Vol. XXX ST. LOUIS, SEPTEMBER 25, 1906. Papers for the original department must be contributed exclusively to th's magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted. A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof. Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose. COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R EDWARDS, M. D., Chicago, Ill. Mr. REGINALD HARRISON, London, England. HOBART A. HARE, M. D., Philadelphia. THOMAS LINN, M. D., Nice, France. FERD C. VALENTINE, M. D., New York. CLINICAL LECTURE. INTERNAL AND EXTERNAL URETHROTOMIES.* REGINALD HARRISON, F. R.C.S. LONDON. Consulting Surgeon to St. Peter's Hospital. INTERNAL URETHROTOMY. some IT is a good plan for patients about to undergo this operation or any other involving a possible wound of the urethra to have their urine sterilized or adulterated with preparation of boric acid, as mentioned previously. The magnesian boracite (vide Martindale's extra Pharmacopeia) will be found preferable for this purpose to pure boric acid which often causes indigestion. The former may be given in teaspoonful doses in plenty of water three times a day, for three or four days preceding the operation. In selecting this operation, the surgeon should satisfy himself beforehand as far as it is possible to do, by the examination of the stricture and the perineum, that the urethrotome may be made to cover the full extent, in depth and length, of the tissue This is No. 2 of a series of lectures on this subject, delivered at the London Post-Graduate College. No. 1, on The Urethrotomies, appeared in the issue of September 10. To follow: (3) TheCombination of External and Internal Urethrotomy. No. 6 forming the contraction, otherwise the operation will be of little permanent advantage. Operation. The urethrotome I have used for many years is that known as Maisonneuve's. Some improvements in the instrument have recently been made by Mr. Thompson Walker. It is adapted to the narrowest and most intricate forms of contraction, and as a rule requires no preliminary dilatation by other instruments. Further, it can be made to complete its object by a single linear incision of sufficient depth to provide by careful after-treatment, as will be described, for the introduction of an ample splice of new tissue for the permanent enlargement of the contracted portion of the urethra. Multiple internal incisions are to he avoided as tending to increase the amount of cicatrix. After many years' trial, I have not found Maisonneuve's operation open to objections that have been raised against it. These are that it may divide tissues unnecessarily or on the other hand, insufficiently. Though I have been in the habit of using the larger blade which cuts up to No. 23 Charriere (No. 14 English) I am not aware of there being any evidence of this having been excessive. On the other hand, when by the use of test bougies immediately after the section has been made, and before the patient leaves the room, there are indications that the stricture has not been sufficiently freed, a supplementary division of any remaining fibres or bands. may be readily made by the use of Civiale's urethrotome, which will now enter easily. If at the time of operation, the surgeon finds it impossible in one or both of these ways to quite free the stricture, he should not hesitate to perform in addition an external urethrotomy on the lines which will be described in cases where the combined operation is premeditated. This further proceeding in no way adds to the risk, whilst it greatly favors the prospect of success. The technique of Maisonneuve's urethrotomy commences with the introduction of the fine filiform guide. To save time, this may previously be passed in the ward, but where there is difficulty or hitching this maneuvre be greatly facilitated by including it whilst the patient is under the anesthetic. When the position of the guide is verified by the ease with which it moves it is secured on the metal director, and then the latter is made to follow its leader into the bladder; this is usually indicated by the escape of a little urine along the groove. If the stricture is extremely tight and there has been some hesitation in following up the guide to the bladder, the deposition of the director or metal portion should be tested by introducing the finger into the rectum. By this means the relationship of the instrument to the canal can be readily ascertained or adjusted. If this prove correct, the urethotome blade should be placed in the groove of the director and gently and but firmly pushed along until the stricture is divided. Care should be taken to hold the director in correspondence with the median line of the body, as taken from the umbilicus downwards. The operator should not do more than divide the stricture, avoiding touching the internal sphincter of the bladder, which though never strictured is usually temporarily contracted around the instrument. Therefore when the stricture is felt to be divided the surgeon should stop short of pushing the knife to other end of the groove or staff. In Mr. Walker's modification of this urethrotome the groove stops at the curve in the director, so that any risk of wounding the neck of the bladder or prostate is avoided. I have rarely seen much hemorrhage when this precaution is taken. On the other hand, considerable bleeding may follow the unnecessary lesion of the prostatic ring. The completeness of the operation should then be tested by the successive introduction of bougies. For this purpose Lister's metal bulbous instruments may be used, beginning for instance, with No. 12 (English) and gradually running up to No. 15. A catheter should then be passed-metal for preference -and the parts well sluiced with boric solu. tion with which the bladder is finally filled. And now commences that part of the treatment which is as important as the complete division of the stricture. As I can find little or no reference in text-books to the object now aimed at it will be necessary to describe it in detail. It relates to the permanent enlargement of the strictured portion or portions of the urethra. By the incision which has been made the urethra is at once enlarged at its strictured portion, so as to permit a bougie not less than the normal size of the urethra being readily passed into the bladder. Otis demonstrated that the normal size of the urethra was considerable larger that that usually accepted. On this discovery modern lithotrity, as invented by Bigelow and universally practised, is used. The after-treatment of an internal ureth In this way it has been been demonstrated that endoscopically it is possible not merely to stretch a stricture, or to suddenly enlarge it by cutting it across, but to introduce a splice or interval of new tissue corresponding with the area of the cleft. With this object in view and after the stricture has been divided in the manner described and the completeness of the division fully tested provision should be made for the retention of a catheter for some days. Unless this is done there is no guarantee that the incision may not close, either partially or in whole. The occasional introduction of a bougie as a substitute for the retained catheter is no safeguard against this liabil ity, and the intermittent use of this instrument is in itself a cause of irritation, which a properly adjusted retained catheter should be free from. Everything depends upon the manner in which a catheter is tied in. If it is done well it proves a comfort to the patient in voiding urine, if on the other hand, it is not artistically planned it is the reverse. A little trouble on the part of the surgeon makes all the difference. The catheter should be made of the finest silk be coated with the best varnish suited for this purpose. After many trials I have found the French make of catheters for this purpose, as a rule, better than the English. I have frequently retained the former for ten days without removing them. Others' in similar cases, I have had to withdraw in forty-eight hours, and found them corroded and commencing to be covered with phosphates. This should not happen with good tying-in catheters. A retained catheter must be as correctly adjusted as a tracheotomy tube. Its length within the bladder should be carefully determined by means of a syringe before it is fixed. It should not project too much within the bladder, or it will excite irritation; on the other hand it should be sufficiently within the bladder so as not to occasion retention. I seldom tie in a catheter larger than No. 9 or 10 English. These sizes are more comfortable to the patient than higher numbers. Their object is to keep apart the sides of the incision through the stricture until some degree of healing has been obtained. This usually occupies from three to ten days when the catheter may be dispensed with. The section of the stricture relative to the retained catheter is here shown. The catheter will be seen maintaining the cleavage. The mode of fastening the catheter in when its length for drainage purposes has been accurately determined by trials with a syringe is by securing it with stout silk to the penis by one or two circles of rubber plaster. The escape of urine should be controlled by a movable plug of ivory or hard wood removable when necessary by the patient or his attendant. It is of great importance in all these cases to obtain a nurse who has been well trained in surgery of this kind. These persons are by no means too abundant. As long as the catheter is retained it should be washed out together with the bladder at least twice a day with warm boric solution, and care should be taken to have a suitable bed and mattress for bladder drainage purposes. A patient who lies in a hole will not drain well. After the retained catheter is finally withdrawn, a point which is usually determined by the feeling of freedom with which the instrument may be moved relative to the urethra, the use of a bougie is not resorted to for some days, when a trial examination may be made with a soft instrument. In a considerable proportion of cases, thus dealt with it will be found that no further instrumental treatment is necessary. A precaution and until proof of the cure is well established, the occasional use of a bougie is recommended. All patients who have once had stricture should be instructed how to use a bougie. The failures to cure strictrue are for the most part traceable tc the want of such treatment as I have described after the division of the stricture has been made. EXTERNAL URETHROTOMY. This operation is applicable to exceptionally contractile strictures and to others where the urethra, perineum, and even the scrotum, may be included in a cicatricial mass which is undilatable and outside, the reach of internal urethrotomy. These cases may be subdivided into two: (1) When the patient is able to void urine with difficulty and pain and with a liability to attacks of sudden retention, and where the urethra is instrumentally impassable; and (2) when the conditions are similar, with this difference, that the strictured canal is open to some small instruments. This two-class division is obviously an arbitrary one, dependent for the most part on varying degrees of contractility, spasm, the presence of false routes or passages, and also the individual skill of the operator. Impassable strictures (not occasioned by prostatic hypertrophy) must be regarded from two points of view: First, in respect to temporary measures which may be necessary for relieving urgent retention of urine; and secondly, relative to the radical treatment of the stricture. It must be remembered that no stricture can be strictly regarded as "impassabla" which admits or has recently admitted prior to a complete retention of urine the passage of urine naturally, even in drops or in a fine stream. This knowledge should serve as an incentive to endeavoring patiently and with gentleness to reach the bladder by the natural though contracted channel, and later on to attempt if necessary, the restoration of the latter by a more radical proceeding. The great improvement that has taken place in the means for relieving retention of urine by catheterism during recent years has largely reduced the number of so-called im. passable strictures. In fact it may be said that no stricture can be regarded as impermeable, unless the patient is or has been for some time provided with a urinary fistula. In practice, however, this refinement in reference to the term "impassable" cannot always be acted on. A sudden retention of urine occurs, the bladder becomes painfully distended, and by no ordinary methods can the practitioner give relief artificially in the direction of the natural passage. Urgency of this kind is best temporarily relieved not by forcible catheterism, but by tapping the bladder with an aspirator or fine trocar, preferably in the form of pneumatic aspiration, immediately [above the pubes where it is uncovered by peritoneum. This is a rapid and painless process, and may be repeated almost indefinitely-thus the patient is immediately relieved, time is provided for reflection as to what is best to be done of a more radical nature, and no further damage is inflicted on the already disordered urethra. Instances are not infrequently met with where the removal of tension in this way enabled the bladder to regain its power over the stricture, and dilatation with some form of instrument was again resorted to with satisfactory results. Should, however, this not prove so, and the urethra continues to be fitful, and at times impermeable both to urine and catheters or bougies, the operation known as "Wheelhouses" for impassable stricture may be advised. This proceeding is so well appreciated, and is to be found in all text-books that I need not refer to it at length. I have not bad much experience with it, as being brought up somewhat skeptical about impassable strictures, unassociated with one or more urinary fistula, I have generally succeeded in overcoming difficulties by patience, oil and filiform guides and so dealt with the stricture on the lines advocated in the previous article. Wheelhouse's operation, which is that of choice in impassable strictures, may be stated as consisting in opening the normal of the urethra on a special staff, half an inch in front of the stricture in searching by sight and probe-director for its contracted orifice, and having found it, dividing the stricture of the director thus used, and so restoring the canal to its normal dimensions. The stricture having thus been divided a drainage tube is introduced and the case treated on the lines described in the previous article. Wheelhouse's operation, having for its object the relief of retention where a stricture is impassable, may be made to answer the purposes of a perineal section, as described and applied in the next section to the combination of the two urethrotomies. External urethrotomy, or perineal section without a guide in the form of a grooved metal staff passed fairly along the contracted urethra into the bladder upon which the division of the stricture can be safely accomplished, is an obsolete operation, which is not to be advised. For instrumentality impassable strictures it bas given place to Wheelhouse's method, whilst strictures which are passable, though for definite reasons requiring external section, are best treated by the combined operation which will next be described. DR. ALBERT H. DOLLEAR, some time assistant to Dr. F. P. Norbury at Maplewood Sanatorium, Jacksonville, Ill., has been appointed assistant physician to the Western Illinois Hospital for the Insane at Water town. LEADING ARTICLES OUR DUTY TO PROSPECTIVE MEDICAL STUDENTS. A. L. BENEDICT, M. D. BUFFALO. THE complaint is sometimes made that the medical profession is being crowded beyond the limit of tolerance, by recent graduates, sought by the colleges for mercenary reasons, and to the disadvantage of the existing medi. cal body. Whatever truth there may have been in this complaint, in the past, the present is no time for recrimination. Never before has the medical profession been so well organized nor possessed of so great influence. For approximately fifteen years, it has been impossible for anyone, not reasonably well qualified according to both general educa tional and technical standards, to graduate in medicine, excepting by gross evasion of the law or by seeking states and colleges notoriously behind the times in their requirements. During these fifteen years, approxi mately a quarter of the medical profession, as it existed at the beginning of the period, have passed away and, without malice, it may be said that many of the funerals were urgently needed. In many ways conditions have been modified so as to tend to restore the influence of the practitioner of medicine, to restrict the teaching of medicine to a class of teachers, and to render this class independent of the fees of students, but, on the contrary, dependent for their tenure of prestige, if not actually of their positions, upon the quality of the students graduated. These tendencies have not reached the point of actual fulfilment of ideals and, still, they are genuine and they have already reached a point at which optimism is warranted. Speaking approximately by statistics, the United States now has a few less than 180 medical schools, with an average attendance of 150 students. In the aggregate, these schools graduate about 5,000 annually, receiving, each year, about 7,000 new matriculants, of whom 2,000 are estimated to be weeded out by one process or another, before the completion of the course. Very few of the 7,000 fail to come under the influence, at one time or another, of some of the hundred thousand and more practitioners of medicine. Thus, the onus of the complaint can and should be referred back to its source. First of all, each one of the army of more than a hundred thousand medical men, should realize his personal influence and responsibility in the matter. Not only in an aggregate, economic sense, but in an individ ual, professional sense, does the status of the profession depend upon the thoroughness with which each physician does his duty in controlling medical matriculations. Secondly, while the economic problem of demand and supply ought to be considered by every trade and profession, this problem should not be studied in the narrow way of financial competition. There are undoubtedly too many physicians in the country-at least half of the existing body could be removed without overtaxing the strength of the other half to care for the health of the country. At least a thousand of the five thousand annually added to the profession, represent a surplus beyond the vacancies created by death in the profession and by additions to the population. Still, conditions are by no means so acute as to justify or even to excuse the attempt, arbitrarily to exclude worthy aspirants from pursuing a medical course. It is proper, however, to set before each prospective medical student, a candid presentation of the facts governing the financial and business status of the medical profession. A considerable proportion of the young men who contemplate medical practice have no special predilection for the work. They are seeking a dignified, not tco laborious, and well paid occupation. Without being either lazy, actuated by false pride, or mercenary they select medicine as a life work, largely on business principles such as govern purchase and investment of any kind. If the real facts were presented to them, without prejudice, they would, in a large number of individual cases, choose some other profession or business, and in so doing, a substantial benefit would accrue both to themselves, to our own profession and to the community generally. In other cases, special reasons render it advisable that a given youth should be directed. into other channels of activity. It often happens that medicine is chosen because certain scientific studies, in which the high school or college student is especially interested, bear upon the practice of medicine. In many such cases, the abilities of the individual are of such a rank that he could do better work and attain a better standing by confining himself to the particular science in question. In other cases, aside from a reasonable allowance for the carelessness of youth, the boy who would like to study medicine is so heedless and so utterly unable to do things in the right way that it is a mercy both to himself and to others, to direct him toward lines. of activity in which mistakes may involve only slight commercial loss and not danger to human life. Again, with due allowance for immaturity, some boys lack the moral nature which is de manded of the physician. Some one has well said that the physician must practice with his heart as well as his head, and many men, well enough adapted to a useful and honest business life, are not capable of the self-sacrifice, attention to details and disregard of personal convenience, which are part of the physician's duty. Physical vigor is a desideratum for the physician, and yet, in this age of the world, many men of delicate health manage not only to do useful work in medicine, but to acquire a state of health not anticipated in their youth. More important is mental health and strength, for, incidental to the practice of medicine are many emergencies and experiences which call for ingenuity and clearheadedness and which work disastrously upon a neurotic taint. The time is past when the fool of the family should be selected to study medicine and the strain and actual exposure of medical studies demand at least a reasonable degree of physical and mental stamina, and the absence of positive disease and morbid tendencies. It is, at once, the right and the duty of every physician to demand that the young man to whom he stands in the place of a preceptor-however much the old legal status of the preceptorship, has been modifiedshall somewhat exceed the strict legal reqirements of the matriculant. The time is not ripe to require more than a high school education preliminary to admission to the medical school. Yet, the individual preceptor may and should insist that any student for whom he is morally responsible should give an overflowing measure. It may not be wise for any physician to say to every student, that he must take a full college course, but it is feasible to point out to him the broadening influence of at least a year of scientific and literary study in advance of the legal requirements. Too often, the preceptor assumes the narrow view that his student ought not to know more than he himself does. But advance is the spirit of the age and the wise father, preceptor or advisor, realizes that more is expected of the present than of past generations. Medicine, in particular, has developed in very recent years so largely along scientific lines, that further progress, or even the proper use of what we have already gained in principles, demands a broader and longer course of preliminary training than could have been considered necessary even ten years ago. Moreover, attainment is purely relative and the conditions at present are such that a college education demands no greater sacrifice and places a man in no higher grade than an academic education a generation ago. |