covering of the bladder, and thence to the external surface of the
intestines.
The bladder becomes thickened, and lymph is effused between its
coats, from repeated attacks of inflammation, or from long continued
irritation in consequence of resistance to the expulsion of its
contents. The mucous membrane is thickened, relaxed, and of a
flocculent appearance; the fibres of the muscular coat are enlarged,
and, bulging out, form projections along their course; the mucous
membrane is extended often to a considerable extent between the
projections of the enlarged muscular fasciculi, forming pouches. The
cavity of the organ is generally diminished in proportion to the
thickening of its parietes, and there is a loss of balance betwixt the
retaining and expelling powers.
_Irritable_ bladder is generally a symptom of some other affection.
There is profuse mucous discharge; frequent micturition; pain,
increased by distention of the organ, and relieved by evacuation.
The coats are more vascular than in the natural state; sometimes the
muscular is strengthened, and ulceration of the mucous membrane is not
infrequent. Occasionally this latter tunic is the seat of tumour.
In the treatment of inflammation of the bladder, after removal of its
causes, antiphlogistic means occupy a prominent situation, and are to
be regulated according to circumstances. Leeches to the perineum and
hypogastrium—soothing injections into the rectum—opium or hyoscyamus,
either by the mouth or in the form of suppository—fomentation and the
warm bath—are all valuable remedies in this affection. When injections
into the rectum are used, they should not exceed three or four ounces,
and they should contain from thirty to sixty drops of laudanum, or a
corresponding quantity of the liquor opii sedativus. But an anodyne
suppository is perhaps more simple and more efficacious. The effect
of these remedies is almost instantaneous; all pain goes off; the
patient becomes quiet, loses all recollection of his former sufferings,
and often remains in a state of great comfort for twelve or sixteen
hours. The suppository may be repeated as need be; the preferable time
for its exhibition is the hour of sleep. Camphor, given by the mouth
in full doses, is a powerful remedy for allaying irritation of the
bladder, from whatever causes induced; as is copaiba, less nauseous
and more trustworthy than cubebs or buchu. The copaiba will often
remove speedily the most intense irritation, when all other means have
failed. The bowels are to be kept gently open, and all stimuli disused;
diet should be low, drink copious and bland. Washing out the bladder
with anodyne or other fluids, and the application of blisters to the
perineum and neighbouring parts have been recommended, but are often
more injurious than useful.
_Of Stricture of the Urethra._—By stricture is understood a narrowing
or contraction of a mucous canal, from deranged action, or from
morbid alteration of its structure. It may arise from relaxation and
turgescence of the parietes, or from effusion of lymph either under
the lining membrane, or on its surface. Spasmodic stricture has been
spoken of by some writers, but is most probably an imaginary disease.
An irritable urethra, in which organic disease does not exist to any
great extent, may contract at some point, diminish the stream of urine,
and prevent the introduction of instruments, or retain them by closing
firmly round, and in such circumstances the obstruction does probably
depend on spasm of the muscular fibres surrounding the urethra; yet to
such a state of the canal the term stricture cannot be applied with any
degree of propriety.
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.
[Illustration]
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.
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.