2. Common causes of acute on chronic retention:

Enlarged prostate.

Stricture of the urethra.

Nervous disease.

In the first group there is no risk from emptying the bladder completely, but in the second group the patient should always be confined to a warm bed before a catheter is passed, and the urine should be drawn off slowly, as the bladder must never be emptied suddenly and completely when there has been long-standing back-pressure.

In acute cases on a chronic cause the final complete retention is due to congestion and spasm, so that the first step is to attempt to influence these, and in this way most cases can be relieved without the passage of a catheter.

An adult is given thirty minims of laudanum by the mouth, or a suppository containing half a grain of morphia, and is then placed in a hot bath, in which he lies for twenty minutes if the heart will stand it, and is instructed to pass his water into the bath. An additional remedy of value is to inject into the urethra thirty minims of the following solution: Cocain. hydrochlor.

Adrenalin hydrochlor. (1 in 1000)
Aq. destill.

gr. 4.
miij.

mxxx.

If these measures fail to relieve a catheter must be passed without further delay.

A. In cases of stricture start with a No. 10E olive-headed gum-elastic catheter and work down to No. 4E. If none of these will pass lower sizes of gum-elastic bougies must be tried, and if these fail catgut or whalebone urethrotome guides. If a fine bougie is passed it should be left in for twelve hours, as urine will gradually dribble out along the sides of the bougie, and when the bougie is removed it is usually found that a much larger size of bougie or catheter can be passed (No. 4E), and if not that the stricture can be dilated up to No. 8-10F.

If the urine is foul and the patient's condition bad it may be better to perform an internal urethrotomy or even an external urethrotomy straight away, so as to permit of free drainage of the bladder, but in other cases intermittent gradual dilatation may be carried out (see Ch. I, Sect. V).

If there are many false passages or if a catheter cannot be passed supra-pubic puncture must be performed.

Supra-pubic puncture.-The pubic skin is shaved and

rendered surgically clean. The bladder must be distinctly felt before proceeding further, as it is not safe to trust to percussion. Take Take a straight pleural needle that has been boiled, and feeling for the bladder with one hand, plunge it straight inwards and slightly downwards into the bladder just above the pubes. The urine can be drained off by syphon action, a long rubber tube being attached to the end of the needle and allowed to hang over the edge of the bed, or by means of an aspirating bottle or a Dieulafoy's aspirating syringe. Before withdrawing the needle squirt a little boracic lotion through it to empty it of septic urine, withdraw it quickly and cover the puncture with gauze and collodion. Suprapubic puncture may be repeated as often as required till further help can be obtained.

B. In cases of enlarged prostate.-A No. 8E gum-elastic condé catheter should be passed, and not more than sixteen ounces of urine drawn off, or a No. 4E catheter can be passed and tied in so that the urine comes away slowly. The bladder should never be emptied suddenly and completely by way of the urethra.

If sixteen ounces are withdrawn every four hours the bladder will be emptied in one to two days, when the question of further treatment must be considered (see Ch. I, Sect. IV). If there are false passages or a catheter cannot be passed, supra-pubic puncture must be performed.

If there is clot retention the best course is to open the bladder by supra-pubic incision, lift out the clots, control the bleeding point and establish supra-pubic drainage (see Ch. I, Sect. IV).

c. In acute gonorrheal cases.If the preliminary de-congestive measures fail to relieve the condition, a catheter should be passed and the urine be withdrawn.

D. For retroverted gravid uterus.-A catheter should be passed at once, de-congestive remedies being useless, and the patient be kept in bed and watched. A catheter is passed every four hours, and in a day or two the uterus will usually right itself, but if it fails to do so it must be replaced in proper position by manipulation. If this cannot be done premature labour may have to be induced.

E. For impacted calculus.-The stone can usually be pushed back into the bladder and dealt with by litholapaxy.

F. After operation.-Little urine is secreted during the first twenty-four hours after an operation, owing to the low bloodpressure and the thirst of the tissues for water, so that there

need be no hurry to pass a catheter. If the patient is unable to gratify a desire to pass water, if the bladder causes pain and if it can be felt to be distended, hot fomentations should be applied to the hypogastrium and a hot enema of soap and water administered. If urine is not passed within an hour a No. 10E rubber catheter that has been boiled must be passed and the condition relieved. In certain highly strung patients this process may need to be repeated for a week or ten days after an operation.

G. In hysterical cases (functional retention).—The diagnosis is often difficult, as the practitioner may not feel sure that there is not some anatomical cause at work which he has failed to detect either locally or in the nervous system.

The condition is almost confined to females of neuropathic stock. Though the bladder may be greatly distended appears to cause little pain or inconvenience.

it

A catheter must be passed to confirm the diagnosis from ovarian cyst and the bladder emptied. Very often the condition will not recur, but if it does so the next step is to administer a watery purge such as the pulv. jalapa co., when the bladder may be emptied at the same time as the bowel.

If this fails the bladder cannot be left in a state of overdistension, so that a catheter will have to be passed twice a day, while arrangements are made for some form of treatment by suggestion.

CHAPTER IV.

CATHETERS AND BOUGIES.

THE catheters in common use are made of rubber, gumelastic, or silver plate.

Bougies are made of gum-elastic, steel, whalebone, or catgut.

Gum-elastic instruments are woven out of fine silk or thread, and the gum-elastic varnish is then worked into them. They vary in pliability with the colour of the varnish, and may be bright yellow, brown, red, or black.

There are two scales of measurement. The English scale is an arbitrary scale and runs from 1 up to 16. The French scale is named after Charrière, and each number represents the number of millimetres in circumference-No. 1 is 1 millimetre, No. 2 is 2 millimetres, and so on up to 45.

A great variety of shapes will be found in the instrument catalogues, but for general use we recommend olive-headed gum-elastic bougies, steel bougies after the Sir Henry Thompson pattern, olive-headed catheters for stricture retention cases, and for prostatic retention cases condé gum-elastic with the Mercier curve.

A catheter or bougie must be smooth throughout, and care should be taken in choosing a catheter to see that there is no dead space in the tip beyond the eye which will act as a harbour for bacteria and grease.

If it is desired to tie in a catheter (catheter à demeure) the self-retaining catheter of Pezzer may be employed or an Escat's muzzle, or a gum-elastic catheter can be passed and a safetypin pushed through it just outside the meatus to which tapes are attached on either side. The tapes are fixed to the sides of the penis with strapping.

(For precautions in passing a catheter see p. 278.)

Cleansing and Sterilisation of Instruments.

After the use of any instrument it should be wiped clean

of grease, and then rinsed and syringed through with hot. soda solution to remove the remainder of the lubricant.

Metal and rubber instruments should be boiled and dried before being put away. Metal instruments can be dried in spirit, or wiped dry while still hot and put away in a dry case. To dry the interior of a metal instrument twist a little cottonwool round the end of the stylet, soak it in 98 per cent. spirit and push it through the catheter.

The old gum-elastic catheters could not be boiled, but the modern catheters will stand being plunged into boiling water for a few minutes without degenerating, so that this method of sterilisation can now be adopted and is especially advisable in dealing with a nerve case.

Ureteric catheters can be sterilised without degeneration of fabric if they are boiled for five minutes in a saturated solution of ammonium sulphate, or they can be wrapped in lint and hung in a steam steriliser for two hours, or they can. be sterilised by the formalin method.

Two other methods may be employed for the sterilisation of gum-elastic instruments.

1. The dry method by means of formalin vapour.

2. The wet method by means of corrosive sublimate solution. All traces of grease must be removed before applying either of these methods, and before passing an instrument so sterilised it should be laid out in sterile water or boracic lotion to remove the irritating strong antiseptic on the sides of the catheter.

1. THE FORMALIN VAPOUR METHOD.

A closed metal chamber is required with a tray on the floor and shelves above to hold the catheters. Two drachms of 40 per cent. formalin are poured into the tray, and the chamber is closed for twelve to twenty-four hours. After this time the formalin is removed and the instruments lying in the chamber are ready for use.

Glass tube sterilisers are on the market with patent indiarubber corks which have a small chamber to contain "paraform powder," a powder that gives off formalin vapour. The instruments are dropped into the glass tube and corked up for twenty-four hours in the vapour.

Instruments must be thoroughly dried before being exposed to formalin vapour. A simple method is to drop them for a moment into spirit and then blow them dry with a bellows.