The seven books of Paulus Ægineta, volume 2 (of 3)

by Aegineta Paulus

SECT. LIX.—ON CATHETERISM, AND INJECTION OF THE BLADDER.

When the urine is suppressed in the bladder, owing to some obstruction, such as a coagulum, or stones, or from any other cause, we have recourse to catheterism for the removal of it. Wherefore, taking a catheter proportionate to the age and sex we prepare the instrument for use. The mode of preparation is this: having bound a little wool round with a thread, and introduced the thread with a sharp rush into the pipe of the catheter, we adapt the wool to the opening at the head of the catheter, and having cut off the projecting parts of the wool with a pair of scissors, we put the catheter into oil. Having then placed the patient on a convenient seat, and used fomentations, if nothing prohibit, we take the catheter and introduce it at first direct down to the base of the penis, then we must draw the privy parts upwards to the umbilicus, (for at this place there is a curvature of the passage,) and thus push the instrument forwards. When in the perineum it approaches the anus, we must bend the member with the instrument in it down to its natural position, for from the perineum to the bladder the passage is upwards; and we must push the instrument forwards until it reach the cavity of the bladder. We afterwards take out the thread fastened into the opening of the catheter, in order that the urine being attracted by the wool may follow, as happens in syphons. Such is the method of introducing the catheter. But since we have often occasion to wash an ulcerated bladder, if an ear-syringe be sufficient to throw in the injection it may be used, and is to be introduced in the manner described above. But if we cannot succeed with it we may fix a skin or the bladder of an ox to the catheter, and throw in the injection through its opening.

Commentary. Although we have treated succinctly of strangury and retention of urine in the [Third Book], it may be proper, before explaining the ancient methods of introducing the catheter, to give some further account of the causes of these complaints, and the opinions entertained by the physiologists with regard to the functional offices of the urinary organs. Galen states that the bladder is possessed of two faculties, a retentive and an expulsive, both of which arise from muscular power; that the retentive resides in the neck of the bladder, and is of the voluntary kind of powers; but that the expulsive belongs to the class of natural or involuntary powers, being of the same kind as the peristaltic faculty of the intestines. When a person, then, makes water voluntarily, it is by suspending the voluntary action of the sphincter vesicæ, that is to say, of the retentive faculty of the bladder, whereby the expulsive or peristaltic powers are brought into action, and the contents of the bladder are thereby evacuated. He properly adds, however, that this involuntary or expulsive faculty may be assisted by the action of the voluntary muscles which surround the bladder, especially the recti muscles of the abdomen. Retention of urine, therefore, may arise from the loss of either of these faculties. The expulsive faculty is most commonly lost, either from over-distension of the bladder, as when its contents have been allowed to accumulate too far, or from injury of the spinal marrow which supplies it with nerves. Rhases remarks that when retention of urine proceeds from debility of the expulsive faculty, the bladder may be evacuated by merely making pressure above the pubes.

According to Rhases, retention of urine arising from derangement of the retentive faculty, that is to say, from its no longer being under the control of the will, may be occasioned by inflammation, by some swelling, such as a fleshy tumour forming in the meatus urinarius, or by the presence of some foreign body, such as a stone, a clot of blood, or the like. He alludes several times to this fleshy tumour in the passage, by which he probably means either an enlargement of the prostate gland, or stricture of the urethra. He calls it a very intractable case. For a fuller exposition of the ingenious speculations and opinions stated above, see Galen (De Locis Affectis, iv, 4); Rhases (Contin. i and xxiii.)

Celsus describes very accurately the operation of catheterism. The tube or catheter, he says, should be made of copper, and the male catheter ought to be somewhat bent, smooth, and neither too large nor too small for the passage. The length of the largest male catheter should be 15 inches, of the middle-sized 12, and of the smallest 9; the largest female catheter should he 9, and the smallest 6 inches. The patient is to be laid on his back, and the surgeon standing by his right side, and holding the penis in his left hand, is to introduce with his right the catheter into the urinary passage; and when it reaches the neck of the bladder, the instrument along with the penis is to be bent downwards and introduced into the bladder. When the water is evacuated the catheter is to be extracted. The female passage, he remarks, is shorter, and is discovered by a sort of mammary protuberance above the vagina, by which he evidently means to describe the clitoris. The operation, he adds, in this case is less difficult. (vii, 26.)

The operation is mentioned by Aëtius and other of the Greek authorities, but none of them describe it fully but Paulus.

Albucasis recommends a catheter made of silver. His account of the operation is evidently borrowed from our author. He describes and gives a drawing of an instrument for throwing injections of oil and water into the bladder when inflamed. It is a tube of silver or copper having the bladder of a ram attached to it. (Chirurg. ii, 59.)

Avicenna and Serapion mention the operation but do not describe it minutely. Haly Abbas directs us to make the patient sit and to pour warm water and oil upon the penis. This is evidently recommended with a view of producing relaxation. The ordinary steps of the operation are very properly described by him. (Pract. ix, 45.)

Rhases gives a fuller account of catheterism, and all the circumstances connected therewith, than any other ancient author. He very properly forbids the catheter to be introduced when the retention arises from inflammation at the neck of the bladder. (Ad Mansor. ix, 73.) He first gives Antyllus’s description of the operation, which is very accurate, but similar to our author’s. He recommends us, before attempting the introduction of the instrument, to put the patient into a warm bath, or to apply hot fomentations to the parts. He then directs us to lubricate the instrument with oil or thick mucilage, and to introduce it into the passage until it arrives at the under extremity of the penis, when it is to be gently pushed upwards in the direction of the navel, turning it to one side or another according as it encounters obstruction. He states that it is best to have the openings of the catheter in its sides as they are less likely to be obstructed by clots than when in the extremity. He also mentions that he was sometimes in the practice of using a ductile instrument of lead which accommodated itself to the passage.

Both Serapion and Rhases mention the operation of puncturing the bladder. Rhases says that when there is retention of the urine and the bladder is inflamed, if the case be urgent, and there be reason to apprehend that the introduction of the catheter would aggravate the symptoms, it may be proper to make an incision in the perineum into the side of the bladder, and to draw off the urine with a canula. Both add, however, that there is danger of the wound not closing. (Cont. xxiii, 2.)

The ancients seem to have fancied that it was necessary to fill up the internal cavity of the catheter with wool, or some such substance, in order to produce a vacuum when drawn out, believing that the catheter in this case acted upon the principle of the syphon. See Alexander Aphrodisiensis (Prob. ii, 59.) It is singular that they should have fallen into this mistake, when Galen, as we have mentioned above, had so clearly explained that the evacuation of the bladder is accomplished by the action of its expulsive powers whenever its retentive faculty is suspended or overcome. The earlier writers on surgery likewise adopt the notion that the cavity of the instrument requires to be filled up with wool. See Guido de Cauliaco (vi, 2.) They describe stricture of the urethra under the names of hypersarcosis and caruncula in meatu urinario. See Henricus Regius (An. Med. 44.)