the length of the period, between the cause and the first symptoms of stricture noticed, to be: after gonorrhoea, shortest period two years; longest, thirteen years after urethral chancre, shortest period ten months; longest, three years after injury, shortest period four months; longest, eighteen months. The statement in the latter table of statistics, doubtless literally correct, tends to mislead. After a traumatism, of the crushing kind, to the perinæum, for instance, the classical course of events is as follows:

From œdema and effusion of blood, at first, there is more or less obstruction to the flow of urine; perhaps, if the canal is severed, there is retention. If the latter has not occurred, inflammation comes on, and the size of the stream is still further diminished. Now inflammation subsides and repair begins, and, with this repair, contraction goes hand in hand. Consequently, after a transverse or crushing wound of the urethra, where repair begins stricture commences. It may not manifest itself by retention, or, indeed, by any symptom which the patient observes for four months or for several years, but it is there none the less.

If the injury has been slight, or the canal only partly involved, no appreciable symptom may occur for years (ten or twelve), as when boys have been kicked at school, have fallen on a fence, or been thrown upon the pommel of a saddle. The point of importance is this: traumatic stricture comes early because the violence causing it is greater (usually) than the violence of simple inflammation of the urethra. Let the violence be trifling, and the interval may be exceedingly long.

With this understanding, then, the deductions to be drawn from the above statistics are confirmed by daily observation: namely, that the symptoms of stricture appear earlier after a traumatism than after gonorrhoea, the date of their appearance measurably proportionate to the extent of the injury, and that the greatest divergence is noticeable after gonorrhoea. It is totally exceptional, however, for symptoms of organic stricture to come on "immediately after or during the attack" of gonorrhoea-as Thompson states occurred in ten of his cases-unless stricture existed previous to the attack, unnoticed by the patient, as sometimes undoubtedly occurs.

IRRITABLE AND RESILIENT STRICTURE.—A stricture is said to be irritable when it is sensitive, easily excited to inflammation from slight causes, rebellious to the use of instruments, fretting as it were under their employment. A resilient stricture (so named by Syme) is one which, without being necessarily irritable, is elastic, India-rubber-like, contracting quickly after being dilated, sometimes to an extent greater than existed before the use of the dilating instrument. Traumatic strictures are sometimes of this type, as are strictures following strong injections of nitrate of silver.

CHAPTER VI.

STRICTURE OF THE URETHRA.

Instruments and their Use.-Filiform Bougies with Manoeuvres alone, and as Guides.-Bougies.Bulbous Bougies.-Catheters.-Sounds.-Scale.-Advantages of Steel Instruments.-Instruments for Divulsion with Manœuvres.-Instruments for Internal Urethrotomy with Manoeuvres. -Perineal Urethrotomy with and without a Guide.-Rectal Puncture.-Supra-pubic Puncture.Dieulafoy's Aspirator.

BEFORE passing to the diagnosis, symptoms, and treatment of stricture, it is better at once to describe the instruments to be used, the methods of manipulating them, and the operations in which they are employed, in order to avoid endless repetition.

Great mechanical ingenuity has been displayed in the construction of instruments for the detection and treatment of stricture. Such of them will be mentioned as are considered best suited for these objects. Space will not allow a description of more than the type instruments of each class.

The instruments which it is necessary for the surgeon to possess in order to be able to meet the requirements of all cases of stricture are: different varieties of bougies, sounds, and catheters with a scale; instruments for divulsion, internal and external urethrotomy, and an aspirator.

BOUGIES.

FILIFORM OR HAIR-LIKE BOUGIES are such as measure one millimetre or less in diameter-size No. 3 (one millimetre diameter) being the smallest size that can be accurately measured on a scaleplate. There are three varieties of filiform bougie: the French, English, and whalebone. They are all made conical, narrowing down to a fine point, and gradually increasing for an inch or two until the full size of the shaft is reached. The whalebones are olive-tipped.

Whalebone filiform bougies have displaced all others at the present date. The black woven French filiform is still used as a guide to certain cutting urethrotomes (Maisonneuve), being furnished with a metallic end for the purpose of being screwed upon the latter. The device is not a good one. The caps become loosened and the bougie may be left in the bladder. The Maisonneuve urethrotome, or any other, can be conducted into the bladder as well upon a whalebone guide as following a soft one. The yellow English filiform instruments have no especial value; they are a little stiffer than the French, but not as good as the whalebone.

Soft filiform bougies are also constructed two feet long, to serve as guides, by being introduced into the bladder, and then threaded through a soft French gum-elastic catheter open at both ends (Fig. 27). Over such a guide a catheter may sometimes be safely conducted into the bladder, but a long whalebone does better. This is equivalent to the other device of a conical catheter, so arranged as to screw into an armed (screw-tipped) filiform bougie (Fig. 28).

WHALEBONE FILIFORM BOUGIES are thin, hair-like strips of whalebone, very smooth, conical, with slightly bulbous points. By dipping them into hot water, the end may be variously shaped (an expedient employed in difficult catheterism in the last century)-twisted into spiral, bent into zigzag (Fig. 29), a modification which is of vast assistance in threading tortuous strictures and escaping false routes and lacunæ. The instrument may be rotated during its passage, and its point be thus presented at different portions of the circumference of the canal, so as finally to engage it in the orifice of the stricture. These bougies, about two feet long, are also used as guides for larger instruments, not

FIG. 27.

G.TIEMANN & CO

FIG. 28.

by being screwed upon them, but threaded through. a metallic loop made for the purpose, upon the under side of the instrument which they are to guide an adaptation of Desault's principle-the latter being known as "tunneled " instruments. Prof. William H. Van Buren* originated this device. These guides render splendid service as conductors, but three cautions are necessary in their employment for this purpose:

FIG. 29.

1. The guide should be eighteen inches long. No cracked, bent, fissured, or frayed-out instrument should ever be used. A short guide serves, but less well.

2. In employing a whalebone as a guide, it should be first introduced into the bladder, then threaded into the instrument to be guided, and the latter pushed gently down to the strictured point, while the whalebone is held stationary at the meatus. If force be used here, the slender guide may double up and a false passage be made; but this may always be avoided by gently and continuously retracting the

* Refer to note, page 127, first edition of this treatise.

guide, as the conducted instrument is passing the dangerous point, and until it reaches the bladder. The length of the guide easily allows this to be done.

3. The loop of the instrument to be conducted should always be amply large, and be smoothed off in front so as to have a rounded and not a cutting edge; and, if the movement of extracting the guide, as the tunneled instrument is being introduced, can not be performed as above described, both instruments should be

withdrawn; for, if the one be pushed forward forcibly, or the other pulled back, there is dan

G.TIEMANN & 10.

FIG. 30.

ger of cutting off a portion of the whalebone and leaving it in the canal-an accident which has occurred in very competent hands.

Large whalebone bougies, having several inches of filiform tip and then suddenly growing

larger in the shaft, have been devised by E. A.

Banks, of New York. They are equivalent in their use to a filiform bougie and tunneled sound.

MANEUVRES.- -Regarding the method of introducing filiform bougies, a few words will suffice. Their fine points are liable to catch, chiefly in the lacuna magna, but also in any of the numerous sinuses of Morgagni, in any false passage, or against membranous bands and folds of the urethra, in the tortuous turnings of a stricture, or in the softened reticulated membrane behind it. With the whalebone bou

Showing lacunæ and false passages in which the points of filiform instruments are liable to be caught.

gie-often with any filiform instrument-these obstacles may be generally surmounted. There are two special manoeuvres for accomplishing this:

1. When an instrument catches, partially withdraw and slightly rotate it, pushing it forward while making the rotatory movement. This device rarely fails in finally engaging the instrument in the orifice of the stricture, especially if the filiform point be bent or twisted in any direction (spiral zigzag), so that its extremity may lie outside of the axis of the shaft of the instrument.

2. An excellent method of finding the orifice of a stricture, especially where false passage exists, consists in cramming the urethra full of filiform bougies, engaging their points in all the lacunæ and false passages, and then trying them, one after another, until that one is pushed forward which is presenting at the orifice of the stricture, when it will at once engage.

The use of filiform bougies in threading tight strictures is greatly facilitated by first injecting the urethra full of warm oil. Filiform bougies, intelligently used, make impassable strictures the greatest rarities in a surgeon's practice.

BOUGIES. Of other bougies (not filiform) the French and English conical only need be described-the blunt are not useful, nor are the olive-tipped of as much service as the simple conical. French conical bougies are black, woven, and covered with gum. They come of all sizes, and are necessary in the treatment of stricture up to size 12 or 15 (F.). The olive-tip is of advantage in the large, objectionable in the small sizes. When choosing olive-tipped bougies, preference should be given to such instruments as are rather stiff, but have a long, slender, flexible neck, supporting the bulb. When held vertically, bulb upmost,

77

A

FIG. 32.

B

and touched upon the olivary tip, the neck should yield at once (Fig. 32, A). Such an instrument will guide itself safely and override obstructions. The olivary points found on the English conical bougies are useless, as far as any advantage derived from the bulb is concerned, from a neglect to make the neck of the instrument flexible (Fig. 32, B).