In retention of urine, there is commonly no time to investigate the cause, since the urine must be immediately removed by inserting into the bladder a silver catheter delineated in Fig. 8 of Plate DXV, which is done, either while the patient stands, or lies on his back, by the surgeon grasping the penis with his left hand, while with his right he enters the point of the instrument into the urethra, the handle being over the left groin of the patient ; the catheter is then slowly and cautiously conducted along the urethra, bringing its handle to the mesial line, while ttie penis is at the same time pulled upon it, until the operator considers the point of it in the membnnous portion of the canal, when he is to relax the member, and bring forward the han dle to a right angle with the body, and ultimately depress it, pressing upwards the point of the ca theter with the fore-finger of his left hand in the perineum. If he is foiled in its introduction, he should partially withdraw it, and insert the fore finger of his left hand in the rectum and press up wards its point as he glides the instrument onwards: this latter attention is especially requisite when diseased prostate gland is the cause, or he may try a smaller-sized instrument. If he is still foiled, be ought to try a flexible gum catheter after the man ner of inserting a Bougie, which is, to withdraw the stilet, make the patient stand before him, grasp the penis with the left hand, and gently, elongate it, so as to make the urethra a straight canal ; then in sert this catheter cautiously. If these trials fail, and the patient is not suffering severely, he should be bled to fainting, and the introduction of the ca theter again attempted ; or he may be put first into a warm bath before being bled ; and if the catheter does not pass along, a tobacco glyster as di rected in hernia may be used : but no violence whatever should be employed in the attempts to in sert the catheter, for the surgeon may rest assured that whenever blood flows at the meatus urinarius, he has ruptured the mucous coat of the urethra, is in the corpus spongiosum, or cellular tissue in the vicinity of the•membranous portion, and has begun to make a false passage, so that he ought to desist, and puncture the bladder. Male catheters are of different shapes, varying chiefly in their curves. Lieutaud employed a straight catheter, which is now used by Mr. Amussat and others in Paris ; a surgeon should have them of different curves, and longer and shorter in the beak, and of smaller and larger diameters. The French, when foiled in the introduction of the common catheter, occasion ally use a conically pointed one, which is termed a sonde conique, and which they force onwards from the point of resistance in the urethra into the blad der. If the operator succeeds in its introduction, the instrument should be kept in the bladder until all irritation is subdued by antiphlogistic means, when the cause ought to be investigated, and if pos sible removed. Mr. Amussat, in the Bulletin des Sciences Medicales for October 1825, describes a most ingenious apparatus for relieving retention of urine, by forcing an injection of warm water along the urethra.
The female catheter is delineated in Fig. 10 of Plate DXV. although a male one is equally ser viceable, and is inserted while the patient is in bed with her limbs in a bent position, by the right hand of the surgeon holding the instrument, being con ducted under the right thigh, when the clitoris is to be felt by the middle finger, and the point of the cathe ter glided downwards about an inch into the meatus urinarius, and then its handle gently depressed and pushed upwards and backwards around the sym physis pubis. The operator is nearly equally liable to injure the mucous coat of the female urethra, and hence ought to proceed with the same precaution as in the male.
The urinary bladder is punctured at the perineum and per rectum in the male, per vaginam in the fe male, and above the pubes in both. The operation per rectum is much the simplest and safest, and can be done even in cases of enlarged prostate gland. The patient's nates are brought to the edge of the bed, and his feet placed on chairs widely sepa rated, so that the position nearly resembles that adopted for the lateral operation of lithotomy ; the operator then inserts the fore and middle fingers of his left hand oiled into the rectum until he feels the prostate gland, when he conducts along them the trocar and canula delineated in Fig. 11 of plate
DXV, sheathed to the space formed by this gland and the fold of the peritoneum named the cul de sac, and the vesiculce seminales, and then plunges the trocar with the canula into the bladder, depressing at the same time its handle, so that the instrument may run parallel with the patient's body ; the tro car is next removed, and when the urine has been evacuated, the canula is fixed by tapes run through the hole at its exterior aperture and around the loins and thighs of the patient, this aperture being plugged up with a piece of wood, and the patient afterwards laid in bed, with directions to remove this plug when the bladder feels distended.
After this operation, there may continue such a degree of inflammation or inflammatory fever, as to require active antiphlogistic treatment, and in such an event the canula ought not to be plugged up. The surgeon ought next to investigate the cause, which he is to endeavour to remove ; but whatever that may be, he should at the end of 48 hours, by which time suppuration will have ensued, substitute a flexible gum catheter for the silver one, as the lat ter will excite ulceration of the bladder ; a small papilla will direct him, and as the urinary bladder and rectum are intimately united in the healthy state in this space, he can scarcely introduce the instru ment between them. When performing this opera tion on a stout fat man, the operator must expect to experience difficulty in feeling the prostate gland, and reaching the space beyond it. In the female, the bladder is easily punctured from the vagina, the operator calculating the length of the urethra, and if the canula requires to be left, it should be fixed with a T bandage, and care taken that it does not slip into the bladder. The after treatment is the same as that directed in the male.
Stricture of the urethra frequently ensues from gonorrhoea, (described in the article MEDICINE un der Syphilis, Vol. XIII. p. 30.) and every patient who has been once affected with this complaint, has more or less contraction of the urethra, in conse quence of the injury done to the canal, but if left alone to nature the apparent stricture will be re moved, while if bougies be used, it will be aggra vated. Stricture also arises from stimulating medi cines taken internally, from stimulating injections, ulcers in the urinary canal, injury of the urethra, calculus in the bladder, and excess of veuery. It has likewise occurred in those who have resided in a warm climate, and in people of a naturally irri table urethra, and so early in life as eleven years of age. It is divided into the spasmodic and perma nent, and a combination which is termed the mixed stricture ; it occurs in every part of the urinary canal, but most frequently just behind the bulb, which is between six and seven inches from the meatus urinarius ; next, anterior to the bulb, or about four and a half inches ; thirdly, three and a half inches ; fourthly, close to the meatus ; oc casionally in the prostatic portion ; and on some rare occasions, at all these places in one in dividual. Spasmodic stricture consists in a tem porary contraction of the longitudinal fibres of the urethra ; permanent stricture, in a greater or smaller contraction of the passage from thickening, which is consequent on an effusion of coagulable lymph, that becomes more and more organized, and ultimately hard and of a white colour. Sometimes this permanent stricture is so narrow or short, as to resemble the constriction made by tying a thread round the urethra, and is named the corded or ring stricture ; at other times, only one side of the canal is contracted ; while occasionally, cases occur where the whole diameter is contracted for a con siderable extent, and this has been termed by some the ribbon stricture. There is always an enlarge ment of the urethra immediately behind the stric ture, considerable thickening of the coats of the urinary bladder, enlargement of the ureters, with affection of the kidneys.