Part 64

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.

Immediate recourse must be had to the firm silver catheter, 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.