The pathology and treatment of stricture of the urethra, and urinary fistulae

Front matter

m

I

THE

Preface To The Third Edition

The last edition of this work having been long out of print, I have prepared a new one, and will indicate briefly the main changes which have been made.

I have reduced the bulk of the work by upwards of eighty pages ; first, by removing matter which in the former edition related to controversial points under discussion at the time of publication, but since, for the most part, settled, and therefore no longer necessary to be reconsidered in detail here.

Secondly, I have removed entirely all the " illustrative cases." These appeared at the outset of my work to be necessary ; and some were cited in support of statements which were at that time not generally accepted. Another reason for removing the cases is, the conviction that it is a better and simpler method for me, after another ten years' experience, to give its results in the form of opinions, as simply aud briefly expressed as possible, unincumbered by those guarantees which might naturally be expected from an author in an early part of his career. On the other hand, several additions have been made in various parts of the work, relating to treatment, the result of therapeutical progress and more extended observations. On the whole, I have endeavored to produce in the present and somewhat smaller work a more useful epitome of the subject than the original and larger one contained.

35 Wimpole Street, Cavendish Square, London, June, 1869.

Preface To The Second Edition

The first edition of this work being published as a Jacksonian Prize Essay, it was not possible to alter or add to the manuscript originally sent to the College of Surgeons.

But a new edition having been called for, the Author has determined to make considerable additions, and to re-write several portions of the work, for the purpose of embodying the results of increased observation and experience. Besides a few additions to the first two chapters, rendered necessary by the result of recent investigations, the chief alterations may be briefly indicated as follows :

Firstly: The Chapter on "Dilatation" is considerably extended, chiefly in relation to the practical management of patients submitted to the numerous varieties of treatment which claim to be considered under this head.

Secondly : Much new matter is added to the Chapter on " Internal Incisions," for the purpose of illustrating a mode of practice which has proved, beyond doubt, to be extremely valuable in certain cases, as* well as of indicating those to which it is especially applicable.

Thirdly : A large part of the Chapter on operations by " External Incisions " is re-written. The increased experience which has accrued since the date of the first edition, and the modifications in practice it has suggested, rendered this necessary. Very extended data, consisting of almost the entire English experience of the last ten years, have been collected with much care and

PREFACE TO THE SECOND EDITION. Vll

labor, in order to present the reader with the means of arriving at an accurate estimate of the operation of External Division.

Fourthly : The subject of "Fistulas," including that of "Plastic Operations ou the Urethra," is treated at length ; this portion of the work is almost entirely new.

Fifthly: The following are minor changes: Illustrative Cases, which originally occupied the Appendix, are now placed in the text ; each chapter being immediately followed by those appropriate to its own topic. Many of these examples also are new, the Author having substituted cases which have been under his own observation for those which in the first edition were reported from the practice of others. Many inaccurate statements having been made in relation to the origin of our present modes of treatment, an attempt has been made to render more complete the historical portion of the subject in each department. Numerous woodcuts have also been added.

In conclusion, the Author desires to offer his very grateful acknowledgments, first, for the extremely flattering reception which the original edition met with from his professional brethren. Several of the suggestions for its improvement, offered in various critical notices, appeared to be valuable, and have been carried out. If permitted to particularize, he must confess that, after all, the most flattering appreciation of his labors was that which appeared in the appropriation of thirty pages of the second chapter, without acknowledgment, and their literal translation into the French, by a Foreign Surgeon, as " his own proper observations." The " rechauftee," so produced, was received as an original paper by the " Societe de Chirurgie" of Paris, in 1856, and has been published and favorably reviewed in the neighboring capital as the work of the individual who placed his name on the title-page. It would be impossible for the Author to omit this opportunity of presenting his sincere and cordial thanks to the Press of this country, of France, and of America (in the latter the fraud was first discovered and exposed), for the prompt

Vlll PREFACE TO THE SECOND EDITION.

and complete manner in which it hastened to lay bare and publish to the world the fraud in question. To the " Societe de Chirurgie" of Paris, he next begs to offer a public expression of his gratitude, for the prompt and generous manner in which it denounced the plagiarism, accorded more than justice to the original Author, and gave the utmost publicity to its unanimous resolutions on the subject. To the "Societe Anatomique" of Paris it is also his pleasing duty to render similar homage.

Lastly, the Author desires to express a grateful sense of his obligations to numerous professional brethren, chiefly hospital surgeons of this country, metropolitan and provincial, who, to his inquiries respecting the subject of the Ninth Chapter, have fully responded, in many cases at no mean sacrifice of time and labor, and have placed at his disposal extremely valuable experience, which in no other manner could have been presented to the profession, as evidence on a question hitherto much obscured by the incomplete statements to which generalization from insufficient data has given birth.

16 Wimpole Street, Cavendish Square, Sept. 7, 1858.

Preface To The First Edition

The following work consists of the Treatise to which the Jacksonian Prize, for the year 1852, has recently been awarded by the Council of the Royal College of Surgeons of England.

The subject named by the Council, and announced for public competition in the summer of 1851, was, " The Pathology and Treatment of Stricture of the Urethra."

From these terms it may be inferred that a comprehensive view of the various important lesions commonly understood to be included under the denomination of Stricture, as well as of others which are intimately related to them, was required by the Council.

In the following attempt to execute a task of such magnitude and extent, the Author is painfully conscious of the degree to which he has come short of its accomplishment. The subject is one which embraces very wide and important relations. The possession of manual dexterity, and a practical familiarity with the best mechanical appliances on the part of the surgeon, are absolutely indispensable to the successful treatment of Stricture ; but these alone constitute only a part of the agency which must be brought to bear upon a large proportion of the cases which he meets with in practice. An acquaintance with the pathology of the entire genito-urinary system is necessary, and must be patiently and assiduously cultivated. The numerous sympathetic relations with every part of the animal economy which this important part of it sustains, through the medium of the

X PREFACE TO THE FIRST EDITION.

nervous s}Tstem, have constantly to be recognized and apprehended. To enter fully on the consideration of these topics ■would require, not one volume, but several. A brief review of those which are to be regarded as possessed of primary importance could only be attempted within the limits of this work. On these grounds, therefore, no apology appears to be necessary on the Author's part, for offering so large a volume to the notice of his professional brethren.

It may be desirable, very briefly, to denote the plan which has been adopted in the arrangement of the materials which constitute the work.

Firstly : The observations and opinions of those writers who have paid especial attention to the subject, are, on most points, collated and adduced. In each case the writer's words are quoted, and direct reference is made to the page and edition of his book.

Secondly: Original researches have been made, as far as it has been within the Author's means to do so, and their results are compared with the foregoing. Thus, the Chapter on the Pathological Anatomy of Stricture is mainly a digest of the facts now exhibited in the Principal Museums belonging to the Medical Schools of London, Edinburgh, and Paris, in which each preparation has been individually examined by himself. A reference is made in the text to various specimens of importance, and an account of these is placed in the Appendix, the bulk of which is thus somewhat increased, rather, however, for the purpose of facilitating the student's acquaintance with unquestionable examples and illustrations of the facts stated, than to furnish a body of matter possessing general interest and value.

Thirdly : In relation to the natural history, and to the treatment of Stricture, a certain number of cases, hitherto unpublished, have been placed in the Appendix, under the head of " Reported Cases," for the purpose of illustrating numerous points connected with these divisions of the subject. Following

Preface To The First Edition. XI

these is a " Table of Cases," 220 in number, each containing a very brief statement of the chief incidents in the history of the patient, and his present condition, condensed from fully-reported cases only, upon the aggregate of which have been founded, in a great measure, the Chapters on "The Symptoms," and on " The Causes of Stricture."

It has been deemed necessary to discuss somewhat at length the " qiuestio vexata " of the present day, viz., that of cutting operations for Stricture performed from the perineum. Certain data required for this purpose will be found under the head of " Outlines of Cases," which are merely very short histories, containing the principal facts bearing upon this question.

Lastly : Respecting the anatomical relations of the normal as well as of the diseased urethra, no pains have been spared in order to develop the best practical mode of conveying, as far as this can be done on paper, sound information upon this important subject. It will be seen that a great number of bodies have been examined to supply the facts related. One, out of several illustrative preparations which were sent in to the College of Surgeons with the Essay, contained portions of the corpus spongiosum from not less than twelve bodies, to illustrate a point in its anatomy referred to at pages 53-55.

The Author has now only to present his grateful acknowledgments to the Council of University College, London, for permission freely granted in any way to make use of the valuable Case-books of the late Mr. Liston ; — to Mr. Erichsen, the esteemed Professor of Surgery in the College, for liberty to examine and publish the cases of any patients under his care in the hospital, which might illustrate the subject; — to those gentlemen who have readily assisted him in the pursuit of information respecting patients formerly under their care, among whom he is especially bound to name Mr. Syme, who has also afforded him every facility for observing his practice, both public and private ; Mr. Fergusson, Mr. Cock, and Mr. Coulson, besides numerous others

Xli PREFACE TO THE FIRST EDITION.

in various parts of the country, who have most promptly responded to his inquiries ; and lastly, to his old friend and formerly fellow-student, Mr. Squire, late surgeon to the St. Marylebone Infirmary, for the invaluable opportunities he has at all times afforded him of prosecuting practical researches at that institution.

16 Wimpole Street, Cavendish Square, December, 1853.

Appendix

The examination of urine for clinical purposes, chiefly in connection with the subject of Difficult Micturition, . . 323

Notes relating to Preparations in the Museum of the Royal College of Surgeons, illustrative of Organic Stricture and its consequences, referred to in Chapter II, on " The Classincauion auu ramuiugY u± olijujuuico ui mc In the Museum of Guy's Hospital, .

ua, .

. 333

" " Bartholomew's Hospital,

. 335

" " St. George's Hospital,

. 336

» " St. Thomas's Hospital,

. 33?

" " University College, .

. 338

" " Middlesex Hospital, .

. 339

" " King's College Hospital,

. 339

" " London Hospital,

. 340

" " Royal College of Surgeons, Edinburgh, . 340

Table of Cases analyzed at page 134, 343

, 357

LIST OF WOODCUTS.

PAGE

1. Transverse section of pelvis, 56

2. Stricture of the urethra, from a preparation, 81

3. Ditto ditto, 81

4. Ditto near external meatus, ........ 81

5. Polypoid growth in urethra, 87

6. Ditto from verumontanum, ......... 88

7. The healthy urethra, showing divisions, 96

8. A bulbous sound, 149

9. French flexible bougie, with bulbous end, 150

10. Natural curve of urethra and instrument, 151

11. Ill-formed catheter, 153

12. Instruments : relations of axes of shaft and point, 154

13. Catheter formed on urethral curve, ....... 156

15. Diagram of urethra, 159

16. The French gauge, 161

18. Probe-pointed catheter, 175

19. Leroy D'Etiolles' twisted bougies, 178

20. Urethral endoscope, 182

21. Catheter with siphon, 188

22. Perreve's instrument, .......... 194

23. A distending instrument, . . . . . . . . . 196

24. Caustic instruments, 214

25. 26. Urethrotomes, straight, 226

27. Ditto curved, 227

28, 29. Urethrotomes : old models, 231

30. Civiale's urethrotome, 231

31. Urethrotome of Charriere, ......... 233

32. Ditto of Key bard, 234

33. Ditto of Trelat, 235

34. Bistouri cache for stricture at meatus, 237

35. Syme's staff, 257

36. Position of staff, 258

37. Director, 260

38. Lace suture, 306

40. Urethroplasty operation, 308

DESCRIPTION OF ENGRAVINGS.

PLATE I.

Sections of the Corpus Spongiosum Urethrse, made at different distances from its posterior extremity, but all within the limit of the bulbous portion ; a median fibrous partition is seen in two. In the lowest figure, in which the section was made farther back than in the former, two or three intersections appear. (See p. 54.)

PLATE II.

SEE PAGE 32? IN APPENDIX.

Microscopical appearances of Urinary Deposits. Pig. 1. — Uric acid, in its chief varieties of form and appearance, as occurring in the urine. 2. — Urates of soda.

Oxalates of lime. 3. — Phosphates of ammonia and magnesia.

Phosphate of lime.

PLATE III.

SEE PAGE 328 IN APPENDIX.

Fig. 1. — Pus corpuscles.

Ditto, after the application of acetic acid. 2 Blood corpuscles, natural; after immersion in urine. Epithelium. Exudation corpuscles. 3. — Urinary casts.

M m, or i

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URINARY STRICTURE AND FISTULA.

Chapter I. The Anatomy And Physiology Of The Male Urethra

Method of pursuing the inquiry — Anatomical relations of the urethra proper — Length of the urethra — Measurements of width — Dilatability ; casts of the urethra — Sir E. Home's observations — Mr. Guthrie's — Anatomical divisions of the urethra — Mucous membrane of the urethra — Glands \ rugae; transverse sections — Vessels and nerves — The deep fascia? of the perineum — The muscular tissues; involuntary muscular fibre — Hunter's views of the muscularitv of the urethra — Home's researches — Kolliker's researches — Mr. Hancock's — Directions for demonstrating the involuntary muscular fibres — Investigations by Professor Ellis — The voluntary muscles which act upon the urethra — Two sources of muscular action upon the urethra — Function of the neck of the bladder — Sphincteric function of the compressor urethra? — Function of the levator prostata? — Erectile tissue — Internal structure of the corpus spongiosum at the bulb — Relation of the bulb to the surface of the perineum,rectum, &c. — Structure of the bulb in relation to hemorrhage — Direction of the urethra — Relations of the fasciae — The urethral curve — Variations from the normal direction.

It will be essentially necessary, in order to understand fully and clearly the subject of this essay, in its numerous and important relations, first, to study closely the anatomy of the healthy male urethra, and inquire into its physiological action and uses. In doing so, I shall collect and review the labors of those distinguished observers who have hitherto devoted their attention to the work, and compare them with the results of those investigations which I have myself been able to make, by repeated dissections, and researches into certain conditions of the organ, which are illustrated in the tables and drawings accompanying this volume.

It will be unnecessary to adduce any reasons in support of

18 ANATOMY OF URETHRA.

this mode of proceeding. The study of anatomical and physiological science is too generally admitted as the only sound basis on which to conduct intelligent researches into the meaning of pathological phenomena, as a general principle, to admit of the adoption of any other course. But in the particular case before us, of the Pathology of Stricture of the Urethra, none who have paid any attention to it will deny, that it is especially essential, in order to arrive at truth, in relation to many disputed points in the pathology of this very complex organ, to obtain all the light on its structure and functions, which dissection of the healthy part, and observation of its healthy actions, can afford. I say " complex organ," because, although the urethra, strictly speaking, is a canal merely, and comprehends no more, as the term itself implies,1 yet, as it is so intimately connected with certain muscular and other tissues, which together constitute the surrounding structure, and, as we shall hereafter see, is so greatly affected through the medium of their influence, much more than the canal itself is necessarily presented for our consideration.

We shall accordingly examine, first, the urethra proper ; and, secondly, the neighboring parts which can exercise any influence, mechanically or vitally, upon its form and condition.

1. The Urethra Proper. — This term applies to the canal which leads from the urinary bladder to the external orifice, meatus winarius, at the extremity of the penis, in the male, or within the vulva in the female. It may be regarded as made up of a mucous membrane, and certain tissues adjacent, which, for the present, may be included under the general term, " submucous," and the nature of which shall be presently examined. The length of the urethra in the adult male has been differently stated, for it varies considerably in different subjects, as it does also in the same individual, under different circumstances, since the parts are exceedingly extensible, and may be readily made to correspond to any given measurement. These sources of difference are sufficiently obvious to the anatomist, and forcibly prove the necessity of following some constant method, in the examination of each urethra, if accurate results are to be attained, i

Accordingly, with a view to the solution of this question, I

1 Urethra, from ct/gov, urine, and t§«£«, to ran.

LENGTH OF URETHRA. 19

have pursued the following course, with a considerable number of bodies, which it has fallen to my lot to examine. The penis and bladder having been carefully removed from the pelvis, in the usual manner, the entire passage is laid open along tbe upper aspect. The parts are then placed, being first moderately extended, upon some smooth polished surface, as on -a common earthenware dish, and so permitted to take, by their own elasticity, any form or length which their component structures may determine. The measuring tape is then applied. The average result of the application of this process to 16 adult bodies is as follows :

Total Length, from anterior border of uvula vesicae to

meatus urinarius externus, ...... 8£ inches.

Dividing the canal in the usual manner into spongy, membranous, and prostatic portions, we have —

Length of spongy portion, 6$ "

" membranous ditto, ..... | "

" prostatic ditto, . . , „ . . 1J- "

The greatest measurement was 9 inches, the smallest 7f inches. Of the 16, no less than ten presented measurements which did not deviate more than a quarter of an inch from the average, and ranging within f ths of an inch only ; that is to say, between 8£ and 8f inches inclusive.

Mr. Briggs, formerly of the Lock Hospital, has made some investigations into the subject, which came to my knowledge since many of the post-mortem measurements just recorded had been ascertained. His experiments were made upon the living subject ; and, inasmuch as the practical benefit of these researches must be found in relation to the use of instruments during life, it is confessedly of more importance to ascertain, if possible, the length of the canal in that condition, than after death. He states, that the average length of the urethra is about 7| to 7§ inches. I have made many such measurements also, and I believe 7 inches to be nearer the truth.1

1 Mr. Briggs, late of the Lock Hospital, published the results of a series of experiments made upon a number of persons during life, with a view to arrive at conclusions respecting the normal length of the urethra. His measurements were taken by means of a graduated catheter passed into the bladder. He esti-

20 LENGTH OF URETHRA.

It will therefore be borne in mind, that these two measurements of 7 inches and of 8| inches, respectively, relate to the average length of the urethra in the two conditions of life and death. That this difference exists it will be particularly important to recollect, since all accurate researches into the pathological anatomy of stricture are, of necessity, confined to an observation of the parts after death, while, in relation to treatment, the measurement during life is that which alone must be remembered.

But it will be very obvious that, during life, the length of the urethra in the same individual greatly varies with its vascular condition. Erection considerably increases it, and it is, of course, the opposite condition, or that of flaccidity, which is denoted in the estimates given. But in different individuals, as with all other organs of the body, these, in particular, appear to vary in

mated "the average length of the urethra to be 1\ to 7f inches." — Treatment of Strictures by Mechanical Dilatation. London, 1845, p. 9.

Again he says: "In a plaster cast of a vertical section of the male pelvis, I find the following to be the proportion of the several parts of the urethra. From the orifice to the membranous part, 6£ inches. From thence to the bladder, 1| inches. Total, 8J inches." — Ibid., pp. 11, 12.

Mr. Whately examined 48 subjects of different statures, and fomid the average length to be 8£ inches. " In each of these classes there were some differences in size, and in many of them considerable variations in the length of the projecting part of the penis. The number of tall men was 16. Of these the following is an exact measurement of the different distances from the extremity of the penis to the bladder in each of them, taken while the former was held firmly on the catheter to prevent it from shrinking.

Sixteen tall men. Twenty-three of middle stature. Nine short.

1 at 10 inches. 3 at 9J inches. 1 at 9£ inches.

16 23 9

— Improved Method of Treating Strictures. London, 3d edition, 1816., pp. 68-69, in a note.

Mr. Benjamin Phillips says : " The experiments I have made by injecting the erectile tissue composing the corpora cavernosa decidedly confirm the accuracy of Whately 's calculations, and justify me in stating the average length of the urethra as varying from eight to nine inches." — Treatise on the Urethra. London, 1832, p. 2.

LENGTH OF URETHRA. 21

size somewhat, especially to the superficial observer. Still there is reason to believe that less difference really exists than is generally imagined. I confess to have been formerly somewhat surprised to observe how much alike organs, which appeared to differ greatly in the matter of size while attached to the body, became, when slit up and laid open throughout their whole extent, with the bladder connected ; a result which is due to the fact that considerable variation exists in the relative amount of the organ which remains pendant and unsupported, as compared with the part which is fixed and attached, in different individuals, and so partially concealed from the eye, the two bearing an inverse proportion to each other ; or. at all events, where the length of the organ appears to be remarkable, the difference is often mainly to be accounted for by the greater development of the pendant portion, and is far less observable in the remaining part ; the amount of the former sometimes depending greatly upon normal peculiarity in the size and form of the scrotum (just as in disease we sometimes find the penis almost hidden by a scrotal hernia, or a large hydrocele) ; also in some small degree upon the distance beneath the symphysis pubis, at which different urethras emerge from the pelvis, some not dipping down so deeply beneath the arch as others by three-eighths of an inch, and so making a smaller and a shorter curve than the latter. This fact will be more fully noticed hereafter. Nevertheless, canals differing considerably in length, may be found in health, while unusual length may be a sequence of disease, as seen in cases of enlarged prostate ; but setting these aside, a range of between eight and nine inches will include a very large proportion of the whole number, all being treated in the manner above described. It is easy to account for the discrepancies which appear, in comparing the measurements of different observers, when it is remembered that the urethra of eight inches may easily be stretched into ten. The same remark will hold good with reference to the relative length of the different divisions, no very obvious or defined mark existing in the urethra to determine any lines of demarcation between them ; notwithstanding which their measurements are calculated with so much nicety, as very frequently to be expressed in lines. Next, as to the width of the passage. This it is exceedingly difficult to reduce to figures, from its natural dilatability in the healthy con-

22 WIDTH OF URETHRA.

dition. Anatomists have stated three, four, and five lines as approximative measurements. Surgeons have recorded the passage of calculi through it of four lines or more in diameter, which must of course indicate the amount of extensibility enjoyed by the narrowest portions of the canal. The mucous membrane after death, when treated in the manner already described, is accordingly found lying in long, but minute and narrow folds, which are readily obliterated by stretching it in a transverse direction, when laid open, to about double its natural width. In this condition, but unstretched, we obtain measurements as follows ; and these, it will be remembered, although denoting the circumference, represent about half what it really amounts to when the passage is ordinarily dilated :

The neck of the bladder, or commencement of the prostatic portion, measured, T% to T6^ inch.

The centre of the prostatic portion, . . . • tV

Beginning of membranous, or end of prostatic portion, . T5ff to T6^

Middle of membranous part, T6ff

End of ditto, close to the bulb, . . . . • ts

Bulbous part of spongy portion, t7q

The part within the glans, T6g-

Meatus externus, ........ t5q

Thus it will appear that, relatively to each other, different parts of the canal bear certain constant proportions. For example, the external meatus itself is the smallest, except when, as very rarely happens, a congenital contraction exists about a quarter or half an inch from the extremity, and of course within view ; next is the point of junction between the membranous portion and the bulb ; while the centre of the prostatic portion, and the sinus of the bulb, are the largest.

After all, it is the relative, rather than the actual, size of the various parts of the passage, which is of the greatest consequence to the practical surgeon, and the foregoing measurements may be most advantageously viewed, as possessing relative rather than absolute value. Again, in the living body, the walls of the passage are closely applied to each other in a state of inaction, so that the diameter is only calculable when distension occurs from some cause ; and as this has been seen to correspond, within certain limits, to the amount of pressure exerted upon them, any statement respecting it must be liable to some modification. Indeed, the question of the diameter of the urethra

EXTENSIBILITY OF URETHRA. 23

must be considered as resolving itself, to a certain extent, into the measure of its capability of being extended ; and this is of greater practical import than the mere width of its mucous membrane, when slit up after death.

One of the best modes for determining extensibility is the formation of casts of the urethra by means of injections of wax, or, better still, of fusible metal. The former have been frequently employed ; among others, by Sir Everard Home, who paid considlrable attention to this subject, and he gives the result of experiments on two bodies, one of eighty, and the other of thirty years of age; the measurements recorded being those of the diameter of the casts, at different parts of its course.1

"THE DIAMETER OF THE CASTS OF THE URETHRA IN DIFFERENT PARTS.

At | inch from the external orifice, .... 59„inch. ^inch.

At 4| inches from ditto, 27o 2V