Elements of Surgery

by Robert Liston

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.