CHAPTER V. 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 lastnamed 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, Ureters, &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of urine, varying considerably in quantity, just as the amount of obstruction itself varies, unless the fluid be withdrawn by artificial means.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 thus occasioned is considerable, no urine at all may be 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 DISTINCTION BETWEEN OVERFLOW AND INCONTINENCE. 83 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 even the errors in practice which sometimes occur, especially to the student, in connection with this subject. 84 ORGANIC OBSTRUCTION THE CAUSE OF RETENTION. 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 habitual 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, when 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. It is not entered upon. here, because I have preferred regarding it as a question of fact, rather than as a theme for abstract reasoning. The * 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 Hopitaux, 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, &c. Paris, 1856. obstruction is, or is not present; if the former, it may 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. In nineteen cases out of twenty, excluding two other classes of cases which will be immediately named, the symptoms described are invariably associated with permanent obstruction of some kind, as may generally be verified during life, or, more perfectly, after death. The exceptional cases referred to are, first, those in which there is a cerebral or spinal lesion of some kind, which paralyzes more or less completely the nerve functions of motion, voluntary and involuntary, of sensation, or of sensation and motion combined, of the whole body below the situation of the injury. In such cases the body and neck of the bladder are alike affected, still the result is retention and overflow of surplus. urine,—the very condition, it may be remarked in passing, which is affirmed on the local paralysis theory (as above shown) to be the result of paralysis of the body and nonparalysis of the neck. The second exceptional case is that in which, under the influence of certain circumstances, a healthy individual voluntarily retains his urine for a considerable period, in spite of urgent desire to pass it. The not infrequent result is that the muscular expelling apparatus of the bladder is overstretched, loses its tone, and is more or less unequal, for a certain period of time, to perform contraction in a normal manner. More or less chronic retention results, and may continue unless relieved in the ordinary way. To this state also the term paralysis has been employed; but as there is no evidence whatever that the lesion consisted in any loss or impairment of the nervous force transmitted to the viscus, it is indicative of a better pathology, and conduces to a 86 EFFECTS ON MICTURITION OF ENLARGED PROSTATE. better apprehension of the case in hand, to call it simply as it is, Overdistention, or, if preferred, Atony of the bladder. It is perfectly gratuitous in such a case to imagine a lesion in any part of the nervous system to account for this phenomenon, and it is, therefore, undesirable to speak of it as a paralytic condition of the bladder. The phenomena produced by obstruction at the neck of the bladder caused by enlarging prostate, in connection with the function of micturition, may be briefly recapitulated as follows, and connected step by step with the organic changes which arise in the progress of the affection. OBSTRUCTION AT THE NECK OF THE BLAD DER FROM ENLARGED a. Increased efforts to ex ORGANIC RESULTS. Corresponding Hyper pel urine through giving rise to trophy of the muscular |