Treatment of Permanent Stricture.

This is divided by most authors into dilatation, cauterization and scarifications, followed by dilatation. The invention of the bougie and flexible catheter was considered by John Hunter as a very great improvement, in the treatment of strictures and other diseases of the urinary organs. And from that time to the present, they have been extensively used, not to say abused, in the treatment of strictures. Every tyro thinks he must try his skill in introducing this foreign body into the urethral passage. Precise instructions are given as to the mode of operating to effect this purpose, almost all of which, it is acknowledged, fail to ensure success. The curves of the canal-its unequal diametersthe fold and lacunæ of the lining membrane-the spasmodic action of the longitudinal and circular fibres-the contractions of the sphincter vesica, enlargements of the so-called third lobe and lateral lobes of the prostate gland, in addition to the very obvious one of permanent stricture, or morbid growth in the passage-are all so many difficulties which frighten the novice in his timid attempts at the introduction of a proper instrument. Our predecessors do not, however, seem to have been so timid; but, from their own experience, no doubt, caution us against using too much force, and either bruising the parts or producing an "artificial passage," and not always in the right direction, even the rectum having been entered, according to some writers. In these cases it is evident that a very unwarrantable amount of force must have been injudiciously applied. The very irregular course of the passage when several strictures exist, makes it necessary to be careful, and to humour the parts during the introduction of the instrument. As a general rule, we agree with the distinguished teacher, Professor W. Gibson, that a metallic sound, of proper or moderate dimensions, warm, and well oiled, is the easiest introduced: metallic catheters, not too large, come next. The passage seems to become straight, or rather the inequalities yield better, to these instruments, particularly when they fill well the diameter of the canal. I have seen a spasmodic stricture overcome in this way when all others had failed.

The process of dilatation presupposes of course the introduction of some dilating body-which shall press outwards the parietes of the stricture or strictures. Where the contraction is considerable, a very small bougie is gradually introduced and allowed to remain, sometimes for several hours. After this, one a size larger, say the next day or shortly after, this to be followed by one still larger, until the diameter is increased to the natural size. Dr. Physick, we have understood, was accustomed to require his pa

tient to obtain for himself a dozen bougies and catheters, of assorted sizes; from the smallest up to one almost twice as large as the natural size of the canal. Dilatation was carried to the extent of enlarging the urethra to a very considerable extent beyond the usual size. This was with the view of preventing too sudden contraction in the strictured part afterwards-which, however, was almost sure to take place, particularly in the cartilaginous forms of the disease where Sir B. Brodie says the dilation is "so important."

There are we believe, at least two forms of permanent strictures, perhaps three, in which something like a radical cure may be expected from the introduction of the metallic dilator. These are firstly; the thread-like stricture, which divides the passage in the form of a thin diaphragm, and is torn by the instrument in an attempt to part it. The hemorrhage which follows, indicates the rupture of some small vessels. We have seen a number of cases where this appeared to be the case; and the cures were at once complete and permanent. Secondly, when soft, fleshy or polypic growths obstruct the passage, as they do those of the ears, rectum or uterus, these bodies being of a soft friable nature, easily give way, and are destroyed by the solid instrument. Thirdly; in the case of simple bands, as explained by Sir A. Cooper, when these bands are not too strong and resistent; they are perforated, and broken up by the means taken to dilate the

urethra.

With regard to the use of the gum catheters, in strictures, Sir B. Brodie, after decribing the mode of introduction, &c.-points out the cases to which he conceives them to be applicable, as fol. lows: Istly. When time is of much value, and it is of great consequence to the patient to obtain a cure as soon possible. 2dly. When a stricture is grisly and cartilaginous, and therefore not readily dilated by the ordinary methods.

3dly. Where from long continuance of the disease the urethra has become irregular in shape; or where a false passage has been made by previous mismanagement. Under these circumstances, if you can succeed in introducing a gum catheter, and let it remain for a few days in the bladder, you will find your difficulties at an end; the irregularities will disappear, and the false passages will heal.

4thly. Where a severe rigor follows each introduction of the bougie. This disposition to rigor is such, that it is impossible to proceed with the treatment in the ordinary way. Observe, in these cases, when the rigor takes places, it seldom follows the use of the bougie immediately. It almost always occurs soon after the patient has voided his urine, and seems to arise, not as the immediate effect of the operation, but in consequence

of the urine flowing through the part which the urine has dilated. Now, if instead of a bougie, you use a gum catheter, and allow it to remain, the urine flowing through the catheter, the contact of it with the urethra is prevented, and the rigor is prevented also."-Braithwaite.

We beg leave to differ from the Baronet in reference to the two first cases mentioned. We do not consider that the treatment with the gum catheter is the most speedy in all cases. Nay, there is a class of cases in which the gum catheter is of no more effect than any other instrument which cannot be introduced. In the three cases stated above, where a cure is the result of a destruction of the parts, it may be an expeditious method; but even in those, the metallic sound or catheter is far better, and more certain. In the second case, or that in which the "stricture is grisly and cartilaginous," it is notoriously a very uncertain instrument as far as a cure is concerned. So much so, that cases go on daily, in spite of all attempts at dilation with the gum catheter, until the passage in portions of its course is well nigh and even entirely obliterated. In both these cases, we should be disposed, particularly in the latter, to counsel very different treatment. But we must proceed with the treatment.

The objects to be attained by the forcible entry of a bougie or sound or fluid, are, according to the best authorities: 1st. A free passage, at least temporarily, for the urine. 2d. Such an amount of dilatation as will relieve the patient from the immediate effects of the stricture. 3d Ulceration of the strictured part, which will result in the destruction of the morbid deposit, and in this way leave the passage clear. 4th. It is supposed that dilatation, carried to a certain extent, will, without producing ulceration,induce such an action in the parts as will result in their absorption; and in this way cure the disease. Precise directions are given as to the amount of pressure, and time of its continuance, necessary to the accomplishment of these objects, without producing the much dreaded and really to be feared, artificial passage, with all its terrible consequences. The materials used for these purposes are, 1st. Wax or plaster cloth bougies. 2d. Gum elastic do. 3d. Catgut or gelatinous bougies; these of course for the smaller strictures. 4th. Bougies made of the bark of the American elm. 5th. Bougies of ivory softened. 6th. Metallic bougies either flexible or inflexible. 7th. Water or some other bland fluid forcibly injected, so as to induce an expansion of the stricture.

With respect to the first object to be obtained by the use of these instruments-we prefer decidedly the metallic inflexible sounds, or catheters, and next to these the wax bougies.

The second object may in our opinion be better and more certainly obtained, by well polished metallic instruments, always used with the greatest care, and in most cases adding very little more force than the weight of the instrument itself. We prefer introducing the instrument in the old way, viz. with its convex side upwards until the point reaches the curve, then gradually performing a semi-circular curve, without, however, allowing the instrument to stop in its course. The cito, in judicious hands, is the most likely to be the tuto and jucunde, in this neat little operation. Next to the metallic, the wax bougie armed with a good stilet, bent to the proper curve. Experience, however, proves that the relief is but temporary, in a great majority of the cases treated in this way.

The third object to be obtained, viz. ulceration, or such an amount of irritation as will induce a discharge, is recommended by Dr. Hunter, and many of the best surgeons up to the present day. The instrument is to be carefully introduced to the stricture and the extremity allowed to come in contact with the indurated parts. Gradual but firm pressure is to be applied for from five minutes to fifteen or twenty, and this to be repeated from day to day until the stricture begins to yield, and the instrument makes progress in the canal. Very great caution is necessary, in adjusting the instrument and applying the requisite degree of force. It is in this practice, that so many false passages are made-even through the substances of the prostate gland. Our view of this mode of treatment, in the cases where it is generally recommended, is that it is bad practice, and should not be resorted to in the present day. It appears to us to be altogether behind the age. The invention of the wax bougie and catheter was a great improvement in the days of Hunter and Pott, and certainly some improvements have been added since. These rough and uncouth processes should be placed along with many others, which have been entirely abandoned in modern days.

The fourth object, namely, the production of such an action in the parts as will induce absorption without ulceration, is too uncertain, except in the three cases mentioned, to be relied upon in a disease of so serious a character as permanent stricture.

One word in reference to the forced injections of fluids as a means of dilatation, and we have finished this part of our subject. A good epitome of the matter is given by Velpeau in the following words: "Trye, qui en a parlé le premier en 1784, dit en avoir retiré les plus grands avantages, et Somering avance que si le plus fine bougie ne peut pas franchir le rétrécissement, il injecte de l'huile dans le canal, dont il ferme aussitôt l'orifice, et qu'il presse ensuite d'avant en arrière pour faire marcher le

liquide. La méthode de Bruninghausen est un peu differente: an moment où le malade veut uriner, il comprime l'urètre avec force derrière le gland, force le fluide à rétrograder, et croit détruire ainsi le retrécissement. En 1822 M. Despiney de Bourg a proposé un liquide purement émollient, poussé avec une seringue. M. Citadini qui a publié un travail sur ce sujet, conduit une sonde ouverte jusqu'à l'obstacle, tient l'urètre solidement appliqué sur elle, et s'en sert comme d'un siphon pour injecter avec toute la force nécessaire de l'eau tiède, ou tout autre liquide approprié, dans le canal. M. Amussat, qui s'est cru l'inventeur des injections forcées, se comporte a peu près comme M. Citadini. It veut qu'on applique une compresse autour de la verge, pour qu'il ne reste aucun vide entre la sonde et les parois du canal, puis qu'on adapte une bouteille de caoutchouc remplie d'eau au pavillon de cette sonde, et qu'on pousse l'injection en compriment la poche élastique avec un tourniquet: mais on sent bien que, le principe étant posé, il importe peu que le liquide soit projete par l'intermède d'une seringue, d'une soche en gomme élastique, du doigt, ou de tout autre manière."

The application of caustic to strictures was practised by Dr. Hunter, and has maintained its position in surgical practice ever since. Hunter's plan of application, was a very simple one. The end of a bougie was removed; the caustic (nitrate of silver) introduced, fastened with a piece of wax; and, the distance to the stricture having been previously measured, the caustic bougie was carefully and quickly introduced, and maintained for a moment in contact with the obstruction. This was repeated from time to time, as the case demanded, or the parts would permit; until a moderate sized instrument could be introduced. Various portes caustiques have been invented, for the purpose of more effectually applying this medicament. That of Ducamp was designed to enter the stricture and cauterize from within outwards. The instrument of Lallemand was designed to pass the stricture and after projecting the caustic from a lateral opening in the silver catheter, the instrument was withdrawn, and, thus made to act upon the stricture, from behind forwards. These two processes and their modifications necessarily involve the passage of the strictured part. The treatment by caustic has found favour among the English and American surgeons, particularly the former. The French, however, as is common where the practice is popular on the other side of the channel, have never heartily adopted cauterization as a means of curing stricture. Sir E. Home, Sir A. Cooper, Sir B. Brodie, and a host of other distinguished British and continental surgeons have given their testimony in opposition to the use of caustic in stricture. It is probable that when it is at all proper, the simple plan of Hunter