Clinical Lectures on Stricture of the Urethra

B. Hill
1879 BMJ (Clinical Research Edition)  
IN describing the mode of operating by internal urethrotomy, I need not take up your time with showing you the numerous armament of in--struments, each of which is intended to carry out the special fancy of its contriver for cutting through the stricture. They may all be collected into two classes: those which cut from behind towards the meatus urinarius, and those which cut as they proceed backwards along the passage. Civiale's, which I have here in my hand, is a good representative of those
more » ... entative of those which cut from behind forwards, and is, perhaps, more generally used than any other urethrotome constructed on that principle. It consists of a stem with bulbous extremity, from which can be protruded a sharp knife. It has two disadvantages: the first, that it cannot be employed for very narrow strictures-those too narrow for its bulb to pass through-as it cuts when withdrawn along the passage. Next-a far more serious objection-there is no means for fixing the stricture in the perineum, so that it is difficult to obtain sufficient division of the fibrous tissue. The knife often slips through without doing more than scoring the tissue it ought to divide. The absence of any means for fixing and tightening the tissue to be cut is a defect that belongs to nearly all urethrotomes, and which has been a principal cause of the uncertainty of cure attributed to internal urethrotomy By a moment's reflection, you will comprehend that division of the non-expanding fibrous tissue is far more likely to be accomplished if the bands to be cut be held steady and stretched before the sharp edge attacks them. Everyone adopts this principle before cutting a bit of string; he pulls tight the string before the knife crosses it. Having pointed out this cardinal principle in the construction of an efficient urethrotome, but of which too many instruments are devoid, I will proceed to describe to you the one which I have now employed for some years. This urethrotome or "wedge-incisor" is devised in accordance with the following principles. I. It approaches the stricture from before backwards; hence it divides all anterior bands as they are approached before the deeper contractions are attacked. And, further, tie narrowest stricture through which a filiform bougie can be passed may be at once divided without a preliminary dilatation by wearing catheters. 2. The constricting fibres are alone attacked, and are cut until they yield sufficiently to give to the urethra at the strictured parts the same calibre it has at the unstrictured parts; but the cutting edge does not invade the normal highly elastic vascular tissue. 3. All fibres to be cut shall be fixed and stretched tightly before the knife reaches them. Before operating, the patient, if not in condition for it, is prepared by rest in bed and attention to the natural functions. When fit, his temperature is normal; his urine acid, or at least neutral, nearly free from pus and albumen, and of specific gravity not lower than 1012 or IOIO; in amount, forty or fifty ounces per twenty-four hours. Later on, I shall explain the importance of these conditions. The urethra itself should also be clear of purulent discharge or active congestion. These precautions having been observed, the patient is first anesthetised; and, if the natural gauge of the urethra have not been previously ascertained, the passage is explored by a bullet-sound, or, if there be stricture near the meatus, by the urethrometer; the largest bullet--sound or widest expansion of the meter that slides without force along the urethra in its non-strictured part being taken as the size to which the strictured part must be incised. Should the meatus be too contracted to permit the wedge to enter, that is divided by a touch of a bistoury. The meatus being freed, a split sound is next passed to the bladder. The two halves of this sound are welded together at the point, but separated for the rest of their length. When closed, they equal in size No. 2 of the English and No. 8 of the French scale. (See Fig. 44 ) When the stricture is tight or tortuous, the introduction of the split sound is facilitated by previously passing a filiform guide-bougie (No. 2 French) of silkworm gut mounted with a screw-head, to which the split sound may be screwed. Should it be doubtful whether the guide has reached the bladder, a No. 3 French (No. 34 English) flexible catheter is screwed to the guide-bougie, and the whole pushed onwards till the catheter has passed eight inches inwards. A small exhausting syringe is then applied to the catheter, and a few drops of urine are drawn through it. The communication with the bladder being Fig. 4 . put beyond doubt, the catheter is withdrawn and unscrewed from the guide-bougie; the split sound is screwed on instead, and then guided into the bladder. In practice, this preliminary testing of the path followed by the guide-bougie is seldom needed; the presence of the end of the bougie in the bladder is sufficiently indicated by the freedom with which it can be pushed in and withdrawn, having no tendency to slip out spontaneously, as has the bougie which is engaged in a false passage or is only partly through a stricture. The split sound being thus safely in the bladder, a wedge containing a concealed knife is then pushed down the urethra between the halves of the split sound, on which it runs in dovetail grooves. The wedge separates the blades of the split sound, and when a stricture is approached sets tight the constricting fibres. The knife is then pushed forward between the separated blades, and, dividing the tense fibres, allows the wedge to advance until it traverses the urethra fr6m end to end. The knife retreats within the wedge, and is only protruded when a tight band opposes the free passage of the wedge. Thus, band after band of fibres are cut, and a calibre is given to the urethra, equal to the size of the easily fitting bullet-sound previously used. The size of the wedge employed depends upon that of the urethra, and may be obtained either by having a wedge that expands like a parallel ruler, and so can be set to any size, such an one as I hold in my hand; or by having a 883 Dec. 6,1I879.]
doi:10.1136/bmj.2.988.883 fatcat:zgty3kntgbglzg7iw65l47k2ke