A DESCRIPTION OF THE Instruments and Apparatus OF TIIE AITTIIOK, WITH DIRECTIONS FOR THEIR USE, IN OPERATIONS ON THE Genitourinary Organs. BY F. N. OTIS, M.D., Clinical Professor of Genito-Urinary Diseases in the College of Physicians and Surgeons, New York. NEW YORK: 0. P. PUTNAM’S SONS, 4tii Ave. & 23d St. 1875. A DESCRIPTION OF THE Instruments and Apparatus OF THE AUTHOR, WITH DIRECTIONS FOR THEIR USE, IN OPERATIONS ON THE Genito-Urinary Organs. BY F. N. OTIS, M.D., Clinical Professor of Genito-Urmary Diseases in the College of Physicians and Surgeons, New York. NEW YORK: < G. P. PUTNAM’S SONS, 4th Ave. & 23d St. 1875. DESCRIPTION OF TIIE INSTRUMENTS AND APPARATUS OF W. N. OTIS, M. D., (clinical professor in the college of physicians AND SURGEONS, NEW YORK,) WITH DIRECTIONS FOR THEIR USE. The Urethral Scale.—This is graduated by the French millimetre from 1 m. in circumference to 40. On the op- posite side are the numbers of the English scale. “ The scale for grading the sizes of instruments has never been very accu- rately fixed, except in France.”* The French scale (Char Here- filiere) increases by one millimetre in circumference. This is a recognized standard scale in all countries, at the pres- ent day, and the sizes of all other scales must be translated in- to this, in order to become intelligible in descriptions of cases. It is not rare to find urethrae with normal calibre of 40. The entire set, from 8 m. to 40, is absolutely essential to every sur- 'I A. 5vvo a-, sows xvx. geon wlio desires to make complete and accurate urethral measurements. The stricture which will permit, say 25 of this scale, to pass without obstruction, will often hold distinctly and firmly upon a bulb measuring 26f. It is thus shown that the gradation of this scale is not too fine, and that no numbers can be dispensed with. * Genito-urinary diseases, Drs, Van Buren and Keyes, New York, 1875, p. 4 The Urethra-meter.—With this instrument an accurate measurement of the normal urethral calibre may be made, in any case, within the compass of the instrument, the bulb of which can be made to ex- pand from 20f to 45f.* The dial, near the handle, indicates, in millimetres, the exact amount of ex- pansion of the bulb. Introducing it closed (and covered with the rubber cap which serves to protect both the instrument and the urethra) down to the bulbo-membranous junction, by means of the screw at the handle, the bulb ex- pands up to the point of the sensation of full- ness felt by the patient. The hand on the dial will then point to the figure representing the nor- mal calibre of the canal under examination. Strictures in the regions anterior to the bulb may also be accurately defined and measured by this instrument. When the bulb is suddenly arrested in withdrawal, the screw should be gradually turned until the bulb is permitted to pass. The position of the hand on the dial will then indi- cate the calibre of the stricture. It should, how- ever, be borne in mind, that, when the urethra is very sensitive, spasmodic contraction may simu- late an organic stricture. It is therefore neces- sary to verify the results of this examination, with the bulbous sound, before deciding that true stricture exists. If the latter instrument defines a contraction at the same point, by measurement, and, when passed beyond it, is distinctly held on return, the proof of organic stricture is complete. When the urethral contractions are below the calibre of the F. G. Otto should be well oiled and presented at the meatus. If it passes in readily, this may be accepted as representing the normal calibre. If only a smaller size will enter, the dif- ference between this size, and that indicating the normal calibre, will show the exact amount of contraction present at this point. This contraction should be divided so thoroughly that the full-sized bulb can enter without the least sense of obstruction. The bulb should then be advanced along the canal. If deeper obstruction is met, a smaller-sized bulb should be selected, and when one is found which just passes the contracted point, slightly stretching it, on attempting the withdrawal of this bulb, it will be firmly held by the posterior border of the stricture. The distance between the point of arrest of the large bulb and the point of holding of the smaller, carefully measured, will give you the position and length of the stricture, and the size of the smaller bulb will indicate its calibre. The same method of procedure will apply to the diagnosis of any remaining contractions of the deeper portions of the canal. In the curved portion the shaft of the bulb should be bent to correspond with the sub-pubic curve. The Bulb-Pointed Bistoury "or Meatotome is e. r/£’Af/r/uv-c'0-/yy hemann-gq-ny 6 intended for division of contractions at or within an inch of the meatus. This, well oiled, should he advanced into the me- atus,while the end of the penis is supported by the fore-finger of the opposite hand, and carried along, with the bulb point bearing against the superior wall of the canal, until well behind the posterior border of the contraction. It should then be depressed, and the cutting edge drawn slowly and firmly down, cutting deeply in withdrawal, and carefully pre- serving the vertical direction of the natural orifice. The tissues in this locality are usually dense and resilient, and the firm support of the finger under the glans is required to effect a proper division, which should never be expected, or attempted, in a single cut. An incision having been made, its extent should be ascertained by the larger bulb, and if, as is more than probable, it fails to pass, or if, in passing, it is caught on return, the same proceeding should be repeated until the free passage of the full-sized bulb in en- trance and withdrawal is secured. The haemorrhage following may be slight, ceas- ing after a few moments’ pressure, or it may be profuse, requiring some mechanical appliance for its arrest. A short Urethral Tube of silver or gutta-percha two m. below the normal calibre may be introduced and fastened by means of a narrow band- age, the pressure of which, bearing upon the tube, will effect the desired result. The danger of free haemor- rhage is not past until healing of the cut surfaces is well advanced, and should be provided for in all cases for at least forty-eight hours. The Spring Tampon may be con- veniently used for the same purpose. It consists of a steel or German silver .-G.tFemAN N & CO- 7 wire, bent so as to form a spring with parallel arms, the upper of which is provided with a fenestrated end, which helps to hold the instrument in place, while upon the lower a little styptic cotton or lint is wound. The arms are approximated by a thumb-screw, until they readily enter the canal, to a point just behind the incision, when, by loosening the screw, the pressure just sufficient to arrest the haemorrhage may be readily made. The full-sized bulb should be passed daily, or at least every other day, until healing is complete. Should the least re-con- traction occur, it is an evidence that some fi- brous bands have escaped division, and the oper- ation must be repeated, if a perfect result is desired. The after treatment of a urethrotomy consists in keeping the divided tissues from re- uniting, and this is most effectually done by the daily passage of a conical steel sound. For dividing deeper strictures, the simplest, and which answers a good purpose in dense narrow stric- tures, is the Bulbous Urethrotome. This in shape is like the bulbous sound, so constructed that, after passage through a stricture, a broad blade con- cealed in the bulb is drawn forward through the contracted point, by means of a handle which traverses the hollow shaft of the instrument. The blade is pushed back through the stricture into its place of concealment, and the instrument withdrawn ; and if the bulb has been of sufficient size to make firm resistance, on attempted with- drawal before, and meets with none after incision, it is probable that the test by a bulbous sound, of the size of the normal canal, will show that the division has been complete. The bulbs of this urethrotome are readily changed, and range in size from 20f to 40f. 8 Ill order, however, with certainty to divide completely any stricture, by the internal method, the principle of dilatation (which to a certain limited extent obtains in the bulbous urethrotome) must be prominently combined with the incis- ion, and this is best seen in the Dilating Urethrotomes, of which there are four. No. 1 con- sists of a couple of parallel bars, which are separated at will by means of a screw at the handle. The upper bar carries a canula, in which a narrow blade is concealed and is made salient by being drawn forward, or pushed backward over a short elevation on the floor of the canula. The canula, being movable, enables the operator to elevate the knife at any point along the upper bar without moving the instrument. The bars when closed represent a size of 23f ; when fully separated, 40f. The instrument is introduced closed ; the bars are then separated by means of the screw at the handle, until the full size of the normal urethral cal- ibre is reached. The blade, which has been previously adjusted to emerge at the point of stricture, is then drawn forward, and the stric- ture thoroughly divided. By loos- ening the screw which fixes the position of the canula in the bar, the knife may be raised and the canula drawn forward, thus cutting any desired distance. The amount G. TIE MANN &. CO. 9 of dilatation is registered on a scale near the handle. This is a strong, efficient instrument, but cannot well be made of a less calibre than 23f. Dilating Urethrotome No. 2 is designed for a wider range of strictures. This, when properly made, may be closed to 20f and dilated to 45f. It has the further advantage of distending only a limited portion of the canal contiguous to the locality of the stricture ; but the incision can only be made of one length, corresponding to the length of the bridge over which the blade runs. This, as usually arranged, is about one inch. The blades in this, and in the pre- viously described, should be capable of pro- jection, not less than one nor more than two millimetres. The amount of dilatation is in- dicated on a dial plate near the handle. Dilating Urethrotome No. 3 should measure 18f when closed, and be capable of expansion to 45. It is curved so as to pass readily through the curved portion of the ure- thra when this is necessary. It is thus well adapted for the division of deep strictures. The cutting apparatus of this instrument dif- fers entirely from urethrotomes Nos. 1 and 2. In No. 3 the blade is guarded at the top like that of M. Maisonneuve, for the purpose of avoiding incision of the healthy portions of the canal in introduction; in the same way it limits the incision or withdrawal. This instru- ment is introduced closed, and without the knife, unless the stricture is very large. The knife is then carried down, the screw at the handle turned until the hand on the dial in- dicates two or three millimetres beyond the previously-deter- G. TIE MANN & 00. 10 mined normal calibre of the canal, and the blade is then drawn through the stricture or stric- tures. The instrument is then closed to 25f and withdrawn. Partial closure prevents pinch- ing of mucous membrane. The results are ascertained b}r examination with the full-sized bulbous sound. If a trace of stricture is left, the operation should at once be repeated, either using a wider blade or dilating two or three more millimetres. In very resilient strictures two or more at- tempts are sometimes unavoid- able before complete sunder- ing of the strictures is effected —nothing short of which can produce permanent beneficial results. The guarded blades of this instrument should not project more than four millimetres, nor less than three, above the shaft; and the guard should not exceed | m. in breadth, as hiore than this will hold be- hind the stricture and prevent easy division. In case of very dense and resilient stricture a perfectly plain blade mayr be used, always in such event turning the instrument down as soon as the blade has passed through the stricture. No. 3. Geo. Tiemann & Co. 11 Dilating Urethrotome No.4 is like No. 3, except that it is smaller, quite straight, and can be used in division of stric- tures down to the bulbo-membran- ous junction, without the necessity of dilatation of the deeper portions of the canal; hence, for all opera- tions in the ante-membranous re- gion, it is much to be preferred to the longer curved instrument. In skilled hands it may also be used to advantage in the deeper parts of the canal. It is made with less difficulty, is of smaller diameter (16f), and more easily managed in the straight portion of the urethra. The haem- orrhage following operation with the dilating urethrotome, after the manner described, is usually slight, and ceases on slight pressure with the fingers at the points of incision —often without it. In some cases oozing continues and may require the introduction of the Endoscopic Tube.—This is six inches in length and of a calibre 28f m. to 32, and provided with an enter- ing shaft to facilitate introduction. The tube is introduced to a point beyond the in- cisions, and pressure made by a narrow retaining bandage sufficient to control the haemorrhage. The shaft is withdrawn when the patient desires to urinate, which he readily does through the tube, thus preventing contact of urine with the freshly-cut surfaces. Even if no haemorrhage occur, it is well to introduce this tube, for the first twenty- four hours, whenever urination is necessary. The tube, for x Xi.'SYX'X & MUSAX. G. TIEMANN-CG. N. Y. 12 easy introduction, should be about two sizes (millimetres) be- low the estimated normal calibre of the canal. By means of the endoscopic tube, ocular exami- nations may be easily made at any point in the straight portion of the urethra. For controlling haemorrhage at or near the meatus urinarius, shorter tubes, called meatoscopes, are used. Solid Conical Steel Sound.—The form most convenient is that figured above (Plate 15), the curve of which corresponds to an arc connecting the ends of a right angle measuring 1| inches. At the commencement of the curve, the size gradually diminishes, un- til, at the rounded extremity, it is one-fifth smaller than the shaft. For facility of intro- duction, and easy adaptation to the sub-pubic curve, simplicity of manufacture, and conven- ience in practice, it has my preference to all other varieties. The sizes run from 28t to 40, corresponding to the range of normal urethral calibre. Thus far, the extreme No. 40t has been met, once in fifty cases of adults ; the op- posite extreme, No. 28f, only once in three hundred. The average is about 32. For preventing pain, irritation, and inflam- matory action after operation, the Cold Water Coil is valuable. This apparatus is formed of a line of the small-sized India-rubber tubing of one-six- teentli of an inch calibre, and six or seven yards in length. At the middle portion this tubing is coiled upon itself, so that, by half a dozen turns or more, it presents sufficient ca- pacity to loosely encircle the entire penis. TJEMANN-NY 13 This coil, with the length of tubing proceeding from it, forms an apparatus through which, on placing one extremity of tlie tubing in a bowl or tumbler of ice-water, exhausting its contained air (by suction, or by drawing the tube through the finger), a siphonic current is established through the coil. The discharge-pipe being placed on a lower plane than the water-supply, the current may be kept up until the vessel is emptied. The rapidity of the flow can be regulated, either by raising or lowering the end of either tube, which is the simpler plan ; but the more convenient one is by a tapering, double, silver tube, attached to the discharge-pipe, a sponge being fitted to the inner tube. This sponge, when the inner tube is pushed down into the smaller end of the outer tube, becomes com- pressed and gradually obstructs the flow of water, until not a drop will exude. This contrivance may be regulated so that either a free stream can pass, or that the single drops shall follow each other, more or less rapidly, with the regularity and precision of a timepiece. By means of this arrangement, I have been able to apply cold to the penis, or scrotum, continuously and conveniently, 14 both to the patient and the surgeon. The coils of tubing are re- tained in position by a band of cotton or linen cloth. A ready method of constructing this apparatus is by placing a strip of thin cloth, six inches in length and two in breadth, length- wise, upon a large speculum or a four or six ounce vial. The tubing, taken at the middle of a piece six or seven yards long, is wound around the vial, and, after the requisite number of turns are made, the projecting ends of the cloth are doubled over the coils, and stitched to the under layer, between the turns of tubing. If, after completion, the turns are found too small, they may be readily enlarged by drawing the tubing through the cloth to any desired extent. I have found this simple contrivance of essential service in the acute form of gonorrhoea, reducing inflammatory action promptly, and thus giving relief to painful micturition and erections. It has proved of great value in keeping down inflammation, and in preventing erections after the operation of circumcision. I habitually use it for the same purpose in operations for stricture, and with results more prompt and satisfactory than those hitherto attained by any medication or application with which I am familiar. In examinations of the bladder for stone, where stric- ture is present, it is often difficult, on account of the contrac- tion and the more or less spasm usually associated with it, to get sufficient play through the urethra to make an efficient ex- amination of the bladder. Besides, in irritable subjects, when no stricture is present, spasm of the compressiores urethrae, not unfrequently holds the exploring instrument so as to impede, if it does not quite prevent, the examination. For the purpose of avoiding this embarrasment the Canulated Exploring Sound may be used. It, is simply an ordinary sound upon which a metallic or hard rubber canula, seven and a half inches in length, is made, so as to be movable on the shaft of the sound. When slid down against 15 the shoulder at the commencement of the curve, and fastened by the screw at the proximal end of the canula, it may be used in the ordinary way; but when it is held by stricture or spasm, the screw is loosened, allowing the play of the sound through the tube. The Dilating Catheter is used in the preparatory dilata- tion of strictures too small to admit the necessary instruments Exploring Sounds. c. TIE MANN 8--CO. Dilating Catheters. F.C.OTTO A SONS N.Y. 5 TPEMAN-W-Cer - NV for immediate operation. I have designed the accompanying modification of Sir Henry Thompson’s* probe-pointed cathe- * Thompson on Stricture of the Urethra. London Ed., 1858, p. 181. 16 ter. It consists simply of a fine probe-pointed silver tube, eleven inches in length and three millimetres in circumference at its point, gradually increasing in size, so that at six inches it is six millimetres. This tube is traversed by a steel stylet throughout its length. Carefully insinuated through a close stricture, by the aid of a finger in the rectum, until its point may be supposed to have reached the bladder, the stylet is removed, and a small syringe is applied to its proximal open- ing. If the instrument has passed the sphincter vesicce, on a withdrawal of the piston, the urine will appear in the barrel of the syringe. The instrument may then be confidently pressed onward until the stricture is dilated to the largest capacity of the tube. A second tube, of corresponding form, but with dimensions ranging from four millimetres at the point to eight millimetres, may then be similarly used. In cases where, on account of the extreme closeness of the stricture, or from its divergent or tortuous course, a difficulty in passing the instrument occurs, Dr. Gouley’s whalebone guide-bougies will prove serviceable.* These are used as in his grooved, canulated staff, viz., by the previous introduction of the guide-bougie into the bladder, threading the dilating catheter upon it and following it down through the stricture. Succeeding in this manoeuvre, the guide-bougie may be removed, the pres- ence of the dilating catheter in the bladder tested by aid of the syringe, the stylet introduced, and the stricture dilated as previously described. The whalebone guide-bougies, to be used in this manner, require to be from sixteen to eighteen inches in length. They are easily made of any desired length and fineness, and, by steaming, or rapid passage through the flame of an alcohol lamp, may be moulded at the extrem- ity to any curve or angle deemed most likely to adapt itself to the eccentricity of the stricture. In comparison with all other instruments for the same pur- * Gotiley oh Diseases of the Urinary Organs. New York, 1873, p. 51. 17 pose, the relatively smaller calibre of the dilating catheter must give it an important advantage, in cases of stricture of extreme tenuity. Through its successful use, the earliest pos- sible assurance of entrance into the bladder, may be acquired. It is of simple construction, of flexible material, and of uni- form strength. It will, I feel confident, enable the judicious and experienced surgeon to accomplish a satisfactory dilata- tion of many strictures, which, without its aid, would necessi- tate a puncture of the bladder or the perineal section. F. N. OTIS, M.D. 108 West Thirty-Fourth Street, New York, June 17th, 1875.