On the operation of opening the urethra in the perinaeum / by Thomas Bryant.

  • Bryant, Thomas, 1828-1914.
Date:
[1858]
    coiisec[ueiic6^ unless some steps be taken to let out tlie urine, extravasation must follow, with all its dangers. Tlie question then for determination is—what is the best step to be taken ? And I answer most unhesitatingly, the perineal section.-’^ By such an operation the extravasated blood is let out, the chances of the extravasation of urine are removed, and, what is more, by Ihe passage of a catheter and its subsequent rest in the urethra, a more complete and per- fect cure is likely to follow than when the junction of the divided passage is left to chance, for it is from such cases that the w’orst and most intractable forms of stricture are produced, and in which a subsequent perineal division of the urethra is generally called for. Case, i—J. B—, set, 35, when jumping over a post injured his perinseurn ; the accident was followed by bleeding from the urethra and extravasation of urine. When admitted, catheterism was impossible ; the urethra was laid open in the perinseurn, and an instrument passed and left in for a week; the wound gra- dually healed, and the urine was drawn off regularly by a catheter, and upon the 17th day the perineal wound had ceased to afford any passage to the urine, and the man left well. When this rupture of the urethra is associated with other pelvic injuries, the argument in favour of the operation is much strengthened; the dangers resulting from extravasation of urine would in such cases be evidently magnified, and the necessity for an easy and direct flow of urine becomes more apparent. By this operation such a result is easily obtained, and, unless a catheter can be passed, it should be performed. When required in organic stricture.—Having thus briefly pointed out some of the cases in which the division of the urethra in the perinseurn may be called for, I pass on to the consideration of the cases of organic stricture in which such a ])iactice may be requii’ed, and without entering into the many points which have excited so much anger and dispute, I believe few surgeons will denv that there are cases where the
    •j uretlirais completely obliterated. The Museum at Guy^s Hos- i|,pital positively proves the fact. With respect to the impermeability of the urethra, I will [ .not say more, than that most surgeons do occasionally meet ' with cases where the passage of a catheter is a very difficult ^ttask, and at times impossible, unless the instrument is forced ! through all opposing structures j practically, such cases are I'impermeable, and are to be treated accordingly. The surgeon [ j\who has to treat finds an obstruction which he cannot fairly » 'overcome, and although another may believe (and perhaps I irightly) that in his hands the difficulty would be conquered, t: The fact remains that the surgeon who has to treat the stricture I i finds it impermeable, and he must consequently adapt his 'rtreatment to the difficulties with which he has to contend; and presuming that he is a competent man and of average [liability, and remembering that surgical rules (as others) are < for the many, and not for the expert few, I proceed with my [ subject, commencing with those forms of stricture which are n permeable. The following short conversation which I held with a i I Scotch gentleman who was visiting Guy^s Hospital after a il long residence in Edinburgh, may, perhaps, help us to under- : stand the cause of the discussion which has been so violent I about impermeable and obstructed urethras. Upon asking [ him many questions about the treatment of cases of stricture, » and in what manner a case of impermeable stricture would ; be treated in the north, he answered by denying the ex- I istence of such a case; for, argued he, a stricture is merely ' a contracted canal. When the urethra is therefore closed, it is ! no longer a canal, and consequently cannot suffer from ! stricture. It was thus evident that, although we employed the same words, we meant very different things; and I venture to conclude that this is reallv the cause of much of %> the difference of opinion which has arisen upon this subject. It may, perhaps, be fairly stated as a general opinion— “That in cases of organic stricture, where the passage of a catheter is possible and not difficult, where it does not pro- duce either any injurious or painful constitutional or local dis- turbance, and where, after dilatation of the stricture, an occasional passage only of the instrument is required to main-
    tain an open channel, no other surgical means can be called for.'' Such an opinion, I think, is fairly held by all surgeons, and any other treatment must require very great and positive evidence of its value, before it can be substituted for such simple means. But, unfortunately, such simple treatment is not sufficient for all cases of permeable stricture, and a second statement, I believe, may be made, -which is as generally enter- tained as the preceding : That cases of stricture do occur occasionally which are so exquisitively sensitive, that the passage of a catheter, however skilfully performed, is followed by such severe constitutional and local disturbance, as to produce more harm than good, and in which it is clear some other method of cure must be employed. And others, which are relieved by means of the catheter and ai’e even fully dilated, but which have a tendency to contract again immediately upon the omission of the treat- ment." In the former case the treatment aggravates instead of re- lieving the symptoms; in the latter it must be continued for life, to preserve an open passage. Under such circumstances it is clear that some other plan of treatment must be adopted, and I believe the most bene- ficial to be the “ external division" of the stricture from the perinaeumj and it is to Professor Syme that we are here espe- cially indebted for having so ably recalled our attention to the treatment of such troublesome and painful cases. Case of Irritable Stricture. Case ii.—E. H—, set. 28, was admitted with an irritabl^ stricture of six j^ears' duration; the passage of a cathete^ produced intense pain and constitutional disturbance, with- out affording any relief. “ External division" of the urethra was performed, and an elastic catheter passed and left in for two days; upon the fourth day nearly all the urine passed through the wound ; upon the eleventh day the wound had nearly healed, and in one month he left well. Contractile Stricture. Case hi. J. H—^ jet. 39, had had stricture for nine
    lyears, with frequent catheterism, and several attacks of retention; and five years previously his bladder had been ipunctured per rectum. Dilatation of the urethra was but .of temporary benefit. “ External division^^ of the urethra was jperformed, and a small calculus behind the stricture was re- 1 moved; the catheter was left in for four days, and in one 1 month he left well. Case iv.—J. G—, set. 29, admitted with stricture of :thirteen years’ duration. He had been relieved frequently I by catheterism in different hospitals, and one year previously had been punctured per rectum. The operation of ‘^external division of the urethra was performed, and a No. 13 I catheter left in the bladder. In six weeks the wound had i quite healed, and he left able to pass his urine in a full • stream. Case v.—H. R—, set. 44, with stricture of thirteen years^ duration, was admitted for the purpose of being operated upon. Plis urethra was permeable and was not very contractile, :but he had made up his mind to be cut,"’^ and the operation >of “ external division was therefore performed. The stricture was a very long one. In eighteen days the wound had ceased to allow the passage of the urine, and in one month he left well. Impermeable Stricture. Having thus disposed of those cases of stricture which are permeable, and which occasionally demand the operation of division of the urethra from the perinseum, I pass on to Hhe consideration of those which are not permeable, and which may also demand the same operation. In the majority of cases there is but little doubt that by constitutional means, such as perfect rest, opium, mild altera- tives, and local depletion, the urethra will at last admit the passage of an instrument; and wdien this improved condition has been obtained, the treatment of the case becomes the same as has been just described under the heading of per- ’meable strictures; but every now and then cases come before the notice of the surgeon where such a favorable result
    cauBOt be secured, and, consequently, his treatment must be adapted to the wants of the individual case. This impermeability may be the result of great irritability of the passage, of its gradual contraction, or of both combined ; or it may result from perfect obliteration. Constitutional and local treatment may at times relieve some of these con- ditions, but occasionally all means fail, catheterism becomes impossible, and, as a consequence, some other plan of treatment must be adopted; and it is in such cases that the operation of dividing the urethra in the periuseum becomes of value. Case vi.—The following case well illustrates the subject; Robert M—, set. 50, who had suffered from stricture for six vears, was admitted with a urethra which would not admit the passage of the smallest instrument, and the attempt pro- duced severe local and constitutional disturbance. Chloro- form was given, but the urethra was still impermeable; con- sequently the perineal section was performed, and a catheter left in for two days. The man progressed favor- ably, and left, after four months’ residence in the hospital, cured. Obliterated Urethra. The cases of stricture in which the urethra is oblite- rated are certainly too hopeless to treat by catheterism, caustics, or any other such means. The hope of relief by the operation now under consideration is also not great, but it certainly offers the best chance for the unfortu- nate sufferer. It is not often that the urethra is ever wholly destroyed ; some small portion of it is generally only involved, and by the operation of perineal section ” this portion may be remodelled to form a useful urethra. Such cases, uncomplicated with perineal or other fistula, cannot be seen, as the urine must find its way out, and its general course is through the perinseum. Under the following heading, therefore, will cases be given to illustrate the treatment. Oipanic Stricture with Perineal Fistula. The next, class of ca>es in which the operation of dividing