1845 The Lancet  
Assistant-Surgeon to St. Thomas's Hospital. THE author commences his paper by pointing out the difficulty of curing urinary fistula generally, but much more especially those which are situated in that part of the urethra anterior to the scrotum. In illustration of these remarks, he quoted the opinions and experience of Professor Dieffenbach, who had been repeatedly foiled in his attempts to cure even a small fistula, in this position, before he ultimatelv succeeded. The author then refers to
more » ... r then refers to the various modes of treatment which had been adopted in these cases, and gives the palm to that which consisted in renewing the lost structure by a plastic operation. This part of the subject was further illustrated by reference to Professor Dieffenbach's practice, as the author acted, in his own case, upon the principle laid down by the Berlin Professor, though he deviated in the mode of carrying it into effect. This principle consists in extending, as much as possible, the surface by which adhesion might talie place. The subject of the operation in the present instance was a wineporter, who had permanent stricture, for which he was operated on by Mr. Clark, in July last; but being of intemperate habits, and not-very good constitution, he had acute inflammation of the testicle, followed by sloughing of the scrotum and penis, which, after the healing process was completed, left an aperture in the urethra one inch and a quarter in length, occupying a small portion of the scrotal division of the passage, and extending forwards a considerable distance anterior to it. The following were the steps of the operation for the closure of this opening:-A small inverted portion of skin was first dissected out from the scrotal extremity of t:e fistula; four incisions were then made, two of which extended downwards and outwards over the scrotum, and the other two upwards and outwards on the sides of the penis; a lateral flap was thus marked out on each side, which was then dissected up, and the two being brought together, surface to surface, over the fistulous opening, were maintained in that position by lateral splints of leather, and sutures passed through the latter and the skin. A semilunar incision was then made on each side to reduce the anticipated tension, when swelling came on ; a full-sized gum-elastic catheter, which had been passed prior to the commencement of the operation, was left in the bladder. Adhesion took place throughout the whole extent of the flaps, except at the two points, one being at the scrotal extremity of the fistula, the other between the lateral supports ; these were freely touched with caustic, and soon closed. A small portion of the margin of one flap sloughed. The operation was performed in November, and at the present date (June 10th) the patient continues to pass his water freely, and in a full stream. There is no contraction of the penis or any part of the passage, and the cicatrix is scarcely visible. The perineal opening still allows of the occasional escape of a drop of urine. Mr. LE Gpos CLARK remarked that three months had now elapsed since the operation had been performed. He had lately seen the patient, who now passes his water in a full and natural stream. The parts, also, had so far assumed their natural appearance as to render it difficult to suppose that any operation had been performed. Mr. CURLING confirmed the statement of the last speaker respecting the appearances of the parts operated on. The opening in the perinaeum was, however, not quite closed, a few drops of urine still occasionally passing through it. This was attended with very little inconvenience. Mr. ACTON inquired if he was right in attributing to the author of the paper the opinion, that the stricture and fistulous opening were the result of the use of injections? He regarded this opinion as opposed to the highest authorities on the subject, and hoped that it would not go forward as one generally entertained by the Society, as it would give currency to the belief, that stricture was produced by injection, rather than by the chronic inflammation the injections were employed to remove. He regarded such a doctrine as injurious. The case of M. Le Gros Clark showed the accuracy of an observation which he (Mr. Acton) had made in his treatise on " Venereal Disease," to the effect, that no single operation was sufficient to remedy fistula in these situations, and that we could only expect to be successful after repeated attempts with the knife and caustic, as he had observed in M. Ricord's practice in several instances. Mr. LE GROS CLARK, in answer to Mr. Acton's observations respecting the production of stricture by the use of injections, said that his (Mr. Clark's) observations went to show that this result was not to be expected when the injection was used under proper medical advice. When improperly used by the patient himself, as in the present instance, and of too great strength, stricture might, and he believed did, sometimes ensue. What was the opinion of surgeons generally on this point? Injections, he believed, were now rarely used in the treatment of gonorrhcea in our hospitals ; at least, he knew they were not used in St. Thomas's Hospital, and this was, probably, from the fear of producing results such as those alluded to. , Mr CÆSAR HAWKINS inquired whether, in M. Ricord's operations, the parts were brought together at their edges, or, as in Mr. Clark's case, at their surfaces? Mr. ACTON replied, that he had seen many modes of proceeding in these cases, but the one most generally successful was that which was related and delineated in the Clinique Iconographique, in which M. Ricord made an artificial opening into the membranous portion of the urethra, immediately behind the bulb, and allowed the urine to pass off by means of a gum-elastic catheter, fixed in this opening. He then pared the edges of the fistula situated anteriorly to the artificial opening, and brought them' together bv means of pins on a bougie introduced into the urethra. The fistulous opening closed after several applications of nitrate of silver, and in three months the artificial opening was' allowed to heal, which it did most speedily. Mr. DAVIS (Hampstead) had seen thousands of cases in which injections were employed, at a time when he was a " surgeon" in the army. Injections of a sedative kind were first used, such as the infusion of digitalis, or tincture of that plant, or of opium with water, followed, when necessary, by stimulating injections. When judiciously used, and of a moderate strength, he had seen no evils result from injections, many of the men having been under his observation for years afterwards. Mr. LE GROS CLARK, in his paper, had confined his observa-' tions to the injudicious use of injections, and not, as members seemed to suppose, to their employment under proper advice. Mr. DAVIS had spoken of the subject generally, and not at all in allusion to Mr. Clark's case. Mr. CLARK explained that injections might produce stricture, by first causing hernia humoralis, the inflammation of which extended along the cord to the urethra; and formed the stricture. Mr. STANLEY regarded the paper as valuable, inasmuch as it carried out the principles of Dieffenbach. He had no doubt that' many cases that he had seen years ago might have been remedied had these principles been understood. He had in no instance had the opportunity of applying this principle to the urethra, but in many cases of deformity of the face, he had used it with success. He alluded to one case in particular, of a girl who losthalf of her lower lip from sloughing, as the result of mercury. He obtained a new lip from the skin of the neck, not on the principles of Talicotius, but by partial dissection, and simply' pushing up a flap of skin ; the cut edges of the divided portions soon assumed the rose-red colour of the natural lip. Mr. BROOKE remarked, that two of the steps of this operation appeared to have failed from the inefficiency of the means employed. He alluded to the sloughing of one of the sutures of the urethral fissure, and the unsuccessful attempt to close the perinteal fistula by a common pin suture. Neither of these circumstances, he considered, would probably have occurred, if his bead suture had been applied, a description of which had been some time since laid before the public. In this patient the vis vitæ was evidently at a low ebb ; and whenever this is the case, experience teaches us that a comparatively slight degree of pressure is sufficient to arrest circulation, and destroy vitality in the parts submitted to its action. Thus, it appeared, the soft parts compressed between the pieces of leather used in one of the urethral sutures, and between the pin and ligature in the perinseal, had perished. As no pressure is exerted on the edges held in contact by the bead suture, sloughing, as the result of pressure, cannot occur, and he had invariably found that union took place as readily between the beads as at any other part of the edges or surfaces in contact. Mr. Brooke expressed his intention of laying before the Society, after the summer recess, several cases illustrating the efficacy of the suture, and its superiority over others now in use. A gentleman, forty-five years of age, having suffered for some hours from a severe attack of abdominal pain, resembling ordinary colic, after slight exertion fell down in a state of syncope. The author, who was called in, found him apparently insensible, with a pallid countenance, and cold extremities, but able to swallow. : i Brandy was freely administered, but an hour elapsed before the -
doi:10.1016/s0140-6736(02)50600-0 fatcat:v7l6jdwilncvpiif6ragvxseai