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.)
SECT. LX.—ON CALCULUS.
The cause of the formation of stones, and that in children they are formed most readily in the bladder, and in adults in the kidneys,—all this having been explained in another place, we now proceed to the method of performing lithotomy, but shall first give the symptoms of stones lodged in the bladder. The patients then void urine of a watery consistence with a sandy sediment; and from constant itching the member is now relaxed and again stretched in an uncommon degree, because, owing to the irritation, they are perpetually handling it, more especially in the case of children. When the stone falls into the neck of the bladder a sudden retention of urine takes place. Of those cut for the stone, children to the age of fourteen are the best subjects for the operation, on account of the softness of their bodies: old men are difficult to cure because ulcers of their bodies do not readily heal; and the intermediate ages have an intermediate chance of recovery. And again, those who have larger stones recover best because they have become habituated to the inflammation, whereas those who have smaller recover with difficulty for the opposite cause. These things being so, when we proceed to the operation, we first have recourse to shaking the patient, sometimes by means of assistants, and sometimes by making him jump from a height, in order that the stone may be forced down to the neck of the bladder. We have then to place him sitting in an erect posture, with his hands under his thighs, in order that the bladder may be forced down into a small space. If then we ascertain by feeling externally that the stone with the shaking has fallen down to the perineum, we proceed immediately to the operation; but if it has not descended, we must introduce the index finger of the left hand well oiled, or, if an adult, the middle also, into the anus, and with the fingers in a supine direction we search with them for the stone, and, bringing it down gradually to the neck of the bladder, we fix it there, pushing it out with the finger or fingers when so fixed; and having given directions to the assistant to press down the bladder with his hands, and ordering another assistant to raise the testicles in his right hand, and with the other to stretch the perineum to the other side from that upon which the incision is to be made, we take the instrument called a lithotome, and between the anus and the testicles, not, however, in the middle of the perineum, but on one side, towards the left buttock, we make an oblique incision, cutting down direct upon the stone where it protrudes, so that the external incision may be wider, but the internal not larger than just to allow the stone to fall through it. Sometimes, from the pressure of the finger or fingers at the anus, the stone starts out readily at the same time that the incision is made, without requiring extraction; but if it does not start out of itself we must extract it with the forceps called the stone-extractor. After the removal of the stone, having stopped the bleeding by manna of frankincense and aloes, comfrey, misy, and such like styptic powders, and having dipped wool or compresses in wine and oil, we apply them; and also apply the bandages for calculous diseases, namely, that having six legs. But if there be any apprehension of hemorrhage we must apply a compress which had been soaked in oxycrate, or water and rose-oil, and placing the patient in a reclining posture, bathe the parts frequently. After the third day, having loosed the bandages, and poured much water and oil into the wound, we may dress it with the ointment called tetrapharmacon (basilicon) on a pledget, removing them and dressing often on account of the acrimony of the urine. If inflammation come on, we must have recourse to the cataplasms and fomentations proper for it. And we may also inject into the bladder oil of roses, oil of camomile, or butter, unless some inflammation prevent. In like manner, if the sore become spreading, or otherwise malignant, we must suit the applications to the state of it. When the ulcer is freed from inflammation we may loose the dressings, and use diachylon plaster to the groins and bottom of the belly. During the whole time of the treatment, the thighs must be bound together, which contributes to the cure with the other remedies. If the stone, being small, fall into the penis, and cannot be voided with the urine, we may draw the prepuce strongly forwards, and bind it at the extremity of the glans. We must next apply another ligature round the penis behind the member, making the constriction at its extremity next the bladder, and then make an incision down upon the stone, and bending the penis we eject the stone, and undoing the ligatures we clear away the coagula from the wound. The posterior ligature is applied lest the calculus should retreat backwards, and the anterior, in order that, when untied, after the extraction of the stone, the skin of the prepuce may slide backwards and cover the incision.