Part 62

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.

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.