Surgical Anatomy Part 40

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.

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Plate 57.--Figure 10.

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 quant.i.ty is supplied, is the measure most likely to succeed in closing the ca.n.a.l.

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Plate 57.--Figure 11

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 ca.n.a.l.

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Plate 57.--Figure 12.

Fig. 13, Plate 57.--In this figure the ca.n.a.l 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 ca.n.a.l from the dorsum of the p.e.n.i.s. The proper direction of the ca.n.a.l might be restored by obliterating the false pa.s.sage, provided the urethra remained perforate in the direction of the meatus.

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Plate 57.--Figure 13.

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.

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Plate 57.--Figure 14.

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 s.c.r.o.t.u.m; and by another, b, in front of the s.c.r.o.t.u.m. At the latter place the ca.n.a.l beneath the p.e.n.i.s 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 pa.s.s by the proper meatus into the urethra as far as the point where this portion of the ca.n.a.l fails to communicate with the other. The under part of the s.c.r.o.t.u.m presents a cleft corresponding with the situation of the scrotal septum.

This state of the urinary pa.s.sage 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 ca.n.a.l behind the stricture; 3rdly, the formation (on an abscess opening externally) of a fistulous communication between the ca.n.a.l 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 ca.n.a.l 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 pa.s.sed into the ca.n.a.l. 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 impa.s.sable 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 pa.s.s perforce a blunt pointed instrument like a catheter into the bladder. In some instances the stricture is slightly pervious, the urine pa.s.sing in small quant.i.ty by the meatus. In others, the stricture is rendered wholly imperforate, and the ca.n.a.l 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 pa.s.sing 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 pa.s.sing 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.)

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Plate 57.--Figure 15.

Fig. 1, Plate 58.--In this figure the urethra appears communicating with a sac like a s.c.r.o.t.u.m. A bougie is represented entering by the meatus, traversing the upper part of the sac, and pa.s.sing 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 ca.n.a.l 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 repet.i.tion 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 pa.s.sed into the bladder, the tumour should be punctured prior to taking measures for the removal of the stricture. (Sir B. Brodie.)

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Plate 58.--Figure 1.

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 pa.s.sages likewise are mentioned as more liable to be made in these places than elsewhere in the urethral ca.n.a.l. These occurrences--the disease and the accident--would seem to follow each other closely, like cause and consequence. The frequency with which false pa.s.sages 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 circ.u.mstance will of course favour the accident. An additional cause why the catheter happens to be frequently arrested at this situation and to perforate the ca.n.a.l, 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 pa.s.sage which was made in the ca.n.a.l between the two constricted parts.

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Plate 58.--Figure 2.

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 ca.n.a.l 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 ca.n.a.l 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 pa.s.sage of the urine, and its removal cannot be effected by other means, an incision should be made to effect this object.

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Plate 58.--Figure 3.

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 ca.n.a.l.

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Plate 58.--Figure 4.

Fig. 5, Plate 58.--In this figure is represented a small calculus impacted in and dilating the membranous part of the urethra.

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Plate 58.--Figure 5.

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.

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Plate 58.--Figure 6.

Fig. 7, Plate 58.--A stricture is here shown situated at the bulb.

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Plate 58.--Figure 7.

Fig. 8, Plate 58, represents a stricture of the ca.n.a.l in front of the bulb.

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Plate 58.--Figure 8.