Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson.

  • Thompson, Henry, Sir, 1820-1904.
Date:
1882
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Licence: Public Domain Mark

Credit: Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson. Source: Wellcome Collection.

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    ' others who have failed in a previous attempt. And in using it always remem- ber that anything felt at the end of the instrument like obstruction can only denote that you are not in the right route, or are leaving it. No force is to be applied in such circumstances. The urethra is not narrowed, it may be some- times a little close and rigid, perhaps, when you reach the prostate ; but if you find any obstruction, you should withdraw and find another route, to the right or to the left. But in applying a catheter in these cases, remember that the position of the patient himself is by no means a matter of indifference : I mean only in the pre- sence of signs that the bladder is greatly distended. If these are strongly marked I advise you to pass the instrument with the patient in the lying position. On the other hand, if the bladder is not much dis- tended, perhaps it is as well, or better, to pass the catheter standing, in which posi- tion the viscus is more readily emptied. I have known great danger arise in re- moving a large quantity of water from a patient when in the standing jDosition. I have even known death occur suddenly from this cause. Had I time, I could tell you the history of a case in which a charge of manslaughter was brought against a surgeon in a court of justice in relation to such an occurrence. The circumstances were all well known to me, for I was summoned to defend a brother practitioner, who was unjustly charged in connection Avith the case. It was the fact that a eatheter had been passed in the upright position, and that the patient fell dead from syncope when six pints of urine had passed; just as a patient with ascites might do if you tapped the abdomen in the same position. No doubt it was an error, but nothing could be more mon- strous than to make it the ground of a criminal action. It is a very inst^-uctive ■case, and I mention it to show that when the bladder is large, esi^ecially in old men, you may have fatal syncope, arising in the way I have described. 1 always take care, if I find the bladder is very large, to pass the catheter when the patient is lying down. It is advisable also, in these cir- cumstances, to draw off only part of the urine; and after a quart or so has passed, to wait a little before the bladder is com- pletely emptied. It may be said, ' Why, in describing the treatment of prostatic retention have you not mentioned hot baths and opium ? ' I reply that I have not done so in these particular circumstances, because they by no means favour the hope of good results from delay, or from expectant treatment; and furthermore, it is necessary to have regard not only to the present state, but to what may be the future condition of the bladder, after the emergency has dis- appeared. Thus, it is by no means un- likely that if the bladder is permitted to remain over-distended, say for a day or two, it will not readily contract again. In the case of an old man's bladder, thoroughly distended by long retention, it is very likely not to recover its powers. Although the patient may have made water fairly up to the time of retention, if you leave him to the influence of opium, hot baths, and treatment of tliat kind, and the bladder is permitted to dis- tend meantime, you Avill very likely have more serious chronic retention afterwards than if the instrument had been used at the outset. Again, if you have had a great deal of trouble in passing the catheter, I suppose you Jiad better leave tlie instrument safely tied in ; but it is not always the most desir- able course in these cases. If there is not much difiiculty you should rather with- draw it, and use it again; because the prostate is irritated, perhaps injured by an inlying catheter. Unlike stricture, which is often v/ell treated by an inlying catheter, the prostate is always more or less disturbed by it; but less harm accrues from a flexible than from a silver instrument. Better still if you can pass a vrlcanised india-rubber catheter, which is the only one which lies harmlessly in the urethra in a case of prostatic enlarge- ment. It may sometimes be insinuated by a series of short, quick pushes, thus [illustrating the method] ; or, failing in that manner, by mounting it on a stylet of any curve which may be desired, and subsequently withdrawing the stylet. It is not difficult to keep it in its place if properly tied-in, using the supra-pubic hair for the purpose, as you have so often seen {see Fig. 11, p. 26); and the instru- ment has the merit of rarely becoming encrusted with phosphates, while its flexi- bility permits the patient to move about his room. A short metal tube within the stem renders it more secure ; or the upper five inches may be stiffened by coating it with collodion, and it can then be easily