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"Cutting into the perineum without the assistance of a precise guide, exposes to the serious danger of opening the urethra on the wrong side of the stricture, of breaking through the deep fascia, and of wounding the artery of the bulb, so as to incur the risk of urinary extravasation and haemorrhage, while pressure being the only means available to suppress the latter, must greatly tend to promote the former evil. It is therefore no wonder that this procedure has been looked upon as a forlorn hope, warrantable only in cases of impermeable stricture. But while admitting, as I have already done, that in some rare cases the urethra may be actually obliterated, 1 maintain that no stricture is impermeable, and that if a drop of urine is able to escape, a director of sufficiently small size may be introduced; and in support of this position I appeal to the fact, that although patients alleged to labour under impermeable contractions, have come to me for relief from the most distant parts of Scotland, England, and Ireland, from the Colonies, and from America, I have never, either publicly or privately, been unable to pass an instrument since I became satisfied that there was no true impermeability.
"Some advocates of impermeability, indeed, allege that those who deny the existence of this condition effect a passage by force; but as the stricture is tougher than the sound urethra, and as, therefore, any passage accomplished by force must necessarily be a false one, which would aggravate the patient's case instead of remedying it, the satisfactory result of treatment affords a most complete refutation of such statements. As already said, it is far from my intention to allege, that the introduction of instruments, may always be accomplished with ease. In general, I have succeeded at the first attempt; but in many cases, have had to wait days, or even weeks, before the passage could be hit. Indeed, on three occasions—one in private and two in public—I found it necessary to open the urethra anteriorly to the stricture, so as to obtain the assistance of a finger placed in the canal, to guide the point of the instrument."—Pp. 33-36.
One of the two cases that occurred in public is given in detail, as Case XIV., where Mr Syme, after mentioning that he had been for two months unable to pass a bougie through a stricture reported impermeable, gives the following account of the plan he adopted :—
"As I had little doubt, however, that the difficulty arose from the form of the urethra where the false passage entered it, rather than from mere tightness of the stricture, I resolved to lay open the urethra on a director in front of the stricture, and then endeavour to guide the director through the stricture by means of my forefinger introduced into the wound. For I had found, in a former case, that the tip of the index finger being inserted into the part of the urethra in front of the stricture as into a thimble, afforded the means of guiding on an instrument through the stricture with unexpected facility. Accordingly, on the 31st August, the patient being under chloroform, I measured with a large bougie the distance of the stricture from the external orifice, and having introduced a director rather larger than No. 1 bougie for the same distance into the urethra, I pushed it in as far as it would go, and being thus sure that the end of the director was in the false passage, 1 made an incision in the middle line of the perineum, and laid open on the director the contiguous parts of the urethra and false passage. Having then introduced my finger into the wound, I succeeded in guiding the director through the stricture, and divided it in the usual manner by running the knife along the groove. I had now no difficulty in passing a full-sized catheter into the bladder."—Pp. 94-96.
This case appears to throw an entirely new light upon the subject of relieving retention of urine by operation when the catheter cannot be passed in the ordinary way. And although Mr Syme tells us that he has never yet found puncture of the bladder necessary for retention of urine depending upon stricture, he must admit that if a case like the above had come to him with urgent retention, before he had hit
s upon the expedient there made use of, he must have had recourse to puncture of the bladder. For though the difficulty in that case arose from complication, with a false passage, rather than from tightness of the stricture, yet it was not on that account the less insuperable in the ordinary way. The great obstacle to the management of strictures at the bulb unquestionably is the difficulty of guiding small instruments with precision in that part of the canal, and the means now furnished by Mr Syme for facilitating this process, appears to us a most valuable addition to surgery; and we need scarcely point out the contrast between the results of this method, and those of "groping in the perineum without a guide."
"It is the preposterous system of 'tunnelling,' as it has been called—or attempting, by long continued pressure, to pass large bougies or catheters through a tight contraction—that gives rise to the greatest difficulty in introducing instruments, since there is thus formed a cul de sac beyond the stricture, but nearly in the proper direction of the canal, so that if small instruments are afterwards used, false passages are apt to be formed at the bottom, while the true one exists at the side of the excavation."—Pp. 36, 37.
For a description of the mode of performing the operation of division of a stricture by external incision, we must refer the reader to the work, where he will find a representation of Mr Syme's new staff, which, by giving accurate information as to the seat of the stricture, "has wonderfully facilitated the process, and also rendered it much more sure of being effectual."
"The only sources of danger that can be attributed to theoperation, are bleeding and extravasation of urine; and in order to estimate the importance due to them, it is necessary that the true position of strictures should be ascertained." Here Mr Syme makes the im
f)ortant announcement that "the seat of contraction may be positively imited to that portion of the urethra which extends from the bulb to the orifice," and "the ground upon which he makes this statement is that in all his experience (viz., in 108 cases), he never found it necessary to cut farther back than the bulbous portion, for the conveyance of a full-sized instrument into the bladder," although in many of the cases the stricture was previously believed to be in the membranous position.
"It being then assumed as a fundamental principle, that incisions for the remedy of stricture do not require to be carried farther back than the bulb of the urethra, it follows that there is no occasion for cutting through the deep fascia of the perineum or extension of the triangular ligament, and consequently, that if the urine should become extravasated, its diffusion must be limited to the scrotum and other external parts. But if a large catheter he retained in the bladder, there is no risk of any such occurrence, and therefore this source of danger may be put entirely aside."—Pp. 42, 43.
Serious haemorrhage can proceed only from the arteries of the bulb, and a figure is given showing the lateral position of these vessels, and making it evident that they "cannot be wounded by any incision in the'middle line."
"By these considerations in regard to the security from extravasations of urine and hemorrhage," says the author," I was originally led to expect that the operation would prove nearly, if not entirely, free from danger ; and this anticipation has not been disappointed. Having declined no case presented for treatment, and operated at all ages, from 77 downwards, as well as under every variety of complication from long existence, alleged impermeability, and the false passages of previous mismanagement, I have now performed the operation 108 times, with only 2 fatal results that can be ascribed to it."—Pp. 44, 46.
To some persons these exceptions will probably have the effect of proving the rule, for though, for our own part, we never doubted Mr Syme's good faith, there has been in some quarters a wonderful unwillingness to admit the truth of his statements regarding the safety of the operation. Both the deaths are thought to have occurred from pyaemia; but one of the patients appears to have been in a state hardly suitable for operative interference of any kind. The other case is by no means a clear one; and we cannot but regret exceedingly that permission was not obtained to examine the body, considering that the result was attributed to a fall upon the knee and head in a fainting fit, and that "symptoms of cerebral excitement presented themselves and assumed an alarming character," so late as four weeks after the operation. We cannot but think some cerebral lesion more likely to have been the cause of death than pyasmia. Be this as it may, the mortality from this operation has certainly been very slight in Mr Syme's hands, and this we confess we have no difficulty in understanding; no surgeon would speak of the extraction of a calculus from the spongy part of the urethra by an incision in the middle line as a dangerous operation, and admitting, as we must, that the disease is limited to that part of the canal, why should a medium incision through a stricture be fraught with greater danger, provided always that the operator be skilful and divide the indurated textures upon a proper guide?
One instance of hemorrhage occurred "in the 98th case," but this was under very "peculiar circumstances," for which we must refer the reader to the work; and Mr Syme "ventures to express the hope, that as the appearance of one swallow is admitted not to make a summer, one instance of bleeding in a hundred operations will not be regarded as good ground for apprehending hemorrhage." So far from there being any risk of the wound remaining fistulous, it may be stated that of all the means hitherto devised for the remedy of fistula in perineo, a free division of the contracted part of the canal is the most effectual, as might be expected from the state of matters concerned."
"While the operation may thus be regarded as exempt from the risk of hemorrhage, urinary extravasations, and fistulous effects, it is here proper to remark, that there are not unfrequently symptoms of an alarming character, and which under other circumstances would justly excite the most serious apprehension. These are rigors occurring alone or associated with bilious vomiting, suppression of urine, or delirium. They generally present themselves during the first two days, and are seldom met witli beyond the third. In the great majority of cases they pass off in a few hours without the slightest disagreeable consequences; but on rare occasions, just as in the feverish attacks attendic: the introduction of a bougie, leave some local derangement, such as a swelled testicle or abscess of the scrotum. There is no treatment required on the occasion of these attacks, and if the surgeon has had sufficient experience to fed confident that there is no real danger, he will be able to administer the only practicable relief by assuring the patient and his friends that the state <A nervous irritation will quickly subside."—Pp. 52, 53.
With regard to the effects of the operation, we must again leave the author to speak for himself:—
"The good effects of the operation may be divided into immediate and remote. The first extending to a period of some months' duration, and the latter existing through the remainder of the patient's life. Now, whatever may hare been the condition of the stricture, whether irritable, contractile, or obstinate, and whatever may have been the severity or duration of the symptoms, complete relief in the first instance has invariably resulted from every operation that I have performed. Instead of the slow and frequently interrupted progress of improvement which usually attends the use of bougies, all the distressing symptoms quickly disappear, not unfrequently without an hour's de
and loaded with mucus, it becomes clear and limpid. The frequent and distressing calls to micturition are succeeded by a state of blissful repose. The most obstinate and unyielding contraction admits with ease instruments of the largest size; and the most irritable stricture which could not previously be touched without the production of spasms and ague, permits the passage of bougies without the slightest uneasiness either immediate or consecutive. The urine, instead of being passed by drops or escaping incontinently, flows freely in a copious stream, and the patient, however much worn down by sufferinc, speedily regaining his appetite and strength, appears to his friends like a new edition of himself. The relief thus obtained having proved no less permanent than complete in many cases of the most hopeless character, I think the fair presumption is, that when relapses do take place, there must be some reason for such exceptions from the general rule, and that the duty of practitioners consequently is, not to search out these failures as objections to a proposal for the remedy of contractions confessedly incurable through other means, but rather to study the subject in a candid spirit of inquiry, with the view of ascertaining the circumstances essential to success."—Pp. 53, 54.
In case XVI. will be found a description of the post-mortem ap
Eearances of the urethra of a patient who died of aneurism, having een operated on two years previously for a tight stricture at the bulb, accompanied with induration of the perineum :—
"A white depressed line of cicatrix, on the inner surface of the urethra, extending, in the mesial line, half an inch forward from the extremity of the bulb, corresponded exactly with the line of cicatrix in the integuments and intermediate textures. The urethra in this part was rather wider than natural, from having a slight funnel-shaped depression on the lower surface, and, before being opened, easily admitted a No. 12 bougie. In other respects the coats of the urethra presented a perfectly natural aspect, and the spongy tissue of the bulb, as well as the neighbouring parts, were free from induration.
"No one," observes Mr Syme, "looking at the urethra, which remained thus sound and ample at the part where it had been so long and tightly contracted, although two years had elapsed since the operation without any means being used to prevent relapse, could entertain a reasonable doubt as to the recovery proving permanent, however long the patient might have lived ; and such a result should stimulate our exertions to discover, so that they may be avoided, the errors of performance to which any recurrence of the symptoms
If the urine has been thick
tSkt may have happened ought to be attributed, rather than to the principle the operation."
Most of the cases given in the work, while examples of the diffe;nt forms assumed by the disease, tend to prove the permanence of hie cure; and with regard to this point we would particularly refer I le reader to the first case, alluded to in an early part of this notice s having appeared in the first edition. "Thirteen years have now lapsed," yet the patient, who " has never required the bougie, in ;-very respect enjoys the most perfect health."
In proceeding to consider the causes of the relapse that has occurred in some cases, Mr Syme complains that he has been left almost alone in the investigation of this subject, and that " little, if any, additional information has proceeded from other sources" during the last five years.
"That the rapacious quacks who have so long made stricture of the urethra a. profitable source of gain should oppose the introduction of an efficient method For rescuing the victims of their extortion from the toils of an incurable malady, is not at all surprising; and that members of the profession who have not acquired the art of passing instruments safely through urethral obstructions should view with coldness a proposal essentially requiring for its successful application the utmost familiarity with operative manipulation, is quite consistent with what was to be expected. But that the leading members of the profession should have displayed such apathy in regard to a matter so deeply affecting the interest of their patients, could hardly have been anticipated. . . . The most obvious and certain cause of relapses would appear to be adhesion by the first intention between the edges of the incision made through the strictured part, which must restore the state of matters that existed previously to the operation."—Pp. 65, 56.
And that this cause does sometimes come into operation will be strikingly illustrated by a case of stricture at the very orifice of the urethra, in which the condition of the part could be accurately observed.
u If the stricture is tight, the presence of a full-sized catheter will go far to prevent approximation of the cut edges; but if it be of that dilatable kind which requires the operation merely to remedy a spasmodic or resilient tendency, the risk of reunion will be considerably greater; and it is accordingly in such cases that I have found the disease most apt to return. At the expense of somewhat prolonging the process of recovery, it will therefore be prudent, with the view of promoting its permanency, to allow the urine in the first instance to pass through the wound, which may be easily done by introducing the finger occasionally, so as to feel the surface of the catheter."—Pp. 58, 59.
u Another cause of relapse," Mr Syme has "no doubt, is making too limited an incision through the stricture; since the canal is frequently, if not always, contracted on each side of it into a conical form—so that if the whole of this part is not divided, the portion remaining may reproduce the symptoms." "As in all wounds and injuries of the urethra contraction of the canal is apt to occur, if a full-sized instrument is not occasionally introduced during the process of healing, this precaution should not he omitted," particularly during the early period of the treatment after the operation.