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SOMETIMES SUDDEN RETENTION OF URINE.

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tarily during sleep, or even in the day on making any effort which requires straining, or, in other words, a strong contraction of the abdominal muscles, is very apt to think that his water passes with unusual-indeed, perhaps, with too much freedom; and the last thing in the world he dreams of is the existence, in his own person, of any obstruction in the urinary outlet. The condition of such a patient, too, has sometimes been overlooked, even by his medical attendant, and no specific investigation of the bladder is made. The apparent freedom of micturition has masked the real malady, and the treatment is directed only to those symptoms which have been productive of most discomfort or anxiety to the patient; it may be, only to the general malaise, or some febrile condition not uncommonly resulting from the hidden cause. The march of events, however, must ultimately arouse suspicion as to the state of the bladder; a catheter is passed, and, greatly to the astonishment of the patient, and sometimes scarcely less so in the view of those who have long watched him closely, some thirty or forty ounces of urine, or even a very much larger quantity, may be drawn off, notwithstanding that the act of micturition has been just performed. Now, it is during the prevalence of such a state of things that unaccustomed exposure to cold and damp, or undue indulgence in alcoholic drink, or in sexual excitement, may suddenly produce congestion of the already enlarged prostate; and a condition of complete retention, thus induced, may be the means of discovering the existence of the affection for the first time. After this the habitual distension may be greatly lessened in degree by the daily use of the catheter, but it rarely or never happens that the bladder is able to regain the power of evacuating its contents completely, as it does after simple over-distension of its coats, resulting from unnatural retention, when there is no organic obstruction at the neck.

The last stage may sometimes be indicated more by the signs of a gradual decline of the powers of life, than by those of advancing obstruction; on the other hand, the final symptoms are

sometimes those of rapid depression, consequent on sloughing of a portion of the organ, and repeated hæmorrhages, with or without the infliction of instrumental injury; or of gradual exhaustion, from constant discharge of pus and mucus from the bladder; or, lastly, of uræmic poisoning of the system, from the failure of the eliminating function of the kidney.

CHAPTER IX.

THE EFFECTS OF ENLARGED PROSTATE IN RELATION TO THE FUNCTION OF MICTURITION. RETENTION. INCONTINENCE.

ENGORGEMENT AND OVERFLOW.

Retention of Urine, more or less considerable, the general result of Enlarged Prostate.-Contrast between Retention and Incontinence.-Retention due to Obstruction, not to Paralysis.-True Paralysis of the Bladder extremely rare, except from Lesion of a Nervous Centre.-Overdistention and Atony of the Bladder.-Tabular View, showing various degrees of Obstruction and corresponding results. -Engorgement and Overflow.-Importance of last-named Symptom.-Commonly confounded with Incontinence.-When does real Incontinence exist ?-The effects on the act of Micturition produced by the various organic changes in the Bladder, Uterus, &c., which occur as the result of Enlarged Prostate.

MECHANICAL obstruction, which may be situated either at the neck of the bladder or in the urethra, is the chief cause of chronic retention of urine; that is, a state in which the patient, being unable by his unaided efforts to empty the bladder, retains there a certain portion of urine, varying considerably in quantity, just as the amount of obstruction itself varies, unless the fluid be withdrawn by artificial means. By far the most common cause of this condition is enlarged prostate; and when the obstruction is considerable, it may be that no urine at all is passed by voluntary effort. The bladder then becomes permanently distended, unless the catheter be employed; and the fluid gradually increasing in quantity, at length opens out the orifice, and flows off spontaneously. To designate this phenomenon the term Incontinence was originally applied, and is still employed by many, although it has long been well known that the condition so described is in reality the very reverse of incontinence, since the bladder already contains too much, and the surplus only overflows, the viscus often retaining much more than its

capacity, in a state of health, would admit of. The bladder is in fact engorged and the urine overflows.

The phenomenon of involuntary micturition in elderly persons is very frequently accounted for, not on the ground of existing obstruction, but on that of paralysis affecting the bladder. It is supposed that either the neck or the body of the bladder may be separately paralyzed, the remaining portion retaining its normal supply of nervous influence-a pathological state the existence of which it would be very difficult if not impossible to prove, and which, if it be an actual occurrence, is certainly extremely rare. On this theory, however, it is said that when the neck is paralyzed and the body unaffected, the vesical outlet becomes patent and incapable of contracting, and that the urine flows off as fast as it escapes from the ureters, while the bladder itself remains empty. The term Incontinence has been employed to designate this condition also, although it presents a state which is the exact reverse to that already so described. But in this case, whether a nervous lesion be the cause of the phenomenon or not, the term is appropriate, because the bladder is unable to retain; the condition may, therefore, be very accurately described as one of incontinence of urine.

On the same theory, also, retention of urine is supposed frequently to be caused by the converse form of paralysis of the bladder, that is, when the neck retains its nervous supply, and the body losing it, becomes unable to expel its contents. Thus it will be seen that the term Incontinence comes to be frequently applied to precisely opposite states of the containing function of the bladder. Hence the misunderstanding, the difficulties, and the grave errors in practice which sometimes occur, especially to the student, in connection with this subject.

Now, without discussing here at length the question already raised, as to whether these local deprivations of nervous influence do, or do not, take place-in the one case affecting only the neck of the bladder, at other times the body alone-I have no hesitation in affirming that in a great majority of the cases in which

THE COMMON CAUSE OF RETENTION OF URINE.

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babitual retention of urine, with overflow of a surplus portion, exists, the cause is palpable and physical, and not impalpable or dynamical; a fact which in each individual case may be ascertained by examination; in other words, there is an organic obstruction in some part of the urethra, situated either at its commencement in the neck of the bladder, where it is usually constituted by enlarged prostate; or in a portion of the canal anterior thereto, where it usually takes the form of permanent or organic stricture.

We are, I believe, indebted to Mercier of Paris for first calling attention forcibly to the important fact that organic obstruction, not local paralysis, or impaired nervous supply, is the great, and almost universal, cause of the various states which are described as retention and incontinence, when existing in elderly individuals who present no sign of impaired nervous power in other parts of the body. To his able discussion of the subject I would refer my readers for the arguments in favour of this view. not entered upon here, because I have preferred regarding it as a question of fact, rather than as a theme for abstract reasoning. The obstruction is, or is not present; if the former, it may generally be verified. Experience alone has led me to reject the impalpable cause, and to appreciate the material one, and to an extent sufficient to warrant me in referring to the fact alone for corroboration of the assertion made above.

It is

In 19 cases out of 20, excluding two classes of cases which will be immediately named, the symptoms described are invariably associated with permanent obstruction of some kind, as

See Recherches Anat. Path. et Thérap. sur les Maladies des Organes Urinaires et Génitaux, considérées spécialement chez les hommes agés. Part II. chap. i. Par L. Aug. Mercier, Paris, 1841. Also, Recherches sur les Valvules du Col de la Vessie, Paris, 1848. By the same. Chapter iv. And more recently by the same author, a paper, "Sur l'Inertie, ou Atonie de la Vessie," &c. Gazette Médicale, 1854.-The local paralysis theory was defended by Civiale, in a reply to the above, in the Moniteur des Hôpitaux, Feb. 8, 1855. Mercier's rejoinder appeared in the same journal, April 10 and 12. See, also, these two memoirs, with some additions, in his latest work, Recherches sur le Traitement des Maladies des Organes Urinaires,

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