On Spasmodic Urethral Stricture from Anal Fissure BY L. BOLTON BANGS, M.D. SURGEON TO ST. LUKE’S AND CHARITY HOSPITALS, NEW YORK Reprinted from The Medical Record, January 19, 1889 NEW YORK TROW’S PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1889 On Spasmodic Urethral Stricture from Anal Fissure BY L. BOLTON BANGS, M.D. SURGEON TO ST. LUKE’S AND CHARITY HOSPITALS, NEW YORK Reprinted from The Medical Record, January 19, 1889 NEW YORK TROW’S PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1889 ON SPASMODIC URETHRAL STRICTURE FROM ANAL FISSURE.1 The brief clinical record which I shall present to you this evening contains no novelty, and is entirely within the line of your experience, but it seems to me worthy of your consideration, not only because it may give an op- portunity for discussing an interesting subject, but also for the purpose of giving me the advantage of your criti- cism upon the correctness of my observations. It is probably within the memory of many of those present that some years ago an argument was made against a Fellow of this Academy who had then, and has since, written largely upon spasmodic stricture of the urethra, and who denominated such conditions by the title of “ urethrismus; ” and although there may yet be some surgeons who deny the existence of permanent spas- modic contracture of the muscles of the urethra, forming an obstacle to the exit of fluids and the introduction of instruments, still I think that a large number of observers have confirmed the statements of Dr. Otis. The case here recorded seems to me to be, without doubt, one of more or less permanent stricture of the urethra, due to reflex action of the spinal cord from an irritation at the anus. The subject of this report was aged forty-one, a painter 1 Read before the New York Academy of Medicine, Section in Surgery, January 14, 1889. 4 by trade. Twenty years ago he had syphilis, followed by secondary symptoms, but for many years he has had no evidence of it whatever. For several years he has been subject to attacks of painter’s colic, and at such times the associated constipation has been very obstinate. About six years (he thinks) ago he began to have indescribable sensations in the region of his bladder, and pain during urination, but he had never had any urethritis or disease of the urethra or bladder to which these sensations could be attributed. About two years ago he acquired a spe- cific urethritis which lasted‘acutely some weeks; then became chronic, and finally terminated at the end of six months. Six months later, that is to say, about eighteen months ago, he had an attack of painter’s colic, accom- panied by constipation, and then experienced intense pain in the rectum, which was most marked after defeca- tion. This pain became constant, gradually increased to extreme intensity, and he suffered from it, both after and before a stool, or, as he expressed it, “ whenever it begins to fill up down there.” With this pain in the rectum, he had a gradually in- creasing difficulty of urination, the urine passing in a small stream, and at times only in drops, accompanied with pain in the penis and in the pelvis generally. At length the difficulty of expelling the urine became such that his physician was compelled to resort to the use of the catheter, in order to relieve the bladder of a certain amount of urine which was retained. For the two months preceding his coming under my observation his troubles, both as regards the pain in the rectum and the dysuria, increased so greatly that the use of the catheter was continuous, and the latter finally set up a mild form 5 of urethritis, which aggravated his symptoms. The pain referred to the rectum and to the bladder became so se- vere that he was obliged to resort to hypodermic injec- tions of morphia. When I first saw him, the man’s condition war pitiable. He was anaemic, weak, and in constant pain, unable to empty his bladder without the use of the catheter, and under the necessity of being con- stantly under the influence of morphia. He was un- able to discriminate between the pain in his bladder and that in his rectum. He was tormented with frequent desire to urinate, and although he could expel some urine with great straining, the feeling that his bladder was not emptied was so intense that I could hardly restrain him from passing his catheter, which he always carried in his pocket for the purpose. I sent him into St. Luke’s Hos- pital, and on the next day examined him. His meatus urinarius admitted 32 French bougie k boule. At four and three-fourths inches was a stricture of 26 French. A solid sound of the latter size (26 French), after being obstructed for a few seconds at the membranous urethra, slipped into the bladder. On withdrawing, it was strongly held by the urethra, which alternately relaxed and con- tracted upon the instrument until the latter was free in the penile portion. Up to this time it had seemed to me that his urethral difficulty was the principal one, and pos- sibly the cause of his rectal pain. But here was evidently a spasmodic condition of which there could be no doubt, and I questioned what was the cause of it. It is true that such a condition in the deep urethra might be due to a stricture of large calibre in the penile portion, and if it had been nearer to the meatus I should have paid more attention to it; but inasmuch as the patient com- 6 plained so greatly of the pain in the rectum, I thought that perhaps the secret of the trouble might be found in or about the latter. On exposing the anus it was found to be violently contracted. The anal region was very sensitive and it was only with great difficulty that he could be induced to relax the sphincters sufficiently to enable me to find that he had three bluish-red exceed- ingly painful fissures of the anus. This seemed a good opportunity to test the question of cause and effect by observing the result of treating the anus alone. Accord- ingly he was etherized, and the sphincter-muscles were paralyzed digitally until the whole anus was pulpy. Noth ing whatever was done to the urethra, and his catheter was taken away. 'This was on June 7th. On the 9th it was recorded, “ The patient passed urine and faeces spontaneously, and with much less pain, being but slight during urination and not nearly as great after defeca- tion.” From this time on his improvement was progressive. There was none of the spasmodic straining to empty the bladder, there was no retention of urine, and the urethritis gradually subsided. 'Ten days later, a sound as large as could be insinuated through the stricture at 4J inches, namely, 30 French, was easily passed into the bladder, without any resistance and without any spasmodic con- traction about the instrument upon its withdrawal. On June 26th he was discharged from the hos- pital cured. For the past six months he has been inter- mittently under my observation. He has been treated for the “ painter’s colic,” and has had none of the obstinate constipation, no pain in his rectum, and no trouble what- ever with his urethra or bladder. A brief analysis of this 7 case will make clear the points to which I wish to call your attention. He seems to have had some mild symptoms referable to the urinary apparatus six years ago, but whether these were due to any rectal disease at that time, I am unable to say. He might have had slight disease which healed spontaneously. At all events, there was an interval of comparative freedom from suffering, up to the severe at- tack mentioned in th'e history, and soon after he had urethral and bladder symptoms added to those of his rectum. It is plain that the constipation, associated with his ead-poisoning, was the exciting cause of the fissures, to which may be reasonably attributed the pain in the rectum. As these progressed, his sufferings continued to increase in intensity, and the symptoms became so commingled that it was impossible for him to discriminate between those of difficult urination and those from the fissures of the anus. Without doubt the attack of urethritis from which he had just recovered greatly increased the sensi- bility of the urethra, and the response to the reflex action became of a higher grade and rendered the contracture of the muscles more persistent. It will be observed that the stricture of large calibre in the urethra received no treatment, and, therefore, it seems to me that the conclusion is inevitable that the per manent contraction of the muscles of the deep urethra in this case was due to a reflex from the spinal cord, set up by an intense irritation of the sphincter ani, as evidenced by the entire relief afforded by the treatment of the latter. 127 East Thirty-fourth Street.