spasm and swelling of the urethral mucous membrane from some recent chill or irritant becomes superadded to the organic narrowing, and affords the explanation of the sudden blocking up of the urethra.