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Congenital And Pathological Deformities Of The Prepuce And Urethra Stricture And Mechanical Obstructions Of The Urethra

Sources: Surgical Anatomy

When any of the central organs of the body presents in a form differing

from that which we term natural, or structurally perfect and efficient,

if the deformity be one which results as a malformation, ascribable to

an error in the law of development, it is always characterized as an

excess or defect of the substance of the organ at, and in reference to,

the median line. And when any of the canals which naturally open upon

/> the external surface at the median line happens to deviate from its

proper position, such deviation, if it be the result of an error in the

law of development, always occurs, by an actual necessity, at the median

line. On the contrary, though deformities which are the results of

diseased action in a central organ may and do, in some instances,

simulate those which occur by an error in the process of development,

the former cannot bear a like interpretation with the latter, for those

are the effects of ever-varying circumstances, whereas these are the

effects of certain deviations in a natural process--a law, whose course

is serial, gradational, and in the sequent order of a continuous chain

of cause and effect.

Fig. 1, Plate 57, represents the prepuce in a state of congenital

phymosis. The part hypertrophied and pendent projects nearly an inch in

front of the meatus, and forms a canal, continued forwards from this

orifice. As the prepuce in such a state becomes devoid of its proper

function, and hence must be regarded, not only as a mere superfluity,

but as a cause of impediment to the generative function of the whole

organ, it should be removed by an operation.

Fig. 2, Plate 57, represents the prepuce in the condition of

paraphymosis following gonorrhoeal inflammation. The part appears

constricting the penis and urethra behind the corona glandis. This state

of the organ is produced in the following-mentioned way:--the prepuce,

naturally very extensible, becomes, while covering the glans, inflamed,

thickened, and its orifice contracted. It is during this state withdrawn

forcibly backwards over the glans, and in this situation, while being

itself the first cause of constriction, it induces another--namely, an

arrest to the venous circulation, which is followed by a turgescence of

the glans. In the treatment of such a case, the indication is, first, to

reduce by gradual pressure the size of the glans, so that the prepuce

may be replaced over it; secondly, to lessen the inflammation by the

ordinary means.

Fig. 3, Plate 57, exhibits the form of a gonorrhoeal phymosis. The

orifice of the prepuce is contracted, and the tissue of it infiltrated.

If in this state of the part, consequent upon diseased action, or in

that of Fig. 1, which is congenital, the foreskin be retracted over the

glans, a paraphymosis, like Fig. 2, will be produced.

Fig. 4, Plate 57, shows a form of phymosis in which the prepuce during

inflammation has become adherent to the whole surface of the glans. The

orifice of the prepuce being directly opposite the meatus, and the parts

offering no obstruction to the flow of urine, an operation for

separating the prepuce from the glans would not be required.

Fig. 5, Plate 57.--In this figure is represented the form of the penis

of an adult, in whom the prepuce was removed by circumcision at an early

age. The membrane covering the glans and the part which is cicatrised

becomes in these cases dry, indurated, and deprived of its special sense.

Fig. 6, Plate 57.--In this figure the glans appears protruding through

the upper surface of the prepuce, which is thickened and corrugated.

This state of the parts was caused by a venereal ulceration of the upper

part of the prepuce, sufficient to allow the glans to press through the

aperture. The prepuce in this condition being superfluous, and acting as

an impediment, should be removed by operation.

Fig. 7, Plate 57.--In this figure is shown a condition of the glans and

prepuce resembling that last mentioned, and the effect of a similar

cause. By the removal of the prepuce when in the position here

represented, or in that of Fig. 6, the organ may be made to assume the

appearance of Fig. 5.

Fig. 8, Plate 57, represents the form of a congenital hypospadias. The

corpus spongiosum does not continue the canal of the urethra as far

forwards as the usual position of the meatus, but has become defective

behind the fraenum praeputii, leaving the canal open at this place. In a

case of this kind an operation on the taliacotian principle might be

tried in order to close the urethra where it presents abnormally patent.

Fig. 9, Plate 57, represents a congenital hypospadias, in which the

canal of the urethra opens by two distinct apertures along the under

surface of the corpus spongiosum at the middle line. A probe traverses

both apertures. In such a case, if the canal of the urethra were

perforate as far forwards as the meatus, and this latter in its normal

position, the two false openings should be closed by an operation.

Fig. 10, Plate 57.--The urethra is here represented as having a false

opening on its under surface behind the fraenum. The perforation was

caused by a venereal ulcer. The meatus and urethra anterior to the false

aperture remained perforate. Part of a bougie appears traversing the

false opening and the meatus. In this state of the organ an attempt

should be made to close the false aperture permanently.

Fig. 11, Plate 57, shows a state of the urethra similar to that of Fig.

10, and the effect of the same cause. Part of a bougie is seen

traversing the false aperture from the meatus before to the urethra

behind. In this case, as the whole substance of the corpus spongiosum

was destroyed for half an inch in extent, the taliacotian operation, by

which lost quantity is supplied, is the measure most likely to succeed

in closing the canal.

Fig. 12, Plate 57.--Behind the meatus, and on the right of the fraenum,

is represented a perforation in the urethra, caused by a venereal ulcer.

The meatus and the false opening have approached by the contraction of

the cicatrix; in consequence of which, also, the apex of the glans is

distorted towards the urethra; a bougie introduced by the meatus

occupies the urethral canal.

Fig. 13, Plate 57.--In this figure the canal of the urethra appears

turning upwards and opening at the median line behind the corona

glandis. This state of the urethra was caused by a venereal ulcer

penetrating the canal from the dorsum of the penis. The proper direction

of the canal might be restored by obliterating the false passage,

provided the urethra remained perforate in the direction of the meatus.

Fig. 14, Plate 57, exhibits the form of a congenital epispadias, in

which the urethra is seen to open on the dorsal surface of the prepuce

at the median line. The glans appears cleft and deformed. The meatus is

deficient at its usual place. The prepuce at the dorsum is in part

deficient, and bound to the glans around the abnormal orifice.

Fig. 15, Plate 57, represents in section a state of the parts in which

the urethra opened externally by one fistulous aperture, a, behind the

scrotum; and by another, b, in front of the scrotum. At the latter place

the canal beneath the penis became imperforate for an inch in extent.

Parts of catheters are seen to enter the urethra through the fistulous

openings a b; and another instrument, c, is seen to pass by the proper

meatus into the urethra as far as the point where this portion of the

canal fails to communicate with the other. The under part of the scrotum

presents a cleft corresponding with the situation of the scrotal septum.

This state of the urinary passage may be the effect either of congenital

deficiency or of disease. When caused by disease, the chief features in

its history, taking these in the order of their occurrence, are, 1st, a

stricture in the anterior part of the urethra; 2ndly, a rupture of this

canal behind the stricture; 3rdly, the formation (on an abscess opening

externally) of a fistulous communication between the canal and the

surface of some part of the perinaeum; 4thly, the habitual escape of the

urine by the false aperture; 5thly, the obliteration of the canal to a

greater or less extent anterior to the stricture; 6thly, the parts

situated near the urethral fistula become so consolidated and confused

that it is difficult in some and impossible in many cases to find the

situation of the urethra, either by external examination or by means of

the catheter passed into the canal. The original seat of the stricture

becomes so masked by the surrounding disease, and the stricture itself,

even if found by any chance, is generally of so impassable a kind, that

it must be confessed there are few operations in surgery more irksome to

a looker-on than is the fruitless effort made, in such a state of the

parts, by a hand without a guide, to pass perforce a blunt pointed

instrument like a catheter into the bladder. In some instances the

stricture is slightly pervious, the urine passing in small quantity by

the meatus. In others, the stricture is rendered wholly imperforate, and

the canal either contracted or nearly obliterated anteriorly through

disuse. Of these two conditions, the first is that in which catheterism

may be tried with any reasonable hope of passing the instrument into the

bladder. In the latter state, catheterism is useless, and the only means

whereby the urethra may be rendered pervious in the proper direction is

that of incising the stricture from the perinaeum, and after passing a

catheter across the divided part into the bladder, to retain the

instrument in this situation till the wound and the fistulae heal and

close under the treatment proper for this end. (Mr. Syme.)

Fig. 1, Plate 58.--In this figure the urethra appears communicating with

a sac like a scrotum. A bougie is represented entering by the meatus,

traversing the upper part of the sac, and passing into the membranous

part of the urethra beyond. This case which was owing to a congenital

malformation of the urethra, exhibits a dilatation of the canal such as

might be produced behind a stricture wherever situated. The urine

impelled forcibly by the whole action of the abdominal muscles against

the obstructing part dilates the urethra behind the stricture, and by a

repetition of such force the part gradually yields more and more, till

it attains a very large size, and protrudes at the perinaeum as a

distinct fluctuating tumour, every time that an effort is made to void

the bladder. If the stricture in such a case happen to cause a complete

retention of urine, and that a catheter cannot be passed into the

bladder, the tumour should be punctured prior to taking measures for the

removal of the stricture. (Sir B. Brodie.)

Fig. 2, Plate 58, represents two close strictures of the urethra, one of

which is situated at the bulb, and the other at the adjoining membranous

part. These are the two situations in which strictures of the organic

kind are said most frequently to occur, (Hunter, Home, Cooper, Brodie,

Phillips, Velpeau.) False passages likewise are mentioned as more liable

to be made in these places than elsewhere in the urethral canal. These

occurrences--the disease and the accident--would seem to follow each

other closely, like cause and consequence. The frequency with which

false passages occur in this situation appears to me to be chiefly owing

to the anatomical fact, that the urethra at and close to the bulb is the

most dependent part of the curve, F K, Fig. 1, Plate 56; and hence, that

instruments descending to this part from before push forcibly against

the urethra, and are more apt to protrude through it than to have their

points turned so as to ascend the curve towards the neck of the bladder.

If it be also true that strictures happen here more frequently than

elsewhere, this circumstance will of course favour the accident. An

additional cause why the catheter happens to be frequently arrested at

this situation and to perforate the canal, is owing to the fact, that

the triangular ligament is liable to oppose it, the urethral opening in

this structure not happening to coincide with the direction of the point

of the instrument. In the figure, part of a bougie traverses the urethra

through both strictures and lodges upon the enlarged prostate. Another

instrument, after entering the first stricture, occupies a false passage

which was made in the canal between the two constricted parts.

Fig. 3, Plate 58.--A calculus is here represented lodging in the urethra

at the bulb. The walls of the urethra around the calculus appear

thickened. Behind the obstructing body the canal has become dilated,

and, in front of it, contracted. In some instances the calculus presents

a perforation through its centre, by which the urine escapes. In others,

the urine makes its exit between the calculus and the side of the

urethra, which it dilates. In this latter way the foreign body becomes

loosened in the canal and gradually pushed forwards as far as the

meatus, within which, owing to the narrowness of this aperture, it

lodges permanently. If the calculus forms a complete obstruction to the

passage of the urine, and its removal cannot be effected by other means,

an incision should be made to effect this object.

Fig. 4, Plate 58, represents the neck of the bladder and neighbouring

part of the urethra of an ox, in which a polypous growth is seen

attached by a long pedicle to the veru montanum and blocking up the neck

of the bladder. Small irregular tubercles of organized lymph, and

tumours formed by the lacunae distended by their own secretion, their

orifices being closed by inflammation, are also found to obstruct the

urethral canal.

Fig. 5, Plate 58.--In this figure is represented a small calculus

impacted in and dilating the membranous part of the urethra.

Fig. 6, Plate 58.--Two strictures are here shown to exist in the

urethra, one of which is situated immediately in front of the bulb, and

the other at a point midway between the bulb and the meatus.

Fig. 9, Plate 58, represents the form of an old callous stricture half

an inch long, situated midway between the bulb and the meatus. This is

perhaps the most common site in which a stricture of this kind is found

to exist. In some instances of old neglected cases the corpus spongiosum

appears converted into a thick gristly cartilaginous mass, several

inches in extent, the passage here being very much contracted, and

chiefly so at the middle of the stricture. When it becomes impossible to

dilate or pass the canal of such a stricture by the ordinary means, it

is recommended to divide the part by the lancetted stilette. (Stafford.)

Division of the stricture, by any means, is no doubt the readiest and

most effectual measure that can be adopted, provided we know clearly

that the cutting instrument engages fairly the part to be divided. But

this is a knowledge less likely to be attained if the stricture be

situated behind than in front of the triangular ligament.

Fig. 10, Plate 58, exhibits a lateral view of the muscular parts which

surround the membranous portion of the urethra and the prostate; a, the

membranous urethra embraced by the compressor urethrae muscle; b, the

levator prostatae muscle; c, the prostate; d, the anterior ligament of

the bladder.

Fig. 11, Plate 58.--A posterior view of the parts seen in Fig. 10; a,

the urethra divided in front of the prostate; b b, the levator prostatae

muscle; c c, the compressor urethrae; d d, parts of the obturator

muscles; e e, the anterior fibres of the levator ani muscle; f g, the

triangular ligament enclosing between its layers the artery of the bulb,

Cowper's glands, the membranous urethra, and the muscular parts

surrounding this portion of the canal. The fact that the flow of urine

through the urethra happens occasionally to be suddenly arrested, and

this circumstance contrasted with the opposite fact that the organic

stricture is of slow formation, originated the idea that the former

occurrence arose from a spasmodic muscular contraction. By many this

spasm was supposed to be due to the urethra being itself muscular. By

others, it was demonstrated as being dependent upon the muscles which

surround the membranous part of the urethra, and which act upon this

part and constrict it. From my own observations I have formed the

settled opinion that the urethra itself is not muscular. And though, on

the one hand, I believe that this canal, per se, never causes by active

contraction the spasmodic form of stricture, I am far from supposing, on

the other, that all sudden arrests to the passage of urine through the

urethra are solely attributable to spasm of the muscles which embrace

this canal.