Elements of Surgery

by Robert Liston

Stricture may be caused by inflammation or long-continued irritation of the urethra, however induced—by mismanaged virulent gonorrhœa—by stimulating acrid injections—by piles, and other irritations about the fundament—by calculi passing along the urethra. That gonorrhœa is a very frequent cause of stricture has been long known—“If the case be slubbered over, and long delayed, caruncles arise in the urethra, and in progress of time a carnosity.” The passage or lodgement of calculi in the canal has induced stricture even in children: and calculus in the bladder is supposed sometimes to produce disease in the urethra, and vice versâ. Strictures are often caused by falls or blows on the perineum, and such cases are of the very worst kind; in some the urethra becomes almost entirely obliterated; in most the stricture is extensive and callous; and in all the disease is overcome with difficulty.

When stricture is suspected, the urethra must be examined. A soft white-wax bougie is very well adapted for ascertaining the state of the parts, but must be used very gently. If pushed forwards rashly and with force, the instrument yields before the stricture, and when withdrawn, is found twisted like a screw, or doubled backwards on itself. The vessels of the urethra may be torn, and hemorrhage, with great pain, ensue. The bougie should be slightly curved in its farther extremity, warmed either at the fire or by friction with the fingers, and well oiled, previously to its introduction. It is then passed softly along the canal till its progress is arrested; thus the situation of the stricture is ascertained. Then a little more pressure is employed for a short time; if the instrument have not become insinuated into the constricted part, it will resiliate on removal of the pressure from its free extremity; if it is passed into or beyond the stricture, it is firmly grasped by that part of the urethra, and retained; thus we discover the degree of contraction; and from the extremity of the bougie receiving and retaining the impression made on it by the contracted part, we can form an accurate diagnosis regarding the nature and extent of the stricture. The information thus acquired is afterwards acted on.

The principles on which the cure is to be conducted are the same in almost all cases; but the particulars of the treatment must vary according to circumstances. In slight cases, the gentle introduction of a moderately-sized bougie produces a cure by removing the irritability or susceptibility of the surface; the relaxed membrane is stimulated by the distention made with a bougie, and soon regains its natural tone. It may be necessary to repeat the introduction of the bougie a few times, at considerable intervals. In tight organic stricture something more is required; the constricted part must be dilated gradually. Much dexterity and management is often required to pass an instrument through a tight stricture, particularly if inflamed; and in such circumstances the attempt should not be made but on good grounds, and to relieve urgent and dangerous symptoms; but after a bougie or catheter, however small, has been got past, the disease is completely under the control of the surgeon, and a cure must follow if the treatment be properly conducted, and if the bladder and kidneys have remained tolerably sound. The effect of an instrument passed through an organic stricture is to remove the irritability of the lining membrane, to excite the absorbents to remove the newly-formed parts, and to dilate the passage: it may be supposed to act in some measure on the same principle as a bandage applied to a swelled extremity. The instruments introduced must be gradually enlarged till one readily passes of the full size; that is, one that enters the orifice with some difficulty, and fully distends the rest of the canal. Numerous contrivances have been employed for the dilatation of strictures; but the preferable instrument is a silver catheter, or a sound made of silver, of steel, or of plated metal. A soft or gum-elastic bougie is sometimes useful in ascertaining the nature and situation of the stricture; but in the treatment it must give place to the metallic, slightly conical at the point. This, in the hands of a well-qualified person, can be more surely and readily directed than a flexible one, and in its use there is less risk of injury being inflicted on the passage; besides, it does not yield to the action of the diseased part. The practitioner must be provided with a full assortment of catheters and metallic bougies, each one differing from the other in size; for, as already observed, the size of the instrument passed must be gradually increased; and, besides, the calibre of the canal varies much in different individuals; what is a full size for one person may be but a trifle in the urethra of another. The bougies are arranged by what is termed a size-plate, or gauge, a flat piece of metal, containing fifteen or sixteen circular perforations, which commence about the size of a small crow-quill, and gradually enlarge in diameter. These apertures are numbered, and the bougie which fills one has the corresponding number imprinted on it. By reference to the numbers, the surgeon is at once made aware of the progress he has made towards a cure.

In the more common and simple cases, a regular and gradual ascent in this scale is all that is required, allowing a proper interval to elapse betwixt the introductions. But in tight and unyielding stricture, small, firm, silver catheters are required, one of these of a size proportioned to the contraction of the canal—and the calibre often must be extremely minute—is passed through the stricture or strictures by dexterous, persevering, and at the same time gentle pressure in the proper direction. If the diseased part be anterior to the bulb, it can be grasped between the fingers of the left hand, whilst with the right the instrument is insinuated into it; thus the part is steadied, and the course of the catheter made more certain and safe. If it be posterior, assistance in the introduction, and information as to the direction and progress of the instrument are obtained by the forefinger of the left hand being placed in the bowel; and this is the more necessary when the stricture is of an elastic nature. Considerable experience is requisite to enable the surgeon to be aware of the progress he is making with the instrument, and whether or not it is advancing fairly in the canal; much information as to this is imparted by the sense of feeling. If the point of the instrument be within the contracted part, it will be felt embraced and obstructed, and on withdrawing the pressure, it will be stationary; if it have not entered the stricture, but is pushing it before it, resilience will be felt as soon as the pressure is either diminished or removed. The sensation imparted when the instrument has left the canal, and is entering into a false passage, is of a peculiar grating nature, and when once felt, will scarcely be forgotten or mistaken. By means of a good knowledge of the natural course of the urethra, and an acquaintance with the feelings just alluded to, but which cannot be graphically described, the surgeon of experience is enabled to avoid blunders, and to pass an instrument with safety through the tightest strictures. It is, however, an operation of very great difficulty in aggravated cases, perhaps the most difficult in surgery; facility in passing the catheter is acquired only by practice and experience. The greatest caution is required, along with considerable fortitude and perseverance.

When the instrument has been fairly lodged in the bladder, it is to be retained. A tape is attached to each of the rings at the neck of the catheter, is brought under the thigh, and fastened to a bandage passed round the waist; this simple retentive apparatus is quite effectual, and suits the erect as well as the recumbent posture. A peg, of metal or wood, is placed in the mouth of the catheter, that the patient may be kept dry, and at the same time have it in his power to relieve the bladder as often as necessary. The instrument should be retained for twenty-four hours at least, and, if the patient can bear it, for forty-eight, or even more. At first it occasions considerable uneasiness, pain, and excitement, but these gradually subside; when severe, they may be allayed by opiates. The parts make efforts to get rid of the foreign body, and these efforts are salutary. Discharge takes place from the membrane, and oozes by the side of the catheter; relaxation occurs, often to a very great extent; and, on moving the handle of the instrument, it is found to be not only less firmly grasped, but to possess considerable freedom of motion in the contracted part. Thus a most successful inroad is made upon the disease, and the after treatment thereby happily abridged. The instrument is withdrawn, and time afforded for the parts to become quiet. After the lapse of two, three, or four days, according as the uneasy feelings disappear, a larger instrument is introduced, and retained perhaps for half an hour; and the successive introduction of instruments—sounds being now adopted—at proper intervals, and in proper graduation, is continued as in ordinary cases. Sometimes, though rarely, the good effects of the first introduction and retention of the instrument quickly disappear, the stricture becoming tight and unyielding as before; when this takes place, the practice is to be repeated, but not till after several days, and then the instrument will be retained with advantage for a longer time than before, provided no untoward symptoms are caused by its lodgement. There are very few strictures, indeed, which will not yield to this treatment, when judiciously planned and perseveringly followed.

Fistulous openings generally close in a short time, when once the urethra has been widened. Their contraction may sometimes, however, prove slow and imperfect, even after the stricture has been entirely removed, and the application of the cautery may be requisite; to accomplish this, when the opening terminates in the rectum, a speculum ani is required, by which to view the aperture, and ascertain its site, and along which to pass the heated wire with safety to the bowel. The cautery is not to be applied so as to produce an extensive slough, and much loss of substance, but lightly to the edges. On the separation of the superficial eschar, the margins are raw, excited, and swollen, with a disposition to granulate; and during cicatrisation of the sore, considerable contraction takes place, independent of the formation of new matter. After the contraction thus effected has occurred to its full extent, and not before, the cautery is reapplied; and by a few repetitions of the instrument at long intervals, the opening is brought to close.

At one time attempts to destroy the contraction of the urethra, by the application of caustic to the stricture, were in great vogue; but the total inefficiency of such practice is now generally acknowledged. The armed bougie was in many cases applied hundreds of times, at considerable intervals; and the mode of treatment, though trying, tedious, and hurtful to the patient, must have proved useful to the surgeon—but to him alone. Years were spent in such trifling, and not unfrequently serious consequences followed this treatment, or rather neglect, of the disease. Cutting catheters are dangerous, as well as inefficient for the cure of stricture; thrusting at the end of a long stricture can avail but little, and in the hands of most practitioners the instrument is as likely to perforate the coats of the urethra as to enter the stricture.

Incision of stricture may be required in retention of urine, scarcely otherwise. The practice is noticed under the treatment of retention. In stricture anterior to the scrotum, it is well to avoid incision, if possible, as it generally is so, for a wound there is healed with difficulty, if at all.

Retention of Urine is not to be confounded with suppression of the secretion from the kidneys, arising from disorder of the structure or function of these organs. The kidneys perform very important functions in the animal economy, and complete suppression of their secretion under any circumstances is a very suspicious and dangerous occurrence.