be retained. A tape is attached to each of the rings at the neck of
the catheter, is brought under the thigh, and fastened to a bandage
passed round the waist; this simple retentive apparatus is quite
effectual, and suits the erect as well as the recumbent posture. A
peg, of metal or wood, is placed in the mouth of the catheter, that
the patient may be kept dry, and at the same time have it in his
power to relieve the bladder as often as necessary. The instrument
should be retained for twenty-four hours at least, and, if the patient
can bear it, for forty-eight, or even more. At first it occasions
considerable uneasiness, pain, and excitement, but these gradually
subside; when severe, they may be allayed by opiates. The parts make
efforts to get rid of the foreign body, and these efforts are salutary.
Discharge takes place from the membrane, and oozes by the side of
the catheter; relaxation occurs, often to a very great extent; and,
on moving the handle of the instrument, it is found to be not only
less firmly grasped, but to possess considerable freedom of motion
in the contracted part. Thus a most successful inroad is made upon
the disease, and the after treatment thereby happily abridged. The
instrument is withdrawn, and time afforded for the parts to become
quiet. After the lapse of two, three, or four days, according as the
uneasy feelings disappear, a larger instrument is introduced, and
retained perhaps for half an hour; and the successive introduction
of instruments—sounds being now adopted—at proper intervals, and in
proper graduation, is continued as in ordinary cases. Sometimes, though
rarely, the good effects of the first introduction and retention of
the instrument quickly disappear, the stricture becoming tight and
unyielding as before; when this takes place, the practice is to be
repeated, but not till after several days, and then the instrument will
be retained with advantage for a longer time than before, provided
no untoward symptoms are caused by its lodgement. There are very few
strictures, indeed, which will not yield to this treatment, when
judiciously planned and perseveringly followed.
Fistulous openings generally close in a short time, when once the
urethra has been widened. Their contraction may sometimes, however,
prove slow and imperfect, even after the stricture has been entirely
removed, and the application of the cautery may be requisite; to
accomplish this, when the opening terminates in the rectum, a speculum
ani is required, by which to view the aperture, and ascertain its site,
and along which to pass the heated wire with safety to the bowel. The
cautery is not to be applied so as to produce an extensive slough, and
much loss of substance, but lightly to the edges. On the separation
of the superficial eschar, the margins are raw, excited, and swollen,
with a disposition to granulate; and during cicatrisation of the sore,
considerable contraction takes place, independent of the formation of
new matter. After the contraction thus effected has occurred to its
full extent, and not before, the cautery is reapplied; and by a few
repetitions of the instrument at long intervals, the opening is brought
to close.
At one time attempts to destroy the contraction of the urethra, by the
application of caustic to the stricture, were in great vogue; but the
total inefficiency of such practice is now generally acknowledged.
The armed bougie was in many cases applied hundreds of times, at
considerable intervals; and the mode of treatment, though trying,
tedious, and hurtful to the patient, must have proved useful to the
surgeon—but to him alone. Years were spent in such trifling, and not
unfrequently serious consequences followed this treatment, or rather
neglect, of the disease. Cutting catheters are dangerous, as well as
inefficient for the cure of stricture; thrusting at the end of a long
stricture can avail but little, and in the hands of most practitioners
the instrument is as likely to perforate the coats of the urethra as to
enter the stricture.
Incision of stricture may be required in retention of urine, scarcely
otherwise. The practice is noticed under the treatment of retention.
In stricture anterior to the scrotum, it is well to avoid incision,
if possible, as it generally is so, for a wound there is healed with
difficulty, if at all.
_Retention of Urine_ is not to be confounded with _suppression_ of the
secretion from the kidneys, arising from disorder of the structure or
function of these organs. The kidneys perform very important functions
in the animal economy, and complete suppression of their secretion
under any circumstances is a very suspicious and dangerous occurrence.
In the healthy state of the urinary organs, when the powers of each
correspond, the urine passes without almost any exertion on the
part of the patient; the action of the levator ani and abdominal
muscles is scarcely required. But when either structure or function
is disordered, the balance between the parts is upset; additional
assistance is necessary for expulsion of the contents of the bladder.
The symptoms of retention differ according to the state of the parts
and the cause which has induced it. The bladder varies in size, and
in distensibility. In some cases the organ yields readily to the
accumulation of fluid within it, rising high in the belly, reaching
even the umbilicus, and forming a large, oval, tense, fluctuating
swelling, apparent to the most careless and casual observer. The
swelling and fluctuation are in such circumstances so distinct, that
the disease has actually been mistaken for ascites. Again, all the
symptoms of retention may exist, and all its bad consequences result,
without any apparent swelling of the abdomen. But then the distended
bladder can always be felt by the finger introduced into the vagina or
rectum; indeed its posterior fundus bulges in towards the cavity of the
gut, in every case, before it ascends upwards in the abdomen. Sickening
and agonizing pain, with great anxiety and ineffectual straining,
generally attend distention of the bladder to any great degree. When
the distention is allowed to continue, urinous fever supervenes, the
circulation is accelerated, the patient perspires profusely, and
exhales a urinous odour; delirium comes on, followed by sinking, and,
if the cause is not removed, coma terminates the distressing train of
symptoms. In other instances the painful feelings subside after some
time, and the urine is discharged involuntarily from the urethra. The
ureters lose the valvular structure of their vesical terminations, and
become dilated; the pelvis and infundibula of the kidneys also enlarge,
and all are distended by the accumulating urine. On relieving the
bladder artificially, the pressure is taken off the secreting part of
the kidneys, their secretion is generally renewed with great vigour,
and the bladder is again filled rapidly. If the bladder is not relieved
the secretion of urine is suppressed.
In many cases the urethra—the bladder more rarely—sloughs or ulcerates,
unless preventive measures are adopted, and extravasation of urine
takes place into the cellular tissue of the pelvis, of the perineum,
of the groins, of the lower part of the abdominal parietes—into
the cellular substance of the scrotum, and of the penis—the parts
infiltrated depending of course on the point at which the urinary
canal has given way. Under such circumstances the patient is sometimes
rapidly destroyed, the extravasated urine appearing to induce speedy
sinking, similar to the effects of inoculation with a most virulent
poison. If the urine escapes into the cavity of the abdomen, the
patient inevitably perishes, and that very speedily; and when the
cellular tissue of the pelvis is the seat of the extravasation, little
hope can be entertained of recovery, though the fatal termination
may not be so rapid as in the former case. When the urine is effused
into more external parts, as into the perineum or scrotum, the danger
is also imminent, if the fluid is allowed to accumulate and become
extensively infiltrated; but when it freely escapes externally, either
spontaneously or by incision, there need in general be no great
apprehension of immediate danger. In such cases the aperture in the
urethra is found to be at first irregular and ragged; afterwards its
inner surface becomes rounded off, and a papilla presents externally.
The infiltrated cellular tissue is dark, fetid, broken down, and
soft, sometimes seemingly in part dissolved by the putrescent urine;
and, when the patient has survived a considerable time, it frequently
resembles closely in appearance a portion of suppurated lung. When
active practice is not adopted after extravasation of urine has taken
place, the cellular tissue around sloughs along with the integuments;
rapid depression of the powers of life ensues, with great disturbance
of the sensorial functions. Death very soon relieves the patient from
his sufferings; some few struggle through, and recover, after losing
the coverings of the penis, of the testicles, and of the perineum.
The causes of retention are many; but the surgeon must know them all,
as the treatment must vary according to the cause. They may be divided
into such as weaken the power of expulsion, and into such as impede the
progress of the urine in the urethra.
Retention of urine is caused by paralysis of the bladder, from
over-distention, from injury or disease of the spinal chord, from
pressure on the spinal chord or nerves. In such cases the bladder often
attains a very large size. At first the accumulation produces all the
uneasy symptoms formerly mentioned, but after some time these subside,
and the urine drains away according as it is secreted, without,
however, the original accumulation and tumour being diminished. This
state of the urinary system is very common in old people, who neglect
natural calls to empty the viscus during the night, or while sitting
socially after dinner. The uneasiness gradually goes off, and when they
at length think of making water, none can be got to flow. Sometimes
they remain in this state—the bladder full, and becoming more and more
distended—for days, drinking gin and water, juniper tea, or other
popular remedies. Incontinence then takes place, and the dribbling of
the urine affords considerable relief; this state of matters is often
allowed to continue for weeks. Thus the power of expulsion may be lost
for ever, though sometimes it is regained even under very unfavourable
circumstances. I recollect attending a man upwards of eighty, labouring
under retention of urine with incontinence, and whose bladder required
relief by the catheter for ten or twelve days; at the end of that
period the bladder regained its expulsive power and retained it; and
cases are on record in which the power of expulsion has returned
after the lapse of several months. Retention thus induced is often
complicated with disease of the prostate gland or of the urethra. The
patient, perhaps, has been for a long time incapable of emptying his
bladder completely; a portion of the urine always remains in the most
dependent part of the viscus, and the quantity retained becomes greater
and greater, until from some slight cause the power of expulsion is
lost entirely. In these cases the bladder, though much increased in
capacity, is also much thickened.
Retention from inflamed urethra, attended with swelling and spasm about
the neck of the bladder, is preceded by hardness and tenderness in the
course of the urethra, and a smarting felt when a drop of urine passes
along. Retention not unfrequently takes place during gonorrhœa, from
the dread which the patient has of making water; and from the swelling
of the lining membrane.
Retention from abscess in the perineum was formerly noticed.
Retention from injuries in the perineum. The urethra is either severely
bruised, perhaps lacerated, or torn completely across; and if the
patient attempts to make water before proper means are adopted, blood
and urine are extravasated into the cellular tissue exterior to the
canal. In cases of slighter injury, retention may occur on account of
the inflammatory swelling of the parts supervening secondarily.
Retention from stricture of the urethra is of very frequent occurrence,
and most difficult to manage. The state of the urethra and bladder
in this disease has been already adverted to, but it is necessary to
bear in mind the thickening of the latter, and the dilatation which
uniformly takes place behind the stricture. All the urgent symptoms of
retention may, in this case, arise from the accumulation of but a few
ounces of urine. The bladder contracts frequently and very forcibly,
causing great suffering. Temporary relief is experienced when the
urethra gives way by ulceration, and the urine becomes extravasated
into the cellular texture; the patient gets up, and, if in the dark,
thinks that the stricture has yielded, and that he is passing urine
naturally. But soon he feels a glowing heat in the perineum; the
parts swell and become livid; violent constitutional symptoms come
on, the discoloration advances, the integuments slough, ill formed
matter is discharged, and disorganised cellular tissue mixed with
putrid sanies is exposed. The parts exhale a urinous odour, which,
when once smelt by the practitioner, can never afterwards be mistaken.
Occasionally œdematous swelling of the penis takes place, particularly
of the prepuce, when it has been pulled at and bruised during the
patient’s efforts to make water, and this must not be confounded with
infiltration of urine; I have seen it occur some time after the bladder
had been relieved by the catheter. Infiltration of putrid serosity
into the cellular tissue of the prepuce, the subcutaneous tissues of
the penis, scrotum, and lower part of the abdomen, occasionally also
takes place to a great extent, after the bladder has been relieved by
the catheter, the coverings are destroyed, and the patient may, even
despite of active treatment, perish in consequence. In such cases, a
small quantity of urine may possibly have escaped into the cellular
tissue before the bladder has been relieved, so as to commence the
mischief.
Retention from the lodgement of calculi. Temporary obstruction to the
flow of urine is sometimes experienced from calculus in the bladder.
Complete and fatal retention has arisen from calculi having become
impacted in the urethra, and been allowed to remain there, blocking up
the passage entirely.
Retention from affections of the prostate gland and neck of the
bladder, inflammatory or indolent. In acute inflammation of the
prostate gland and cervix vesicæ, the other parts around swell, the
mucous membrane becomes turgid, and the mucous secretion is increased.
Suppuration may take place, and an abscess, chronic or acute, form
in the substance of the gland, or in the cellular tissue exterior;
the parietes of the abscess may give way, and the matter discharged
into the bladder, into the rectum, or into the cellular tissue of
the perineum. Bloody and mucous discharge from the urethra, frequent
desire to make water, sudden stoppage of the urine whilst making water,
pain in the glans penis, and other symptoms of stone in the bladder,
followed a fall on the back. Afterwards, a tumour pointed into the
rectum, and was opened; purulent matter was profusely discharged, and
afterwards urine escaped through the aperture. The patient died in
three weeks, from irritative fever, with gastro-enteritic symptoms.
Along with thickening of the bladder, and disease of its mucous coat,
there was found a large abscess of the cellular tissue, communicating
with an abscess in the third lobe of the prostate gland, and that with
the cavity of the bladder.
When the affection is less acute, the prostate slowly enlarges, from
opening out of its texture, and deposition of new matter in the
interstices, it becomes hypertrophied. The whole gland may enlarge
uniformly, but generally one part protrudes more than the others. When
the third lobe enlarges, it necessarily projects into the bladder, or
into the prostatic portion of the urethra, and there, acting like a
valve, causes much more formidable obstruction to the flow of urine
than does enlargement of the lateral lobes; the obstruction is the more
complete the greater the distention of the bladder. At first, this lobe
is but slightly prominent, and of a conical form; but as it enlarges,
its regularity of shape disappears, the tumour is nodulated, and in
general somewhat pyriform. It occasionally projects to one side of the
passage. The affection is seldom met with, unless in old people.
In consequence of prostatic enlargement, pain is felt in the perineum,
with occasional throbbing, and a sense of weight; there is frequent
desire to make water, the bladder is irritable, and discharges ropy
mucus. There is more or less irritation of the lower bowels; there
is an almost constant desire to empty the rectum, from a feeling of
fulness there, and pain, often severe, is felt on going to stool; when
the enlargement is great, the bowel is considerably compressed, and
the feces, when solid, are passed flattened like portions of tape.
Frequently there is thin mucous discharge from the urethra. In making
water, the urine, as it were, hesitates, and after a while passes
away, at first in drops, and afterwards in a scanty and irregular
stream; pain is felt at the point of the penis, in the loins and
hips, and often in the inside of one or both thighs. On attempting
to pass the catheter, its extremity is obstructed in the prostatic
region, and the swelling can be felt by the finger introduced into the
anus. Examination of the tumour, per anum, is very often a painful
proceeding; it is best accomplished after a catheter or sound has
been introduced. The disease is often coexistent with calculus in
the bladder. The tumour is very seldom malignant, but proves both
troublesome and dangerous from its size. The bladder may become
distended in consequence, though retaining the power of partially
relieving itself; or the urine may come away involuntarily after some
time; or retention may be complete, and, if not relieved, the bladder
may slough.
It is to be recollected, that in retention of urine, from whatever
cause, and particularly in that arising from prostatic enlargement,
the urethra is elongated, and the bladder rises into the abdomen like
the gravid uterus. The reason of such change of relative situation is
sufficiently obvious, being chiefly mechanical.
Fungous, or other tumours, furnishing blood or vitiated puriform
matter, now and then grow from the internal surface of the bladder,
unconnected with the prostate gland. Worms, too, occasionally lodge
in the bladder. Either of these circumstances may induce retention of
urine. Another cause of obstruction is hernia of the bladder.
There is no disease in which the patient is more liable to be ‘bungled
out of his life,’ than in retention of urine. Great credit is to be
gained by judicious and skilful management of the various stages,
and by expert use of the catheter in difficult cases, when other
practitioners, perhaps, after being foiled, have proposed operations
alarming to the patient, and, in themselves, dangerous. In no disease
are patients more grateful for relief, for in this the agony is often
unbearable. Immediate abatement of all painful symptoms follows skilful
and prompt measures; and the superior science of one man over others
is made apparent to the most ignorant observer. In over-distended
bladder from paralysis, the catheter can in general be passed without
difficulty. It should be of a large size, and its introduction should
be repeated as often as nature calls for relief, perhaps three or four
times during the twenty-four hours, until the viscus regains its tone;
and this, unless irrecoverably lost, will generally be restored in a
few weeks at most. Repeated introduction of the instrument is here
preferable to the retaining of it; the latter measure should always be
avoided, unless absolutely indispensable, for a foreign body lodging
in the urethra and neck of the bladder must always be a source of
more or less irritation; and experience shows that the bladder sooner
recovers its tone when the instrument is introduced only to draw off
the urine, when the uncomfortable feelings of distention come on,
than when it is constantly retained. The patient soon learns to pass
the instrument himself, and thereby saves the surgeon from frequent
attendance, whilst, at the same time, the bladder is opportunely
relieved. Stimulants, as the tinctura lyttæ, given internally, with
external friction, blistering, and the application of strychnine to the
raw surface, may contribute towards restoration of the muscular power
of the organ. Injections into the bladder have been recommended, but
are both hurtful and inefficient. Enemata, containing turpentine, or
other stimulating fluids, are of service.
In retention from inflamed urethra, the catheter should, if possible,
be dispensed with. The introduction of it is excruciatingly painful,
and will certainly aggravate the original affection. Blood should be
abstracted both from the system and from the perineum; fomentations,
with the warm bath or the hip bath, are afterwards to be employed.
The retention is usually induced by hard exercise, or intemperance
in living; these of course must be abandoned, and their opposites
enjoined. Camphor alone, or combined with opium or hyoscyamus, is to be
given internally in large doses. Opium may also be useful, administered
in the form of an enema or suppository. If relief is not soon afforded
by such soothing measures, the bladder must be relieved by the
catheter; and if the surgeon be foiled in the introduction of this,
as he ought not to be, the only resource is to puncture the bladder
from the rectum—a harsh measure, to be sure, and one not indicative of
surgical talent, but still preferable, in the eyes of both patient and
practitioner, to death.
In retention from abscess in perineo, a little delay is allowable
under the employment of palliatives, when the affection is acute. The
abscess must be freely opened as soon as its seat is discovered; and
until the evacuation of the matter, the use of the catheter should be
deferred if possible. In cases of chronic abscess, the catheter must be
used, and does no harm.
In retention from injury of the perineum, the catheter should be passed
before the patient attempts to make water, and the instrument must be
retained; thus extravasation of urine in addition to the blood into
the cellular tissue will be avoided. If extravasation has occurred,
the perineum, scrotum, or other parts, must be freely incised wherever
the urine has been effused, in order to prevent the direful effects
of lodgement of that fluid; and then the catheter should be passed
and retained as in the former instance. If the surgeon be foiled in
introducing an instrument, as he may be, and if the prostate be sound,
the bladder must be relieved by puncture from the rectum.
Retention from stricture is, as already observed, the most difficult
to manage. No time can be put off in bleeding or warm bathing, in
giving internal remedies, or exhibiting enemata. The viscus is making
violent exertions to relieve itself, and if these are left unassisted,
or not rendered unnecessary, they may prove the patient’s destruction.
The system may be drained of blood, and the body parboiled, without
the patient being relieved. The case requires immediate and decided
practice; for whilst the surgeon is consulting about what is to be
done, the urethra may give way, and the patient be lost. The discharge
of a small quantity of urine may follow the introduction of small
flexible bougies, up to the contracted point, but the bladder is not
relieved. The throwing of cold water on the thighs may, in slight
cases, induce such contraction of the expelling muscles as may overcome
the resistance in the urethra, and this method has been had recourse
to after failure with the catheter; but he must be a very poor surgeon
indeed who is foiled, when such practice afterwards proves successful.