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On Strictures of the Urethra. By JAMES BRYAN, M. D., Lec
turer on Surgery, formerly Professor of Surgery in Castleton, Vermont, late Surgeon and Physician to the Philadelphia Dispensary, Member of the Philadelphia Medical Society, &c. &c.
In the whole range of surgical disease, there is unquestionably no one more inconvenient, distressing and obstinate, ihan "Stric. ture of the Urethra.” Confined, as it is, to no age,- for according to the best authorities, it is found in youth and childhood,
continuing, as it generally does, during the whole of life after an attack, liable to occur at any moment, and placing in jeopardy the very life of the individual-it has ever been a subject of deep interest to the surgeon.
Unlike many other serious and persistent diseases, it is, unfortunately, one of very common occurrence. If, as Dr. Hunter says, “nearly every man has had gonorrhea,” so we may say, a large per centage, of those who have been thus afflicted, have obstructions to the free passage of the urine, in some form or other. Strictures of the urethra may be classified as follows: Ist, Spasınodic stricture. 2d, Permanent stricture. 3d, A combination of the first two.
Spasmodic Striclure. Spasmodic stricture is a a simple closure of a portion of the urethral canal, by the contraction of some of the muscular fibres which surround it. This spasm may be in the circular fibres of the urethra itself; the compressores urinæ, or other portions of the muscular tissue, acting upon the passage. It is induced by some irritation, either local or general, either in the urethra itself, or acting upon some distant part, and producing the disease hy sympathy. Like other diseases of this nature, it is found most frequently in persoas of a nervous and excitable temperament. T'he irritation of gonorrhea, in any or all of its stages, produces this form of stricture; it is not of course in this, or in purely sympathetic cases, dependent upon organic changes, in ihe form of deposits, for its existence. Although very distressing for the time being, producing for hours together complete suppression of the urinary discharge, yet it must be considered as a temporary disease. The application of cold water to the parts and cold io the feet, as recommended by Dr. Hall-or the reverse, warm baths, pediluvia and scmicupia-are means which very frequently succeed in relaxing the stricture. In addition to these, the introduction of a catheter or sound, the use of opiate enemata, or, according to Dr. Hunter, " the crumb part of a new baked loaf, warm from the oven, applied to the perineum;" a blister to the groin; hot steam to the scrotum and perineum, &c. &c. 01 all these, the best by far and most certain, as well as the most expeditions, is the introduction of the catheter, previously warmed and oiled for the purpose, I have found it advantageous, in cold weather, either to allow the patient to remain in bed, or be in a warm room during the introduction of this instrument.
In some cases the disease assumes the character of periodicity, and I have had to evacuate the bladder at stated periods for several days, before the disease gave way, and this entirely independent of that form of stricture which sometimes takes place during the cold stage of an intermittent fever. When caused by some local irritation, the final cure of the disease must of course be sought by the removal of the cause. The old adage need scarcely be repeated, which says that “the removal of the cause cures the effect.”
Permanent Stricture. “ A permanent stricture” (says Sir Everard Home)“ is that contraction of the canal which takes place in consequence of coagulable lymph being exuded between the fasciculi of muscular fibres, and upon the internal membrane, in different quantities, according to circumstances; and, in the same proportion, di. minishing the passage for the urine at that part, or completely closing it up."
This form of the disease is the result of inflammatory action in the tissues around the urethra, producing a deposit of coagulable lymph, which, by its bulk, infringes upon the diameter of the passage. As a general rule, the deposit is slow in its progress, and requires a considerable time to attain sufficient size to materially interfere with the passage of the urine. The symptoms consequently develope themselves gradually. Most generally, the origin, according to Sir A. Cooper, may be distinctly traced to one or more attacks of gonorrhea, and this agrees with our experience. At the same time wounds of the parts, particularly contused wounds-a transfer of intlammatory action from neighbouring parts-are known to produce the same effects. The character which these deposits assume, (and they do not involve the lining membrane of the urethra, which, on the contrary, is corrugated in folds in the passage, over the uneven surface,) is that of a hard cartilaginous ring, partial or complete. The extent of the deposit, which may be felt through the parietes, as a hard substance along the urethra, varies considerably. According to Hunter and others, it is generally not greater than that represented by a pack thread, tied around the canal. Sir B. Brodie speaks of its being sometimes an inch or
aninch and a halfin extent; and in a case which was treated by my. self, it extended more than two inches along the passage, and could be felt externally by the patient and surgeon with the finges. Mr. Samuel Cooper, in his Surgical Dictionary, mentions a case of fistula where the entire rrethra beyond, was closed. The nuniber of strictures also varies in the same case; in many cases there is but one; in others there are two, three, or more strictures. As the diameter of the passage varies in different parts of its course, so the seat of stricture varies. Where the diameter is diminished or curved, the predisposition to stricture seems to be greater than in other parts. Hence the curve of the canal and the bulb, as it is called, are very commonly seats of the disease. In my experience, I have found that the most common seat is about 54 inches from the external orifice; next to this, about 7 or 74 inches; and lastly, about 34 or 4 inches from the extremity of the penis. I have also seen them just within the orifice, and so small that a fine violin string of catgut, or small straws, were used by the patient to keep them open for urination.
Symptoms. The first symptom of stricture is the obstruction, more or less complete, which it causes to the free passage of the urine. The stream will be changed in shape, forked, turned from its usual course, or fall perpendicularly from the mouth of the urethra in great drops and scattering. Some few drops will be retaived in the passage, which will pass off after the rest, producing considerable inconvenience. The patient sometimes has to get up at night two or three times to evacuate his bladder, which is done with difficulty and with considerable effort. A weight and uneasiness is felt in the region of the perineum, and not unfreqnently a gleety discharge issues from the urethra, which may be mistaken for gleet itself. The stream of urine gradually diminishes, inducing strong, "straining” efforts to accelerate it, until almost no stream passes, and the urine falls in drops or stops entirely. The latter, however, generally occurs after exposure to cold or other causes of inflammation, which, setting in, in the strictured part, closes the passage entirely ;-or the closure may be induced by the spasmodic action of the niuscles, as we shall see when speaking of the combined forın of the discase. From a few weeks to eight or ten or more years, may, however, pass in the progress of the disease, ere this state of things takes place. One case lately treated by me, resulted from a very severe attack of gonorrhoea, contracted nine years before. The progress of the disease was gradual, until relieved by an operation. In another case, also cured by an operation, rather more than three years had elapsed. In a third case, about one
year, with repeated gonorrhæas, had induced a confirmed stricture,
In the early stages there is commonly very little pain or inconvenience; the impediment to free urination, which the patient may refer to any other cause than the right one, being the only symptom. In some cases considerable pain accompanies the disease. A patient now sitting by me says, to the question in reference to pain, that he never had any, but adds, that "now and then” he would feel pain in the vicinity of the anus, appa: rently rheumatic, which would wake him up at night, and would be relieved by pressure. The pain existed particularly when he was costive. 'Never suspected a stricture; the stream, he says, gradually diminished, but was variable. For a few days the obstruction would be considerable, and then for a month or two, it would be as usual, never, however, returning to the natural size of the stream. These paroxysms gradually became more frequent, the urine “dribbling” away with difficulty, until at length it entirely ceased, and he was forced to apply for immediate relief. The difficulty in urinating not only varied on different days, but at different times in the same day. An attempt in the morning would sometimes be a partial failure; an hour or two after, the attempt would be more successful. It affected his mind, and was itself affected by mental emotions. The latter, particularly anxiety of mind, increased the difficulty, while the appetite and spirits were affected by the disease. This, in fact, is known to be the case in most of the diseases involving the urinary or genital organs. One patient tells me that the venereal appetite in him, although of a pretty warm temperament, has been for years merely passive. 'The testicle, one or both, it is well known, also, sometimes become enlarged and painful, which may be mistaken for a very different disease. Whether the disease affects the procreative function or not, I am not able to say: but two gentlemen, both married men of four or five years ing, have neither of them children, and they attribute the fact to the disease.
Mixed Stricture. The mixed form of the disease is one exceedingly com: mon. The local irritation of the sub-inflammation, which no doubt exists in the stricture deposit, is sufficient to excite the spasmodic action of the muscular fibres, longitudinal or other, especially in nervous individuals. And these spasms are frequent sources of great pain and considerable danger. They no doubt react upon the strictured part, and assist in keeping up that amount of irritation which is essential to the progress of the disease. In these cases we have all the symptoms of simple spasmodic stricture, made more or less permanent by the perma
nent deposits. The other and more general symptoms are all more intense from the general susceptibility of the system.
Consequences. The consequences of long continued obstruction and stricture on the bladder and neighbouring organs are various. The blad. der becomes, from the increased action, thickened and contracted, so that it sometimes will contain not more than one-fourth of the normal amount of urine. Hence the frequent disposition to evacuate this viscus. The mechanical obstruction, continuing for a certain length of time, will induce ulceration of the urethra, opening through the perineum; and we may have one or more fistulæ in perineo. This takes place sometimes in a short time, from acute inflammation setting in, establishing the suppurating process, which, in most cases, opens through the perineum. In other cases, when relief to the permanent obstruction of the passage is not obtained speedily, we may have rupture of the urethra or bladder, by which the urine is infiltrated into the neighbouring cellular tissue, and mortification and gangrene of the parts follow. Even death may be the consequence of this accident. We are of the opinion, however, that this result, particularly the phlegmonous inflammation opening in the perineum, can be avoided in most cases by the judicious surgeon. Some of our best writers speak of this as a matter of common occurrence. Certainly when it depends on the mechanical obstruction of a stricture, it ought to be avoided; the passage being easily opened by a proper instrument for that purpose. The enlargement of the ureters and pelvis of the kidneys, with more or less disease of the latter, are consequences of long continued obstruc tion of any kind in the urinary passages.
Treatment of Stricture. The treatment necessarily divides itself into that which is appropriate to spasmodic, permanent, or the mixed form of the disease. In reference to the first, where it is simple and uncom. plicated, the methods stated under the caption, “spasmodic stricture,” will be found generally successful; being merely symptomatic or nervous. The modes of treatment there mentioned, particularly for immediate relief, the introduction of a moderate sized, smooth, warm, well oiled metallic sonnd, will be found effectual. The use of terebinthinates, opiates, or anti-spasmodics may be proper for the purpose of permanently curing the disease. Where some irritation, either in the organs of digestion, on the general surface, (such as a blister, for instance) or in the bladder, produces the disease, the removal of the irritation will result in the cure of the stricture.