Mechanical Treatment of Stricture of

the Urethra.

BY D. S. YOUNG, M. D.

Prof. of Surgery in the Cincinnati College of Medicine and Surgery.

As the title of this paper implies only a reference to the mechanical department of the treatment of stricture in the urethra, we shall ignore, as far as possible, all other subjects in connection with it, either as to the symptoms, pathology or general treatment, and only refer to them as they may incidentally arise, as specially bearing upon any of the principles and instruments involved or described. Nor have we much that is new or original in the limits of the subject we have chosen, but more especially intend to investigate the causes which render instruments safe and efficient. At the same time hope to place a few of the principles involved in a more philosophical and practicable light, from information derived from experiment and observation, by which several well-known and well-established articles of our armamentorum can be modified and improved so as to further our success in the examination and treatment of stricture.

The situation, length, diameter, firmness, and number of strictures in the urethra, and the pathological changes which these circumstances may originate, are about as uniform in this lesion as in any other requiring instrumental interference; consequently, instruments have been devised to meet the several indications, acting upon principles which are vital

and must always be employed in any that can be invented. Various instruments have been adopted for the accomplishment of rupture, expansion, and the application of caustics, all requiring that the stricture be passed by a staff. We shall desist from describing or commenting upon only such of these as belong to the method and instruments we propose to investigate and describe.

The following headings will include all we shall attempt to describe and illustrate: In texture - solid, metallic, and whalebone. As to pliability-flexible, inflexible, elastic, non-elastic, and a combination of the last two.

These forms always verging according to the situation of the stricture, and to have a bulbous point-its size as small as possible. The obstruction to be passed in every instance by a sound or exploring staff, and all incisions to be made from before backward. When the operation is performed outside of the canal-perinial section, the staff is to be passed through the stricture upon a minute sound, or by having a small flexible metal explorer attached, so as to precede the main instrument. The rapid method of dilatation, the dilator being conducted upon an exploring staff or bougie.

The reasons for advocating the solid instrument are, that no material from which the soft and yielding ones are made will resist the heat and moisture of the urethra, when constructed with sufficient minuteness to admit of its being forced through a narrow stricture with eccentric openings. and a tortuous course, and it is my belief, that in those cases where the filiform bougie of Maisonneuve is passed, after great patience and labor, a small metallic instrument would, in most instances, have succeeded in a much shorter time and with greater facility. I am sure that the delicate metallic instrument has succeeded quite readily where the weak flexible one has failed after frequent and protracted attempts had been made by experienced hands. The filiform explorer has many more glaring defects. First, from its extreme pli

ability, it is almost impossible to detect, in many instances, in stricture seated far back in the canal, whether the instrument is traversing the urethra, or is being folded up in the passage, only to be discovered after it has become impacted to such an extent as to be felt from the exterior of the canal, or when it is withdrawn. We may anticipate that this impaction is going on when the instrument is within the obstruction and passing with difficulty. Its point, perhaps, has already penetrated beyond the stricture, but from the inability to define its true situation, the surgeon withdraws it, suspecting that the resistance in the constricted part is the impacting process, thereby losing what had cost him already much labor, from this inability to define his true position, which, if he could have properly understood, would have led to success. The great advantage claimed for these minute, weak instruments is their not being liable to injure the urethra. While we admit this, we also assert and believe that they are as little capable of accomplishing anything, in a great majority of difficult cases. And we also believe that

firm and efficient instruments are sufficiently safe, but that their capabilities necessarily render them susceptible of injury when in the hands of careless and inexperienced manipulators.

The advantages of the solid or metallic instruments are their small size, and power to resist the effects of heat and moisture. When once entered into the urethra, they can be retained there, throughout a whole sitting. Their superior firmness imparts to the touch, both of the operating hand, and the finger externally applied, their true position. They are not subject to be doubled up before a stricture, or when partly within the strictured track. The bending, or diversion from the direction which they were intended to take, is immediately perceptible to the operator, and can be rectified without withdrawing the instrument. When composed of flexible, non-elastic metal, like annealed copper, they can