THOMPSON'S RAPID DILATOR.

This instrument which Thompson devised for rapid dilatation-his expressed object being to stretch as much and tear as little as possible --still has a useful place among the instruments for the treatment of stricture. Its inventor has practically discarded it in favor of the urethrotome. In this country it is still used as a dilator, and as a divulsor (to stretch a strictured point so as to tear it) in appropriate cases. The American instrument is modified by being tunneled, and is made stronger and to open more widely than the original instrument (Fig. 40).

In using it, the slender (size 12) shaft is passed so that its point of greatest dilatability is placed in the strictured area. This is easily accomplished by first locating the stricture with a bulbous sound, and then introducing the divulsor until the inch-marks upon the shaft indicate that it has reached the proper depth. Now, by turning the screw-head in the handle, the blades are made to separate laterally to an extent indicated by markings upon the slot in the handle.

When it is used upon a deep stricture, as the blades are being again approached after the divulsion has been accomplished, a bit of mucous membrane is liable to be caught in the angle of the blades, near the tip of the instrument. This is to be avoided by slowly pressing the tip of the instrument forward into the bladder as the blades are being approached.

Divulsion, or tearing the stricture, is a rough manoeuvre, and has of late years lost favor among surgeons. I formerly thought better of it than now, and at the present date very rarely have recourse to it. Internal urethrotomy is, undoubtedly, a better operation for all strictures situated anteriorly to the bulbo-membranous junction, but deeper than that point, although I still believe it to be as safe as extensive internal urethrotomy, yet I believe it not to be as safe as perineal (external) section.

Yet the instrument has three important uses :

1. To pass over a whalebone guide in cases of very tight strictures, so as to dilate them moderately in the (a) anterior urethra, in order that the rather large shaft of the dilating urethrotome may be made to

pass; in the (b) deep urethra, in order to make it possible to take up the treatment with sounds in gradual dilatation.

2. To divulse stricture of the deep urethra in the occasional cases where that operation seems to be called for when the patient refuses external section, and a choice lies between divulsion and deep extensive internal urethrotomy.

3. To pick up and remove * small foreign bodies from the urethra. If divulsion be practiced, it is proper to perform it after the bladder has been voluntarily emptied, or to pass a soft rubber catheter immediately afterward, and tie it in for forty-eight hours. I have gradually come to the belief that such drainage of the bladder is of assistance in averting urethral fever, both after divulsion and after deep internal urethrotomy. The end of the catheter is left open to drain into a urinal, and the patient is kept in bed for about three days. No sound needs to be passed until the seventh day after divulsion, when, if the operation has been sufficiently extensive, a full-sized steel sound will enter. After this the cure is perfected and maintained with the steel sound.

No after-dressing is required. Hæmorrhage is usually very mod

erate.

Holt's, Voillemier's, and other divulsors I consider less accurate in their use, and less suitable for divulsion, than Thompson's dilator.

INSTRUMENTS FOR INTERNAL URETHROTOMY.

Four cutting instruments only need be described suitable for dividing strictures in different portions of the urethra.

The straight bistoury is the best instrument for dividing strictures at and quite near the external meatus. These should always be cut upon the floor of the urethra to an extent sufficient to cut through all the morbid fibrous thickening which constitutes the stricture.

The finger is placed beneath the urethra, and, with the bistoury, the stricture is to be slowly and thoroughly cut through until the finger on the outside recognizes that nothing of the former hardened ring is left between the edge of the knife and the integument. Bleeding, generally moderate, is sometimes profuse. The best method of arresting it is to pinch together the cut edges, arresting the flow temporarily. Then wipe off the glans penis until it becomes perfectly dry. Then wrap it around many times with a strip of rubber plaster one quarter of an inch wide and ten inches long, wrapping in all the head of the penis in a circular manner. This will always and without fail permanently arrest hæmorrhage. The pendulous urethra fills up with blood which can not escape, and clots filling the canal. At each act of urination this dressing must be removed, and immediately after

* Keyes, "New York Medical Record," March 6, 1875.

urination reapplied. This the patient can do perfectly well for himself.

The meatus tends to heal promptly. My custom is to pass a fullsized steel sound through the cut at 24, 48, 72, and 96 hours' interval, respectively, after which the cut is nearly well, and a sound twice a week will perfect the cure in a week or ten days.

CIVIALE'S URETHROTOME.

This instrument has a small straight shaft terminated by a flattened bulb which conceals a rounded blade (Fig. 41). By means of a mechanism in the handle, this blade may be protruded to an extent indicated upon a register in the handle. The bulb is to be passed

FIG. 41.

through a given stricture, withdrawn until it encounters the stricture, when the blade is to be protruded, and the stricture is cut by withdrawing the instrument. It is a very safe urethrotome. Thompson uses it (slightly modified) almost exclusively. It is most serviceable. in cases of single linear well-defined stricture of the pendulous urethra.

Several modifications of this instrument have been devised-bulbs of varying sizes being screwed upon the same shaft. Hæmorrhage is arrested, as after meatotomy, by wrapping a long strip of rubber plaster about the glans penis. After-treatment is the steel sound of full size passed, as in the case of meatotomy. The sound should not enter the bladder when the stricture which has been cut is situated in the pendulous urethra. This rule applies to the after-treatment in all the varieties of cutting in the pendulous urethra.

MAISONNEUVE'S URETHROTOME.

This instrument is serviceable where it becomes necessary to incise stricture situated deeper in the urethra than four inches. It consists of a hollow wire with a linear opening on that side which corresponds to the roof of the urethra. The knife, of different sizes, cutting from before backward, and from behind forward, with its exposed obtuse angle always blunted, is attached to the end of a long stylet which fits into the groove of the instrument. The blade is prevented from slipping out by a projecting shoulder on either side, which runs inside. the hollow wire. Bumstead has advantageously modified the original instrument by making the knife run only to the beginning of the curve, instead of up to the point, and by making the tube a little more solid. Bumstead's instrument has the blade on the lower side

(Fig. 42). This urethrotome is to be used with a screw-tipped filiform bougie. It is proper to cut the meatus below, the pendulous urethra above, the curved urethra below.

It is introduced, following its guide, and depressed until the straight portion of the tube has passed the stricture. Then the blade is entered, pushed rapidly down, as far as it will go, and immediately retracted.

The objection to this instrument is, that if a large blade is used the healthy urethra is incised longitudinally, often for its whole length anteriorly to the stricture; an accident perhaps of no very great moment, but entirely unnecessary, while, if a small blade is used, the whole thickness of the stricture is not cut through. Voillemier has tempted to overcome this objection by adapting a shield to the blade from which the latter may be protruded when the stricture has been reached, but the modification is com

at

G. TIEMANN-CO.

TIEMANN

plicated and unsat

isfactory (Fig. 43).

Another objection, applicable to all instruments for incising the deep urethra, is the liability to hæmorrhage if the incision. is sufficiently deep to be effective. Such hæmorrhage at the bulbous portion of

FIG. 43.

FIG. 42.

the canal may be very difficult to control. The after-treatment is the same as after all other operations.

The best way to control hæmorrhage in the deep urethra after deep internal urethrotomy is by a padded perineal crutch, the leg of the crutch resting against the foot-board, counter-pressure being effected by elevating the head of the bed.

G.TIEMANN &.00.

FIG. 44.

OTIS'S DILATING URETHROTOME.

This powerful instrument (Fig. 44) is a very valuable one for cutting strictures in the pendulous urethra. It has a straight, oval shaft, about size 20 (a smaller instrument and a correspondingly lighter one is made, but the stiffer one is the better). The end of the shaft is tunneled for use in the deeper urethra, if necessary upon a whalebone guide. The two segments of the shaft are separated by turning the screw in the handle, the extent of separation being registered upon a plate upon the handle. The possible extent of this separation is forty-five. The knife is narrow, concealed in the shaft at a point near the end of the instrument. It is disclosed by withdrawal, when it rides upon a ridge which is continuous up to the handle. The instrument is introduced until the point of emergence of the knife is about half an inch behind the deepest stricture to be cut. The blades are then separated until the stricture is well upon the stretch. The knife is withdrawn, cutting the tense tissues. The instrument may be then still further screwed up if desired, and the cutting continued to any extent— upon the roof of the urethra. The whole roof or a portion of it may be cut. The knife is then returned, the instrument unscrewed and withdrawn. Cocaine makes the operation comparatively painless. A full-sized sound is then introduced to prove that the cutting has been effectual. Hæmorrhage is arrested as in meatotomy, and the after-treatment is as before with sounds.

Wyeth's urethrotome, a similar and cheaper instrument, serves very well as a substitute. It is not as strong an instrument as that of Professor Otis.

INSTRUMENTS FOR EXTERNAL PERINEAL URETHROTOMY.

Besides some of the special instruments already described, only two others are requisite to meet the requirements of external section.

1. A simple staff, broadly grooved on its convexity, the groove running off at the end, and the instrument not conical (Fig. 45). This instrument is introduced as far as the stricture, when the latter is impervious, and is cut upon in the operation of perineal urethrotomy without a guide. It may be used with a guide, the latter being a whalebone bougie, introduced through the stricture (Fig. 46). In