proportioned in size to the tightness of the stricture, and the
difficulties afforded to its introduction must be overcome by skill
and perseverance; it is no easy matter to pass the instrument in
many cases, and particularly when ineffectual attempts have been
made previously. By gentle insinuation, and perseverance in moderate
pressure, properly directed, the obstacle can always be overcome,—and
that without the infliction of any injury to the parts. I may here
observe, that I have never yet been foiled in passing the catheter,
though very many severe and difficult cases have fallen to my lot; in
other words, I have never been obliged to abandon my attempts to obtain
an exit for the urine by its natural passage, and, as a last resource,
to mutilate and endanger a patient by making an unnatural aperture
in his bladder. Yet circumstances may soon occur to me in which the
introduction of an instrument along the urethra shall be impossible; no
man, it has been said, can be always wise or always fortunate; and he
who pretends to invariable success must be either a knave or a fool.
Should the surgeon fail in passing the catheter, the bladder must be
relieved at all hazards; and if the prostate be sound puncture by the
rectum may be performed. This is neither a difficult nor a dangerous
operation, else it would not be so often resorted to; it does not
require so much skill and management as does the passing of a catheter.
Neither is it painful to the patient; the parts to be perforated are
thin, there is scarcely any effusion of blood, and all is done in the
dark. But it is an operation which should never be thought of, unless
as a last and desperate remedy; it is one in which I have had no
personal experience, though when a student of surgery I have seen it
done a few times. The procedure gives temporary relief, but then the
urethra still remains to be put into a proper condition; a man cannot
always void his urine and excrement through one common cloaca. If the
urethra be cleared, the recto-vesical aperture may soon close. After
the bladder is relieved, the urethra may become quieter, and admit
of an instrument being more easily passed; but it is of very great
consequence to effect the introduction of a catheter at the first.
Rather than puncture the bladder, the stricture should be cut down
upon, and an opening made into the dilated part of the urethra
behind the obstruction. A firm silver catheter is passed down to the
stricture, and retained there by an assistant; an incision in the
line of the central raphe—supposing the constricted part to be in the
perineal region—is made over the extremity of the instrument, the
contracted part of the urethra is divided, and the catheter passed on
into the bladder. Thus, even in the worst cases, the natural canal is
at once established. In every instance of difficulty and complication,
the catheter, however passed, should be retained for two or more days.
The above is the only admissible mode of puncturing by the perineum.
It has been proposed to reach the bladder from the perineum either
by extensive incisions or by the random thrust of a long trocar; the
latter mode is unscientific, the former is unnecessarily painful,
serious, and difficult; both are dangerous, and to be avoided.
The symptoms of extravasation of urine have been already detailed.
The practice must be bold, and adopted without hesitation or delay.
No bulging or fluctuation in the perineum is to be waited for. It is
to be kept in view, that the escape of urine into the open cellular
tissue may occur in a case of bad stricture, from rapid ulceration or
sloughing, without any of the dilated portion of the canal behind,
induration or abscess having preceded it; in the greater number of
cases the infiltration arises from the giving way of the parietes
of a cavity comunicating with the canal. Urinary infiltration thus
supervenes upon urinous abscess. Extravasation can never be mistaken or
overlooked by a man of any experience, and who is endowed with common
observation. The effect and extent of the perineal fascia must be borne
in mind; it diminishes or precludes—when the point at which the urethra
has given way is interior to it—external appearance of the mischief,
and by confining the deleterious fluid increases the infiltration
internally. A free and deep incision holds out the only chance of
relief; punctures or trifling scratches are worse than useless; neither
is there any need of passing bougies or catheters, or of puncturing the
bladder.
The following instructive case may be briefly detailed. A man applied
at a public hospital for relief, with a large swelling in the
hypogastrium, occasioned by extensive infiltration of urine into the
cellular tissue of the abdominal parietes. The tumour was mistaken for
distention of the bladder, and a long trocar was plunged in above the
pubes without a drop of urine escaping. The patient died during the
night. The bladder was found contracted, and the external cellular
tissue of the abdomen full of urine, from the giving way of the urethra.
When judicious and energetic practice is adopted without delay,
patients often make wonderful recoveries. The following may serve as
an example:—An elderly man laboured under retention, and his bladder
became distended to a very great degree; attempts had been made to
relieve him, but proved unsuccessful. A catheter was passed, and
retained for three days. During my absence in the country retention
again occurred, followed by extravasation. On my return I found him
insensible, but immediately turned him round in bed, and opened the
perineum freely, giving vent to fetid urine, sloughs, and matter.
Next day he was delirious, and knew no one; he hiccoughed, and had
cold extremities; “he fumbled with the sheets,” and “his nose was
as sharp as a pen.” A physician in attendance, well acquainted with
disease, declared that he could not live six hours. But the urine had
a free exit, the hiccough ceased on the exhibition of spiritus ammoniæ
aromaticus, and wine and brandy were poured into him liberally, the
only favourable symptom being, that he still retained the power of
swallowing—when that is lost, all is generally lost. He took soup along
with the stimulants readily and greedily, and, to the astonishment of
every one, recovered rapidly; afterwards the stricture was got rid of,
and restoration to perfect health completed. Many cases of similar
import might be related, all showing the great danger of extravasation
of urine, and the advantage of early and decided treatment. I once
also witnessed, in the Royal Infirmary, an unexpected recovery from
extravasation into the corpus spongiosum urethræ. This occurrence is
always attended with most imminent risk; and is generally the result
of retention from stricture. The urine escapes into the bulb, or
anterior to it. Alarming constitutional symptoms quickly supervene;
rapid sinking is threatened. The whole penis, scrotum, and perineum
are swollen, but the swelling is hard, and most marked in the glans
and along the course of the urethra. The glans blackens, unhealthy
abscesses form in the spongy body, and before these give way, or
at least before the sloughs begin to separate, the patient usually
perishes. The man to whom I allude, however, recovered, retaining
a part of the penis, as well as a considerable portion of its
integuments; the rest sloughed and were discharged.
In regard to retention from swelling at the neck of the bladder, it may
be observed, that spasm of that part of the viscus has been, by some,
considered as a cause of the affection; it is not easy to explain or
understand how this should occur, and such an idea is a bad one for him
to entertain who enters on the treatment of the disease. The capacity
of the bladder varies much in cases of enlarged prostate; in general
the organ bears a good deal of distention, and the urgent symptoms
do not appear rapidly. Nevertheless, it is the duty of the surgeon,
immediately on being called, to relieve the bladder. When the prostate
is very large, and retention has continued long, it is impossible to
reach the cavity by a common catheter. Those who employ this instrument
in such cases are often much puzzled; they continue long in their
fruitless endeavours, and, from rashness, generally produce a discharge
of much blood, but no urine; they then become alarmed on finding the
instrument always filled with coagulum, and suppose that blood has
been effused into the bladder, and that the symptoms of retention have
been thus introduced. A catheter is to be used, which is two or three
inches longer than the common one, possessing a larger curve, of such
a size as to admit of being passed easily, and not so small as to
render it liable to interruption from entanglement in the lacunæ of the
urethra. The posterior part of the urethra is elongated to no slight
extent by the enlargement of the prostate, and, besides, the whole
canal is stretched by the distended bladder rising high in the abdomen.
In short, the bladder is farther away from the surgeon than it is in
other cases of retention, and he requires an instrument proportionally
long in order to reach it. No time is to be put off. A cautious and
persevering endeavour must be made to bring away the urine by the
natural passage. Force is prejudicial and unnecessary. It is true
that the projecting third lobe of the prostate has not unfrequently
been perforated by the catheter, and no unpleasant consequences have
resulted, the urine continuing to flow, perhaps freely, through the
artificial opening there; but still it is always an injury, often an
unnecessary injury, and as such to be avoided. The catheter is to be
passed steadily on till it approaches the prostatic region; it is then
to be guided by the forefinger of the left hand introduced into the
rectum, and when the point is lost in passing through the gland, the
instrument is carefully carried forward by depressing the handle, and,
if long enough, it will infallibly reach the urine and relieve the
bladder. It must, indeed, be a very extraordinary case in which the
bladder cannot be reached with the catheter.
When enlargement of the prostate, whether of the whole gland or
principally of the third lobe, presents an insuperable obstacle to the
passage of the catheter, and when the surgeon has taken care to assure
himself that such is the case, I conceive that he ought to perforate
the gland in the direction of the natural course of the urethra, not
with the catheter, but with an instrument better adapted for the
purpose—a long canula, or catheter with open end, very slightly curved
towards the extremity, provided with two wires, one blunt and bulbous
at the extremity, the other pointed as a trocar, both made so as to
project a short way beyond the end of the canula. The canula is passed
on to the resisting body, its orifice occupied by the bulbous wire,
which is then withdrawn, and its place supplied by the trocar, the
instrument being held steadily in the proper direction. The trocar, or
stilet, is pushed forwards along with the canula; the former is then
withdrawn, and the latter retained. This proceeding I consider quite
safe in the hands of an experienced surgeon, one well acquainted with
the urinary passages—but not otherwise. It is in every way preferable
to puncture of the bladder above the pubes, to puncture behind the
prostate, or to puncture of the prostate along with wound of the rectum.
As before noticed, I never have had occasion to puncture the bladder
but once—and that was above the pubes, and for an unusual affection
of the bladder, the particulars of which have been already detailed.
The result of the experience of several eminent surgeons, both in this
country and abroad, is similar.
Elastic gum catheters have been recommended in this affection, and it
is said that after the instrument has been passed to the prostatic
region, its entrance into the bladder is facilitated by gently
withdrawing the stilet, the point of the catheter being thereby
curved upwards, and, as it were, lifted over any central projection
of the prostate that may impede its straightforward introduction. But
according to my experience, this instrument is far inferior to the firm
and long silver catheter.
In all cases of retention when the urine cannot be brought away per
vias naturales, and when no farther assistance or advice can be
procured immediately, the surgeon should puncture the bladder rather
than leave the patient to his fate; and the operation should be
performed early. He must not temporise till all chance of recovery has
gone by. By not operating till late, in this or any other disease, when
by the delay no reasonable chance of saving the patient remains, our
department of the profession is brought into discredit and contempt.
Delay is more dangerous than even the worst mode of making an opening
into the bladder; and while life exists, the patient should have his
chance. Some defer extreme measures from day to day, either from
hesitation or from a false hope that matters may ultimately change for
the better, but the delay of one hour is in many cases most hazardous.
In retention from disease of the prostate extravasation of urine is
more dangerous—more certainly fatal—than in other circumstances.
Here a part of the vesical parietes gives way by sloughing, and the
fluid is effused within the ilio-vesical fascia; in other cases the
extravasation is usually beyond that fascia, and beneath the fascia of
the perineum.
_Puncture by the Rectum_ is, in cases of enlarged prostate,
inadmissible and highly dangerous; the operator must either perforate
the gland, or enter the cavity of the abdomen. Even in the healthy
state of parts, there is very little space between the posterior part
of the prostate and the reflection of the peritoneum. The operator
having ascertained that the prostate is sound, and the rectum empty,
introduces the fore and middle fingers of the left hand into the bowel,
and along these passes a trocar and canula from four to five inches
in length, of moderate calibre, and of a curve rather greater than
that of the sacrum. He places the point of this instrument on the part
to be perforated, and fixes it there, the point of the trocar being
hitherto withdrawn within the canula; the stilet is then protruded,
and both carried onwards into the bladder. The part to be perforated
is immediately behind the prostate and in the mesial line. _ Puncture
above the Pubes_ is easily enough performed when the bladder is
capacious, but it is at best a dangerous operation. The wound is made
through loose cellular tissue; urinary extravasation into that tissue
is apt to occur, and often proves fatal. If the bowels are inflamed, or
evince a tendency towards inflammatory action, the danger is increased,
for a formidable wound is made in the immediate vicinity of the bowels.
The operation has been resorted to when the catheter might have been
passed without much difficulty; this statement may appear harsh, but
it is too true, and can be borne out by indisputable facts. It is
brought forward more as a caution to the young than as a reflection
on the senior members of the profession. Some patients have recovered
from the operation, and lived in misery for months and years, passing
their urine through a canula retained in the wound. An incision is made
above the symphysis pubis, in the mesial line, dividing the integuments
and cellular tissue, to the extent of from one to two inches; on thus
exposing the coats of the bladder, a flat trocar with a canula is
pushed into the cavity of the viscus, at the lower part of the wound;
the trocar is withdrawn, and the urine evacuated.
The treatment of enlarged prostate is palliative—attention to the
general health, the occasional administration of anodyne suppositories
or enemata, prevention of accumulation in the lower bowels, either by
gentle laxatives or the throwing up of bland fluid, and the avoiding as
far as possible all sources to excitement, of mind as well as body. The
radical cure, it has been said, is extirpation of the gland, but the
cool proposal of such an operation would indicate either ignorance, or
dereliction of principle, or mental obliquity, or all combined.
In retention from effusion of blood into the cavity of the bladder, a
long catheter will sometimes evacuate the urine, and after some time
also the blood; for the latter, though at first coagulated, ultimately
becomes dissolved in the urine, and passes off along with it, even
through a catheter of no very large calibre. Should this fail, and the
symptoms continue urgent, an exhausting syringe should be employed,
well adapted to the extremity of the catheter. After the urine has been
thus evacuated, should a suspicion remain of coagula being still in the
bladder, tepid water may be injected with the view of promoting the
breaking down of the clots, and then the exhaustion may be repeated.
_Incontinence of Urine_, as already observed, is a common result of
distention of the bladder and of stricture. But it also occurs as a
primary affection, particularly in young people, from irritability
of the posterior part of the urethra not suffering the urine to
accumulate within the bladder as in ordinary circumstances. It is
sometimes removed by the application of a blister to the perineum,
and by the patient attending to empty the bladder at intervals during
the night. Attention to the state of the bowels is necessary in such
cases. The clearing them of worms or sordes, and the exhibition of
tonics is sometimes also useful. Children, and even mothers, sometimes
have recourse to a more effectual method, the application of a tight
ligature round the penis. But of the folly and danger of such practice,
the following may serve as an example. A. R., when 8 years old, passed
a brass curtain-ring over his penis to prevent incontinence of urine
during the night, and thereby escape chastisement, to which he had
been frequently subjected. Great swelling soon took place round the
ring, and he was unable to remove the jugum. He experienced much pain
and difficulty in voiding his urine; the integuments under the ring
gradually ulcerated, the ring appeared to sink into the substance of
the penis, and the swelling subsided. The integuments met and adhered,
the foreign body was concealed, and all uneasiness soon ceased. The
penis performed well all that was required of it; the urine passed
easily, and after a while he became the father of a fine family. When
between fifty and sixty years of age, he applied to me. For some years
previously difficulty in making water had been coming on, and frequent
desire to pass it in the night-time rendered him very uncomfortable.
He was under the necessity of having a vessel constantly in bed, and
was generally disturbed every half hour. The penis had become very
unserviceable, and he was now anxious to have the ring removed. A
broad hard substance was felt surrounding the penis, close to the
symphysis; an incision was made into the urethra at that part, and a
calculus easily extracted. The uneasy symptoms quickly disappeared,
and the patient recovered with a small fistula at the incised part,
which could have been removed without difficulty, had not all treatment
been obstinately resisted. The calculus resembled a prune in size, of
a crescentic form, with one of the apices detached, and was apparently
composed of uric acid, coated with the ammoniaco-magnesian phosphate.
On making a section of it, about two-thirds of the brass curtain-ring,
partially decomposed, were found firmly impacted in the centre. It
would appear that a portion of the ring had speedily made its way into
the urethra, had been acted upon and washed away by the urine; while
the remainder, coming more gradually in contact with that fluid, had
become incrusted with deposit, and formed the nucleus of the calculus.
It is strange that the penis should have been efficient,—that the
erectile tissue should have remained pervious—after having been cut
completely through near the symphysis.
_Of Gonorrhœa Præputialis vel spuria._—By this term is understood
discharge of puriform matter from the lining membrane of the prepuce,
and from the surface of the glans, accompanied with an itching and
smarting sensation. The affection may arise from mere inattention
to cleanliness, the natural secretion being allowed to collect and
deteriorate; or from the application of acrid matter, gonorrhœal,
or leucorrhœal. It often attends discharge from the urethra, and is
usually met with in those who, from the natural tightness of the
prepuce, uncover the glans with difficulty, if at all. It may occur
without impure connexion; mucous discharge accumulates, becomes
acrid from stagnation, and is washed away by profuse secretion of
puriform matter; the parts then become quiet, and resume their healthy
functions, but are apt from slight causes to be again the seat of
discharge. Generally, the surfaces of the prepuce and glans are relaxed
and turgid, but there is no breach of continuity; in neglected cases
there is superficial patchy ulceration, and sometimes a deep and
sloughing sore. The matter is often confined by tightness of the
præputial orifice, and mischief thereby occasioned to the glans;
a large purulent collection forms, and, if the case is neglected,
ulceration takes place, either of the glans or of the prepuce, or of
both; the latter becomes thin, and at length gives way; the aperture
thus formed extends, and occasionally is of such a size as to admit
of protrusion of the glans. Œdematous swelling generally takes place
to a great extent in such cases. The glands of the groin sometimes
swell, and through inattention may suppurate. The absorbents of the
penis may also become turgid and painful. Tenderness of the glands and
prepuce often exists, in a greater or less degree, for years; in such
circumstances the affection may be termed gleet of the prepuce, and is
usually the consequence of irritable urethra.
The treatment consists in cleanliness and rest, applying astringent
washes to the parts, and suspending the organ. When swelling of the
prepuce or inflammation of the lymphatics is threatened, constant rest
must be enjoined. In obstinate cases, disease of the urethra is to be
suspected as the cause, and the state of that canal should therefore be
ascertained; if derangement of structure or function is detected, then
means must be forthwith adopted for its removal, the applications to
the prepuce and glans being at the same time not neglected. Mercury can
be of no use.
_Phymosis and Paraphymosis_ are often connected with gonorrhœa of the
prepuce, or of the urethra. The edge of the prepuce may be rendered
tight by inflammation, swelling from effusion, or cicatrisation
of sores; the tightness also attends irritability of the urethra,
particularly in young subjects; often it is congenital. The affection
is termed _Phymosis_ when the prepuce occupies its natural relative
situation, but cannot be drawn back so as to uncover the glans. The
contraction exists in various degrees; sometimes the orifice is so
tight that the flow of urine is obstructed, the præputial cavity
becoming swelled and distended every time the patient attempts to
make water. In other instances the uninjected glans can be exposed
either in part or entirely, though with difficulty. In consequence
of the præputial cavity being frequently filled with urine, in cases
of great contraction, urinary concretions have even formed or been
detained there or in the orifice of the urethra, giving rise to very
annoying, and sometimes alarming, symptoms. In consequence of Phymosis,
the urethra and bladder may become diseased. It is often attended
with profuse puriform discharge, with sores of different kinds, or
with warty excrescences on the glans and prepuce; sometimes the whole
surface is completely covered with granulated prominences of various
sizes, some large, but the majority small, some broadly attached,
others suspended by narrow necks; all generally furnish discharge of
thin acrid matter. Adhesion may take place between the raw surfaces of
the prepuce and glans, provided the parts be not frequently displaced
for the purpose of ablution.