Elements of Surgery

by Robert Liston

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.

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.