The essentials of bandaging /

by Berkeley Hill

Sounds are solid, being of steel, plated or gilt. Their curve varies, and is generally 20 or 30 degrees more obtuse than that of the catheters.

Bougies are made of the same materials as the flexible catheters; they are kept straight, and the more supple they are the better, the black bulbous-ended bougies being the most useful variety for dilating the urethra.

Fig. 88.—The Olive-headed bougie.

Olive-headed Bougies (Bougies olivaires) are used for exploring the urethra in cases of gleet, where the discharge is often kept up by a stricture or a tender patch of chronic inflammation of the mucous membrane. They are made of metal, or of black gum mounted on a very flexible leaden wire; the latter kind are far preferable. The stem of the instrument is slender, no bigger than a No. 3 or No. 4 bougie; the end terminates in a conical point about ¼ or ⅜ of an inch long, expanding at its base to any required size. These bougies are most useful from No. 4 to No. 16 of the English scale, or from No. 10 to No. 24 of the millimetrical scale. The stem should be marked with white rings an inch apart, so that when the instrument is passing over a tender part, or is arrested by a stricture, the distance of the impediment down the urethra can be at once estimated. In withdrawing the instrument, the wide base of the olive shows the exact position and length of those strictures which are not too narrow for the olive-head to slip by, for it is nipped by the stricture and released as soon as the narrowing is passed. By using instruments large enough to fill the normal urethra, an induration beneath the mucous membrane can be detected in its earliest stage before it has produced symptoms diagnostic of stricture.

Rigid instruments have one advantage over flexible ones, in that their points can be guided by the surgeon; the points of flexible instruments cannot be directed, hence the introduction of the latter into a stricture is less easily managed, consequently bougies with various kinds of points should be kept. But flexible instruments cause far less irritation than rigid ones, and should always be employed instead of the latter when possible: with patience and practice much of the difficulty attending their introduction is overcome. The French bougies, with tapering ends and bulbous points, slip more easily through a stricture than instruments having the same diameter throughout, and bougies with fine tapering points can sometimes be introduced where others fail.

Passing Catheters.—In passing instruments along the urethra the conformation of its interior should be borne in mind. From the meatus to the triangular ligament, the normal urethra, when gently stretched, becomes a straight tube; having, nevertheless, just within the meatus, a pouch in the roof, the lacuna magna, where the point of the instrument may catch if not turned downwards. At the bulbous part the urethra enlarges in capacity by having a slight downward curve in its floor, just before the triangular ligament is reached. In this depression, the beak of the catheter is apt to sink below the level of the passage through the ligament, which is always a fixed point. Beyond the triangular ligament the urethra curves gently upwards, has a floor beset with irregularities, in which the point of the instrument easily catches, if not raised as it passes along the curve.

A Silver Catheter is passed most easily while the patient is in a horizontal position, with the shoulders low and the thighs separated. The surgeon stands on the left side of the patient, and holds the catheter, previously warmed and lubricated with oil or lard, lightly between the thumb and two first fingers of the right hand, the beak downwards and the stem across the patient’s left groin. Then taking the penis between the middle and ring fingers of the left hand, the palm being upwards, he pushes back the foreskin with the thumb and forefinger, and steadies the meatus while introducing the beak of the catheter. This done, he draws the penis gently along the catheter as the point is lowered to the perinæum, but without raising his right wrist until the instrument has travelled 5 or 6 inches along the passage and reached the triangular ligament. The surgeon then carries his right wrist to the middle line of the patient’s body, and while pushing the point onwards, raises the hand round a curve till it again sinks between the patient’s thighs. When the bladder is reached he withdraws the stylet that the urine may escape. Three points of difficulty are usual in passing catheters; the lacuna magna just within the meatus, the triangular ligament, and the prostatic part of the urethra just before the bladder is reached. The first is escaped by keeping the beak along the floor of the urethra for the first two inches; the second is best avoided by raising the wrist as the instrument passes the triangular ligament, and directing the beak against the upper surface of the urethra, lest, being in the enlarged bulbous part, it sink below the opening in the ligament; the third difficulty is overcome by depressing the hand well as the point approaches the bladder.

To pass the catheter in the upright position, the patient is placed against a wall or firm object, with his heels eight or ten inches apart and five from the wall, that he may rest easily during the operation. The surgeon sets himself opposite the patient and grasps the penis with the two middle fingers of the left hand, the palm upwards; he next exposes the meatus with the thumb and forefinger, and his right hand holding the catheter by its middle obliquely across the left side of the patient, he draws the penis on to the instrument till the triangular ligament is gained. He then carries the shaft of the catheter to the middle line and, holding it by its end, brings the right hand downwards and forwards, to carry the point upwards over the obstruction at the neck of the bladder.

The operation should be done slowly and with great gentleness, giving the urethra time “to swallow the instrument,” as the French surgeons express it. Hasty or forcible movements tend to thrust the point against the wall of the urethra, where it hitches, if it does not penetrate and make a false passage. However easy the introduction may have been, the withdrawal of the catheter should be always done slowly to avoid giving pain to the patient.