Diseases of the urinary organs : including stricture of the urethra, affections of the prostate, and stone in the bladder

Front matter

DISEASES

URINARY ORGANS

I

Preface

This work is based on Lectures given at Belle vue IIosjDital, and in the Medical Department of the Univei-sity of the City of New York, and embodies the results of the author's experience in private practice and in the public institutions with which he has been connected. He has endeavored to write a handy-book on the pathogeny, clinical history, and treatment of some of the graver surgical diseases of the male urinary organs, which he hopes may be of service to the practitioner, by pointing out means for their early detection ; for lessening the difficulties of their management ; and indicating, in cases of emergency, what to do and what to avoid.

Though the subject-matter is founded chiefly on personal observation, the claims and teachings of the many eminent men who have illustrated this department of surgery have not been overlooked.

56 West Thirty-eighth Stkebt, New York, February, 1873.

Contents

PBEFACE

LIST OP ILLUSTRATIONS CORRIGENDA vii

XV

xviii

Chapter I. Stricture Op The Urethra, Pathology, Symptoms And Sequelae

Definition of stricture. — Causes. — Idiopathic stricture. — Pathology of stricture.— Bell's views. —D6sonaeaux's views. — No stricture without gleet. — Granular urethritis. — Forms and localities of strictures. — Number of strictures in one urethra. — Progress of stricture. — Symptoms. — Increased frequency of micturition. — Dysury. — Incomplete retention, with dribbling fi-om overflow. — Complete retention. — Alterations in the urinary secretion. — Pathological lesions consequent upon neglected stricture.— Expansion of the urethra in the vicinity of strictures. — Urethral abscesses and fistulse. — Eupture of the urethra, and extravasation of urine. — Rviptiire of the bladder. — Impairment of the generative functions.— Prostatitis and abscess of the prostate. — Acute and chronic cystitis.— Concentric hypertrophy of the bladder. — Ureteritis. — Pyelitis. — Hydronephrosis. —Pyonephrosis. — Constitutional disturbances. — Urinary neuroses. — Reflex paraplegia Page 1-17

CHAPTER 11.

DIAGNOSIS OP STRICTURE. — CATHETERISM. — ACCIDENTS OP CATHETERISM. —

URETHRAL FEYER.

Ducamp's exploring sound.— Civiale's wax bougies. — Bigelow's gutta-percha bougies. —BeU's ball probes or urethra sounds. — Leroy d'EtioUes' bougies-a-boule. — Phillips' bougies-a-noeuds. — Character and size of the urinary stream. — Microscopic examination of the ui-ine. — Manner of using the bougie-^-boule. — The endoscope. — The urethroscope. — Cath-

X

CONTENTS.

eterism. — Curves of catheters. — Sounds and bougies. — Metallic catheters and sounds. — Conical sounds. — Sound gauges. — Manner of introducing sounds. — Accidents of catheterism. — False passages. — Urethral fever. — Suppression of urine. — Pathological lesions in suppression of urine. — Treatment of urethral fever. — Quinine. — Aconite. — Treatment of suppression of urine Page 18-40

Chapter III

CONSTITUTIONAL AND SURGICAL TREATMENT OF STRICTURE OF THE URETH- RA.— TREATMENT OP STRICTURE IN ITS INCIPIENT STAGE. —DILATATION IN SIMPLE CASES.— MANAGEMENT OF DIFFICULT CASES.

Preparatory treatment. — Pressure and over-distension by sounds, and direct applications to the diseased surface, in the incipient stage. — Instrument for over-distending the urethra. — Nitrate of silver solution in granular urethritis. — Sulphate of copper. — Treatment of simple cases of stricture. — Gradual dilatation. — Extent to which a stricture should be dUated. — Catheterism in eccentric strictures. — Benjamin Bell's bougie. — Leroy d'EtioUes' spiral bougies. — Capillary whalebone bougies.— -Manner of introducing whalebone bougies. — The author's tunnelled soimds and catheters. — Caustics rejected by the best authorities. — Electrolysis. . . .41-55

Chapter IV. Treatment Op Stricture By Divulsion

The term divnlsion. — The mode of performing the operation. — Urethral dilators, their history.— The instruments of Luxmoor, of Weiss, of PerrSve, and their several modifications. — The author's modification of Sir Henry Thompson's instrument. — Cases of strictiire illustrative of the treatment by divnlsion 56-75

Chapter V. Internal Urethrotomy

Dr. Physick's and Mr. Stafford's lanceted stilettes. — Civiale's bistouri-cache. — Dr. Jameson's urethrotome. — Maisonneuve's, Voillcmier's aud Trclat's instruments, and their modes of operating. — The author's urethrotomes, and his mode of operating. — Dilating urethrotomes. — Cases illustrative of treatment of strictures by internal urethrotomy 70-08

CONTENTS.

xi

Chapter VI

STEICTTIRES AT THE MEATUS tlRINARITJS AND EST THE FOSSA NATICTJLARIS. —THEIR NATURE, DIAGNOSIS AND TREATMENT.

Congenital variety. — Traumatic. — Chancrous.— Gonorrlioeal. — Frequency of stricture at or near the meatus urinarius. — Pathological effects. — Diagnosis. — Treatment. — Free incision. — The operation. — After-treatment Page 99-111

Chapter VII. External Perineal Urethrotomy

History of external perineal urethrotomy. — Doctors Stevens and Jameson. — Improvements of Mr. Amott. — External perineal urethrotomy upon a conductor an ancient operation, is adopted by Mr. Syme ia 1840. — Objections to Mr. Syme's staff. — The author's instruments and mode of operating. — Preparatory and after-treatment. — Accidents. — Results. — Cases illustrative of the operation 112-171

Chapter VIII. Traumatic Lesions Op The Urethra

Traumatic lesions of the urethra which are not followed by stricture. — Traumatic lesions which are followed by stricture. — Lesions of the urethra from internal injuries. — The arrest of gravel in the urethra. — Repeated, contusions by bougies or catheters roughly used. — Transverse lacerations in the neighborhood of idiopathic strictures from forced catheterism, etc. — The prolonged retention of catheters in the urethra. — Loss of substance from gangrene, etc. — Caustics. — Lesions resulting from external violence. — Transverse incisions. — Lithotomy. — Lacerated wounds of the perinseum involvLQg the urethra. — Torsion of the erect penis. — Breaking the chordee. — Contusion of the perinaaum. —Period of formation of stricture after injury of the urethra. — Treatment of traumatic lesions of the urethra. — Treatment of traumatic strictures of the urethra. — External perineal urethrotomy in narrow traumatic strictures 172-214

XII

CONTENTS.

Chapter IX. Retention Of Urine

Incomplete and complete retention of urine. — Retention of urine from inflammatory swelling- in the urethra. — Retention of urine due to strictiire of the urethra. — Treatment. — Case illustrative of. — Puncture of the bladder with capillary trocars and pneumatic aspiration. — Mr. Edward Cock's operation of tapping the urethra at the apex of the prostate unassisted by a guide staff Page 215-238

Chapter X. V

RUPTURE OF THE URETHRA AND EXTRAVASATION OF URINE. — URETHRAL FISTUL.a5. — RUPTURE OF THE BLADDER.

Rupture of urethra and extravasation of urine. — Effects upon surrounding tissues. — Treatment. — Free incisions. — Warm poultices. —External perineal urethrotomy. — Stimulants and concentrated food. — Urethral fistulse. — Origin. — Treatment. — Dilatation or incision of strictured urethra. — Injections into fistulous tracts. — Incisions. — Constitutional treatment. — Urethro-rectal and urethro-recto-perineal fistulse. — Treatment.— Ante-scrotal fistula3. — Treatment by urethroraphy and urethroplasty.—Rupture of the bladder. — Cases illustrative of. — Causes of. — Dr. Stephen Smith's table. — Primary symptoms. — Progress of cases. — Results. — Post-mortem appearances of viscera. — Post-mortem appearances of bladder. — Prognosis. — Treatment. — Dr. Hamsou's plan. — Dr. Walker's operation 239-258

CHAPTER XL

DISEASES OP THE PROSTATE.

Acute prostatitis. — Causes. — Symptoms. — Termination. — Peri-prostatitis. — Treatment. — Early evacuative catheterism. — Abscess opened by perineal incision. — Chronic prostatitis. — Causes. — Termination. — Symptoms. — Diagnosis. — Prostatorrhcea. — Treatment 259-272

CONTENTS.

Xlll

Chapter XII. Hypertrophy Op The Prostate

Prostatic hypertrophy a disease of advanced life. — General and partial hypertrophy.— Centric hypertrophy. — Alteration of form. — Fibrous tumors of the prostate. — Obstructed micturition. — Involuntary flow of urine indicates retention, and not incontinence. — Consequences of unrelieved retention of urine from enlarged prostate. — Symptoms of hypertrophy of the prostate. — Diagnosis. — Exploration by the rectum and by the urethra. — Treatment. — Catheterism in enlarged prostate. — Treatment of chronic cystitis from enlarged prostate. — Muriate of ammonia. — Topical medication. — Manner of injecting the bladder. — Treatment of atony of the bladder. — Management of retention of urine from hypertrophied prostate. — Puncture of the bladder with capillary trocars. — Dieulafoy's aspirator. — The perineal opi^ration. — Ablation of median prostatic outgrowths Page 273-300

CHAPTER XIII. STONE m THE BLADDER. — TilTHOTRIPSY

Symptoms and constitutional effects of stone in the bladder. — Pathological effects. —Diagnosis. — Treatment preparatory to sounding. — Exploration with Thompson's sound and with light lithotriptor. — Proper selection of operation. — Lithotripsy. — Civiale's early instruments. — Weisse's first curved lithotriptor. — Heurteloup's curved percussor. — Jacobsen's brise-pierre articule. — The modem lithotriptors. — Position of the patient during the operation. — Mode of inti-oducing the lithotriptor. — Seizure of the stone. — Fragmentation of the stone. — Mode of pulverizing fragments.— Impaction of fragments in the urethra. — Immediate removal of detritus. — Clover's aspirator. — Dittel's apparatus. — After-treatment. — Accidents of lithotripsy. — Results of lithotripsy 301-320

CHAPTER Xiy.

LITHOTOMY.

Lithotomy in ancient times. — The Celsian operation. — Germain Colot. — The apparatus major. — Frcre Jacqiies. — Rau. — Ledran. — Cheselden. — The lateral operation. — Frcre Gome's lithotome cache. — Sir Ctesar Hawkins'

xiv

CONTENTS.

gorget. — Dr. Physick'R gorget. — Dupuytren's doable lithotome. — Dr. A. H. Stevens' prostatic bisector. — The lateral operation as now performed. — After-treatment. — Accidents of lateral lithotomy. — Allarton's median lithotomy. — The median operation as performed in the United States. — Medio-lateral lithotomy. — Dr. Buchanan's method. — Mr. Henry Lee's method. — Professor Briggs' lithotome. — Results of lithotomy. .Page 321-347

CHAPTER XV. PERmEAL LITHOTRITT

Dilatability of the vesical neck. — Dilatation by fluid pressure, according to Amott's method. — Dr.WiUis. — Lithectasy. — DUatation by sponge tents. — Mr, John Douglas. — Professor Dolbeau's operation. — SmaU urethral incision.— Dolbeau's six-branched dilator. — Fragmentation of the stone. — Dolbeau's lithoclast. — The author's lithoclasts. — Extraction of the fragments.— Accidents of perineal lithotrity. — After-treatment. — Results of perineal lithotrity 348-364

Index

LIST OF ILLUSTKATIONS.

nQTJRE VAOK

1. Diagram of a linear strictiu'e 7

2. Diagram of an annular stricture 7

Diagram of a spiral or tortuous stricture 7

4. Olive-pointed bougie 20

5. Leroj-^ (d'Etiolles) bougie-a-boule 20

G. Bougie with a half olive 20

7. Bougie with two bulbs 20

8. Phillips' knotted bougie 20

!). Sir Chas. Bell's ball-probe or urethra sound 20

10. Diagram showing the manner of exploi-iug the iirethra with the bougie-

a-bonle 21

11. Diagram shomng the manner of exploring the urethra with the bougie -

a-boule 21

12. Desormeaux' Endoscope 22

13. Dr. Otis' urethral speculum 28

14. Conical sound with curve equal to three-tenths the circumference

of a circle three and a qiiarter inches in diameter 26

15. The author's metrical sound gauge 27

16. The author's metrical sound gauge 27

17. Tbe author's instrument for over-distending the urethra 45

18. Diagram, from Boeclcel, representing an eccentric stricture 50

19. Benjamin Bell's abruptly bent bougie 51

20. Leroy (d'Etiolles') spiral bougie 51

21. The author's tunnelled sound with a whalebone bougie in position 53

23. Tunnelled gum catheter , 54

23. Dr. Otis' dilating catheter threaded upon a whalebone bougie 55

24. Holt's modification of Perreve's divulsor 58

25. Voillemier's modification of Perreve's divulsor 58

I r.IST OF ILLUSTBAXrONS.

VIQVUK

36. The author's modification of Thompson's divulsor 60

27. From nature, showing longitudinal rent in the floor of the urethra after

divulsion

28. Dr. Jameson's urethrotome 77

29. Maisonneuve's urethrotome 79

30. Voilleraier's urethrotome 79

31. Civiale's urethrotome 81

32. Civiale's bistouri-cache gj

33. Charriere's m^ethrotome 81

34. Trelafs urethrotome 81

35. The author's tunnelled urethrotome 86

36. Flexible bougie tied in a knot 88

37. The author's improved tunnelled urethrotome 91

38. Civiale's bistotm-cache 106

39. Diagram showing the manner of incising a stricture of the fossa navicu-

laris with a double instrument 107

40. Congenital hypospadias and stricture 108

41. The author's meatotome 109

42. Diagram showing the manner of applying the dressings after division

of the meatus urinarius 110

43. Diagram showing the dressings applied 110

44. Syme's grooved staff for external urethrotomy . 122

45. A. The author's catheter staif with whalebone guide in the terminal

canal. — B. Catheter staff showing the eye on the concave side. — C. Small grooved silver probe with broad handle. — E. Small hook for catching the loop of silk 123

46. F. The author's grooved and tunnelled catheter staff. — G. Showing the

groove on the bridged portion. — H. Same, showing spiral bougie in position 124

47. The author's beaked bistomy 125

48. From nature, showing cicatrix obliterating the urethra 178

49. Same, showing ai-tificial external uretTiral orifice in perimeum 179

50. Vesical extremities of whalebone probe-pointed bougies 225

51. The author's tunnelled catheter for retention of urine 225

62. The author's tunnelled sound 226

53. Hutchison's catheter for applying ointments to the urethra 271

64. Catheter for injecting nitrate of silver in the prostatic sinus 271

55. Bigelow's catheter syringe 271

LIST OF ILLUSTEATIONS. Xvii

FiaUKE PAGE

56. Sir Henry Thompson's exploring sound 283

57. Over-curved gum instarument for catheterism in cases of centric hyper-

trophy 0^ the prostate 285

58. French olivary gum catheter. _ 287

59. India-rubber bag for injecting the bladder 289

60. The vertebrated catheter, Dr. Caro's model 292

61. Dieulafoy's aspirator 294

62. The author's ecraseur for the ablation of median prostatic valvular out-

growths 299

63. Sir Henry Thompson's exploring sound 303

64. The vesical extremity of the trilabe and perforator, such as Civiale used

in his early operations, showing a perforated calculus within the grasp of the instrument 308

65. First model of Weiss' lithotriptor 308

66. Jacobsen's brise-pierre articule closed 309

67. Same, open for seizure of the stone 309

68. Beak of fenestrated lithotriptor 311

69. Plain -bladed Uthotriptor 312

70. Handle of Charriere's lithotriptor 312

71. Handle of "Weiss' improved lithotriptor 313

72. Mathieu's urethral forceps closed 317

73. Same, open for seizure of a fragment 317

74. Frere Gome's lithotome cache 324

75. Dr. Physick's gorget 325

76. Lithotomy staff 326

77. Lithotomy knife 326

78. Beaked knife 326

79. Sir William Blizard's beaked bistoury 327

80. Straight plain-bladed lithotomy forceps 327

81. Curved Kthotomy forceps 327

82. Lithotomy scoop 328

83. Reduced in size from Dr. Little's paper on median lithotomy, shovring

the staff held in position, the left index, in the rectum, resting against apex of prostate, and the knife plunged in the membranous portion of the urethra 339

84. Dr. Markoe's staff 340

85. Dr. Little's staff 340

86. Dr. Little's director 341 xvm

LIST OF ILLUSTRATIONS.

MOTJEE PAGE

87. Reduced in size from Dr. Little's paper, showing the director in posi-

tion, and the right index entering the prostatic portion of the urethra 341

88. Prof essor Briggs' lithotome 343

89. Dolbeau's dilator, reduced in size 351

90. Dolbeau's dilator, natural size 351

91. Dolbeau's dilator, branches expanded 351

92. From Dolbeau, showing the relative positions of the staff and dilator

during the first step of dilatation. 353

93. From Dolbeau, showing the relative positions of the staff and dilator

during the second step of dUatation 354

94. From Dolbeau, showing the third step of dilatation 355

95. Dolboau's lithoclast, reduced in size 357

96. Dolbeau's lithoclast, vesical end, natural size 357

97. The author's lithoclast, reduced in size 359

98. The author's lithoclast, vesical end, natural size 359

99. The author's lithoclast, the jaws open for seizure of the stone 359

100. The author's curved lithoclast 361

101. From Dolbeau, showing the lithoclast in position, with a calculus be-

tween its jaws 362

A. Dr. Otis' dilating urethrotome 94

B. The author's dilating urethrotome 97

COEKIGENDA.

p. 23, Fig. 13, for Otis's, read Otis'.

P. 94, Fig. A. for Peters's, read Peters'.

P. 177, eighth line from foot, for a spicula, read spicula.

DISEASES OF THE URINARY ORGANS.

Chapter I. Stkiotuee Of The Terethea

PATHOLOGY, SYMPTOMS, AND SEQUELS.

The term stricture — fi-om stringere, to bind — when applied to the urethra, is understood to indicate a permanent morbid condition of the walls of the canal, generally causing a progressive

diminution of its calibre. It is due to inflammation, loss of substance, direct injury, or congenital malformation. Its immediate effect is to impede the flow of the urine.

Many authors admit three kinds of stricture : permanent, spasmodic, and inflammatory. If, however, the term stricture be used in its correct sense, there can be but one kind — the permanent. Spasm of the urethra is doubtless of very frequent occurrence, but does net, properly speaking, constitute stricture, and not a few modem writers have justly noted this distinction. Tet it must not be overlooked that in true stricture — the permanent organic change in the tissues — there is often a very decided tendency to spasm, and that inflammatory swelling, sufficient to cause retention of urine, not unfrequently occurs, in an already constricted canal, or as the effect of exposure and debauch during an attack of gonorrhoea. But neither of these troubles, by itself, comes witliin the above definition.

It is most common in early manhood and in middle life. The

2 CAUSES OF STRICTUUE.

greatest mimber of cases — proportioned to the inliabitants — happen in large cities. It is said to occur more frequently in hot than in cold climates. Persons of nervous temperament, of gouty or of strumous diathesis, and all those given to venereal and other excesses, are particularly liable to suffer from the malady.

Stricture may be idiopathic or traumatic, and it is proper to consider these two classes separately.

Causes. — Idiopathic stricture, while sometimes congenital, is, in the vast majority of cases, the product of urethritis. At one time this view was rejected on the ground that only a minority of the patients attacked with gonorrhoea ever suffered from stricture.

Injections. — Those who entertained this opinion denounced the injections employed against urethritis as the cause of stricture ; this method of treatment was consequently discontinued by many, but stricture still occurred in patients otherwise treated. The truth is, that injections are seldom per se a cause of stricture ; they sometimes assist to produce that result by aggravating and prolonging the already existing inflammation, as would almost any other irritant ; yet if a strong solution of nitrate of silver be used, as in the so-called abortive treatment of gonorrhoea, — which is happily falling into disuse, — ^the most violent and obstinate inflammation will probably occur, and then stricture will surely ensue. Such strong solutions incautiously employed in spermatorrhoea may produce the same result, and these are fairly to be credited with the entire causation of the stricture.

Improper Use of Instruments. — The too frequent and careless introduction of bougies and catheters sometimes causes a urethritis which ends in induration and narrowing of the canal, often to a very considerable extent.

Other Irritants. — Besides venereal urethritis and the causes already mentioned, almost anything that will occasion and maintain urethral inflammation will sooner or later develop stricture ;

rATIIOLOGY OF STEICTUEE.

for instance, masturbation ; frequent and pl-olonged erections of the penis ; the habitual ingestion of substances which render the urine acrid, such as cantharides, turpentine, beer, the sparkling wines, ardent spirits, etc. Those who indulge immoderately in such excitants are apt to suffer from a sul)-acute uretln-itis, which, when neglected, almost always ends in stricture.

PATHOLOGY.

The inquiry into the mode of formation and development of stricture resulting from urethritis is of interest and imj)ortance. The pathology of this disease seems to have been unknown to the ancients, for we find the old authors citing cases of retention of urine caused by what they called " excrescences," " caruncles," " carnosities," " callosities," in the urethra.

The existence of these " caruncles " was not doubted until Dionis called it in question, saying that, in many dead bodies of persons supposed to have suffered from " carnosities," which he had carefully examined, no trace of these so-called excrescences was found ; but the trouble was recognized to be narrowing or stricture of the urethra, caused by " cicatrization of ulcers from gonorrhoea." * Other contemporaneous surgeons came to the same conclusion ; but, in spite of this declaration, based upon extended observations, the erroneous doctrine of " carnosities " prevailed for many years.

Benjamin Bell, one of those who afterwards combated this theory, and helped to establish what is now looked upon as the correct view of the subject, says : " In the more fixed kinds of obstruction proceeding from gonorrhoea, the diameter of the urethra is lessened in two different ways. For the most part it is diminished by a thickening taking place at some' particular

* Dionis. Cours d' operations de chirurgie. Geme tsdit. Paris, 1765. p. 272.

PATHOLOGY OF STEICTUEE.

point in the membrane of the 2:)assage itself, or rather in the corpus spongiosum urethrse, in a similar manner to what frequently happens in the membrane of the nose in cases of catarrh. At other times the urethra is drawn together or contracted, as if a cord were tied round it, without any other disease being perceptible." "In some cases, again, these two affections are

conjoined." *

Mr. Bell's views hold good to-day, for it is clearly proved that the mucous membrane, submucous tissue, and the spongy substance are involved ; sometimes one, sometimes another, 'and often all three.

Thanks to our modern modes of exploration, we are now better able to study the disease in all its stages during life. Mr. Desormeaux, who has done so much toward improving our knowledge of the pathology of stricture, says that " if we consider urethritis, and the consequent stricture of the urethra, as a single affection, whose evolution begins at the moment of contagion and continues to the organic stricture, we are led to recognize, in the progress of this ailment, three different epochs^ to each of which belongs a particular kind of stricture. The first epoch is that of the urethritis, or of the acute inflammatory strictm-e. The last epoch answers to the confirmed, fibrous, or inodular strictm-e. Between these two extremes is an intermediary epoch which originates in the first and prepares the third." f In this middle period he discovered with the endoscope a localized inflammation with granulations, and named it granular urethritis.

Simple urethritis affects the mucous membrane alone ; and if it becomes chronic, and is neglected, the consequent stricture will, in the great majority of instances, be of slow progress, or even

* Benj. Bell on Gonorrhoea Virulenta, etc. Edin. 1793. Vol. i., pp. 258, 259. \ D6sormeaux. De L'Endoscope et de ses applications au diagnostic et au traitement des affections do I'urothre et de la vessie. Paris, 18G5, p. 83.

FORMATIVE STAGE, stand absolutely still for an indefinite period.* But when the urethral inflammation is very se%'ere, these eases being marked by chordee, it involves the submucous tissue, and sometimes even extends to the spongy substance, and an inodular stricture very soon ensues.

1^0 Stricture without Gleet. — It frequently happens that, in acute urethritis, there is a very considerable tumefaction of the mucous membrane, with spasm of the urethral muscles, to the extent of causing retention of urine ; this has been improperly termed " acute inflammatory stricture." The swelling and spasm are an obstacle to the emission of urine, but these soon subside under rest and appropriate treatment, and leave no traces of stricture. If the urethritis be cured without passing into the chronic stage, with gleety discharge, there will probably be no stricture. Yery frequently tlie first, second, or even the third clap yields to treatment, and escapes chronicity ; otherwise every infected patient would suffer from stricture sooner or later, which, we know, is not the case.

Chronic urethritis may continue many years without giving rise to any annoyance, other than a slight discharge of inuco-jDus, — called hlennorrJma, or gleet, — which in most cases has been demonstrated to be due to a granular condition of tlie urethra at one or more points on its mucous surface ; the granulations being similar to those often seen on the palpebral conjunctiva.

Formative Stage of Stricture. — Granular Urethritis, in accordance with the views of Mr. Desormeaux, which I believe to be correct in the main, is the formative stage of stricture ; it is the " intermediai-y epoch which prepares the third epoch, or that of the confirmed stricture." This chronic inflammation, if allowed to progress, ends by destroying the mucous glands, and the mem-

* On Very Wide Stricture of the Urethra. By Z. B. Lewis, M.D. Medical Eecm'd, vol. iv., No. 13, August 15, 1871.

SECOND AND TIIIED STAGES.

braue loses its identity ; its epithelial investinent soon ceases to afford any protection against tlie irritating nrine, as most of the cells are cast off before they are fully developed, and pass away as pus-corpnscles.*

Second Stage. — After a while there is cell-proliferation in the meshes of the mucous membrane, and also in the submucous connective tissue. The protoplasts may multiply so rapidly as to give rise to swelling, and consequent diminution of the calibre of the canal ; this state is termed by Mr. Desormeaux, " chronic inflammatory stricture."

Third Stage. — In time the new cells are transformed into fibrils, after which retraction takes place as in the tissue of cicatrices, and then the true organic or inodular stricture is develoj)ed.t It should be remembered that, in idiopathic stricture, the mucous membrane, the submucous tissue, . the spongy substance, or all three, may be involved ; points of no little importance in connection with the question of treatment.

Forms and Localities of Strictures — For practical purposes, three forms of strictures may be distinguished : the linear

* Mr. Alplionse Guerin denies the existence of granulations upon the mucous surface in' chronic urethritis ; but his conclusion is based upon examinations after death, and not vdth the urethroscope.

f In a paper on the Pathogenesis of Strictures and the Minute Anatomy of the Urethra, Dr. Stilling, of Cassel, pronounced the penis to be an organic muscle, and the process of erection the result of arterial hyperasmia, and not of venous congestion. According to his microscopic examinations, the corpora cavernosa are composed entirely of organic muscular fibres, which surround the arterial ramifications, and divide the sinuses by means of septa ; these sinuses themselves are nothing more than the dilatations of the capillarj' branches of the arteria dorsalis penis, and open resijectively into capillary branches of the veins of the penis. The organic muscular fibres pass into the mucous membrane of the urethra, and thus give contractility to the canal. An inflammation of the urethra causes a degeneration of these muscular fibres in a greater or less degree, and thereby the contractility and diameter of the canal become impaired.

American Journal of Si/p/iihr/raphi/ and Dermatology^ Jwl.v, 1872. Quoted from

the Transactions of the First Annual Congress of German Surgeons, April, 1872.

FORMS OF STRICTURES. 7

(Fig. 1), the annular (Fig. 2), and the spiral or tortuous (Fig. 3).

The linear strictidre is due to the contraction of a narrow cica-

Fig. 1. Fig. 2. Fig. 3.

tricial band, which gives rise, by a duplicature of the mucous membrane, to a thin diaphragmatic septum, sometimes with a central, often with an eccenti-ic orifice, and occasionally not involving the whole calibre of the canal, but forming a valvular crescentic fold. The most unusual and extreme variety of this form of stricture is found in the transverse bands or bridles which are now and then found in the m-ethra.

In the anmdar or hour-glass form there is a constriction as if a cord were tightly tied round the canal, and the stricture may occupy more or less of the urethra, even to nearly its whole extent,* but seldom exceeds five-eighths of an inch in length. Here also the orifice is either central or eccentric ; but the latter is much more common than is generally supposed, and is often a source of great difficulty in passing instruments, as will aj^pear when the subject of difficult catheterism is discussed.

The spiral or tortuous form is of very frequent occurrence, and its devious course is due to irregular contraction of the stric-

* Sir Cliag. Bell, Leroy d'EtioUes, Mr. Lizars, and many others have seen nearly the whole spongy portion of the urethra tightly constricted. Case XV. Chap. V. is an example of this kind.

LOCALITIES OF BTEI0TUEE8.

ture tissue. It is ordinarily from half an inch to an inch in length.

Strictures of all the varieties may be met with in different stages, and these stages have sometimes been mistaken for distinct forms of the disease. Strictm*es of recent and rapid formation are generally soft and yielding as compared with those of slow growth or long existence ; and the induration of the latter may be increased by certain concurrent cii'cumstances. When the spongy tissue is involved, especially when chordee has accompanied the urethritis, the induration -is likely to be extreme, and may be easily discovered by palpation.

Another fact, noteworthy here, and having an important bearing upon treatment, is that the strictm-e tissue is usually more pronounced, more abundant, in the floor of the urethra than elsewhere.

The Favorite Localities of idiopathic strictures of the urethra are : 1st, in the sinus of the bulb ; 2d, at or near the external orifice ; 3d, in the space between the anterior extremity of the bulb and the peno-scrotal junction ; and 4th, in the pendulous portion, or rather in that part of the canal which is included between the base of the glans and the peno-scrotal junction. Stricture is very rarely found in the membranous, and its existence in the prostatic portion is denied by the best authors.

In an examination of two hundred and seventy preparations, exhibiting three hundred and twenty strictures. Sir Henry Thompson found that the constrictions in the region of the bulb were sixty-seven per cent, of the entire number ; sixteen per cent, were found in the region included between the bulb and a point two and a half inches from the external orifice ; and seventeen per cent, in these anterior two and a half inches, including the external meatus.

Number.— Multiple strictures are of more common occur-

PEOGEESS OF STEICTUEES.

rence than is generally believed, as most snrgeons of experience in this branch will testify ; occasionally, however, the number of constrictions in the single urethra is great, if we have faith in the evidence of Hunter, who has seen six in one urethra ; of Lallemand, who mentions seven ; of Colot, eight ; and of Leroy d'Etiolles, who has discovered eleven by means of the gum " hougie-d-houleP It is rare to meet with more than three ; in three instances, however, I detected, with the bougie-a-boule, four in the single urethra, the first being at the external orifice, and the others following with intervals of about one inch. Very frequently there are two ; one at or near the meatus, and the other in the spongy portion, commonly in the region of the bulb.