Elements of Surgery

by Robert Liston

True, organic, or permanent strictures of the urethra vary in their degree of constriction, becoming tighter when irritated by improper treatment, hard living, or exposure to damp or cold; indeed all mucous canals are sensibly affected by cold and damp. From these causes a combination may be produced of permanent stricture and spasmodic action; but, as already hinted, it would perhaps be well that this latter term, applied to urethral stricture, were forgotten, instead of remaining a convenient excuse for want of knowledge or dexterity. Spasms of canals and cavities, unusual membranes, adhesions, sacs, and cysts, are too often met with in the practice of surgery, and are said to prevent the practitioner from accomplishing the objects of his operations, so as to put the patient to a great deal of unnecessary suffering, and even endanger his life. The old writers supposed that obstruction of the urethra arose from growths, warts, caruncles, or carnosities in the passage; and even in the present day such causes would sometimes appear to be more accredited than they ought; small excrescences do sometimes form on the membrane, though very rarely.

The true stricture is the result of inflammatory action in the part: at first possibly serous effusion takes place beneath the membrane, and elevates it into an œdematous swelling, which, according to its extent, obstructs the canal; the lymph is deposited both beneath the membrane and external to it, becomes organised, and forms a permanent and more unyielding obstruction. Strictures are of various kinds. The bridle stricture is rarely met with; a membranous band of organised lymph is said to traverse the canal, and, according to the thickness of this membrane, the flow of urine is more or less impeded; in the majority of cases the morbid formation is thin and delicate, but still sufficient to scatter and diminish the stream. When a soft bougie is introduced, it is resisted by the stricture, and on examining the instrument when withdrawn, the transverse and central impression on its point marks the existence of the bridle. The urethra is sometimes narrowed by a circular membranous ring projecting into its canal, composed of swollen mucous membrane with subjacent effusion, and presenting the appearance of a thread having been tied round the passage. Other strictures occupy a considerable portion of the urethra, from a quarter of an inch to two inches or more; differing from the preceding only in the effusion and membranous swelling being more extensive. Others are irregular, the contraction being not uniform at the narrowed point, and sometimes only one side of the canal is affected. Some are very firm and gristly, the effused lymph having become much condensed after organisation; others are less dense in their structure, and exceedingly elastic. From repeated attacks of inflammation at the constricted part, and around, additional lymph is effused and organised, and thus the extent and tightness of the stricture is increased.

The urethra is generally constricted at those parts which are naturally the tightest; at the orifice—betwixt three and four inches from it—and betwixt six and seven inches from that point; the most frequent site is perhaps anterior to the sinus. Contraction of the orifice is frequently the consequence of cicatrisation, and generally proves obstinate; in some cases the smallest probe is passed with difficulty. Considerable portions of the anterior part of the canal suffer contraction from the effect of ulceration; and congenital malformations of the orifice give rise to many affections both of the urethra and bladder. Contractions in different parts of the canal depend much upon one another.

When a tight stricture exists, the passage anteriorly is never fully distended, and becomes permanently contracted in consequence; whilst more or less dilatation is produced behind the tight part, wherever that may be. The enlargement often is very great, the urine lodges in the cavity formed by dilatation, and can be pressed out in a stream, or dribbles away after the patient supposes that he has done making water. Mucous and sabulous deposits often lodge in it; and calculi are occasionally retained there, may attain a large size, and may give rise to very unpleasant and even dangerous symptoms. Not unfrequently ulceration takes place behind the stricture, and the urine becomes insinuated into the cellular texture; but this tissue immediately around is in general condensed previously to the giving way of the canal, and so prepared by lympathic effusion as to oppose effectually extensive infiltration. Such is not the case, as will afterwards be explained, when solution of continuity in the urethra, or of the cyst of an abscess, takes place in consequence of distention of the bladder.

In the gradual escape of urine by ulceration behind the constricted point—the urethra being neither altogether obstructed, nor nearly so—abscess forms in the cellular tissue, exterior to the ulcerating part. The suppuration is often slow in its progress, and imparts to that part of the perineum a stony hardness. Repeated collections of matter may form, and, if the cause be not removed, numerous openings will form in the scrotum and perineum, and through them fetid matter and urine will constantly and involuntarily distil. The patient is reduced to a miserable state; the neighbouring parts are excoriated, and exhale a noisome odour, his body and bed-clothes are soaked and rotted by the discharge, and the atmosphere to a considerable distance around offends the nostrils. Fistula in perineo is established.

Ulceration and perforation of the urethra from stricture seldom takes place anteriorly to the scrotum; but ulceration often is induced there by retaining instruments long in the passage, and may be followed by sloughing of the integuments, abscess in the cellular tissue, or both. Occasionally the urethra communicates with the rectum in consequence of ulceration, escape of urine into the cellular tissue, and formation of matter. The symptoms of stricture are often much relieved after the formation of fistulous openings; and the cure can then be much more easily accomplished than formerly, the passage being less irritable. When the fistula is free and open, allowing the urine to escape readily, the natural passage contracts, and will become almost entirely obliterated, unless means are taken to dilate it, and to diminish the unnatural opening. Neglected aggravated cases are met with, in which the urine has passed entirely through the false passages for years, the urethra and penis, anterior to the stricture, being both rendered completely useless; but even such cases can, by proper management, be relieved, or permanently cured. Ulceration of the urethra, originating in consequence of stricture, may proceed even after the stricture is removed, and give rise to abscess and fistula.

Many patients labour under stricture, and even tolerably bad ones, without being aware of it. But the surgeon is led to suspect the existence of stricture, by complaints which the patients wish to be relieved of, and which they often suppose to arise from totally different causes—pains in the loins or hips, indolent swelling of the testicle, or of the inguinal glands, irritability about the fundament, gleet. On inquiring about the stream of urine, the patient may declare that it is as good as possible; and many say so without intending to deceive, for the stream diminishes so gradually, that the patient is not aware till after he is relieved that he has been voiding his urine in a very shabby and imperfect manner. On questioning further, it is discovered that the stream is forked or twisted, or divided into several small ones; that there is frequent desire to empty the bladder, during the night particularly; and that at first the urine comes away only in drops. A long time is occupied in passing even a small quantity of urine, and the patient has to strain much; in bad cases he is almost always obliged to go to the water-closet when inclined to make water, lest the contents of the rectum be evacuated by the great exertion of the levator ani and abdominal muscles, necessary to overcome the obstruction in the urethra. By the straining hernia is also frequently induced.

In consequence of the almost constant endeavours to overcome the resistance afforded by the stricture, the bladder becomes much strengthened in the coats, and diminishes in size. All the coats are affected, but particularly the muscular; the surface becomes fasciculated; the fibres grow fleshy and strong, and are collected in large bundles. Cysts form, often of a large size; some are caused by interlacement of the enlarged muscular fibres, others are produced by outward protrusion of the mucous coat. This membrane being, by excessive muscular action in the viscus, pushed between the enlarged fasciculi, dilates into a bag, and forms a cyst of greater or less size, communicating with the cavity of the bladder, generally by a narrow neck; the protruded membrane is thickened by new deposit, and ultimately the parietes of the cyst, in some degree, resemble those of the bladder. Cysts of this description are usually situated near the fundus of the organ, and often attain a large size; in some cases the cyst nearly equals the bladder in capacity; and the two seem to form one large organ contracted near the middle. The secretion from the surface of the bladder and cysts becomes vitiated, is much increased in quantity, and passes off along with the urine or after it—sometimes in solution, often separately. In severe cases the ureters and pelves of the kidneys dilate, and their mucous surfaces also contribute to furnish the discharge, in general slimy, ropy, and tenacious, sometimes puriform. Discharge also takes place from the stricture, or rather from the dilated portion behind it; it is a kind of gleet, very apt to be increased by excess in drinking and venery. After debauchery, the stream of urine—which was previously not much affected, at least to the patient’s observation—comes to be very small; and frequently the urine can be voided only in drops, and that with much labour. Besides, the balance between the retaining and expelling powers of the bladder is often lost, and either incontinence or retention of urine is the consequence. Though the urine be much obstructed, even when the stricture is not very tight, the flow of the semen is not; the degree of contraction must be very great to prevent ejaculation of the latter fluid. Indeed, during the healthy state of the parts, the whole urethra is much narrowed, as well as shortened, during seminal emission in coitu, from forcible action of the surrounding fibres, and injection of the corpus spongiosum; and the momentary contraction of the passage in such circumstances is perhaps greater than almost ever occurs in consequence of disease. Sometimes the seminal fluid passes back into the bladder, from an inverted action of the canal, and is evacuated along with the urine; nocturnal emission is a frequent concomitant of stricture. That an inverted or sort of antiperistaltic motion sometimes exists in the urethra, is shown by a soft bougie being in such cases drawn into the bladder after having been passed but a short way into the urethra.

In cases of bad stricture, the complexion is sallow, the countenance anxious, and the general expression of the features so peculiar as to be almost pathognomonic. The lower limbs become emaciated and weak. Gout often accompanies stricture, and paroxysms of it are induced by irritation of the urethra; the canal itself is said to be sometimes affected with a gouty action.