RETENTION 0E URINE 1) E 1* K N 1) I N O O N S T R I C T r I y E. BY ALEXANDER W. STEIN, M. D„ PROFESSOR PHYSIOLOGY AND HISTOLOGY IN THE NEW YORK COLLEGE OF DENTISTRY, AND OF COMPARATIVE PHYSIOLOGY AND HISTOLOGY IN THE NEW YORK COLLEGE OF VETERINARY SURGERY ; LATE LECTURER ON GENITO-URINARY OR- GANS, UNIVERSITY MEDICAL COL- LEGE, ETC., ETC. 77//.S' PAPER IFAS READ BEFORE THE XEH’ YORK MEDICAL JOURXAL ASSOCIATION, DECEMBER 977/, 1870. NEW YORK: ROBERT J. JOHNSTON., PRINTER, No. 59 DUANE STREET. 1870. RETENTION OF URINE DEPENDING ON STRICTURE. BY ALEXANDER W. STEIN, M. D., PROFESSOR OF PHYSIOLOGY AND HISTOLOGY IN THE NEW YORK COLLEGE OF DENTISTRY, AND OF COMPARATIVE PHYSIOLOGY AND HISTOLOGY IN THE NEW YORK COLLEGE OF VETERINARY SURGERY ; LATE LECTURER ON GENITO-URINARY OR- GANS, UNIVERSITY MEDICAL COL- LEGE, ETC.. ETC. THIS PAPER WAS READ BEFORE THE NEW YORK MEDICAL JOURNAL ASSOCIATION. DECEMBER 9TH, 1870. NEW. jSM&KK : ROBERT J. JOHNSTON, PRINTER, No. 59 DUANE STREET. 1870. RETENTION OF URINE DEPENDING ON 8 T R I C T U R E. Few subjects connected with modern surgery comprehend questions of greater importance than retention of urine, and vet there is hardly a surgical disease upon which so much discrepancy of opinion prevails. The object of these remarks, therefore, is to present those points in the treat- ment of retention, which careful study and experience has taught me to regard as most important. The existence of simple spasmodic stricture, independent of structural change, capable of arresting a lull-sized cathe- ter, has never, I think, been satisfactorily demonstrated, although a number of such cases have, from time to tinie, appeared in print. But that a urethra, already much nar- rowed at some point by an organic stricture, may, by free indulgence in spirituous drinks, exposure to cold, etc., have superadded to it congestion of the mucous mem- brane or muscular spasm, or both, to an extent sufficient to almost entirely occlude the canal, and produce re- tention, is a fact of which every experienced sur- geon must, at some time or another, have convinced himself. \\ e know that a stricture which at one time is impermeable to a No. I bougie, will, under the influ- ence of An anesthetic, or alter a few days of rest, warm 4 RETENTION 01’ URINE baths, diluents, aperients, opium, etc., admit No. 4, 5 or 6. I know from personal observation, that patients with so- called impermeable strictures, are too often made victims of perineal section without a guide, whose strictures would, after judicious treatment, have yielded to gradual dilatation, and have been brought to a successful termination. The more skilful the surgeon the more he will endorse the axiom of Professor Syme, “ that if urine passes out, instru- ments may always, through care and perseverance, be gotten beyond the contraction.” The cases are few which will not yield to the gentle and persevering use of the delicate, flex- ible bougie ; at least, not until these have been faithfully tried, and the treatment by warm baths, opium, etc., proved unsuccessful, should we ever think of the dernier resort of perineal section, unless, of course, there are urgent demands for the immediate relief of the bladder. The best instruments for the relief of reten- tion due to light stricture, are the French filiform bougies; these I regard preferable to whalebone on account of their extreme flexibility. They, unlike the whalebone, have no direction of their own, but follow the sinuosities of the canal, and will sometimes engage in a tight tortuous stricture, which would be impermeable to other instruments. In difficult cases, the plan adopted by Desor- meaux is often serviceable. Several of these delicate instruments (whalebone) are introduced side by side, so as to cover the whole obstruction with points, or if one or more of these instruments enter a false passage, they are allowed to remain in situ, and others introduced, until the natural passage is found, and the bladder reached. The introduction of these delicate instruments is greatly facilitated by first injecting the urethra with oil. The Endoscopic tube is found useful in those instances in which large false passages exist anterior to the stricture. With the aid of good light the orifice of the stricture can be made oiit, and the point of the bougie (for this purpose those made of whalebone are the best) guided through the contraction. DEPENDING ON STIilCTUltE. 5 It is important to remember that not only is the urethra greatly dilated posterior to the stricture, but the lacunae, prostatic and ejaculatory ducts on the floor of the canal are often very much enlarged, readily entangling the point of a fine bougie, and endangering the formation of a very troublesome false passage, one even worse than if it were situated anterior to the stricture. It is not always easy to determine when the instrument has engaged in one of these openings, for in narrow- strictures the bougie is grasped so tightly, that its manipulation is often rendered very difficult. Great gentleness is therefore re- quired, even after the obstruction has been fairly passed. Very little force is sufficient to thrust an instrument through the walls of the urethra. If an instrument has gone seven or eight inches, and becomes arrest- ed, it is necessary to ascertain per rectum its precise situation. If it has engaged in a false passage, it must be partially with- drawn, and with a little pressure upon the point of the instrument, slowly reintroduced. This will materially facilitate the passage of the bougie into the bladder. Having intro- duced the filiform guide, a small silver catheter may now be attached (by means of the screw tips) and followed into the blad- der. (Fig. A) Occasionally Thompson’s probe pointed silver catheter will enter the bladder, when the filiform instruments fail. But great care is necessary in the use of these small inetalic instruments. They are dangerous unless a filiform bougie has been previously introduced, to serve as a guide. These in- struments have often made a way for them- selves into the bladder, and from the ab- sence of difficulty in micturition, which, for Dr. Bumateid’s Catheter, No. 7, (French,) with Guide. [Fig. A.] KENTENTION OF URINE the time obtained, led surgeons to believe that the bladder had been reached, per viam naturale. I will mention one instance out of many which I might cite, in proof of this statement. It was one in which Maisoneuve’s urethrotome had been used without a guide. After the operation, free flow of urine ensued, and it was supposed that the stricture, had been thoroughly divided. It was afterwards impossible to get an instrument into the bladder, the patient was ex- tremely irritable and the passage of the sound produced in- sufferable agony. After waiting for some days, and finding the stream becoming smaller and smaller, an anesthetic was administered, and another unsuccessful attempt was made at catlieterism. Finally it was deemed necessary to perform perineal urethrotomy, and it was discovered that the stricture had not been divided, by the previous operation. The in- strument had made a false passage beside the stricture, which, not being kept pervious by the passage of sounds, gradually closed. I have now a gentleman under observation, who, about six or eight years ago, had a small metallic instrument thrust into a false passage, and on to the bladder. This resulted in extensive extravasation of urine, which subjected him to great suffering and jeopardized his life. Very often the mere at- tempt to pass the obstruction—especially if the point of the instrument has engaged the stricture—will afford relief. The withdrawal of the instrument being followed by a fiow of urine. If retention, with a greatly distended bladder, has existed for some time, it is not prudent to remove all the urine at once. Several deaths have been reported from too sudden evacuation of the entire contents of a highly dis- tended bladder. It is best to withdraw a portion at a time, thus allowing the bladder to gradually regain its nor- mal condition of contraction. When an instrument lias with great difficulty passed a stricture, I believe it to be a safe rule to leave if in position, For two reasons : First, If it is removed, we may subse- quently find it impossible to reintroduce it, and in conse- quence of urgent retention, lie obliged to perform an opera- DEPENDING ON STRICT!’RE. 7 tion, which, owing, perhaps, to extensive renal disease, or some other unfavorable condition of the patient, would be rapidly brought to a fatal termination. Second, The filiform guide in the urethra affords the best means for the subse- quent treatment of the stricture. For example : should the general condition of the patient be favorable to an operation, we may at once attach Maisoneuve’s urethro- tome and divide the stricture from before backwards. This instrument, as recently improved by Dr. Bum- stead, is perfectly safe and reliable. (Fig. lb Or if Yoillemier’s divulsor can be made to pass, divulsion may be pre- ferred to cutting, especially when the stricture is deep-seated. Again, if it is a case for Syme’s method, the grooved staff may be screwed to the filiform guide. This will greatly facil- itate the operation of external divi- sion. Thus, the filiform guides can be made to fit either of these instru- ments, so that the character of the operation need not be decided upon, until after the introduction of the guide.* If, on the other hand, the patient has diabetic, or albuminous urine, a bad constitution, a nervous, irritable temperament, etc., we may resort to the milder method, by gradual dilata- tion, or if this is not feasible, the con- tinuous plan of Sir H. Thompson may be adopted. A careful examination of the urine should be regarded as a snie ova von, * The cre-it of this practical suggestion belongs to my friend, Dr. Bumstead. 8 KENTENTION OF UltlNE in the treatment of all urethral strictures. No man is qual- ified to undertake the treatment of these bad cases, who neglects to examine into the condition of the renal organs. Not until such examination has been made, can we judi- decide upon the proper treatment to be adopted in each individual case, or can we duly estimate the danger? that might, in some instances, accrue from too active inter- ference. I am convinced, that if such examinations were made in every instance, and the significance of an abnorma condition of urine duly appreciated, the death per centage of these cases would be materially diminished. While it is the part of conservative surgery to avoid the knife as long, and whenever, such a course is justifiable, we must keep in view the serious consequences, which will in- evitably result from prolonged over-distension of the blad- der, not only endangering rupture of the urethra, and extrava- sation of urine, but also the injurious effect that continued pressure will exert on the structure and function of the renal organs. Structural change of the kidneys is espec- ially to be apprehended, in those who have suffered with re- peated attacks of retention. It is further important to bear in mind, that some of the worst forms of retention may co-exist with constant dribbling of urine; a condition which has not unfrequently been mistaken by surgeons for an inability on the part of the bladder to retain urine, in- stead of recognizing it an omr‘l>w of surplus urine from the over-distended viscus. We learn through the experience of Mr. Jonathan Hutchinson* that retention may insidiously terminate in fatal disease of the kidneys, irit/tmU pain or inconvenience. Retention of urine will, in the natural sequence of events, lead to suppression of that secretion. As soon as the bladder becomes distended, the urine accumulates in the ureters, then in the pelvis of the kidneys, and finally in the tubuli uriniferi. Soon the pressure in the uriniferous tubes becomes so great that secretion of urine is more or less arrested, symptoms of suppression manifest them- selves, and death frequently ensues. * London Lancet, July 4th, 1868. DEPENDING ON STRICTURE. 9 When suppression is due to disease of the secreting structure of the kidneys, the character and composition of the urine differs very materially from those cases, in which it is simply due to mechanical obstruc- tion to the outflow of urine. In the first instance the urine, is high colored, concentrated, and contains casts. In the other—the urine being secreted under a high pressure—it is pale, dilute, and free from casts. If then we have reason to apprehend extravasation or that permanent injury to the urinary organs may result, or the age and suffering of the patient demands imme- diate relief, external perineal urethrotomy or paracentesis, vcsicae must be resorted to. There are those who believe it wiser to puncture the blad- der, on the principle that strictures when once relieved of the irritation of the urine passing over them, spontaneously soften and become amenable to ordinary dilatation. This is true to a certain extent, and puncture of the bladder may in a few instances—as in old, broken-down constitutions, in which it is desirable to save blood and limit incisions—be the only justifiable means of relief. But the advantage in favor of external perineal urethro- tomy is, that it not only affords the necessary relief to the 1 ladder, but aims at once at the cure of the stricture, or the removal of the cause which has induced retention. This operation is perferred by most surgeons to-day, and I believe that traumatic strictures, or strictures complicated with extravasation—even if permeable to instruments—are, by universal consent, regarded as cases for the external operation. I shall not attempt to describe the many ways in which this operation has been performed, but will confine my remarks to the description of those methods which have received most attention. The old operation of perineal sec- tion consisted in passing a large instrument down to the obstruction, and opening the urethra upon it. Then—as Sir H. Thompson remarks—“ by dint of cutting, a way was made for tie1 instrument to go from the urethra before the stricture, to llie urethra behind the stricture.” How often 10 RETENTION OF URINE the stricture itself was divided is most uncertain. It is very probable that, in the majority of instances, it remained un- cut. This operation has been greatly improved by Messrs. Arnott