Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson.

  • Thompson, Henry, Sir, 1820-1904.
Date:
1882
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Licence: Public Domain Mark

Credit: Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson. Source: Wellcome Collection.

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    strum ents, unless retention of urine is present. Now, what are the symptoms of stric- ture ? First, of course, there is the small- ness of the stream, depending upon the narrowed state of the canal. Whatever the narrowing of the canal is, in that pro- portion there must be a narrowing of the stream. Still, it is not to be forgotten that the degree of narrowing varies much at different times in accordance with ex- ternal circumstances, cold, errors in diet, and the like ; one thing only is constant, the stream is always smaller than natural. Next, there is often some straining to pass water, corresponding to the obstruction of the passage ; and the stream itself is flat- tened, twisted, or divided. This condition is accompanied by pain at the seat of stric- ture, and sometimes over the pubes, if there is any cystitis also. Associated with these, it is common to have a little dis- charge from the urethra; indeed, a gleet is often the only thing which the patient notices at first, and the surgeon, finding that this is not readily cured, uses an instrument and discovers some degree of stricture. Frequency of making water, as I told you in the first lecture, is not always present, although it always is so when the case is severe and of longstanding. Supposing a patient to apply to you with all these symptoms, you will en- deavour to see him pass water. He pro- bably lays some stress on the fact that the stream is twisted or divided. Do not attribute much weight to this circumstance by itself, for a stream is often twisted when there is no stricture. This may be due to an alteration in the external meatus; for as the stream issues from the passage it is modified by alterations in the natural shape or extensibility of the external meatus; thus, after repeated inflammation there, the lips of the meatus are sometimes slightly thickened, so that the urine can only issue in a flattened and consequently twisted stream ; a by no means uncommon occurrence. But if there is no other morbid change, however flattened the stream may be, the absolute bulk or volume of the stream is not diminished, and there is no stricture. The question of diagnosis by physical examination next presents itself. Let me at the outset observe that on almost all occasions of examining a patient for the first time with an instrument, one of tolerably full size should be selected. say not less than No. 8, 9, or 10 of the English scale. Nothing is better for this purpose than a slightly curved English gum elastic bougie, with a blunt and not a tapering end. It is neither necessary nor politic to produce an instrument, at first, of greater calibre. Even then the patient will probably remonstrate, and may very likely say, ' Why do you em- ploy so large an instrument? ' Soothe his fears by telling him that you do not pro- pose necessarily to pass it, but mainly to learn what is the condition of the canal. For if you use a small instrument at first, it may pass through a stricture, if one exists, without detecting it; but if the large instrument goes on easily into the bladder, you have the satisfaction of in- forming your patient that he has no con- siderable stricture, and you must look further for the cause of the difficulty. Again, let me warn you that, in pass- ing the instrument -hrough a healthy urethra, it is quite common to meet with circumstances which may mislead you. I have spoken to you of error on the part of the patient, and I am bound to say that the surgeon who is not much practised in these matters may also be deceived. What are the sources of fallacy to whicht he is exposed ? How is it that he some- times fancies there is stricture when there is not ? You may be placed in circum- stances hereafter in which opportunities of often seeing this disease do not occur, and in such it is no great discredit to a man to think that he has found stricture where none exists. If, however, he pro- fesses to be an. operating surgeon such a mistake would be discreditable. But if he has not had much surgical experience, he may encounter some difficulty with an instrument in the urethra, and may sup- pose, erroneously, that it is due to stric- ture. Now, I want to guard you against this; for, though you may not all be operating surgeons, I wish no one to leave any course of lectures which I may give, without knowing precisely what are the sources of fallacy, so that I may not hear of any of you making hereafter such a mistake as that to which I have referred. First, then, observe that close to the external meatus of the urethra is a source of fallacy—I mean the lacuna magna. Next, at a part of the passage which is about five or six inches further [a diagram referred to], the bulb joins the membranous portion, and the canal, from being wide or