« AnteriorContinuar »
On Stricture oftfte Urethra. By Henry Smith, F.R.C.S., Surgeon to the Westminster General Dispensary; formerly House - Surgeon to King's College Hospital. London, 1857. pp. 280.
Mr. Smith commences his work by a consideration of some points connected with the anatomy of the urethra. Those which he particularly dwells upon have an immediate practical bearing: thus, an accurate division of the urethra into different portions is naturally connected with the ordinary seat of stricture. Upon this point there can be no doubt that up to a very recent period most surgeons would at once have said that stricture was generally met with in the membranous portion of the urethra. This opinion Mr. Smith combats; and he gives the results of eighty-five examinations of preparations in the museums of Bartholomew's, Cambridge, King's College, and the College of Surgeons. The seat of stricture was found in the membranous portion in eighteen cases only, "whilst in fifty of the specimens the disease is situated either in the bulb itself or just in front of it." (p. 30.)
In Mr. Henry Thompson's work ' On Stricture of the Urethra,' published three years before Mr. Smith's, there is an analysis of a much more extended series of observations. "I have personally," says Mr. Thompson, "submitted to a close and careful inspection not less than three hundred preparations of stricture of the urethra. I possess notes made on the spot of two hundred and seventy.'* (p. 87.) The conclusion arrived at by Mr. Thompson is, that the junction between the spongy and membranous portions is the point at which stricture is most frequently situated, but, he adds, that a spot about an inch in front of this point is almost as frequently affected. It must, however, after all, be doubted how far the evidence adduced from the examination of preparations is available in determining such a point; because few pathologists will preserve specimens unless they illustrate something which has not, up to that time, generally been received—and consequently during theperiod in which stricture of the urethra was regarded as occurring usually at the anterior point of the membranous portion, a specimen of this disease would not be so likely to be preserved as a specimen of a stricture found in any other situation: one important and practical fact has, however, been clearly demonstrated, namely, that stricture does occur in a large number of cases in the bulbous portion of the urethra; and to this we shall again more particularly refer when we consider the subject of perineal section. Another point of practical interest arising out of the consideration of the anatomy of the urethra is the existence throughout the whole length of the canal of a distinct set of organic or involuntary muscular fibres.
"The occurrence of spasmodic stricture without the existence of any organic disease, has been by most surgeons attributed to the action of the* muscles which surround the back portions of the urethra,—viz., the accelerator urinec, the compressor urethras, and the anterior fibres of the levator ani. . . . Experienee teaches that in the majority of cases of spasmodic stricture an instrument is obstructed at the bulb or membranous portion, where the muscles above mentioned exert their action. ... But it is occasionally noticed that the spasmodic action is particularly appreciable at the anterior portion of the canal." (p. 24.)
The difficulty of accounting for spasm in the anterior part of the urethra has been removed by Mr. Hancock's discovery that the urethra is muscular throughout. In his work lately published, Mr. Hancock "has related some very interesting cases in which spasmodic stricture seemed to depend entirely upon the organic muscular fibres of the urethra." (p. 25.) Upon this point we cannot forbear extracting the following from a MS. copy of notes of Sir B. Brodie's Surgical Lectures, delivered in the year 1810, now before us. It cannot fail to be read with interest, as affording an instance of that intuitive insight which discerns the subtle workings of nature, even before the mechanism by which those actions are performed has been either demonstrated or discovered:
"There is no doubt (says Sir B. Brodie, in a lecture delivered now nearly half a century ago) "that the whole of the canal is muscular. Though such fibres caunot be distinguished, they may be distinguished in larger animals. In hydatids no muscular fibres can be seen, but by what other means can the animal contract and dilate itself? ... The whole of the canal therefore, I say, is muscular."
A third anatomical point upon which Mr. Smith has dwelt, is the ordinary length of the urethra—a point upon which the late Mr. Biiggs bestowed some labour. But as the urethra is surrounded by spongy and erectile tissue, it is evident that its dimensions must constantly be varying. The temperature of a room or the sight of a catheter would be sufficient to produce an alteration in the length of. this sensitive part; we do not therefore think that much practical benefit has arisen from the measurements that have been made, nor are we surprised to hear that "anatomists and surgeons have differed" in the results which they have obtained.
In considering the nature and pathology of stricture, Mr. Smith reviews the effects on the canal in front of the stricture, the effects on the canal behind, perineal fistulae, and various affections of other parts.
With regard to the mode of formation of perineal fistula-, Mr. Smith says they are produced in two ways—
"Sometimes an abscess is formed external to the canal, and at length opens into it. The other method in which the same condition is produced is as follows: the urethra behind the stricture ulcerates, urine escapes from the canal, becomes diffused into the loose cellular tissue of the perineum aud scrotum." (p. 36.)
Mr. Smith surely does not mean to say that whenever the urethra ulcerates, the urine becomes infiltrated in the cellular membrane, as in the formation of a common abscess. The adhesive inflammation may, and does generally precede the ulceration, so in ulceration of the urethra a similar action may and generally docs take. place; and by means of this the urine, after it has escaped from the urethra, may be prevented from becoming effused into surrounding parts. Under such circumstances we have an abscess formed which will probably open externally, but being everywhere surrounded by its layer of lymph, the contents of this abscess are circumscribed, like those of a similar affection situated in any other part. In either case, should the adhesion not be sufficiently firm to circumscribe and limit the disease, effusion will take place, and we then have extravasation of urine from an ulceration connected with the urethra, from the same cause as we have diffuse cellular inflammation occurring in conjunction with suppuration elsewhere.
By far the greater part of the work before us is devoted to the treatme.pt of stricture, and the mechanical means employed for this purpose are considered under three heads:—1. Dilatation; 2. Cauterization; 3. Incision.
With regard to the first, the preference is given, as a rule, to the use of the common wax bougie. Upon this point, we believe that the conclusions avowed are based upon sound reasoning and experience. We would only remark, that it appears to us that the consideration of the use of bougies with a bulbous extremity is somewhat summarily dismissed. These instruments are much used in France, and from the flexible nature of their extremities are often preferred to others. The objection urged by the author, that in some instances, even if such an instrument could be passed through a stricture, "there might be some difficulty in withdrawing it" (p. 80), scarcely requires a serious examination.
"Another mode of treating stricture, by a species of rapid dilatation, has of late been practised by Mr. Thomas Wakley. It is, indeed, chiefly a modification of the plan devised by the Freneh surgeons. . . . The conducting rod is first passed through the stricture into the bladder; and upon this one of the small silver tubes is carried, so as to dilate the stricture forcibly and rapidly." (p. 113.)
Some of the French surgeons have of late years much insisted upon this forcible dilatation of a stricture; and M. Maisonneuve, two or three years ago, invented a sound composed of two halves. These were connected by little metal bars, with a hinge at each extremity, and were so arranged, that by withdrawing the upper half of the instrument it was separated from the lower half for a quarter of an inch or more. By this means, after the instrument was once passed, a stricture could be dilated instantaneously to any requisite extent. But in these various modes of producing rapid dilatation we see no advantage over the ordinary conical bougie, or the sound with an egg-shaped enlargement at one part. Instruments of the latter kind were many years ago kept by Messrs. Savigny and Co., of St. James's-street. The anterior part of the sound might be made to pass readily enough through an ordinary stricture into the bladder, and the enlarged portion following would necessarily dilate the passage according to the degree of force employed. It can matter little whether, in producing this result, a solid instrument is employed as of old; or an instrument composed of two parts, as suggested by M. Maisonneuve; or of many tubes, as recommended by Mr. Wakley.
Seventy-six pages of Mr. Heury Smith's work are devoted to the subject of the treatment of stricture by external section:—a rather large proportion, compared with the small space given to the consideration of constitntional treatment of the patients in these cases.
After a lengthened consideration of the objections to the operation of external section of the perineum, Mr. Henry Smith, although evidently adverse to the operation, arrives at the conclusion that—
"If proper attempts have been continued for a length of time in vain, it is justifiable to make a line opening into the urethra, either cutting through the strictured portion, or penetrating the membranous part, if there is not much appearanee of stricture." (p. 253.)
The words in the above quotation which we have put in italics appear to us important. They show that Mr. Smith contemplates the division of the membranous portion of the urethra in certain cases of perineal section. We dwell upon this point from a conviction that many operating surgeons in common with Mr. Smith consider this as a part of Mr. Syme's proceeding. If, however, we turn to Mr. Syme's description of his own operation, we read—
"In regard to extravasation of urine, there can be no doubt that the circumstanees most favourable to its production are openings through the deep fascia of the perineum. . . . But, according to my proposal, the only fascia concerned is that which lies immediately under the integuments."*
Now it must be evident that Mr. Syme's operation, as he describes it, can apply only to cases of stricture situated in front of the membranous portion of the urethra It would be impossible to divide a stricture in the membranous portion without interfering with the deep fascia. Here, then, two distinct classes of cases present themselves, corresponding to the different situations in which the stricture is commonly found—namely, in the bulb and in the anterior part of the membranous portion. The seventy cases to which Mr. Syme refers in the paper above alluded to, and which he says were performed without any fatal or even alarming symptoms, must, we should think, have been cases of stricture in the bulbous portion of the urethra. We have observed in practice the very slight irritation that has followed a division of this part when the incision has not been carried backward. The possibility of this is prevented in Mr. Syme's mode of performing the operation, in consequence of the back of the knife being towards the deep fascia.'
From the cases related by Mr. Henry Smith, as well as from those which we have ourselves observed, we would venture to say that the operation in question cannot with impunity be performed in cases where the stricture is situated in the membrauous portion of the urethra. The operation then would be either useless or dangerous^ useless, if confined to the bulb; dangerous, if extended farther back. The want of clear statement of the situation of the strictures operated upon, has probably been the cause of much misunderstanding and apparent contradiction with respect to this operation; and we hope in future works upon stricture of the urethra, that this point will receive the attention which it appears so justly to deserve. It is not a little remarkable that Mr. Smith should have failed to have noticed the great difference which appears to us to exist between an external section of the bulbous and of the membranous portions of the urethra, while he so cleverly notes this difference respecting internal section of the same parts:
* Medical and Chirurgical Transactions, vol. xxxvi. p. S59.
"It is almost universally acknowledged (he says) that when stricture is situated anywhere in the straight portion of the urethra, internal incision may be performed with safety; but that, when it is met with beyond the bulb, internal section may be followed by very serious results, such as haemorrhage, inflammation and abscess, infiltration of urine, false passage, and death." (p. 171.)
In concluding our necessarily brief review of Mr. Henry Smith's work, we feel convinced that it has, as he states, been his endeavour to investigate this subject without any prejudice, and that he baa related his cases with the utmost candour and fairness.
Tlie Midland Quarterly Journal of the Medical Sciences. Vol. I. Part I. pp. 192. Birmingham. London. May, 1857.
The present is an age of public journalism. Every morning ushers in a rapidly increasing series of papers, containing an account of the current events of the day, and advocating opinions to suit every grade of political creed. Every profession, and every branch of literature, science, and art, are represented by numerous periodical publications. In no profession is this multiplicity of journals more remarkable than in that of medicine. Every week, month, quarter, and half year beget a host of them, treating of every topic upon which medicine can be brought to bear.
It is not long since we had occasion* to notice the first appearance of the 'Liverpool Medico-Chirurgical Journal,' and we have now to introduce a new claimant for the support of the profession, under the title placed at the head of the present article. It may be considered invidious in us to pronounce an opinion on the necessity or propriety of thus multiplying the already too numerous sources of periodical medical literature ; nevertheless, we would venture to suggest, that it may be questionable whether the true interests of medical science are promoted by this multiplication, or whether these may not occasionally be sacrificed to others of a more private nature. The great number of journals of the present day affords a facility for the publication of many papers which only encumber medical literature, and which in some instances hardly deserve to have seen the light. Another con
• Brit. and For. Med.-Chlr. Bevlew, p. 442. April 1857.