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as improved by Sir E. Home, will be found the most effectual as well as most practical. Sir B. Brodie gives bis objections to the use of caustic for the following reasons.
ist. Although the caustic often relieves spasm, it also very often induces it. It is true that in many instances it enables a patient to make water with more facility ; but in many instances, also, it brings on retention of urine. 2dly. Hæmorrhage is a inore frequent consequence of the use of the caustic, than the common bougie, and it sometimes takes place to a very great and 10 an almost dangerous extent. 3dly. Where there is a disposition to rigor, the application of caustic induces rigors where there had been no manifest disposition to them previously. 4thly. Unless used with caution, the application of caustic may induce inflammation of the parts situated behind the stricture, terminating in the formation of abscess. There are strong arguments against its use, and yet this practice, next to dilatation, is the most generally adopted of any. No writer of eminence speaks upon the subject, however, without shedding some crocodile tears over the bad effects of caustic and dilatating instruments.
Scarification consists in light incisions made from within the stricture either outwards the instrument having perforated the strictured space, or from behind forwards, by means of a lancet. which is made to project from the side of ille catheter which contains it and has been introduced beyond the stricture. By pressing upon the stilet projecting beyond the proximal extremity of the inflexible catheter, the lancet is inade to rise above the surface of the instrument, through a slit-either one side or the other—sometimes on the lower side, when the whole instrument is withdrawn beyond the stricture. In this way, the sharp edge of the blade, comes in contact with the strictured or any other part.
“Three instruments have been devised by Amussat, the peculiarity of which consists in their cutting upon a sliding oval button which is made to hook behind the stricture. 1. One which is called an urethratome, consisting of a conical steel cylinder a little more than half an inch long, armed with eight longitudinal cutting crests, projecting to the extent of a quarter of a line from the surface. This is carried down upon a mandrin, previously passed through the stricture, and the incision made from before backwards. 2. One called a bridle-cutter, (coupe-bride) resembling the exploring sound of the same surgeon. 3. One more complicated than the other two, consisting of a canula, cleft laterally for about half an inch at its anterior extremity for a sliding semicircular blade, and notched upon the opposite side to the depth of a quarter of an inch, to accommodate the rod which moves the little bar at the end. The instrument with the knife concealed, is carried down to the narrowed part. The oval bar is first pushed on with the rod, and then retracted, so
as to hitch against the bridle. A turn is then given to the canula, in order to bring the knife on the same side with the fold, which is to be divided by pressing the blade from before backwards against the bar.” Some twenty cases are reported as treated by an instrument similar to this, by Dr. Victor I vänchich, of Vienna, who has written a learned and practical essay on the subject of strictures, which was published in 1846. It will be seen that all these instruments pre-suppose the stricture passable. They are therefore useless in the impassable form of the disease. Even in the ordinary and most common forms of the disease the orifice of the stricture is found on one side or the other, whereas these instruments are designed to pass through a central opening. Mercier, in his remarks on the anatomy, pathology and therapeutics of strictures of the urethra, published in the Gazette Medicale of April 5, 1845, has the following words on this subject : “L'orifice du retrécissement quelquefois central se trouve ordinairement plus prés d'un coté que de l'autre, et particulièrement de la parte superieure, à en juger par les empreintes qu'ont fait dessiner Ducamp et M. Segalas. On conçait qui cette paroi, qui est adhérente au corps du pénis obeisse moins qui l'inferieure qui est libre à la force centripete qui opère le retrécissement; mais je crois aussi avoir remarqué que l'alteration de tissu existe plus souvent et à un degré plus avancé sur la partie inferieure." The difficulties which accompany the use of these comparatively modern instruments for cutting the stricture, have driven surgeons to the old practice of dilatation; caustic, for the most part, as we have seen, having been proscribed by the most distinguished surgeons. Velpeau, as is usual with him when prejudiced against any practice, uses the following strong and emphatic language against cutting strictures: “C'est donc une méthode que ne pourrait convenir qu'aux brides, aux reserrements valvulaires ou en demi-lune, aux nodosités fibreuses, et qui, hors de là, ne peut guère être tentée que par des gens irréfléchis denués de connaissance précise soit en anatomie soit en chirurgie, ou par des specialistes." He then proceeds to state the instruments used, and begins with that of Dorner, who, Ivánchich says, “ hat eine Röhre angegeben, durch welche ein stilet mit einer Lansettspitte," &c. Hethen speaks of Dr. Physick's, which was an instrument “from which a lancet cutting on its lower edge, could, by means of a stilet, be projected from the entering end."*
The ingenious instrument of Dr. Chew, made in this city by Mr. Schively, in 1828, consists of an ordinary silver sound, either straight or curved, and split at the entering end, so that an elliptical double edged knife can be projected, for a few lines, by pushing on a button which is attached to the stilet of the instrument. The point of the
* Pancoast's Operative Surgery.
knife is blunt and pierced for the passage of a silver wire. This wire, like that of Amussat and others, is the leader of the knife, and must pass the stricture ere the incision can be made-a sad defect, as may be seen by the remarks above on the position of the orifice of the stricture. Yet Prof. Pancoast says: “The probe head of the wire is gradually pushed on separately through the stricture, which it readily passes on account of the central position it necessarily occupies in the canal.” Whether this “central position” refers 10 the stilet or the canal, it is equally fatal to the conclusion, for it is known that the orifice is generally on one side of the canal. The blunt extremity is also an objection; a free incision cannot be made. Dr. Physick’s is objectionable, because it cuts only one side, and that downwards.
Malgaigne, in his Medicine Operatoire, page 668, remarks that, “Les scarifications (ou incisions internes) offrirent sans doute un grand avantage pour la dilatation au canal. Mais aucun des instruments ne nous parait assez sûr dans son action. Il nous parait qu'au scarificateur pour remplir le but, doit, 1, agir sur tout l'éntendue de l'obstacle, et ne pas aller au-delá; 2, agir par incisions longitudinales; 3, inciser de la base du rétricssement á sonborde libre, pour être sûr de le deviser en entier."
This cannot be done by any of the above instruments; hence, we believe, the want of confidence which the profession bas manifested in them. The accompanying cut represents an instrument which we have used with complete success, in the cartilaginous and impermeable form of stricture; in some cases when the popular mode of dilatation had entirely failed--and in fact (which we believe is generally the case in this form of stricture) had only increased the deposit, by keeping up the irritation from time to time, in the urethra. We cannot understand, in fact, how dilatation in this form of stricture, can ever effect a permanent cure. It must produce merely a temporary expansion of the parts, unless it establishes ulceration, which of course would tend to destroy both stricture and urethra.
The objections to cutting, offered by Velpeau, that the incisions will heal by the first intention, we think cannot hold, especially if the stricture be completely divided. The urine will certainly act as a foreign and irritating body, and prevent the adhesion of the parts ; and we have found it so in practice after the use of the above instrument. We have not found that incision is a mere prelude to
more complete dilatation, but would strenuously recommend that no dilatation be resorted to after incision; except merely the introduction, now and then, of a common sized silver sound, as a means of precaution only. To attempt to dilate, in our opinion, would be to bring on additional irritation; and thereby tend to establish the stricture again. The stricture deposit is no doubt kept up by the continual or occasional pressure on the part from within, by instruments, or from without, by the action of the muscles.
The cut represents a flexible catheter,* with a slit in the distal end, perpendicular to the instrument, soine two and a half lines long.
A ring which is thick and strong, is attached to the proximal extremity. The stilet is two lines in thickness, with a button bur, on one end, which moves on a screw thread, to the extent of a quarter of an inch, and may be in this way moved backwards or forwards so as to control the extent to which the stilet is projected into the catheter. The other end of the stilet, has inserted into it a small blade, projecting three lines beyond the point of the stilet and the extremity of the catheter, which is the shape of the pointed thumb lancet, presenting a sharp edge, cutting both ways, upward and downward. The diameter is nearly the diameter of the catheter. The extent, forwards, to which the incision will extend, depends upon the position of the button on the other extremity. Three lines is the extent to which it may be pushed forwards. On account of the tlexibility of both stilet and catheter, the instrument is equally adapted to the straight portion of canal as to the curred. Dr. Physick, it will be remembered, used two instruments, one for the straight, and the other for the curved portion of the urethra.
The following case will illustrate the practice with this instrument.
Mr. S. a gentleman about thirty-three years of age, applied to me for advice for a stricture which had been growing about nine years. It had originated in a most violent attack of gonorrhæa while at sea. Shortly after the cure of the gonorrhæa which was a long time in progress, a slight dificulty in urination was perceived about five and a half inches from the mouth of the urethra. This gradually increased, until, about five years ago, it became necessary to apply for medical assistance. Relief was obtained by the introduction of wax bougies and catheters, in the usual manner. The stricture, however, continued to increase, and defied all attempts on the part of several intelligent surgeons at permanent dilatation. So much had it contracted, that there was danger of a total stoppage, which had in fact frequently taken place for hours at a time, subjecting him to great danger of rupture of the bladder or urethra, and the usual results, fistulæ in perineo. When he applied to me he was totally unable to introduce any instrument, however small, as he bad
*The size of the instrument is reduced two-thirds, in the drawing.
been in the habit of doing, for the purpose of relieving himself. No attempt on my part was successful in introducing an instrument into the bladder, or through any portion of the stricture, which commenced five and three eighths inches from the orifice of the urethra. In addition to this, being of a highly nervous temperament, the mere attempt at the introduction of an instrument, produced at first, fainting. Spasm of the parts also took place on the least irritation. His general health, in other respects, was good. The sexual function, he informed me, was languid, and the effort at coition ineffectual—the semen passing off some time after the orgasm guttatim; he has been married to a healthy and well formed lady for four years. She has had no children, and has not conceived.
After reflecting upon bis case, I began to think that some means should be devised to divide at once this thickened and hardened stricture; for it could be easily felt through the perineum, in the form of a round hard body. I called upon our best surgical instrument makers, but found that they had no instruments for cutting strictures, as they were not used by the profession. After some con sultation with Mr. Schively, I got him to finish me the one represented in the cut. With this instrument, on the 9th of September, after measuring the distance of the stricture, oiling my instrument, &c., I cut the stricture. The patient was seated in a chair, the instrument, with the lancet retracted, passed down to the obstruction ; was held in the right hand with the index finger upon the top of the burr; the index and other fingers of the left hand were pressed upon the perineum, and served to guide the point of the instrument. When it was properly adjusted, so as to cut in the axis of the urethra, the burr was thoroughly pressed upon by the thumb of the right hand, and inade to descend to the end of the catheter, the blade of course projecting its whole extent. The patient did not move a muscle of his face, and after partially withdrawing it, the second incision was made, without pain. The stilet was then retracted, and the whole instruinent withdrawn, when, on introducing a gum catheter, it was found that it would pass half an inch further.
To be sure of producing no mischief, i directed the patient to call the next day at the same hour.
10th. The patient had suffered no inconvenience from the incision, only one or two drops of blood had passed. In introducing the instrument it could be distinctly felt to pass the hard walls of yesterday's cut, requiring a very little more pressure than the other part. Two incisions were made as before, and a gain was made of nearly three fourths of an inch, making the improvement one and three fourth inches. The pain on cutting was rather more to-day than yesterday, but not enough to induce the patient to move the muscles of his face. Several drops of blood passed after the instrument. The stream of urine is rather better.