« PreviousContinue »
tention takes place, it is not a serious disease in itself, and equal to the destruction of life, whereas no such event would take place, were it not for the supervention of this phenomenon.
The subject of retention, and the operations necessary for it, especially catheterism, occupy nearly a fourth of the volume, and from the want of order, the multiplicity of divisions, and the introduction of tedious cases, are spread out to a most tiresome length, and yet not containing full information on the point under discussion. The following is our author's etiology of the complaint.
“ Causes. These are of two kinds, either the want of expulsive power in the bladder, or some insurmountable obstruction that prevents the flow of the urine. The want of expulsive power may be either a total paralysis or mere loss of tone, in consequence of the detrusor muscles having been sprained. The mechanical obstructions may be numerous, such as spasms and inflammation of the sphincter vesicæ, or of the membranous part of the urethra; a coagulum of blood or stone in the bladder ; a calculus lodged in some part of the urethra ; strictures of that canal ; diseases of the prostate gland, or some imposthume forming near the anus." 129.
As it is of great importance to be well acquainted with the various causes of urinary retention, we shall enlarge a little on this subject, and cull information from other sources than the work under revicw.
Mr. Bingbarn takes no notice, that we see, of renal retention of urine, a complaint by no means uncommon. The ureter is liable to inflammation like other membranous canals, and to have its calibre lessened or obstructed by thickening of its coats, by coagula of blood, by calculi, or by tumours in the neighbourhood. In such cases the ureter, above the obstruction, dilates, and ultimately the kidney itself; some remarkable instances of which we lately gave in this Journal. Callisen and other writers have found sereral pints of urine in the pelvis of the kidney, and Desgranges reports instances where the ureter was enlarged to the size of the colon, forming convolutions and pouches of great magnitude. Unfor. tunately the symptoms of this malady are equivocal, and therefore we shall not dwell upon them; but the young practitioner should know that such diseases will occasionally cross his path, and the appearances on dissection should not take him by surprize.
Vesical retention, then, is the disease with which we have most to do, and its etiology is very extensive. Calculi in the bladder sometimes cause retention of urine, and more especially small calculi that happen to get jammed in the passage. In soch cases the calculi must either be pushed back with the catheter, or extracted by means of the admirable forceps invented by Sir Astley Cooper and Mr. Weiss.
A coagulum of blood in the bladder is not a very rare cause of retention, especially after lithotomy. It requires the injection of warm water through the wound or urethra, and then the urine to be drawn off by a cathcter. The same observations will apply where a collection of glairy mucus obstructs the passage and causes retention of urine, in some cases of catarrbus vesicæ.
Irritation or Inflammation of the bladder itself, especially of the neck of the bladder, is perhaps one of the most frequent causes of retention of urine, and this inflammation, congestion, or irritation may be determined by all the causes, local and constitutional, which we have alluded to as productive of vesical catarrh. It may be permitted us here to remark, that when this cause of retention is present, it will be prudent to reduce, in a considerable degree at least, the inflammatory condition of the parts before catheterism be employed. This reduction will, of course, be effected by blood-letting, general and local, fomentations, glysters, antimony, and finally, anodynes. The catheter will then be much more easily introduced.
Paralysis of the Bladder is not an infrequent cause of retention, especially in elderly people, and it is astonishing to what a size the receptaculum urinæ will sometimes reach, under these circumstances. Instances'are related by Lieutaud, Murray, Baldinger, and Beddingfield, where the bladder has contained fifteen, sixteen, and even twenty pints of water. It is well known that in these cases the patient goes on making water, but without ever completely emptying the bladder, and when the viscus arrives at a certain stage of distention, there is a constant dribbling, or an incontinence rather than a retention of urine.
The causes of this complaint are sometimes manifest, sometimes obscure. Over-distention, old-age, affections of the spine, excess of venereal indulgences, onanism, hard labour, are among the principal causes. It is evident ibat the catheter is our principal, perhaps only resource in such cases. But we would recommend our young surgical brethren not to content themselves, as they sometimes do, with drawing off the urine every twelve hours. They should draw it off every six hours at least ; but the best plan is to leave the catheter in the bladder, and thus let the organ keep in a constant state of contraction. Richerand and some other surgical writers have exaggerated the dangers attendant on leaving à catheter in the bladder, by supposing that air will get into that organ, and cause irritation or inflammation. This, we believe, is quite imaginary.* · Of tumours and other disorganizations about the neck of the bladder, determining retention of urine, it is not necessary to speak bere.
Urethral Causes of Retention. These are the most numerous class perhaps of all. Calculi, strictures, foreign bodies, clots of blood, inflammations, organic changes-all these in turn produce retention of urine, and require modifications of treatment according to the cause.
But we must now give some account of our author's observations on retentions.
He remarks that, if retention of urine be not relieved by art, it generally proves fatal. Most usually the bladder ulcerates, or rather sloughs, and the urine escapes into the neighbouring parts. The retention of urine, however, sometimes proves fatal without any extravasation of urine or breach of continuity in the bladder. Mr. Bingham asserts that the bladder is neter lacerated by over-distention. This is a hardy assertion. William Hunter relates the case of a poor woman, whose bladder burst and discharged eight or nine pints of water into the abdomen, which quickly proved atal M. Deschamps relates a similar case in the 48th volume of the Dict. des Sciences Medicales, page 123. We believe, however, that these instances are very rare, and that the ulcerative process is the usual mode of the bladder's give ing way.
The comatose state of brain which usually takes place in. fatal retentions of urine, does not, be supposes, depend on translation of urine to the brain, but is entirely owing to a determination of blood. As all the excretions, and also the effusions ou the brain, in such cases, exhale a urinous odour, we do not see any great improbability that there should be an absorption of urine into the blood, the same as of bile in jaun. dice, and thus irritation of the brain produced. One of Mr. Bingham's discoveries, as noticed in the preface, is the suffocation of some patients labouring under retention of urine," in consequence of the air-cells of the lungs becoming filled with frothy fluid.” Of the exclusive originality of this termina. tion we doubt, for we see Montfalcon allude to it in the article « retention,” in the Dict. des Sciences Medicales, without appearing to consider the observation as any thing new,
In these paralytic cases much may be done in aid of catheterism by frictions with the lytta ; and also by a judicious administration of the tinctura lytta internally.
But be that as it may, the case on wbich the doctrine is founded, does not appear to us to have a single symptom of retention of urine attached to it. Our author was called to a muscular man whom be found stretched out in bed perfectly insensible, with strong indications of congestion in the brain, his pulse 120, hard and full. His wife informed Mr. B. that he had only eaten and slept alternately for several days; and that about twelve hours previously, he had taken for breakfast, half a pound of beef-steaks, with a proportion of ale, and several glasses of gin.
“ I enquired how he made water, and his wife replied very well, and assured me that she had seen him void a pint or more of colourless urine at one time that very day.” 116.
Mr. B. drew off forty ounces of blood from the lemporal artery, which brought him to his senses. Next morning he was found insensible-his breathing making a noise as if the air was forced through mucus, and much frothy fluid issuing from his mouth and nostrils. He died in a few hours. On opening the head, the vessels of the brain were found gorged with blood--the ventricles were deluged with serum-kidneys inflamed "the bladder appeared to be perfectly healthy; it contained a little more than a pint of limpid urine, which distended it to feel tense as a drum head.” Mr. B. found a stricture in the urethra, through wbich he could only force a very fine stream of urine. Now, notwithstanding the drumhead distension, produced by a pint of limpid urine, and the difficulty which our author found in forcing a stream through a dead urethra, we appeal to our surgical brethren, whether there was the slightest reason to put this case down as one of fatal retention of urine? No examination was made of the lungs, and on this case, is erected the novel theory to which our author draws the attention of the profession in his preface. That the man died of congestion and serous effusion in the brain, we have no doubt;-and, that the urinary organs had any thing to do with the fatal termination, we see no evidence.
In the treatment of retention of urine, our author recommends, under all circumstances, when the cause is inflammation or spasm, the warm bath, mild but active purgatives, anodynes, and, perhaps, bleeding. By “bleeding,” he means venesection; for he properly recommends local bleeding in cystitis and in this kind of retention of urine. From having been told by some patients who had complaints in the urethra, that they found much greater relief from bathing with cold water, than froin using water that was warm,” our author is disposed to think, that some cases of retention of urine would be most relieved by cold water. This is loose reasoning in a practical prize essay. Our author, we think, is judicious in pointing out the impropriety of indiscriminate recourse to the catheter as the first measure in every case of retention of urine. “ Retention of urine, (says Mr. B.) resulting from inflammation and spasm, may almost always be relieved by means of the warm bath, anodyne enemas, mild but active purgatives, and the abstraction of blood.” This was the opinion of Pott and Heister. Mr. Bingham has no opinion of the muriated tincture of iron in retentions of urine; and on enquiry among his most intimate friends, the same opinion was elicited. As we have never trusted to this remedy alone, in such cases, we cannot say what is the exact power which it individually possesses in relaxing spasmı about the urinary passages. The infusion of tobacco he prefers to the smoke.
Cathelerism. Our author makes some judicious remarks, on the process of instrumental aid in retention of urine, but they are excessively diluted, as usual, with words and cases, not always the most illustrative. Where the retention has been caused by a voluntary abstinence from discharging the urine too long continued, Mr. Bingham thinks, that we cannot too soon have recourse to artificial means of emptying the bladder," for, in these instances, the spasm of the sphincter vesicæ having been first occasioned by powerful volition, is afterwards continued in consequence of irritation from urine." There are some cases, he observes, wbere a kind of valve is formed over the internal orifice of the urethra, which confines the urine more and more perfectly, in proportion to the violence of the efforts to expel it. These cases can only be relieved by instruments. Elastic gum catheters our author prefers to silver.
“ Used on a stilet they may have the same degree of firmness imparted to them as belongs to the silver ones, and owing to their pliability, if employed without a stilet, they may frequently be successfully introduced in the same manner as a bougie, which is by far the simplest operation of the two, and often constitutes the only means by which an unpractised operator will be able to succeed.” 158.
Mr. Bingham considers it a good plan, to keep the elastic gum catheter on stilets that are much bent, for, by being retained a long time in this shape, they acquire a degree of curvature of their own, which makes them, he avers, very superior instruments for some patients, especially those affected with prostatic diseases.
Here we must stop; for, on running over the remainder of the volume, we found that we could glean little that was worth extracting. Upon the whole, we have been greatly disap