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 enlargement of 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 the instruments, 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 hundred cauterizings would 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.