The treatment of stricture of the urethra and fistula in perineo

Preface To The First Edition

When attention has been long devoted to the attainment of an important object, and when the most elaborate efforts have proved ineffectual for the purpose, it is not easy to persuade those engaged in the pursuit, that they have overlooked a simple and easy mode of obtaining success. The method of treating obstinate strictures of the urethra, recommended in the following pages, was communicated to the profession five years ago, through the periodical press ; and again, two years ago, in a collection of surgical essays ; but, so far as I know, it has not yet been adopted by others even in a single instance. Being deeply impressed with the importance of the subject, I feel it my duty to make another attempt, with the view of awaken-

Preface

ing attention to it, by publishing in a separate form full details of the procedure, together with its advantages, positive and comparative, and also further evidence of its efficacy, from cases in public as well as in private practice. Having done this, I leave the matter to the profession, trusting that, whatever may be their decision, they will at least give me credit for an earnest desire to render the opportunities committed to me conducive to the improvement of Practical Surgery.

Edinburgh, 1st November 1849.

STRICTURE OF THE URETHRA.

There are few human infirmities productive of more distress and danger than stricture of the urethra, when it assumes an aggravated form. The painful, laborious, and frequently repeated efforts to effect micturition, occupying the patient’s time by day, and disturbing his rest at night — the liability to complete retention of urine, with all the risks of abortive attempts to introduce catheters, or the more desperate resource of puncturing the bladder — the involuntary dribbling of water, wetting the clothes and excoriating the person — the feverish attacks — the abscesses, and the fistulas of the perineum — the inability for exertion, whether of body or mind — the irritability

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despondency, and emaciation, with the despair of relief except from premature death, constitute a sad catalogue, which might be greatly extended without comprehending all the evils originating from this fruitful source of misery.

AVith reference to their symptoms and treatment, strictures may be divided into — 1. Imaginary; 2. Slight ; 3. Confirmed ; 4. Irritable ; and, 5. Contractile.

Imaginary strictures constitute a large proportion of the cases that occur in practice. They generally depend upon an erroneous idea of the patient, suggested by some irritation of the urinary organs, or debility in the expulsive power of the bladder, and encouraged either through unskilfulness of the surgeon, who attributes the pain and difficulty resulting from his awkward use of instruments to contraction of the passage, or through the culpable delusions of rapacious quacks whose appropriate field is the remedy of diseases that have no real existence. Such cases explain the good effects attributed to various modes of treatment, which, if the stricture were real, would prove useless, impracticable, or injurious.

Adhere a stricture does exist, but in no great degree of duration or contraction, it may be easily removed by dilatation through the use of various means, such

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as retaining a succession of catheters in the bladder, or introducing bougies frequently for lengthened periods. There is, however, no occasion to place the patient under any such restraint, since the object in view may be more simply, safely, and effectually accomplished by passing bougies with intervals of three or four days, and withdrawing them immediately after their introduction. One or two of the steps in the scale being thus gained each time, the urethra is soon expanded to its natural capacity, without pain, trouble, or confinement.

It is a remarkable fact that strictures frequently pass into the most confirmed state without the patient being aware of their existence. The symptoms steal on so slowly and insidiously, that the flow of urine may be reduced to a thread-like stream little better than a succession of drops, while no suspicion is excited, until an attack of complete retention, or the length of time occupied in evacuating the bladder, leads to an examination of the passage. Not unfrequently the first intimation of there being something wrong is afforded by the formation of a perineal abscess ; and as the explanation usually given to account for this occurrence is not at all correct, the true nature of the process may be here considered.

The ideas which have long been and still are pre-

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valent in regard to perineal abscess and fistula afford an example of probabilities in pathology being assumed as trustworthy instead of the facts ascertained

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by observation. It is said that the urine, impeded by the stricture, presses upon the urethra behind it, and thus causes ulcerative absorption, which forms an opening in the canal that allows a little water to escape into the cellular texture, where it lays the foundation of an abscess. ISTow, if this explanation were correct, the early history of such collections of matter would always present the symptoms of that violent local and general disturbance which is attendant upon urinary extravasation. But so far from this being the case, the perineal abscess usually forms slowly, and insidiously ; and when opened by incision previous to its spontaneous evacuation, is found to contain purulent matter alone, un mixed with urine. It is true, that if an external drain be not afforded, the fluid may discharge itself into the urethra, and then indeed the urine, not only entering the cavity, but being urged into it by the contractile force of the bladder, while the stricture opposes its outward flow, breaks down the circumscribing wall of lymph, and diffuses itself through the scrotum, when an opportunity is presented of seeing what would happen if, in accordance with the generally received opinion, its escape

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were, in the first instance, permitted directly by ulceration of the urethra.

The truth seems to he, that the irritation of the stricture, or of the means employed for its remedy, occasions inflammation in the textures adjacent to the urethra, which, sooner or later leading to suppuration, gives rise to an abscess separated from the canal of the urethra merely by its lining membrane, but thickly covered externally by the fascia and integuments of the perineum. In obedience to the law of progressive absorption induced by the pressure of purulent matter, spontaneous evacuation is nevertheless much more apt to take place outwardly than inwardly, although the resistance of the fascia tends to render

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the passage tortuous and directed towards the hip, scrotum, or anus, instead of the nearest point, which of course coincides with the raphe. In no long time after the matter is thus discharged, or through an incision anticipating this event, ulcerative absorption establishes an opening in the thin denuded portion of mucous membrane that constituted the urethral wall of the abscess, and then the urine escaping in more or less quantity, renders the fistula in perineo com-

Wlien an instrument of any sort can be passed through a stricture, it is generally possible, by careful

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and well-directed efforts, to introduce a succession of larger ones, so as to dilate the contracted portion of the canal to its natural capacity. The process thus accomplished, has been naturally, but perhaps rather unfortunately, named Dilatation ; since this title conveys the idea of a purely mechanical effect, and has doubtless led to many of the plans for treatment which are founded upon the same principle, and executed by similar means as those employed for stretching the finger of a glove. But it should be recollected that while the cause of stricture is effusion into and condensation of the urethral coat, relief is afforded by the opposite action of absorption, which restores the thickened texture to its proper condition, and that the beneficial effect of dilating means depends upon their exciting such a counteracting agency in the living tissue. Any sort of stretching which exceeds the degree requisite for this purpose, so far from doing good, will, therefore, probably increase the evil by reinducing the irritation productive of contraction ; and mere distension of the canal, by the permanent retention of catheters, must not be confounded with the real widening which results from a restoration of the urethral coats to their natural state of capacity and tenuity.

To effect dilatation with this view, the best means are unquestionably metallic bougies, and those made of Berlin silver seem decidedly preferable to any others, as they take a fine polish, are not liable to rust, and being hollow, are guided more lightly than the plated steel instruments used in London, while their moderate expense does not place them beyond the reach of ordinary employment. Ten sizes are sufficient, unless in extraordinary cases, for dilating the tightest stricture to the natural width of the canal ; beyond which there is no advantage in distending it. It is usual to pass bougies while the patient is in the erect posture. But whenever any difficulty is anticipated, he should be placed horizontally ; since the operator can thus judge much better as to the direction of the urethra, which varies with the form of the pelvis, and can also conduct the manipulation altogether more gently. Pain and bleeding are certain indications of the procedure being faulty. The bougie should be rather suspended than held between the tips of the fore and middle fingers, and gently urged on by the thumb, while the fingers of the left hand rest on the perineum to assist in determining the proper course of the instrument. Stretching of the penis and forcible clutching of the bougie are sure signs of awkwardness and incompetency in this department of surgery; and a patient who has once had the instrument

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properly introduced, can always afterwards distinguish between its proper and maladroit employment.

When the existence of a stricture is suspected, the urethra should be examined by introducing a moderate-sized bougie, such as Mo. 8. If one larger than this be employed, it may encounter resistance at the narrowest part of the channel, though there is no real contraction, while one of smaller size may not detect a degree of stricture requiring dilatation. But when a bougie of the size above-mentioned is obstructed, there need be no doubt as to the existence of stricture, and its degree of tightness should next be ascertained by trying a succession of smaller instruments until one is passed. It is unnecessary to say anything as to the preposterous plan of takingcasts of the stricture by pressing upon it the extremity of a soft plaster bougie, since any one at all conversant with the subject must be satisfied that such a procedure can produce no result better than deception of either the practitioner or the patient. The only satisfactory measure of a stricture is the instrument which it allows to pass ; and this being ascertained, the dilatation may proceed from that point, according to the principle which has been explained. But however often the introduction ot instruments may be required for this purpose, the

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greatest care should be taken to avoid all attempts to gain an advance by force in opposition to unfavourable circumstances. If tlie patient is heated or out of order — if be lias exceeded in tlie use of stimulants, or proposes to do so — if be lias performed a journey or is about to undertake one — if the urine is thick or loaded with mucus — if the bowels are constipated or unduly relaxed — if the urethra is inclined to bleed or appears more than usually irritable — if there is pain of the testicles or perineum — and, finally, if the surgeon is in haste or out of humour, the operation ought to be delayed.

However carefully and skilfully this process may be conducted, disagreeable consequences are apt to result from it, and the risk of such occurrences will of course be greater, when there is any impropriety on the part of either the patient or the surgeon. The most frequent are rigors, followed by heat and perspiration, so as to simulate attacks of ague, for which they are often mistaken, especially after exposure to the influence of tropical climates. In geneial these feverish fits pass off without leaving any trace of their existence, beyond languor or weakness, or perhaps some herpetic eruption on the lips. But if the instruments have been used with undue 1 oughness, or the patient has been guilty of any im-

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prudent exposure to cold or stimulants, inflammation of the testicles or an abscess of the perineum may ensue, so as to complicate the case and delay its treatment. False passages also are frequently established, not only by inexperienced practitioners, but by those whose success has led to over-confidence, and induced a want of that extreme caution which is always requisite for the safe guidance of instruments through the urethra. From the dire effects of urinary extravasation it might be expected, that injuries of this kind would be always productive of serious, if not fatal, consequences ; and such, no doubt, the case would be, if the opening were seated on the vesical or inner side of the stricture. But as it is beyond the contraction, and forms an exceedingly acute angle with the direction of the canal, the safe exit of the urine is favoured, while its entrance into the false passage is impeded. The principal inconvenience, therefore, that results from this complication, is the increase of difficulty it occasions in carrying on the dilatation.

Whatever may he the difficulties and danger of the simple dilating process, they are trivial when compared with those attending the use of Caustic ; which, even if it should happen to be correctly applied to the seat of contraction, must expose the

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patient to the risk, not only of immediate irritation, but also of subsequent inconvenience from cicatrisation of the ulcerated part. It seems, indeed, surprising, that an agent so uncertain and hurtful should ever have got the credit of proving beneficial for the remedy of stricture, unless we suppose that in the cases where it appeared to do so there was no real contraction. There is a fashion in diseases as well as in their treatment, and when every uncomfortable feeling about the urinary organs was attributed to stricture or enlarged prostate, any means of remedy could not fail to acquire some portion of confidence. But now, when juster notions are entertained on the subject, it is needless to point out the inexpediency of resorting to the use of caustic under the circumstances in question, which must render its employment unnecessary, as well as in the highest degree dangerous.

There is another mode of treatment that may also be discussed in a few words. This is the method of internal incision, which was advocated by Mr Stafford of London, more than thirty years ago, and has since then found much favour from the surgeons ol France, whose ingenuity has been variously exercised in the contrivance of instruments for the purpose. In all such apparatus the essential con-

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stituents are a sheath and narrow blade contained in it; which may be protruded from the side or the extremity, accordingly as the instrument can or cannot be conveyed through the stricture. In addition to the uncertainty of this procedure in regard to its immediate effect, and the danger to which it exposes the patient from bleeding, as well as the irritation of urine forcibly urged upon a raw surface, the great objection may he mentioned, that whatever relief is thus obtained does not prove permanent. Indeed it would seem from the results of experience— and this I find from my communications with patients treated in London, has been much more extensive than might be supposed from what has appeared in writing on the subject — that so far from lessening the disposition to contract, the internal incision rather increases this morbid tendency, so as seriously to aggravate, instead of alleviating the disease.

A French surgeon, M. Reybard, lias lately endeavoured to maintain that all strictures of the urethra depend upon the formation of a new texture, or lining membrane of the mucous surface, which must be completely divided through its whole extent of length as well as thickness, in order to afford permanent relief. For this purpose he introduces a

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slieatli containing a blade which, when expanded, presents its point not backwards but forwards , so that when the instrument is withdrawn it rips open the canal with a certainty no less unerring than relentless. The Parisian Imperial Academy of Medicine have been so much delighted with this procedure as to express their approbation of it by bestowing upon the author the prize of 12,000 f. (L.450) bequeathed by the late M. d’Argenteuil, for rewarding practical improvements in the treatment of stricture. How far this distinguished body have acted justly in their decision, will appear from the “ Reclamation ” which I took the liberty of transmitting for their consideration.* But I may here remark, that M. Eeybard limited the employment of his dreadful engine to cases of stricture so accommodating as to permit the passage through them of a thick sheath, with the blade contained in it, and held all tighter contractions as beyond the reach of remedy; so that he stopped short of the great difficulty, and merely substituted a bloody, painful, and dangerous procedure for the easy and safe means of dilatation, which are found quite sufficient for the treatment of stricture in its ordinary form of severity. It would be instructive to learn how many members of the Imperial

* See Appendix.

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Academy have adopted in practice a mode of treatment in favour of which they have so strongly testified.

There has long been a general persuasion that strictures, especially when complicated with perineal fistula, are apt to become impermeable, or altogether closed against the introduction of instruments, and it was under this impression that the French surgeons employed an operation which they called, “ Boutonniere.” It consisted in cutting upon the point of a catheter, conveyed down to the seat of obstruction, and after having thus removed the resistance, completing the passage into the bladder. But although it might be possible in this way to reestablish the natural canal, the chances were greatly against doing so ; and although temporary relief might be afforded, there was almost a certainty of future trouble from contraction of the new formed passage, while failure in completing it in the first instance exposed the patient to great danger from the extravasation of urine, so apt to occur when an opening is made into the urethra on the vesical side of any obstruction in its course. B^ow there is nothing of more consequence in the treatment of stricture than knowledge of the fact that this alleged impermeability has no real existence, except in those rare, exceptional cases, where the urethra has been

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divided by violence, and allowed to cicatrise with obliteration of the passage beyond the opening at the seat of injury. It is obvious, indeed, that if the urine is permitted to pass, no matter in how small a stream, or even only by drops, there must be room for the introduction of an instrument, provided it be sufficiently small, and properly guided.

In making this statement, it is very far from my wish or intention to allege that the passage of instruments through strictures is always easy, or to deny that the utmost extent of skill and experience may hardly prove sufficient for overcoming the difficulties presented by an extreme degree of contraction, associated with numerous false routes through the sides of the canal. But if the case, as I have endeavoured to show, is really one of difficulty merely, and not impossibility, the prospect of successful treatment will be rendered much more encouraging by viewing it in the proper light ; and instead of desisting from further attempts under the impression that an insuperable obstacle exists, the surgeon will patiently persevere in the hope of, sooner or later, discovering the true passage, or seek the assistance of his brethren who are more conversant with this department of practice. In teaching surgery, Mr Liston repudiated puncture of the bladder as a proceeding never

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necessary, and always indicative of incompetency on the part of the practitioner, forgetting that daily, or rather hourly exercise in the use of urethral instruments is requisite for any approach to perfection in their use, and that therefore retention of urine would often prove fatal, if not remediable by other means. For my own part, I always taught the operations for puncture of the bladder as procedures which might be fully warranted by the circumstances, and especially in the army, navy, or country practice, prove the onlv available expedients for saving the patient’s life. But on the other hand, when hospital surgeons, who ought to have the best opportunities of acquiring dexterity in the use of instruments, confess that they frequently find it necessary to puncture the bladder, the standard of professional skill is lowered to a degree that must prove injurious to the interests of the public. One of those gentlemen lately published the astounding fact that he had witnessed forty instances of this proceeding ; and if such testimony were accepted without comment, it might afford a shield to great laxity in the treatment of urethral diseases. I therefore think it right to state, that the necessity of having recourse to puncturing the bladder for retention of urine depending upon stric-

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tures, lias not hitherto been regarded as creditable to a public institution ; and that for my own part, during more than twrenty years’ practice in the Royal Infirmary of Edinburgh, I have, as also in private practice, never found it necessary.

What has been said thus far applies to strictures as they usually present themselves, but not to those which may be distinguished as unyielding, irritable, and contractile. In the unyielding form dilatation, though it may be carried on to some extent, is sooner or later arrested by resistance of the tough texture at the seat of contraction ; and if attempts are made to remove this obstacle by forcible distension, the most serious consequences are apt to ensue. In the irritable condition, while all the symptoms of stricture are presented in an extreme degree of severity, the gentlest introduction of instruments is sure to produce great aggravation, not only at the time, but for days afterwards ; so that the patient is distracted between desire to obtain relief, and dread of the effects resulting from means employed with this view. In the contractile, or spasmodic stricture, as it is usually called, no difficulty is experienced in dilating the canal to its proper capacity ; but unhappily with little benefit — the patient still making water laboriously, painfully, and frequently — by

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drops, or in a dribbling stream, which is liable to complete obstruction, through the influence of any local or constitutional disturbance affecting the urinary organs.

For the treatment of stricture in these three forms, whether existing singly or combined together, the means of remedy hitherto employed have proved quite unavailing ; and the patients thus afflicted are deserving to be regarded as a great discredit to surgery. If poor, they frequent hospitals until dismissed by desire from despair of relief, or are declared incurable, or fall victims to practice more zealous than discreet. If rich, they run the gauntlet of European skill — having bougies introduced — caustic applied — internal incisions inflicted ; and so on, until with broken health, disappointed hopes, and perhaps empty purses, they retire in dreary seclusion from society to carry on a dangerous and ineffectual system of palliation through means of the various apparatus collected in the course of their wanderings. That this is not an imaginary or overdrawn picture, must be admitted by every practitioner who possesses any considerable field of observation ; and will also appear from the cases to be found in any large hospital. Indeed, the following fact is of itself sufficient to show how inefficient the

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resources of surgery, have proved in affording relief under the sufferings in question. A French gentleman, the late Marquis of Argenteuil, bequeathed funds sufficient to provide every five years a prize of nearly L.500 in value, for the greatest practical improvement in the treatment of stricture. It is impossible to express more emphatically the amount of torment he had endured, or the imperfect relief he had derived from the treatment which his ample means enabled him so fully to appreciate. The following case affords a good example of the complicated misery resulting from this aggravated form of stricture, as well as in the insufficiency of ordinary treatment, to afford relief under such circumstances, and led me to adopt a mode of procedure that there seems reason to hope will prove sufficient for vanquishing the difficulty in question.

Case I.

In 1840 I was requested by the late Dr Hay to take charge of a gentleman who had suffered long and severely from stricture of the urethra. He was between forty and fifty years of age, of tall stature and robust form. His complaint had existed twenty years, and during the earlier part of this period had been partially alleviated by the introduction of bougies, but had then gradually increased, until at length the suffering occasioned by it was altogether intolerable. During both day and night, the calls to make water were almost incessant, and excited the most violent expidsive efforts, which, aided by a milking-like manipulation of the penis, and pressure along the perineum, never produced anything more than a scanty dribbling discharge. From the bladder being thus imperfectly emptied, the urine was constantly passing away insensibly, so as to keep the clothes wet, with what discomfort to the patient mav be more easily imagined than described. He was peculiarly susceptible in regard to atmospheric changes, and especially in damp weather suffered an aggravation of the symptoms. The urine, when collected on such occasions, was found to deposit large quantities of glairy mucus, from which indeed it was never quite free.

On examination, I found a tight stricture between five and six inches from the orifice of the urethra ; and at the second or third attempt, succeeded in passing the smallest-sized bougie fairly through it into the bladder. I then supposed that, as usual, there would not be any further difficulty in treating the case, and desired the patient to call upon me

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twice a week, unless when the weather or any other circumstance should render a longer delay necessary. The progress, though not rapid, at length enabled me to pass Wo. 5 of my scale, equal to Wo. 1 of that in common use, when I found it impossible to make any advance. Indeed there was little encouragement to persevere in attempting this, as, notwithstanding the degree of dilatation that had been accomplished, there was not any appearance of relief from the symptoms of the disease.

I then proposed to confine the patient to bed, and keep a succession of catheters, gradually increased in size, in the bladder. He made no objection, and was greatly pleased to find that, instead of the irritation he expected, there was at once obtained complete relief from all his previous uneasy feelings. He read and wrote, ate and slept, without the least disturbance, drawing off the urine from time to time, and observing to his great satisfaction that the mucus had entirely disappeared. At the end of ten days I withdrew the full-sized silver catheter then employed, and before twenty-four hours had expired, found the complaint in every respect exactly as it had been before the process was commenced.

Some months after this, I divided the stricture from within by means of a catheter containing a

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lancet blade, which was protruded from its sheath after the instrument had been passed through the seat of contraction, and kept in this expanded state while the catheter was withdrawn. A large bougie was immediately afterwards passed with perfect ease ; and again hopes of success were entertained. But next day things were precisely in the same state as formerly.

Several months having elapsed without any change, it was resolved to combine the two lastmentioned modes of treatment. In the first place, I divided the stricture as before, but on both sides, by means of two lancet catheters, cutting right and left, and then introduced a full-sized catheter into the bladder, where it was retained for a week. For some time afterwards it seemed as if benefit had resulted from this procedure, and the patient, by frequently passing a bougie or catheter through the strictured part, was enabled to make water in a tolerably full stream. But this imperfect relief was of short duration, and by the end of two or three weeks, the frequent calls, laborious straining, and copious mucus, proclaimed that the stricture had regained its former condition.

The patient now protesting that life was not desirable under the torment of his complaint, and en-

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treating me to employ some efficient measure ol remedy, no matter at wliat expense of pain or risk of danger, I resolved to divide the stricture by free external incision. With this view a small staff, grooved on its convex side, having been introduced, I made an incision in the raphe of the perineum from the bulb to the anus, and then feeling for the stricture, which was easily recognised by its surrounding induration — ran the knife fairly through the whole extent of thickened texture. A full-sized catheter was substituted for the staff, and retained for a few days. The patient suffered little from the operation, except some uneasiness from irritation caused by the urine passing through the wound. When it closed he felt quite well ; and he continues to do so, though thirteen years have now elapsed. He has never required the bougie, and in every respect enjoys the most perfect health.