On the Treatment of Stricture.—Having fully described the symptoms and progress of stricture, I proceed to the more pleasing part of treatment. Stricture, if early attended to, is a disease easy remediable: if neglected, itshorrors accumulate, and sufferings the most acute close the scene. Such, however, is the progress of science, that it is almost possible to cure the most inveterate case, at all events to relieve it; but that is no reason why the initiatory notices should be disregarded. Stricture, as must be perceived, is of two kinds, spasmodic and permanent: the treatment of the first is chiefly medical, the treatment of the latter chiefly mechanical. The principal agents I rely upon in the cure of the former, are the warm bath, rest, sedatives, and certain dietetic restrictions; for the removal of the latter, I place unbounded confidence in the practice ofdilatation; and I am of opinion that the other methods, namely, the application of caustic or the scalpel, might be dispensed with altogether, if the dilating method be not delayed too long.
Before commencing the cure of stricture, I need hardly observe, that we ought to be fully satisfied of its existence. Symptoms are not always unerring guides; and, therefore, our reliance should not wholly depend on them.
——“to be once in doubtIs once to be resolved.”
——“to be once in doubtIs once to be resolved.”
——“to be once in doubtIs once to be resolved.”
——“to be once in doubt
Is once to be resolved.”
The only mode of ascertaining the precise condition of the urethra, is by an examination of it, which should not be delayed a moment after suspicion is entertained of the impending evil.
For this purpose, it is recommended that a solid silver sound should be used as the best instrument; because it will pass with much less pain or inconvenience. It should be made conical, that is, smaller at the point than at the shaft, and of a size to pass very readily into the orifice; the shaft or body of the sound should not exceed two thirds of the size of the canal. The sound should be warmed, and afterward it should be well oiled. The directions for examining the urethra pertain to the passage of a bougie or catheter; and as it often falls to the lot of a patient, that he is beyond medical assistance, it behooves him to learn how an instrument should be passed, in order that in emergencies he may officiate himself; besides, it often happens, in cases of diseased bladder, and in those cases where retention of urine frequently occurs, that an invalid can not command the necessary constant attendance of his professional man; and therefore such knowledge will well repay any little time or trouble bestowed in the acquisition. The two annexed drawings will renderthe commonest observer a proficient. The first shows the manner in which the bougie is to be introduced. Where the instrument can be passed thus far, without the assistance of the other hand than that which holds the bougie, it is better, as it keeps the penis and the muscles which influence it in a passive state. When the instrument has passed as far as it will, in the direction the dotted lines denote, it is to be turned gently round, raising the handle toward the abdomen. A slight pressure is then to be madedownward, and the handle of the catheter or bougie at the same time to be borne away from the body. See diagram. The instrument will, if there be no impediment, gradually slip into the bladder. A trial or two will perfect and surprise the novice. The same directions apply to the introduction and use of all other instruments into the urethra. The sensation experienced on having a bougie passed, partakes more of a strange tickling feeling than absolute pain, except there exist stricture, and even then the urethra, on a subsequent trial, is almost insensible to it.
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If soreness or pain is felt, on the sound passing over the affected part, we may presume there is chronic inflammation of the urethra, or that the surface is ulcerated, as in long standing gleet. If the sound meet with an impediment, but proceeds after a little pressure, it indicates a thickening of the mucous membrane, the forerunner of stricture.
I may here observe, that stricture is generally found toexist either within an inch of the orifice, or at about six inches and a half from it, or in the prostate part of the urethra.
If the sound passes, without hinderance, the last situation, but with increased pain, the membrane of that part is diseased, and may extend to the bladder; which will be indicated by the frequent desire to micturate during the night, owing to the irritable state of that organ.
If the instrument be arrested at about six inches and a half, the complaint, in all probability, is seated in the transverse portion of the prostate, and requires very cautious treatment.
When the obstruction is at the very entrance of the bladder, a resistance will be perceived, which, on yielding, will impart a peculiar sensation as the sound enters the bladder. When stricture is thus situated, there is a frequent desire, with almost total inability, to micturate; and when once formed, it is productive of the most serious mischief, unless relieved.
In cases of permanent stricture, the passing of the sound conveys the sensation of going over a ridge. Where it meets with a temporary stoppage, and then passes on, it has probably hitched to a fold of the urethra. Sometimes it will enter the orifice of a dilated follicle; and if much pressure is used, it will occasion considerable bleeding.
The nature and situation of the disease being ascertained, the cure may now be proceeded in, recollecting that no force is to be used, and that too much be not attempted at one essay. Now without entering into an inquiry as to the laws on whichcontractionandelasticityof certain animal structures depend, it is enough for our purpose to know, that the urethra possesses both properties; it may contract so as to oppose the exit or entrance of the smallest stream, and it may be dilated to admit the introduction of an instrument an inch in circumference. The urethra maintains these properties in disease as well as in health, and upon the strength of this fact, is the practice of dilatation in the cure of permanent stricture founded, permanent stricture, it will be recollected, is a positive narrowing of the urethric canal; and as it is the nature of all organic diseases to progress, unless prevented by art, it needs no stronger argument than necessity to show how imperative it is to set about their removal.
The cure by dilatation is as follows:—the seat and size of the stricture being ascertained (both of which can be easily done by the passing of the sound as directed, and the observance of the stream of urine), a bougie in circumference somewhat larger than the calibre of the urinary current, warmed and dipped in an oleaginous mixture combined with some sedative (Forms22,23,24) or stimulant (Form25) according to circumstances, is to be passed to the stricture, and the gentlest pressure is to be employed for the space of five, ten, or twelve minutes, according to the irritation it produces, removing it as soon as any uneasiness is felt.
Even in this very simple operation, a certain dexterity is requisite; for the direction of all urethræ is not alike, and the mere pushing a bougie against a contracted part is not the only likely method of effecting a free passage. Much also depends upon the nature of the bougie—the elastic ones, although assisted in their attempted passage to the bladder, by the smooth and well lubricated sides of the urethra, have a tendency to straighten; and unless considerable rotatory motion be observed, are apt to hitch in a fold of the urethra, especially if the case befall a person of relaxed fibre, and he be much worn down by suffering. The bougies that I employ are constructed uponan improved plan to those in general use, being prepared of a material that will preserve the shape I adapt them to, previously to introducing them, but at the same time sufficiently soft to yield to any accidental tortuosity of the tube they are intended to explore. The bougie then is to be pressed softly, but steadily, against the obstruction, now and then withholding for a minute the bearing, so as to allow a respite to the stretched membrane; then renewing by, what is better done than expressed, an “insinuating” pressure for the space of the time advised above. The patient should not be dispirited, even if the bougie do not perforate the stricture at the first trial; it would doubtless do so, if longer time were employed, but that is rarely advisable, except in cases where the urine can scarcely escape, or much expedition be requisite. Should the operation even be unsuccessful in this first attempt, the patient will find his ability to micturate much greater than before the introduction; but, save in long-standing and obstinate strictures, I rarely find myself foiled, nor do those who practise the same method, if they have patience and skill enough, in overcoming the difficulty at the first interview. A great advantage of the cure by dilatation, independently of its safety and efficacy, is the insignificant pain it occasions; the sensation produced being only like a pressing desire to make water, which immediately subsides on withdrawing the bougie.
Another method of dilating a stricture, where it happens to be of chronic existence, is the passing a plastic catheter into the bladder, and suffering it to remain all night, or even for several nights, stopping up the handle end with a cork or wooden peg, which the patient can remove when he desires to urinate. The urethra, by this means, becomes quickly dilated, and much beyond the size of the instrument. It necessarily confines the patient to his room and couch; but where an expeditious cure is the object, as much may be effected in this manner in six days, as by the ordinary method in as many weeks. Time, however, it must be remembered, is the workingmaterialof nine tenths of strictured invalids, and a week’s lay-up may cost a twelve-month’s salary—a purchase too dear to be generally incurred.
Several other plausible methods have been suggested for the cure of stricture—one by means of an instrument, that the operator could enlarge when it was passed into theurethra, through turning a screw; another, which was to introduce a tube made of some thin skin, and then to distend it with wind or water; a third, and oftentimes, in reality, a very useful and available one, is to compress the penis around the glans, and suffer the urine, as it accumulated, to distend the anterior part of the urethra before the bandage was removed and the urine suffered to escape. But they have their several disadvantages: the processes, with the exception of the last, are complicated and uncertain in their result; the instrument is not so manageable, or so useful, as an ordinary sound; and the gut, instead of distending the strictured part, enlarges the healthy portions of the urethra. The bougie, in proper hands, notwithstanding it is a simple instrument, is the most positive and effectual method of curing stricture as yet, or likely to be, discovered. An entrance, then, having by this means been gained, a bougie of a larger size is to be selected on the next occasion, and the same process repeated. It is never advisable to repeat the operation oftener than once in two days, and when the urethra is irritable, only every three or four days.
By continuing in this manner, the stricture gradually yields, and a bougie as large as the orifice will permit to enter will at last proceed through the whole passage without meeting any obstacle. The operation, notwithstanding this apparent success, should not be wholly laid aside, but continued until the disposition for contraction is entirely removed; and the patient should never rest without occasionally examining his urethra, say once a month (at least once a quarter), lest he encounter a relapse.
Having disposed of the treatment of stricture in its fortunately most usual—namely, the mildest—form, I proceed to consider the treatment of severe kinds—previously to which, a few remarks upon the various kinds of instruments, their structure, shape, and size, will render any subsequent allusion more intelligible.
The diagram here introduced represents the calibre of the various bougies in general use, and the observer will perceive, that as they are made to accommodate themselves to the passage they have to pass, how varied must be the changes which the urethra undergoes. The last outline indicates the natural and healthy bore of the urethra. Bougies are manufactured of different materials: waxen cloth rolled together, elastic and yielding; flexible metal,silver, and gold. The bougies which I employ are constructed upon an improved plan to those in general use: the elastic, as they are termed, although assisted in their attempted passage to the bladder by the smooth and well-lubricated sides of the urethra, have a constant tendency to straighten, and consequently are liable to hitch in all the folds they may encounter, which, in relaxed habits, are very numerous in the membranous portion of the urethra. To obviate such a possibility, I prefer that the bougie should be of such a consistence and manufacture as will admit of its preserving the shape I adapt it to previously to introducing it; at the same time the material to be sufficiently soft to enable it to accommodate itself to any accidental tortuosity of the tube it is exploring.
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Catheters are instruments for the purposes of withdrawing the urine; they are consequently hollow, and are made of the same materials as bougies; but the most useful and to be depended upon are composed of silver. Surgeons, like other men, have their fancies: a catheter, when made of silver, has very little flexibility; accordingly it must be shaped beforehand. Some medical men prefer them quite straight, others with an immense curve. A surgeon should possess many forms, as the direction of the urethra differs almost in all men. The subjoined exhibits not the size, but the shape of the more useful and those most generally used. Figures 1, 2, and 3, suffice in most instances, whereas figure 4 is necessary in cases of enlargementof the prostate gland, which presses up the bladder, and renders the urethral passage consequently longer.
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The French employ not only variously curved instruments, but variously shaped. In peculiar cases they are doubtlessly useful; but they require to be used only by persons of skill and judgment. In the next three kinds are views of such; they are called conical bougies—the first curved, the second straight. They are made of silver, waxen cloth, or India-rubber. The third exhibits a sound, employed to ascertain the seat of the stricture.
I have already alluded to the improved method I employ on finding it necessary to use escharotics. I can not better explain the process than by submitting a sketch of theinstruments, whereby the mode of application will be instantly perceived. The instruments are made of silver. The figures represent No. 8 a curved, No. 9 a straightened, No. 10 ditto, with enlarged head, which puts the areola of the stricture on the stretch, and secures the central part for the application of the caustic, or whatever substance may be employed.
The next kind of instruments are for the purposes of dividing or piercing hardened obstructions—one or two applications creating a passage which a hundredcauterizingswould not effect. When any styptic is applied to a morbid growth, its tendency is to create a slough, or to destroy the part whereto it is applied. In some instances a styptic actually promotes increased action: it may temporarily destroy the part; but the moment the effect is over, a reaction follows, and the excrescence is increased. Such is the case in many long-standing, obstinate strictures; and their removal by perforation or division is rendered indispensable. The practice requires the most careful attention and anatomical knowledge; and no one but a professional man would attempt its employment.
No. 11 sketch exhibits a curved instrument, with the pointed lancet projecting as when applied. No. 12 exhibits ditto, but with a differently formed instrument, consisting of two portions separated, so as to allow a director, in the form of a thin silver wire with a silver knob, to pass for the purpose of exploring the passage which the instrument is to follow and enlarge. It is indispensable in strictures seated upon the soft and deep parts, lest a false passage should be made. No. 13 represents a straight instrument; No. 14 ditto, but with the lancet in reserve—the last a perforator.
The reader has now been made acquainted with the various resources the surgeon has at his command. A few words on their employment will complete the necessary amount of information to render the one as wise as the other. By way of recapitulation, the treatment of stricture is bydilatation,cauterization, anddivision. They are to be estimated in the order of their arrangement. By dilatation is meant the enlarging of the urethral passage through the frequent introduction of bougies of graduated sizes. It is an operation unattended with any considerable pain; its novelty sometimes renders a patient a little nervous, but a complaint is rarely made after a second orthird introduction. Indeed, it is oftentimes courted more frequently than is desirable. The application also of caustic, or even the perforator, produces scarcely the least inconvenience. Hemorrhage, of most things to be dreaded, is less frequent, with cauterizing and cutting instruments (in skilful hands), than the incautious employment of blunt-pointed bougies.
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