Gleet : its pathology and treatment with a memoir on the treatment of stricture of the urethra by subcutaneous division

Preface To The Second Edition

Eight years ago I published my first monograph on Gleet, and the first edition having been exhausted, I was asked to have it reprinted with further observations on the subject. Some of my professional friends observed to me that I omitted to mention granular inflammation as a cause of gleet. The reason why I omitted it was, because in all my researches and inquiries of pathologists, I had come to the conclusion that granular inflammation does not exist in the urethra. I, at all events, have never seen it in the male m*ethra.

That which is called by modern writers granular inflammation, as seen by the help of the endoscope, is only the swollen and injected state of the vessels of the urethra during chronic inflammation. We can artificially produce the same appearance in the healthy urethra by the introduction of a dilating tube or instrument into the urethra for a short time. On withdrawing the instrument and immediately inspecting with the endoscope, the urethra will be found to present the appearance of granular inflammation. I have chosen sound parts of the urethra and different parts and made those experiments, and always came to the same conclusion — namely, that the granules we see by the help of the endoscope are the swollen vessels, but not new formations as we observe in the uterus or in the eye. The ana-

IV

PliEFACE, tomy of the eye and of the uterus is different from that of the urethra. Fibrous tissue or a fibrous membrane is placed in the womb or the eye directly under the mucous membrane, Such is not the case in the male urethra, where a loose vascular tissue forms the subcutaneous tissue of the mucous membrane.

The Memoir on the Treatment of Stricture of the Urethra by Subcutaneous Division was read on the 14th of June, 1864, before the Eoyal Medical and Chirurgical Society, and as I have been frequently applied to for the publication of the said paper, I have thought it suitable to join it to this-monograph. But in reading the title of the memoir I must guard my professional friends against the idea that I propose the subcutaneous division as a general principle and applicable to all kind of strictures of the urethra. The cases, where division is indicated, are quite exceptional. I believe in the largest number of cases dilatation, as I shall state in the memoir, is the best method, when judiciously and perseveringly carried out. The secret of the success of dilatation is not the frequently repeated introduction of instruments, but rather the long perseverance of the introduction of the metallic bougies. There is another and very widespread error amongst surgeons — namely, the belief that the longer the instrument remains in the urethra the better the result. This is contrary to my experience. Twenty to thirty minutes is all that is requisite, and the effect is far more lasting than when the bougie is left twenty-four hours in the urethra.

•^'6. Wl'injjole-street, IF., 1st June, 1866.

Preface

In publishing this treatise on Gleet, my intention • is to elucidate some essential points which are very often neglected, and to make its pathology more generally and more fully known. I not only state instances of my success, but also of my failure, indicating that form of Gleet which may be cured by medicme, and that which requires surgical treatment.

I purposely omitted to fill my pages with long accounts of cases, because the histories of cases are of late related so much in consonance with the writers preconceived ideas on the subject, that the profession at large has begun to lose confidence in them.

I consider that accounts of cases are only valuable when they are pubhcly observed, as in hospitals, in the presence of witnesses. Besides, I did not

IV

PREFACE.

\vish to occupy my pamphlet, and weary the reader, with tiresome cases, as many writers in our day too frequently do, not having sufficient matter wherewith to fill the pages of their works.

Some important pomts I have repeated intentionally, because I consider them of such vital importance in the Diagnosis and Treatment of Gleet that I thought they could _ not be repeated too often, or too strongly impressed on the mind, and particularly on the young practitioner.

Tliis treatise is the result of fifteen years’ patient observation, and m leaving it to the profession, the Author will be happy if it should be the cause of dispelling some erroneous ideas on this disease.

59, AVimpole Street,

December 1, 1857.

Contents

PAGE

DIAGNOSIS 37

PEOGNOSIS 39

I

My first operation in the practice of subcutaneous section was performed in the beginning of the year 1853. An Italian gentleman came under my care, with a tight stricture in the membranous portion of the urethra. In this operation I made use of a grooved director having an intra-perineal bend. When the director was in position, with a very small scalpel I made an incision into the membranous portion just lying before the rectum, and of course I was obliged to puncture the rectum also. The scalpel I introduced with difficulty on my finger ; and, having made the puncture, I withdrew the scalpel, and left my finger in contact with the puncture : then on my finger I introduced a blunt convex tenotome, and pushing it through^ the puncture into the grooved director, I divided the stricture. I should not now act in the same manner, as I would prefer to use only one knife in the operation for the membranous portion, namely, a tenotome cache. The patient had shi-

CASES.

A’-ering on the two following days. The urine was Avithdrawn when required, and never let come in contact with the wound. The patient recovered Avell. I could pass a large-sized catheter after the operation. I lost sight of this patient, as he left this country some time after the operation.

n.

The next case which came under my care, in the summer of 1864, is the following : — The gentleman came to consult me for gleet in February, 1854. In exploring his urethra, I found a stricture just before the scrotum. I tried several kinds of treatment. Graduated temporary dilatation was for some time used. The stricture yielded, but returned as soon as dilatation was discontinued, and slight gleet never ceased. The gentleman, who was on the point of getting married, was anxious to get rid of his gleet, and was willing to undergo any treatment or operation for the sake of being cured. I proposed to him to divide the stricture, as the only reasonable means of ensuring his recovery. He consented, and I divided the stricture subcutaneously; and then for the first time I used my conducting director with the two knobs at the vesical end. I operated on him in

CASES.

my own consulting-room, and he returned to his lodgings in a cab. In the evening he had shivering ; but after some doses of quinine, no more shivering took place. There was a slight swelling in the prepuce and the skin of the scrotum, which after a few days subsided. At the end of eight days he passed his water without a catheter ; and after a month there was no trace of stricture or gleet. I have seen this gentleman frequently during the last nine years, and never found the least trace of stricture. About five months ago, for my own instruction, I passed a bougie a houle, but could not discover even the seat of the operation.

ITT.

My third operation I practised in July, 1855. I found in this case a very tight stricture in the fossa navicularis, into which only a very small elastic bougie could be passed. No progress could be made by dilatation. I could not pass a higher number than 20 of Dr. Bennique’s gauge. I proposed to the patient to divide his stricture, to which he consented, and I divided the stricture with Dr. Eeybard’s urethrotome ; but, after having divided it, I found another very tight stricture at the bulb. I had not the heart to propose to the

OASES.

patient another operation at the same time. Afterwards I tried to dilate the second stricture, but made very httle progress. This stricture was just as tight as the first. I was convinced that it was necessary to divide it, and proposed to do so in the month of September, 1855. It was divided subcutaneously. There was a remarkable feature in this case, which I think right to mention. After the first operation in the fossa navicularis the patient had no shivering, but after the operation at the bulb shivering took place. However, the patient did well, and has never to this day been troubled with stricture. All my patients are treated for six months, at least, by dilatation, and only the metallic bougie is used temporarily. This last proceeding I look upon as a kind of orthopgedic treatment.

rv.

In the year 1856 a patient came under my care with stricture just at the commencement of the bulb. It was very tight, and I tried for a long time to overcome it by dilatation. In the latter end of the year 1861 the patient, during his stay at Dublin, was attacked by retention of urine, no instrument having been passed for some time previously. After suffering for several hourshe called in

CASES.

a surgeon, and was relieved by a batb and a catbeter. On liis return to London he was anxious to avoid another such occurrence, and 1 proposed to him to divide his stricture subcutaneously, which operation I performed in January, 1862. Directly after the operation I passed a large catheter, No. 50 of Dr. Bennique’s gauge, and drew off the water. The patient was treated according to the rules I have already mentioned. On the evening of the day of the operation, in trying to pass a catheter, I found such a spasmodic contraction in the membranous portion that the patient felt great pain when I reached that spot. To this moment I cannot understand that great degree of spasmodic contraction. It could not be ascribed to a second stricture, because, directly after the operation, I passed a very large catheter. As there was then not much sign of there being urine in the bladder, I left the patient quiet for the night. I was rather uneasy about permitting the patient to make water over the cut wound, fearing urinary infiltration. The next afternoon, not being able to pass any-sized catheter whatever, and finding that each time the foreign body touched the membranous portion the spasm strongly increased, I recommended the patient to make water without any instrument, and, after a little while, he made a large quantity of

CASES.

Ill wator naturally, "wliioli caused severe scalding at the cut spot. No bad symptoms whatever followed. He had shivering two days consecutively after the operation, but recovered without the least untoward symptoms, and left his room after eight days’ confinement. At the present time there is not the slightest symptom of stricture (1864). In this case Mr. W. Adams assisted me, and fifteen months afterwards, having seen the patient, again has been able to attest to the complete success of the operation.

Mr. Allingham had the kindness to send me the history of two cases, which were operated on by him by the subcutaneous method, and which I shall here give succinctly, with his permission. I must here state that Mr. Allingham was not aware that I had previously operated after the same method. He was consulted by a gentleman from Calcutta who had a long gristly stricture in the spongy portion with a fistulous opening. All known treatment as dilatation, cauterization with potassa fusa, and internal incision had been tried and failed, and he came to England to have his stricture cut by external incision. Thinking the subcutaneous incision would be effective in this case, he passed a Brodie’s

CONCLUSIONS.

director through the stricture, and divided it subcutaneously. The patient recovered without any bad symptoms. In eight days the fistulous opening Avas cured, and he returned to India weU, being able to pass a No, 12 catheter easily. This case was operated in June, 1860.

Mr. Allingham’s second case was in the year 1862, when a patient came under his care Avith a long stricture at the beginning of the bulb, and extending higher up into the membranous portion ; and in this case also a variety of fruitless treatment preceded the operation. He (Mr. A.) made a puncture into the perineum with a tendon knife, on a grooved staflT previously introduced, and divided the first part of the stricture : afterwards he changed his knife for a posterior tibial long-bladed tenotome, and haAong introduced his finger into the rectum, he felt for the staff ; assuring himself, in pushing forwards the knife subcutaneously through the puncture he had previously made, he completely dmded the indurated tissue. The case did well, Avdthout any untoward symptom but once shivering, and after a month he was discharged cured.

I now draw the following conclusions : —

Firstly. Strictures regarding their physical properties can be divided into dilatable and non-

CONCLUSIONS.

dilatable, but in both cases a new tissue is formed. In tbe one it bas the property of being dilatable, but will retract again ; in the other no dilatation, or very little, can be effected.

Secondly. Division of the pathologically contracted tissue is the only means of cure.

Thu’dly. For division the subcutaneous method is the most proper for easy execution, and for safety of the patient’s life.

HENHY DICK, B.A., M.D.

59, Wwijpole-street, W.

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