Gleet.—Gleet is certainly, as its name implies, a discharge of thin ichor from a sore. Patients usually understand, and medical men usually allow, a gleet to be a discharge from the urethra, which has existed some time, of a whitish color, unattended with pain, and that isnot infectious, by which is meant is incapable of producing gonorrhœa. There are several kinds of morbid secretions, the successful treatment of which depends upon a knowledge of their differences. They may be divided into two principal orders—those secreted from the mucous surface of the urethra or bladder, and those which proceed from the various glands-leading into one or the other. Gleet is a term popularly applied to both, but more strictly relates to that which proceeds from the membrane lining the urinary canal. There is great analogy in inflammatory affections between the mucous membrane of the digestive and pulmonary, as well as urinary passages. In inflammatory sore throat, the secretions assume various appearances; there is a discharge of viscid mucus, of purulent matter, or of a thin watery nature; these secretions are dependant upon the amount and duration of the inflammation present. Exactly in like manner may be explained those issuing from the urethra. They are consequently alike modified by treatment, by diet, by rest, and aggravated by a departure from constant care. It is the nature of all membranes, lining canals that have external outlets, to attempt the reparative process by pouring forth discharges, while those which line the structures that have not, effect their cure by union with the oppositesurface. It is an admirable provision, else important passages might become closed, and so put a stop to vital processes; and in the other case, accumulations ensue that could not escape without occasioning serious mischief. When, however, disease has existed a long time, the operation of the two kinds of membranes is reversed. The serous,[2]through inflammation, take on the character of abscess, dropsy, or other secretions, and the mucous ulcerate or form adhesions, as evidenced in stricture, or ulceration of the throat or urethra. Gleet may be a spontaneous disease, that is to say, may arise from other causes than infection. It may exist independently of gonorrhœa, and be the result of cold, of intemperance, and of general or of local excess. Its long continuance and neglect, however, renders it infectious, and it also gives rise to ulceration, excrescences, and stricture: and when, from other causes, ulceration, or excrescences, or stricture, are set up, gleet is in return generally one of their consequences. Gleet, despite these various occasions, is, after all, most frequently a remnant of gonorrhœa; and it is very difficult to define the time or point where the one ends and the other commences. Pathologists draw this distinction between the two:—they say that gonorrhœal discharge consists ofglobules, mixed with aserousfluid, while gleet is merely a mucous secretion. I confess it difficult for a non-professional person to decide which is which, the resemblance, in fact, being so great—a gonorrhœal discharge being one day thick and yellow, a few days afterward thin and whitish, and at one time in quantity scanty, and the next profuse. Gleet assumes nearly the same changes. The best test for distinguishing them is, by regarding the accompanying symptoms. Where there is pain on passing water, bladder-irritability, tenderness in the perinœum or neighboring parts, and the discharge plentiful and offensive, staining the linen with a “foul spot,” it may, without much fear, be decided to be clap; but where the discharge is next to colorless, like gum-water, for instance, and where there is no other local uneasiness than a feeling of relaxation, and where it has existed for a long period, and was, or was not, preceded by a gonorrhœa, it may fairly be called a gleet. Now wheredoes the discharge of gleet come from? Let us recapitulate its causes; first from clap, which is a specific inflammatory affection. It may therefore be a chronic inflammatory state of the lining membrane of the urethra, of greater or less extent; in which case we would call it chronic gonorrhœa, and which would be owing to a relaxed state of the secretive vessels. We know that when a disease exists for a long while, and is one not positively destructive to life, a habit of action is acquired that renders its continuation in that state as natural as its healthy condition. This is the state of the secretive vessels in gleet, arising from gonorrhœa; and hence the discharge is poured forth, instead of the secretion natural to the urethral passage in its healthy order. Secondly, such may have been the severity of a clap, that ulceration of some portion of the urethra may have taken place. The disease may have got well except in that identical spot which, owing to the constant irritation occasioned by the urine passing over it, struggles with the reparative intention and effort of nature, and exists even for years. Thirdly, when stricture is brewing, which will be explained in an appropriate chapter, the alteration going on gives forth a discharge, and, as I have stated in another part of this work, I here repeat, that a long and obstinate gleet, as the slightest examination would testify, rarely fails to indicate the presence of a stricture. Lastly, gleet may be produced by loss of tone in some or the whole portion of the secretive vessels, induced by one or many of the accidents of life, or the various kinds of physical intemperance when they not only weep forth various kinds of fluids, at irregular intervals, which impair the muscular and nervous energy of the generative organ, but render persons laboring under this description of weakness very susceptible of infection, if they hold sexual contact with those but slightly diseased. Hence persons laboring under this form of debility incur what others escape. An individual so circumstanced would receive a taint from a female having leucorrhœa. Very many inconveniences have arisen from this infirmity, giving birth occasionally to unjust suspicions, and creating alarms of the most distressing nature.
Thus, then, we may have gleet from gonorrhœa, gleet from ulceration, gleet from stricture, gleet from debility and discharges, popularly understood to be gleet, but inreality glandular secretions, which will be considered shortly and separately. Gleet is a tiresome and troublesome disorder. So difficult, occasionally, is its management, that oftentimes the more regularly a patient lives, and the more strictly he conforms to medical regimen, the more deceptive is his disorder. He will apparently be fast approaching to, as he conceives, a recovery, when, without “rhyme or reason,” the complaint recurs, and hints that his past forbearance has been thrown away. It would be dispiriting, indeed, were every case of gleet to realize this description; but it is well known that many do, either from neglect or mismanagement. Now it must be evident that the treatment of gleet depends upon what may happen to be the occasion of it. Where the membrane of the urethra is entire, internal remedies may, and do avail. Copaiba will achieve wonders; the use also of a mild injection, perseveringly employed (as a solution of iodide of iron, or citrate of iron, ten grains to the ounce of water), will give tone and stringency to the weakened vessels, and so correct the quantity, at least, of the secretion. In very obstinate cases, stronger injections, as of the nitrate of silver, twenty grains to the ounce of water, are serviceable; and we are not without many useful internal medical combinations, which, properly administered, conquer this troublesome complaint. In ulceration and stricture, these two causes must be removed, else all efforts are unavailing. In general and local debility, the attention must be devoted to the constitution. Common sense and common reading must give to persons, possessing both, every necessary information. The community are beginning to appreciate the advantages of temperance, air, and exercise, too highly, to need instructions how much of the one or either of the other two are essential to the preservation or recovery of health.
Morbid Irritability of the Urethra.—Of the varied symptomatic sensations, few are more provoking and fretting than some continued troublesome itching or pain that frequently attends the passing of water. There may be no discharge of any kind, but there is either a constant tingling, partially pleasurable sensation, drawing the attention perpetually to the urethra, or there is felt some particular heat or pain during the act of micturition. These feelings do not always indicate a venereal affection; they appear to depend upon local irritation, perhaps induced by amorbid condition of the urine. The treatment consists in temperate diet, moderatively laxative medicines, and now and then local applications. Some cases yield to sedatives topically applied, and alkalies given internally, while others need local stimulants and specific tonics. At all events, whenever there is an unhealthy feeling in those parts, it points out some altered action is going on, which, if not arrested, is likely to end in stricture or gleet, and therefore attention had better be bestowed upon it as soon as possible.
On Stricture of the Urethra.—Of all diseases of the genito-urinary system, stricture must be allowed to be the most formidable. It is not the most difficult to cure; but it involves, when neglected, more serious disturbances—disturbances which frequently compromise only with loss of life. Stricture is a disease unfortunately of extensive prevalence; and in nine cases out of ten is the sequence of a gonorrhœa; and, what is still more comforting, few persons who become the prey to the latter infliction escape scot-free from the former; not because a clapmustnecessarily be succeeded by a stricture, but simply because itis, and all owing to the carelessness and inattention manifested by most young men in the observances so necessary for the perfect cure of the primary disease. One very prevalent notion, and which explains a principal cause of the extension of the venereal disease, is entertained, that the way to give the finishingcoupto an expiring clap, is to repeat the act that gave rise to it: the disease becomes temporarily aggravated, and the impatient invalid probably flies, from an unwillingness to confess his new error, from his own tried medical friend to some professional stranger. From a desire to earn fame as well as profit, the newly consulted prescribes some more powerful means; the discharge is arrested for a while, but returns after the next sexual intercourse; a strong injection subdues the recurrent symptom, which only awaits a fresh excitement for its reappearance. Thus a gleet is established. The patient finding little or no inconvenience from the slight oozing, which, as he observes, is sometimes better and occasionally worse, according to his mode of living, determines to let nature achieve her own cure, and for months he drags with him a distemper that, despite all his philosophy, he can not reflect on without an humiliating diminution of self-approval. So insidiously, however, does thecomplaint worm its progress, that the patient, considering his present state the worst that can befall him, resolves to endure it, since it appears his own constitutional powers are incapable of throwing it off.
In the midst of this contentment, the invalid finds that the process of urinating engages more time than formerly, the urine appears to flow in a smaller stream, and is accompanied by a sensation as though there were some pressure “behind it.” The act of making water is not performed so cleanly as it used to be; the stream differs in its flow, seldom coming out full and free, but generally split into three or four fountain-like spirts, as the annexed drawing displays.
At other times it twists into a spiral form, and then suddenly splits into two or more streams, while at the same moment the urine drops over the person or clothes, unless great care be observed, as witness diagram.
In advanced cases, the urethra becoming so narrow the bladder has not power to expel the urine forward, and it then falls upon the shoes or trowsers, or between them, as observe illustration.
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Persons afflicted with stricture, and urinating in the streets, may almost be detected from the singular attitude they are obliged to assume to prevent the urine from inconveniencing them, and also from the time occupied in discharging it. Some few minutes after making water, when dressed and proceeding on his way, the patient finds his shirt become moist by some drops of urine that continue to ooze from the penis; and it is only as these annoyances accumulate, he begins to think he is laboring under some other disease than the gleet. The next symptom he will experience will be a positive but temporary difficulty in passing his water—perhaps a total inability to do so; it will, however, subside in a few minutes. This will lead him to reflect, andhe will even appease his fears by inclining to think it may be the consequence of his last night’s excess: he resolves to be more careful for the future, and he gets better; his contemplated visit to his usual professional adviser, if he have one, is postponed, and a few more weeks go by without a return of the last symptom. The next attack, which it is very difficult to avert, and which is sure to accompany the succeeding debauch, or to follow a cold or fatigue, does not so speedily subside; the patient finds that he can not complete the act of making water without several interruptions, and each attended with a painful desire resembling that induced by too long a retention of that fluid. In that state he eagerly seeks medical assistance; the treatment generally adopted consisting of some sedative, immersion in a hot bath, or the passage of a bougie. Relief being thus easily obtained, professional advice is thus thrown up, and the symptoms are again soon forgotten. Before proceeding further with the more severe forms and consequences of stricture, which may now be fairly said to have commenced in earnest, a brief anatomical description of the urethra may enable the reader to understand how the constriction or narrowing of that canal takes place.
I have elsewhere stated the urethra to be a membranous canal, running from the orifice of the penis to the bladder, and situated in the lower groove formed by thecorpus spongiosum.
The difference of opinion entertained by some of our first anatomists, on the structure of the urethra, is deserving of notice; for only in proportion to the correctness of our knowledge of it, can we arrive at a just definition of its diseases.
One party assert it to be an elastic canal—whether membranous or muscular they do not say—endowed with similar properties of elasticity to India rubber, or to a common spring. That it is elastic, is beyond doubt; but the mere assertion is no explanation of its mode of action.
Others, from microscopical observations, declare it to consist of two coats—a fine internal membrane, which, when the urethra is collapsed, lies in longitudinal folds—and an external muscular one, composed of very shortfasciculiof longitudinal fibres, interwoven together, and connected by their origins and insertions with each other,and united by an elastic substance of the consistence of mucus. This is the more satisfactory of the two.
They account for the occurrence of stricture in this way. They say that “a permanent stricture is that contraction of the canal which takes place in consequence of coagulable lymph being exuded between thefasciculiof muscular fibres and the internal membrane, in different quantities, according to circumstances.”
A spasmodic stricture they define to be “a contraction of a small portion of longitudinal muscular fibres, while the rest are relaxed; and as this may take place, either all round, or upon any side, it explains what is met with in practice—the marked impression of a stricture sometimes a circular depression upon the bougie, at others only on one side.”
With respect to the change consequent upon permanent stricture, dissection enables us, in some degree, to arrive at the truth. Excrescences and tubercles have been found growing from the wall of the urethra; but in the majority of instances, the only perceptible change is a thickening of the canal here and there, of indefinite length; but whether it be occasioned by the exudation of coagulable lymph, or whether it be the adhesion of ulcerated surfaces, which I contend are more or less present in gleet, is not so easy to determine; at all events, it is undoubtedly the result of inflammation.
With regard to the action of spasm, all we know of it is theoretical; but experience every day furnishes instances of its occurrence.
Spasmodic stricture is generally seated at the neck of the bladder, and may occur to persons in good health, from exposure to wet or cold; from some digestive derangement; from long retention of the urine, particularly while walking, owing to the absence of public urinals; or to violent horse exercise; but more frequently does it happen to those young men who, when suffering from gleet or gonorrhœa, imperfectly or only partially cured, are tempted to commit an excess in wine, spirits, or other strong drinks. Surrounded by jovial society, glassful after glassful is swallowed, each one to be the last. The patient, with his bladder full to repletion, scarcely able to retain his water, yet probably “going” every moment, represses his desire until the party breaks up, when, on encountering the cold air, he finds himself unable to voideven a drop, or if so, but with extreme difficulty. The greater the effort, and the more determined the straining, the greater is the impossibility, and unless relief should be afforded, the most alarming consequences may ensue.
The rationale is this: the patient, opposing the action of the muscles of the bladder, by contracting those of the urethra, they (the latter), from irritation, become spasmodically contracted.
The urine, by the powerful action of the muscles of the bladder, is forced against the contracted portion of the urethra; and by its irritation increases the mischief. Where neglected, or unless the spasms yield, extravasation will take place, mortification ensue, and death follow.
The urethra is situated at the under part of the penis, and is embraced by a substance called thecorpus spongiosum; it (the urethra) consists of several different layers or coats—the inner, the one continuous with that lining the bladder, which possesses the power of secreting a mucous fluid, and the other made up of muscular fibres, which give to the urethra the power of contracting and dilating, that regulates the flowing or jetting of the fluid which has to pass through it. The mucous membrane of the urethra is of a highly sensitive nature, and more so in some parts than in others, as, for instance, in the membranous and bulbous portion of the canal; and hence it will be found, that those are the parts most liable to disease. The mucous membrane has several openings calledlacunæ, for the furnishing a particular fluid to moisten and lubricate the urinary tube: these also are frequently the seat of disease. These are seen in the drawing on page50.
In passing a bougie in contracted and irritable urethra, it sometimes enters the opening marked B, and if violence be used in propelling the instrument, false passages are made.
Independently of the function of the urethra being to discharge the urine, it has also to convey the semen to the orifice of the glans; and here in this act is to be observed the wonderful adaptation of means to an end. During the excitement attendant upon venereal commerce, the seminal fluid accumulates, prior to emission, in the bulbous portion, and when the fitting moment arrives for its ejection, the membranous portion spasmodically contracts, thereby preventing the regurgitation of the semen into thebladder, while the muscles surrounding the bulbous portion contract with energetic force, and so complete the transmission of the generative fluid. Such are the functions of the urethra in health.
A—Signifying the urethra cut open.B—The lacunæ and the cut end of bougie, to show the continuation of the urethra.View larger image
A—Signifying the urethra cut open.
B—The lacunæ and the cut end of bougie, to show the continuation of the urethra.
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A—Signifying the urethra cut open.B—The lacunæ and the cut end of bougie, to show the continuation of the urethra.
A—Signifying the urethra cut open.B—The lacunæ and the cut end of bougie, to show the continuation of the urethra.
A—Signifying the urethra cut open.B—The lacunæ and the cut end of bougie, to show the continuation of the urethra.
A—Signifying the urethra cut open.B—The lacunæ and the cut end of bougie, to show the continuation of the urethra.
A—Signifying the urethra cut open.
B—The lacunæ and the cut end of bougie, to show the continuation of the urethra.
Now, this canal being extensively supplied with nerves, that have more extensive communication with others than any particular ones have in the whole body, and made up, as before stated, of surficial and muscular membranes, and exposed to the performance of several duties which are often unduly called into exercise, can not be supposed to be exempt from the consequences of such misappropriation; and therefore it is very liable to inflammation. From the sensitive nature of the tube, it is very obnoxious to spasm, which may be partial, general, temporary, or continuous: hence spasmodic stricture. This condition is of course dependent upon many causes, excess of diet, fatigue, cold, &c., irritating the general system; when from the local irritation previously set up in the urethra by the forenamed causes—a neglected gleet or clap—the urethra is not long in participating in it: the phenomena are the symptoms recently narrated. Highly restorative as the powers of nature may be to remove disease, she does not appear readily disposedto interfere with the processes set up in the machine she inhabits, for self-defence, to protect itself from the constant irritation produced by the daily flow of acrid urine, which in several cases often produces ulceration; coagulable lymph is thrown out in the cellular structure of the particular diseased part, thereby thickening the walls thereof, and constituting permanent stricture, it appearing preferable to impede a function which a narrowing of the urethric canal does, namely, that of urinating, than of allowing ulceration to ensue, whereby the urine would escape into the neighboring parts, and occasion great devastation, and probably death. Permanent stricture, as its name implies, outlives the patient;it never yields, unassisted by art. I have described the ordinary symptoms of stricture, especially that form induced by gonorrhœa. Stricture may arise from other causes. Inflammation, in whatever way set up, if allowed to go on or remain, will give rise to stricture, and the celerity or tardiness with which it takes place depends upon circumstance. An injury from falling astride any hard substance, blows, wounds, contusions occasioned by riding, the presence of foreign substances, the injudicious use of injections, and lastly, which is as frequent a cause as any one of those heretofore enumerated,masturbation. The violent manual efforts made by a young sensualist to procure the sexual orgasm for the third or fourth time continuously, I have known to be of that degree that irritation has been communicated to the whole length of the urethra, extending even to the bladder; and retention of urine, in the instance I allude to, ensued, and required much attention before it could be subdued. Excessive intercourse with females will give rise to the same effects; not so likely as in the case preceding, inasmuch as the former can be practised whenever desired, while the latter needs a participator. The act of masturbation repeated, as it is, by many youths and others, day after day, and frequently several times within each twenty-four hours, must necessarily establish a sensitiveness or irritability in the parts, and alteration of structure is sure to follow.
The positive changes which take place in stricture in the urethral passage are these: there ensues a thickening and condensation of the delicate membrane and the cellular tissue underneath, which may possibly unite it to the muscular coat. This thickening or condensation is theresult of what we call effusion of coagulable lymph. It will be rather difficult to explain the process; but lymph is that fluid understood to be the nutritious portion of our sustenance or system, and which is here yielded up by the vessels which absorb it, and which vessels abound, with few exceptions, in every tissue of our body. However, it will suffice to say, that where inflammation takes place, there is an alteration of structure, and that alteration is generally an increase. In stricture, this increase or thickening takes place, as I observed before, in particular parts of the urethra, but where the inflammation is severe, no part is exempt, and whole lengths of the passage become occasionally involved. It is true, certain parts are more predisposed than others, as, for instance, the membranous, bulbous, and prostatic portions of the canal; but there are oftentimes cases to be met with where these parts are free, and the remainder blocked up. This effusion or thickening assumes various shapes, and selects various parts of the urethra. The subjoined diagram will convey a tolerably perfect idea of the malady in question; indeed it is a beautiful specimen of simple stricture.
A—The cut edges of the corpus spongiosum.B—The urethra.C—The stricture.View larger image
A—The cut edges of the corpus spongiosum.
B—The urethra.
C—The stricture.
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A—The cut edges of the corpus spongiosum.B—The urethra.C—The stricture.
A—The cut edges of the corpus spongiosum.B—The urethra.C—The stricture.
A—The cut edges of the corpus spongiosum.B—The urethra.C—The stricture.
A—The cut edges of the corpus spongiosum.B—The urethra.C—The stricture.
A—The cut edges of the corpus spongiosum.
B—The urethra.
C—The stricture.
To continue the description of the formidable consequences of neglected stricture.
In protracted and neglected cases, that part of the urethrabetween the stricture and bladder becomes dilated, from the frequent pressure of the urine upon it, induced by irritability of the bladder, which has an increasing desire to empty itself. In process of time, complete retention of urine will ensue, ulceration will take place at the irritable spot, and effusion of urine into the surrounding parts will follow; and the consequences will be, as in the instance of the spasmodic affection,fatal, unless controlled by the skilful interference of the surgeon.
The symptoms of permanent stricture are often as slow in their progress, and as insidious in their nature, as they are appalling in their results, and are seldom distinctly observed by the patient, until firmly established.
He is suffering from a long-continued gleet, and is first alarmed by a partial retention of urine—it passes by drops, or by great straining, or not at all. This usually occurs after intemperance, and is relieved by the warm bath, fomentations, and laxative medicines. This is the first stage, and is attributed to the debauch solely; whereas, at this time an alteration of structure is going on in the urethra. Its calibre is becoming diminished, which necessarily causes the urine to flow in a smaller stream. This is not observed at first; and it is only after a long period that the patient becomes aware of the fact.
The disease proceeds. In the morning, from the gluing together of the sides of the urethra, by the discharge from its diseased surface, the urine flows in a forked or double stream; and then, as this agglutinution is dissolved, it become natural.
There is a greater and more frequent desire to make water, disturbing sleep many times during the night, but unattended with pain, unless the neck of the bladder be affected.
There are also uneasy sensations in the perinœum, a sense of weight in the pelvis, with flying pains in the hips; and in the permanent stricture there is a remarkable symptom frequently prevailing—that is, a pain extending down the left thigh from the perinœum.
As the disease advances, the urine flows in only a very small stream, or forked, twisted, double, or broken, or in drops; and the patient solicits the flow by pressing with his finger on the perinœum, and elongating the canal, somewhat after the manner in which a dairy-maid milks a cow.
The dilatation of the urethra between the stricture and the bladder already alluded to, now takes place; and some urine remains in the dilated part, which oozes through the stricture, making the patient wet and uncomfortable.
There is great difficulty felt, and more time is occupied in getting rid of the last drop of water, than formerly. This sensation continues all along; and the cure is never accomplished until this is finally removed.
If the stricture is still neglected, more severe symptoms come on, and the neighboring parts become affected also.
Thesphincter ani, or the muscles of the anus, are relaxed, from the excessive action of the abdominal muscles; and the fæces pass in small quantities involuntarily. There is a protrusion of the bowel, which adds to the distress, and, by its irritation, brings on a looseness or diarrhœa.
The prostate gland, which is seated near the neck of the bladder, suffers inflammation and enlarges, beginning at the orifice of the ducts, which open into the urethra.
The emission of semen, which often happens involuntarily, is attended with agonizing pain, producing cold shiverings, followed by heat; and fever soon becomes fairly established.
The liver and its secretions become diseased, discharging in the intestines large quantities of vitiated bile. The fever assumes the intermittent character. The discharge from the urethra is greatly increased in quantity, showing the formation and bursting of an abscess of the prostrate gland into it.
The bladder is much thickened and diminished in size, and acutely or chronically inflamed. The desire to make water is continual, allowing hardly a moment of rest; and the patient, in the agony of despair, prays to be relieved from his sufferings.
Soon succeeding the irritation of the prostate, the testicles become involved, the disease being propagated by means of their ducts, which open into the urethra. The testicles swell a little, become uneasy and painful, and a dropsical or hardened enlargement ensues.
When the stricture forms a nearly complete obstruction to the passage of urine, the violent efforts of the bladder to expel it bring on ulceration or rupture of the urethra, through which the urine is forced into the cellular membrane,with all the power of a spasmodically excited bladder.
The scrotum and neighboring parts become distended, erysipelas supervenes, black patches of mortification break out in different places, the febrile symptoms are augmented, and the patient at last irrecoverably sinks into a state of coma or muttering delirium, and death closes the scene. Such is the progress and termination of stricture when neglected.
The reader, if he be an afflicted one, will eagerly turn to the page wherein the treatment of this formidable and distressing malady is considered; and great will be his satisfaction and delight, on finding it remediable by such simple means, and entirely within his own control; more especially if he direct his attention to the disease in its earlier stages.
He must by no means, however, be too sanguine, from these remarks, or indulge in the idea that as stricture is remediable, it is unimportant when the cure be attempted; the longer the delay, the greater will be the cost to the patient; and, furthermore, the slightest deviation from the instructions laid down, will surely aggravate the disease, and increase the embarrassment of the sufferer.
The following diagrams are further explanatory of the stricture in its amplified forms.
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The dark marginal line denote the calibre of the urethra, and the inner lines the actual diameter of the obstructed passage. Figure 1 shows the stricture to be on the lower part of the urethra. Figure 2 the upper part. Figure 3 exhibits a stricture of some length, and a somewhat contracted state of the whole canal. Figure 4 denotes a very common form of stricture, which resembles a flour-bag tied in the middle; it is the least difficult to cure of any, because it signifies that the seat of irritation is limited; but these cases are generally precursory to severer forms, if not promptly attended to. Figure 5 represents a stricture of considerable length, and of course very difficult of removal.
There are many provocatives to stricture, and when once mischief is progressing, it makes up for its slow initiation by giant strides. A patient may have a trifling stricture for years without experiencing much inconvenience. He takes cold, fatigues himself, commits some stomachic or other excess, may possibly have fever, all ofwhich more or less disturb the general economy, alter the character of the urine, and in that manner doubly accelerate the disorganization going on in the urethra. A small abscess may spring upinthe urethra, orbelowit among the cellular membranes and integuments. In either case, it chances now and then to burst an opening and create a communication externally with the urinary passage, constituting what is calledfistula. A person laboring under stricture is always liable to these occurrences. As much mischief is done oftentimes by mismanagement as by neglect. The clumsy introduction of a bougie, or, in other instances, the unjustifiable introduction of one, is likely to, and very frequently does, lacerate the delicate and irritable membrane, and make a falsepassage. Figure 6 exhibits an instance at Nos. 1 and 2; the upper numerical shows a false passage made by a bougie, and an obliteration of the ordinary passage of the urethra, the result of inflammation, constituting an impassable stricture; the lower figure exhibits a false opening made, in the first instance, by a fruitless effort at passing an instrument, when inflammation completed the process. No urine escaped from it of course, because communication was cut off from the bladder by the impassable stricture; the outlet for the discharge of that fluid being through a sinuous opening marked No. 2, the No. 3 denoting the closed end of the urethra. The case happened to a man in very ill health, who was prone to ulceration, and he gradually sunk under exhaustion from debility and premature old age. Figure 7 exhibits a stricture where the posterior part was enlarged by the constant pressure of the urine to escape through the narrowed part of the urethra; ulceration ensued, and a fistulous opening was the consequence; the stricture was seated high up, and the fistulous canal was several inches long, terminating in the upper and posterior part of the thigh; the urine used to dribble through it as well as through the urethra. The patient had been a seafaring man; he was in exhausted health from hot climates and intemperate living, and he died at last of consumption. I have the parts showing the stricture and the fistulous opening by me, in a state of good preservation. In Figure 8 is presented an illustration of extensive ulceration producing two fistulous openings; the state of the urethra was only discovered after death, the patient having concealed his infirmity for many years; he died suddenly from apoplexy, being found dead in his bed by the people of the house where he lodged. Figure 9 portrays irregular and extensive ulceration. The patient died from syphilis, having gonorrhœa at the same time. I have the preparation. Figure 10 shows an impervious urethra, and a fistulous opening through which the urine flowed. The urinary passage was blocked up within two inches from the orifice, and the length of the obstruction was perhaps a quarter of an inch. It was perforated successfully by the lanceted stilette, and the passage thereby rendered continuous; the catheter was worn for several days, and the false opening soon healed after a slight application or two of nitric acid. Numerous other illustrationsmight have been given, but the preceding convey a passable notion of the simplest, and most confirmed, and most severe forms, of the malady in question.
It is melancholy, notwithstanding the resisting and reparative power of nature to avoid so saddening a disease as stricture, that it is so very prevalent, and that it is occasioned by so many causes. Where it is not destructive to life, it is very injurious. It involves, where it is severe, other important organs beside the seat of its abiding; the repeated calls upon the bladder, through sympathy of the irritation, created so near to that viscus, the efforts which at all times it is obliged to make, although assisted by the muscles of the abdomen and contiguous parts to void its contents, at last, and very frequently end in paralysis, and total inability to pass water ensues, except through the aid of the catheter. Independently of which, where so much disease exists as in the urethra, the urine also constantly pressing against ulcerating and irritable surfaces, extravasation of that secretion takes place, and the most formidable and alarming consequences ensue. In the simplest form of stricture, many important functions are disturbed. A very frequent consequence is permanent irritability of the bladder, so that the patient is obliged, ten or twelve times a day, to micturate, and is unable to pass through the night without suffering nearly the same inconvenience. Besides which, the natural sensitiveness of the genital organs becomes speedily and much impaired. I am satisfied that where disorganization of the testicles does not exist, and where the patient is young, or even middle-aged, if he be impotent, he will in nine cases out of ten be found to have stricture. There are exceptions, which shall be named when speaking on the infirmities of the genital system, but in nearly all cases of impuissance there will be found, if not stricture, at least some morbid irritability of the urethra. During the existence of stricture, there is generally a vitiated secretion from the seat of mischief, constituting a gleet; therefore a gleet at all times should be regarded, lest it be an indication of something more than a mere weeping from enfeebled vessels.
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