Part 62

Fig. 12, Plate 57.--Behind the meatus, and on the right of the fraenum, is represented a perforation in the urethra, caused by a venereal ulcer. The meatus and the false opening have approached by the contraction of the cicatrix; in consequence of which, also, the apex of the glans is distorted towards the urethra; a bougie introduced by the meatus occupies the urethral canal.

Fig. 13, Plate 57.--In this figure the canal of the urethra appears turning upwards and opening at the median line behind the corona glandis. This state of the urethra was caused by a venereal ulcer penetrating the canal from the dorsum of the penis. The proper direction of the canal might be restored by obliterating the false passage, provided the urethra remained perforate in the direction of the meatus.

Fig. 14, Plate 57, exhibits the form of a congenital epispadias, in which the urethra is seen to open on the dorsal surface of the prepuce at the median line. The glans appears cleft and deformed. The meatus is deficient at its usual place. The prepuce at the dorsum is in part deficient, and bound to the glans around the abnormal orifice.

Fig. 15, Plate 57, represents in section a state of the parts in which the urethra opened externally by one fistulous aperture, a, behind the scrotum; and by another, b, in front of the scrotum. At the latter place the canal beneath the penis became imperforate for an inch in extent. Parts of catheters are seen to enter the urethra through the fistulous openings a b; and another instrument, c, is seen to pass by the proper meatus into the urethra as far as the point where this portion of the canal fails to communicate with the other. The under part of the scrotum presents a cleft corresponding with the situation of the scrotal septum. This state of the urinary passage may be the effect either of congenital deficiency or of disease. When caused by disease, the chief features in its history, taking these in the order of their occurrence, are, 1st, a stricture in the anterior part of the urethra; 2ndly, a rupture of this canal behind the stricture; 3rdly, the formation (on an abscess opening externally) of a fistulous communication between the canal and the surface of some part of the perinaeum; 4thly, the habitual escape of the urine by the false aperture; 5thly, the obliteration of the canal to a greater or less extent anterior to the stricture; 6thly, the parts situated near the urethral fistula become so consolidated and confused that it is difficult in some and impossible in many cases to find the situation of the urethra, either by external examination or by means of the catheter passed into the canal. The original seat of the stricture becomes so masked by the surrounding disease, and the stricture itself, even if found by any chance, is generally of so impassable a kind, that it must be confessed there are few operations in surgery more irksome to a looker-on than is the fruitless effort made, in such a state of the parts, by a hand without a guide, to pass perforce a blunt pointed instrument like a catheter into the bladder. In some instances the stricture is slightly pervious, the urine passing in small quantity by the meatus. In others, the stricture is rendered wholly imperforate, and the canal either contracted or nearly obliterated anteriorly through disuse. Of these two conditions, the first is that in which catheterism may be tried with any reasonable hope of passing the instrument into the bladder. In the latter state, catheterism is useless, and the only means whereby the urethra may be rendered pervious in the proper direction is that of incising the stricture from the perinaeum, and after passing a catheter across the divided part into the bladder, to retain the instrument in this situation till the wound and the fistulae heal and close under the treatment proper for this end. (Mr. Syme.)

Fig. 1, Plate 58.--In this figure the urethra appears communicating with a sac like a scrotum. A bougie is represented entering by the meatus, traversing the upper part of the sac, and passing into the membranous part of the urethra beyond. This case which was owing to a congenital malformation of the urethra, exhibits a dilatation of the canal such as might be produced behind a stricture wherever situated. The urine impelled forcibly by the whole action of the abdominal muscles against the obstructing part dilates the urethra behind the stricture, and by a repetition of such force the part gradually yields more and more, till it attains a very large size, and protrudes at the perinaeum as a distinct fluctuating tumour, every time that an effort is made to void the bladder. If the stricture in such a case happen to cause a complete retention of urine, and that a catheter cannot be passed into the bladder, the tumour should be punctured prior to taking measures for the removal of the stricture. (Sir B. Brodie.)

Fig. 2, Plate 58, represents two close strictures of the urethra, one of which is situated at the bulb, and the other at the adjoining membranous part. These are the two situations in which strictures of the organic kind are said most frequently to occur, (Hunter, Home, Cooper, Brodie, Phillips, Velpeau.) False passages likewise are mentioned as more liable to be made in these places than elsewhere in the urethral canal. These occurrences--the disease and the accident--would seem to follow each other closely, like cause and consequence. The frequency with which false passages occur in this situation appears to me to be chiefly owing to the anatomical fact, that the urethra at and close to the bulb is the most dependent part of the curve, F K, Fig. 1, Plate 56; and hence, that instruments descending to this part from before push forcibly against the urethra, and are more apt to protrude through it than to have their points turned so as to ascend the curve towards the neck of the bladder. If it be also true that strictures happen here more frequently than elsewhere, this circumstance will of course favour the accident. An additional cause why the catheter happens to be frequently arrested at this situation and to perforate the canal, is owing to the fact, that the triangular ligament is liable to oppose it, the urethral opening in this structure not happening to coincide with the direction of the point of the instrument. In the figure, part of a bougie traverses the urethra through both strictures and lodges upon the enlarged prostate. Another instrument, after entering the first stricture, occupies a false passage which was made in the canal between the two constricted parts.

Fig. 3, Plate 58.--A calculus is here represented lodging in the urethra at the bulb. The walls of the urethra around the calculus appear thickened. Behind the obstructing body the canal has become dilated, and, in front of it, contracted. In some instances the calculus presents a perforation through its centre, by which the urine escapes. In others, the urine makes its exit between the calculus and the side of the urethra, which it dilates. In this latter way the foreign body becomes loosened in the canal and gradually pushed forwards as far as the meatus, within which, owing to the narrowness of this aperture, it lodges permanently. If the calculus forms a complete obstruction to the passage of the urine, and its removal cannot be effected by other means, an incision should be made to effect this object.

Fig. 4, Plate 58, represents the neck of the bladder and neighbouring part of the urethra of an ox, in which a polypous growth is seen attached by a long pedicle to the veru montanum and blocking up the neck of the bladder. Small irregular tubercles of organized lymph, and tumours formed by the lacunae distended by their own secretion, their orifices being closed by inflammation, are also found to obstruct the urethral canal.

Fig. 5, Plate 58.--In this figure is represented a small calculus impacted in and dilating the membranous part of the urethra.

Fig. 6, Plate 58.--Two strictures are here shown to exist in the urethra, one of which is situated immediately in front of the bulb, and the other at a point midway between the bulb and the meatus.

Fig. 7, Plate 58.--A stricture is here shown situated at the bulb.

Fig. 8, Plate 58, represents a stricture of the canal in front of the bulb.

Fig. 9, Plate 58, represents the form of an old callous stricture half an inch long, situated midway between the bulb and the meatus. This is perhaps the most common site in which a stricture of this kind is found to exist. In some instances of old neglected cases the corpus spongiosum appears converted into a thick gristly cartilaginous mass, several inches in extent, the passage here being very much contracted, and chiefly so at the middle of the stricture. When it becomes impossible to dilate or pass the canal of such a stricture by the ordinary means, it is recommended to divide the part by the lancetted stilette. (Stafford.) Division of the stricture, by any means, is no doubt the readiest and most effectual measure that can be adopted, provided we know clearly that the cutting instrument engages fairly the part to be divided. But this is a knowledge less likely to be attained if the stricture be situated behind than in front of the triangular ligament.

Fig. 10, Plate 58, exhibits a lateral view of the muscular parts which surround the membranous portion of the urethra and the prostate; a, the membranous urethra embraced by the compressor urethrae muscle; b, the levator prostatae muscle; c, the prostate; d, the anterior ligament of the bladder.

Fig. 11, Plate 58.--A posterior view of the parts seen in Fig. 10; a, the urethra divided in front of the prostate; b b, the levator prostatae muscle; c c, the compressor urethrae; d d, parts of the obturator muscles; e e, the anterior fibres of the levator ani muscle; f g, the triangular ligament enclosing between its layers the artery of the bulb, Cowper's glands, the membranous urethra, and the muscular parts surrounding this portion of the canal. The fact that the flow of urine through the urethra happens occasionally to be suddenly arrested, and this circumstance contrasted with the opposite fact that the organic stricture is of slow formation, originated the idea that the former occurrence arose from a spasmodic muscular contraction. By many this spasm was supposed to be due to the urethra being itself muscular. By others, it was demonstrated as being dependent upon the muscles which surround the membranous part of the urethra, and which act upon this part and constrict it. From my own observations I have formed the settled opinion that the urethra itself is not muscular. And though, on the one hand, I believe that this canal, per se, never causes by active contraction the spasmodic form of stricture, I am far from supposing, on the other, that all sudden arrests to the passage of urine through the urethra are solely attributable to spasm of the muscles which embrace this canal.

COMMENTARY ON PLATES 59 & 60.

THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND OTHER OBSTRUCTIONS OF THE URETHRA.--FALSE PASSAGES.--ENLARGEMENTS AND DEFORMITIES OF THE PROSTATE.

Impediments to the passage of the urine through the urethra may arise from different causes, such as the impaction of a small calculus in the canal, or any morbid growth (a polypus, &c.) being situated therein, or from an abscess which, though forming externally to the urethra, may press upon this tube so as either to obstruct it partially, by bending one of its sides towards the other, or completely, by surrounding the canal on all sides. These causes of obstruction may happen in any part of the urethra, but there are two others (the prostatic and the spasmodic) which are, owing to anatomical circumstances, necessarily confined to the posterior two-thirds of the urethra. The portion of the urethra surrounded by the prostate can alone be obstructed by this body when it has become irregularly enlarged, while the spasmodic stricture can only happen to the membranous portion of the urethra, and to an inch or two of the canal anterior to the bulb, these being the parts which are embraced by muscular structures. The urethra itself not being muscular, cannot give rise to the spasmodic form of stricture. But that kind of obstruction which is common to all parts of the urethra, and which is dependent, as well upon the structures of which the canal is uniformly composed, as upon the circumstance that inflammation may attack these in any situation and produce the same effect, is the permanent or organic stricture. Of this disease the forms are as various as the situations are, for as certainly as it may reasonably be supposed that the plastic lymph, effused in an inflamed state of the urethra from any cause, does not give rise to stricture of any special or particular form, exclusive of all others; so as certainly may it be inferred that, in a structurally uniform canal, inflammation points to no one particular place of it, whereat by preference to establish the organic stricture. The membranous part of the canal is, however, mentioned as being the situation most prone to the disease; but I have little doubt, nevertheless, that owing to general rules of this kind being taken for granted, upon imposing authority, many more serious evils (false passages, &c.) have been effected by catheterism than existed previous to the performance of this operation.[Footnote]

Figs. 1 and 2, Plate 59.--In these figures are presented seven forms of organic stricture occurring, in different parts of the urethra. In a, Fig. 1, the mucous membrane is thrown into a sharp circular fold, in the centre of which the canal, appears much contracted; a section of this stricture appears in b, Fig. 2. In b, Fig. 1, the canal is contracted laterally by a prominent fold of the mucous membrane at the opposite side. In c, Fig. 1, an organized band of lymph is stretched across the canal; this stricture is seen in section in c, Fig. 2. In e, Fig. 1, a stellate band of organized lymph, attached by pedicles to three sides of the urethra, divides the canal into three passages. In d, Fig. 1, the canal is seen to be much contracted towards the left side by a crescentic fold of the lining membrane projecting from the right. In f, the canal appears contracted by a circular membrane, perforated in the centre; a section of which is seen at a, Fig. 2. The form of the organic stricture varies therefore according to the three following circumstances:--1st. When lymph becomes effused within the canal upon the surface of the lining mucous membrane, and contracts adhesions across the canal. 2ndly. When lymph is effused external to the lining membrane, and projects this inwards, thereby narrowing the diameter of the canal. 3rdly. When the outer and inner walls of a part of the urethra are involved in the effused organizable matter, and on contracting towards each other, encroach at the same time upon the area of the canal. This latter state presents the form, which is known as the old callous tough stricture, extending in many instances for an inch or more along the canal. In cases where the urethra becomes obstructed by tough bands of substance, c e, which cross the canal directly, the points of flexible catheters, especially if these be of slender shape, are apt to be bent upon the resisting part, and on pressure being continued, the operator may be led to suppose that the instrument traverses the stricture, while it is most probably perforating the wall of the urethra. But in those cases where the diameter of the canal is circularly contracted, the stricture generally presents a conical depression in front, which, receiving the point of the instrument, allows this to enter the central passage unerringly. A stricture formed by a crescentic septum, such as is seen in b d, Fig. 1, offers a more effectual obstacle to the passage of a catheter than the circular septum like a f.

Fig. 3, Plate 59.--In this there are seen three separate strictures, a, b, c, situated in the urethra, anterior to the bulb. In some cases there are many more strictures (even to the number of six or seven) situated in various parts of the urethra; and it is observed that when one stricture exists, other slight tightnesses in different parts of the canal frequently attend it. (Hunter.) When several strictures occur in various parts of the urethra, they may occasion as much difficulty in passing an instrument as if the whole canal between the extreme constrictions were uniformly narrowed.

Fig. 4, Plate 59.--In this the canal is constricted at the point a, midway between the bulb and glans. A false passage has been made under the urethra by an instrument which passed out of the canal at the point f, anterior to the stricture a, and re-entered the canal at the point c, anterior to the bulb. When a false passage of this kind happens to be made, it will become a permanent outlet for the urine, so long as the stricture remains. For it can be of no avail that we avoid re-opening the anterior perforation by the catheter, so long as the urine prevented from flowing by the natural canal enters the posterior perforation. Measures should be at once taken to remove the stricture.

Fig. 5, Plate 59.--The stricture a appears midway between the bulb and glans, the area of the passage through the stricture being sufficient only to admit a bristle to pass. It would seem almost impossible to pass a catheter through a stricture so close as this, unless by a laceration of the part, combined with dilatation.

Fig. 6, Plate 59.--Two instruments, a, b, have made false passages beneath the mucous membrane, in a case where no stricture at all existed. The resistance which the instruments encountered in passing out of the canal having been mistaken, no doubt, for that of passing through a close stricture.

Fig. 7, Plate 59.--A bougie, b b, is seen to perforate the urethra anterior to the stricture c, situated an inch behind the glans, and after traversing the substance of the right corpus cavernosum d, for its whole length, re-enters the neck of the bladder through the body of the prostate.

Fig. 8, Plate 59.--A bougie, c c, appears tearing and passing beneath the lining membrane, d d, of the prostatic urethra. It is remarked that the origin of a false passage is in general anterior to the stricture. It may, however, occur at any part of the canal in which no stricture exists, if the hand that impels the instrument be not guided by a true knowledge of the form of the urethra; and perhaps the accident happening from this cause is the more general rule of the two.

Fig. 9, Plate 59.--Two strictures are represented here, the one, e, close to the bulb d, the other, f, an inch anterior to this part. In the prostate, a b, are seen irregularly shaped abscess pits, communicating with each other, and projecting upwards the floor of this body to such a degree, that the prostatic canal appears nearly obliterated.

Fig. 10, Plate 59.--Two bougies, d e, are seen to enter the upper wall of the urethra, c, anterior to the prostate, a b. This accident happens when the handle of a rigid instrument is depressed too soon, with the object of raising its point over the enlarged third lobe of the prostate.

Fig. 11, Plate 59.--Two instruments appear transfixing the prostate, of which body the three lobes, a, b, c, are much enlarged. The instrument d perforates the third lobe, a; while the instrument e penetrates the right lobe, c, and the third lobe, a. This accident occurs when instruments not possessing the proper prostatic bend are forcibly pushed forwards against the resistance at the neck of the bladder.