The practice of urology; a surgical treatise on genito-urinary diseases, including syphilis

Front matter

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover.

Marks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the publisher to a library and finally to you.

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to prevent abuse by commercial parties, including placing technical restrictions on automated querying.

Preface

It is not possible to complete a book of this scope without building upon many other works that have gone before, and it is, therefore, largely contributed to by the labors of others, not only in their writings and opinions expressed in medical meetings, but by their operative methods.

To the numerous contributors in this respect the author is glad to accord recognition here, and especially to refer to such international autliorities as have been the leaders in the advancement of urological science in their respective countries, namely: Sir Henry Thompson of England, Felix Guyon of France, Leopold Casper of Germany, and Edward L. Keyes of America.

The last, by virtue of long association and teaching, more than any other, is responsible for whatever may be found of merit in this volume. To him, therefore, the author must especially dedicate this work, and for its faults and deficiencies, own entire responsibility.

This treatise is designed to propagate what the author considers to be orthodox teaching upon the various subjects contained therein, and has been undertaken only after an experience of over twenty years devoted to this specialized field of surgery.

Realizing that the consideration of any one of the important departments comprised might readily fill a volume by itself and still leave much unsaid, the writer hopes that this book will be one of the many sources of reading upon the subjects.

So far as the maladies treated of are the same in men and women, they are naturally included, but so far as they affect the organs peculiar to women, they are not. There is a tendency for some urologists to embrace the field of gynecology, but that is no reason why a book devoted to urology should advocate such a union by treating the subject in an inadequate manner, as is entailed, for instance, in including gonorrhea in women and omitting what is of prime importance— its complications and sequelae — w^hich indisputably belong to the domain of gynecology.

The subject matter herein is aligned as seemed to be most practical and desirable both from a surgical and clinical aspect, beginning with diagnosis and general technic, and following wath the various abnormalities and diseases of the different anatomical regions, subdividing the operative surgery in like manner.

iii

IV PREFACE

A section on syphilis is also included. This is done because of the demand for it: for while this far-reaching disease is equally claimed by all departments of medicine, its treatment at the present day is surgical, and cannot be undertaken properly, except upon careful surgical principles. Therefore, the main part of the subject will be found somewhat condensed, sufficient detail being given, however, to afford a comprehension of the nature and action of the lesions in the various parts of the body, and particular attention is devoted to the consideration of the latest measures of treatment.

The characteristic features embodied in this volume, which give to it a modern status, are the present local treatment of gonorrhea; the application of serum diagnosis and serum therapy; advancement in cystoscopic and functional renal diagnosis; various features in surgical technic, and the latest on salvarsan therapy.

The author takes much pleasure in acknowledging also the assistance received from the able members of his staff, who, by this aid, have augmented their claim upon his devotion. First and foremost, his chief of staff. Dr. D. A. Sinclair, has been a constant and unfailing support in every imaginable detail; without such help, this work would still be uncompleted. To Dr. Faxton E. Gardner he is indebted for willing and competent assistance in preparing some of the pages on anatomy and embryology, general operative technic and neosalvarsan therapy; to Dr. H. G. Bugbee, for assistance in constructing the section on functional renal diagnosis; and the other members of his staff have rendered aid in many ways.

The excellence of the mechanical part of the production's due to the painstaking efforts of the publishers and the illustrators' skill.

As already stated, this work represents only a part of that which must be completed by others, but if it serves in any one particular to assist in the successful practice of urological diagnosis and technic, it will more than repay for the extensive labor and time devoted to its preparation.

Charles H. Chetwood. 25 Park Avenue, New York Citt, January^ 1913.

Chapter I The Diagnosis Of Sexual And Urinary Maladies

THE UROLOGIST^S ARMAMENTARIUM AND GENERAL TECHNIC

Instruments used in genito-urinary surgery may be classified, from a practical point of view, as essential and not essential. Such division, however, will depend largely upon individual practice. A full equipment or armamentarium will naturally include all of the general outfit of the operating surgeon. The special instruments are those employed by the urologist for diagnosis and treatment in his specialized field of work. These, for the most part, comprise the different types of urethral sounds and catheters, syringes and irrigators, urethroscopes and cystoscopes, and some extra instruments of necessity in certain operations or peculiar to individual operators.

Syringes and Irrigators

Irrigator jar for anterior and deep urethral irrigations. (Fig. 10.)

Urethral nozzles and cut-ofif (Chetwood). (Figs. 8 and 9.)

Urethral clamp (Chetwood). (Fig. 2L)

Anterior urethral syringes — plunger type. (Fig. 1.)

Anterior urethral syringe with bulbous ejector. (Fig. 2.)

Instillator — Keyes-Ultzmann type. (Fig. 4.)

Instillator — bulbous ejector type. (Fig. 7.)

100 c.c. syringe— Janet (Gentil). (Fig. 3.)

Catheters, Bougies and Sounds '

Soft-rubber catheters (N^laton) (No. 10 to 20 French). (Fig. 25.)

Soft-rubber catheters, Mercier or elbowed end, small and large (Fig. 26.)

Woven catheters, bougie or olivary end, various sizes. (Figs 27 and 28.)

Woven catheters, Mercier or elbowed end — blunt — various sizes. (Fig. 27.)

Digitized by VjOOQIC

Woven catheters, Mercier or elbowed end — ^pointed — various sizes. (Fig. 27.)

Woven catheters, double elbowed (bi-coud6) — various sizes. (Fig. 27.)

Elbowed obturator. (Fig. 30.)

Curved obturator. (Fig. 30.)

Silver catheters. (Fig. 29.)

Conical steel sounds (double taper) — sizes 15 to 32 French (Fig. 14.)

Blunt steel sounds — sizes 20 to 30 French. (Fig. 13.)

Kollmann dilators. (Fig. 24).

Bulbous bougies — sizes 10 to 30 French. (Fig. 17.)

Olivary bougies — sizes 6 to 25 French. (Fig. 16.)

Filiform bougies. (Fig. 18.)

Tunneled metal catheters — several sizes. (Fig. 123, p. 288.)

Tunneled metal sounds — several sizes. (Fig. 123, p. 288.)

Guyon steel sounds and filiform guides — three or four sizes. (Fig. 19.)

Stone searcher. (Fig. 187, p. 447.)

For description of urethroscopes, cystoscopes and attachments, see index.

Operative Outfit and Special Instruments

General surgical equipment — knives, hemostatic forceps, etc.

Aspirator.

Aspiratory syringes (for mercurial injections).

Intravenous injection outfit. (See index.)

Litholapaxy instruments. (See index.)

Prostatic operative instruments. (See index.)

Galvano cautery prostatic incisor (Chetwood). (See index.)

Urethrotomes. (See Stricture.)

Other instruments will be mentioned in sections on operative surgery following each subject.

The examining room should be light and well aired, with conveniences for temporary darkening when the cystoscope is used. The artificial light is best produced by electricity. The floor and walls should be constructed of material that can be washed. Two reservoirs, one of hot and the other of cold, sterilized water for irrigation; a boiler for instruments, a full-sized utensil sterilizer, and a large sterilizer for dressings, sheets, gowns, etc., complete the sterilizing outfit.

A useftil table of simple design, that is suitable for cystoscopy and for urethral and vesical lavage is a modification of the Isaacs' table shown in Figs. 10 and 11.

Scales. — Various scales exist to distinguish the gradation of the calibre of urethral instruments; known as French, English and American. The scale was first accurately fixed in France, and there are now two French scales in use, the Charriire, known as the French scale, and the B6niqa6. The former is more generally used in this country, while in France the new B^niqu^ scale is preferred by many urologists.

The French or Charri^re scale expresses its measurement in one-third of a millimeter diameters. No. 1 indicates a diameter of 1/3 mm.; Xo. 2 indicates a diameter of 2/3 mm. The number of an instrument is divided by 3 to ascertain its diameter; that is, a No. 30 French sound has a diameter of 10 mm. or one-third of 30 mm. The number of an instrument in the Btoiqu^ scale is double that of the same instrument in the Charri^re; a No. 60 B^niqu^ sound equals a No. 30 French.

The American scale measures in half millimeters to indicate its diameter. Its numbers equal two-thirds of the French, 20 American

equals 30 French T-^or* ' =.010 cm.)

The English scale averages about 2 less than the American, 18 English equals 20 American.

Lubrication of Instruments. — ^The question of a suitable lubricant for instruments is an important one. Oil has many disadvantages, for boiling alone sterilizes it, and this process is both difficult and dangerous. It smears the prism of the cystoscope, and so cannot be used in cystoscopy. Vaseline and lanolin are open to the same objection, although the former is an excellent lubricant and much better than many of the more modem varieties, but its serious disadvantage is the difficulty of removing the oily coating from the instrument after use. The oil also coats the mucous membrane and thus prevents the action of any medicament employed. Furthermore, an oily coating on a catheter adds to the length of time required to sterilize by boiling.

Among the lubricants commonly used, besides oil, are various combinations of sterilized gum tiagacanth or Irish moss, glycerin, and boroglycerid. There are a number of such preparations upon the market, put up in sterile tubes. To be satisfactory, the lubricant should not be lumpy. It should be thin and smooth, but not watery. The preparation adopted in my clinic consists of the following formula:

Tragacanth 30 gm.

Glycerine 60 c.c.

Distilled water 600 c.c.

Mercury oxy cyanide 1.5 gm.

Note. — This lubricant is similar to one that has been employed in Europe (Guyon and Kraus). In some preparations carbolic acid instead of oxy cyanide of mercury is used as an antiseptic. It has been found that after being exposed to the air it remains sterile eight days (Casper). Investigations have also shown that microorganisms are destroyed or their virulence inhibited by direct contact with the lubricant.

The antiseptic preserves the lubricant for some time, and possesses the additional advantage of not irritating the urethra.

In comparison with oily lubricants, the advantages in favor of this preparation are that the former coats instruments with a film that ofiFers a nidus for microbes, and is not dissolved during the process of sterilization, while the latter lubricant, which is soluble in water, offers no impediment to sterilization, is also readily soluble in fluids used for irrigations, and thus does not interfere with their therapeutic action.

The ordinary method of lubrication is to spread the preparation freely upon the instrument to be used by compressing the containing tube. It is sometimes a good plan to distend the urethra with the lubricant as a means of separating the inflamed walls or of dilating an irregular constriction, before introducing the examining bougie. The introduction of the lubricant is made with the ordinary urethral syringe (Fig. 22).

Syringes and Nozzles. — The usual type of urethral syringe or injector is a 12 to 16 c.c. (3iii-iv) piston syringe with cone nozzle made

of glass or hard rubber. The nozzle is sometimes of soft rubber. (Fig. 1.) As a substitute for the ordinaryurethral syringe, especially for the purpose of washing the urethra before using the sound, for cocainizing the urethra, or for injections of any kind, ^'" \iiun1er typ^e?"*^"- the bulbous syringe (Fig. 2) is most

useful. It is easily cleansed, and may be boiled continually without detriment. It also makes a good hand syringe for patients' use, and obviates the difficulty, often encountered with the piston syringe, of leakage backward.

Injecting the Anterior Urethra. — For this purpose, one or the other of the syringes described (Figs. 1 and 2) is employed. The lips of the meatus being separated, the nozzle of the syringe is gently, but firmly, thrust into the opening so as to completely fill the orifice and prevent leakage alongside, and the fluid is then slowly injected by compressing the bulb or pushing the piston until the canal is comfortably distended. The thumb and index-finger of the other hand meanwhile gently squeeze the meatus against the syringe to avoid leakage, and after the canal is filled, compress the lips together to retain the fluid, the syringe being then withdrawn.

The patient should be instructed in the method of injecting the anterior urethra, when it is required to be done by him. Otherwise, it may be improperly performed and valuable time lost.

When it is desired to retain liquids or lubricant jelly in the anterior urethra, the author's urethral clamp is of assistance, as, while it completely blocks the meatus, it may be left on at will, and does not exert harmful pressure (Fig. 21).

A syringe of generotis capacity (100 to 150 c.c.) (Fig. 3) is an important accessory to the urologist's outfit for bladder and urethral

Fig. 2. — Anterior urethral syringe. Bulb ejector.

lavage and for cystoscopic examinations. The Janet syringe, having a capacity of from 100 to 150 c.c. is a very satisfactory instrument of this kind. One with a glass barrel is preferable, as the metal does not stand the action of the chemical solutions commonly used. I have had best satisfaction with the French (Gentil's) graduated glass sjTinge, in metal frame, with rubber plunger (Fig. 3). This instrument is easily utilized by one hand, and is sterilized by boiling. A metallic tip lessens the danger of breakage, of so common occurrence. The rubber plunger stands long usage and boiling, and the replacing, when necessary, is very simple. There are a number of other Janet syringes made in this country.

Deep urethral syringes are employed for instillations of small quantities of medicaments to the posterior urethra or neck of the bladder.

The Kcyes-Ultzmann instillator (Fig. 4) is a short-curve silver canula of small calibre, with a 2 c.c. syringe attached in one piece, or fitted With a standard thread, when it may be utilized with a hypodermic syringe. The length of the shaft is 15 or 18 cm. (6 or 7 inches), the calibre 15 to 18 French. It is well to be provided with a number of canulas, of different diameters.

The canula of the Bangs' modification of the deep urethral syringe is as large as a fair-sized steel sound (25 F.) and distends the canal when making an application.

The Guyon cantila, a flexible woven instrument with bulbous end, is introduced less painfully in some individuals. To this canula may

V

Fig. 3. — 100 c.c. Bladder syringe.

Fig. 4. — Keyes-Ultzmann deep urethral syringe.

be attached the bulbous and glass syringe for instillation, or the latter may be attached to the diflferent sized silver canulas by having the thread ground down and a hard rubber coupling fitted. These instruments are easily portable, and can be sterilized by boiling or by being kept in an antiseptic solution (Figs. 5, 6 and 7).

Instillation or Injection of the Posterior Urethra. — When this procedure is conducted with the solid canula, the instrument is introduced like an ordinary sound until the end reaches the curved urethra or bulbo-membranous junction, where it often finds resistance. Great gentleness should be practised at this point, and the instrument must

Fig. 5. — Guyon instillator.

Fig. 6.— Aseptic deep urethral syringe.

Fig. 7. — Deep urethral syringe with bulb ejector.

be made to enter without force, or not at all, as this is the location where damage is so often done to the mucous membrane and false passage produced by rough handling. When the deep urethra is entered, the handle of the injector is depressed to an angle of about 45 degrees with the plane of the table, the full contents of the syringe or a few drops of the medicament being then deposited, according to the nature of treatment.

The flexible or Guyon canula for instillation is introduced unlU the olivary end is felt to pass the cut-off muscle, when it is known that itjs in the posterior canal; if there is doubt of this, it is pushed further in, to the point where urine is first obtained, which marks the neck of the bladder, and then withdrawn from 2.5 to 4 cm. (1-1 1/2 ins.) before injecting.

Fig. 8. — Urethral nozzles. {Chetuoot )

Fig. 9. — Author's alternating urethral irrigation clamp.

Irrigators. — Irrigators are employed for anterior and posterior urethral irrigation and bladder lavage. For this procedure are required a glass tank, so suspended that it may be easily shifted up or down, proper length of tubing, nozzles and cut-off or interrupter. The author's two-way blunt-pointed glass nozzle and cut-off scissors will be found convenient and useful for both anterior and posterior

INSTRUMENTS \ND GENERAL TECHNIC irrigation, more especially after a little practice (Figs. 8 and 9). This method is not so clumsy, and allows less splashing than the larger interrupters employed with the Janet nozzles (such as Valentine's and Swinburne's). Many, however, prefer the latter patterns.

Fig. 10. — Anterior urethal irrigation.

Anterior urethral irrigation (Fig. 10) is one of the methods of treating the front urethra when it is the seat of inflammatory trouble (see index); it is also employed as a measure of prevention against infection. The procedure may be accomplished with an ordinary cone-shaped nozzle attached to the tubing of an irrigator jar, in which case the nozzle is partially withdrawn with each inflation of the canal, to allow the escape of the fluid before refilling. In such case it is well to have attached a protecting bell to catch the splash, as is found with the Valentine and Swinburne instruments. I prefer, and have used satisfactorily, the apparatus shown in Fig. 10. This apparatus consists of a reservoir with proper length of tubing. The reservoir is arranged to be elevated or lowered at will and attached to the end of the tubing is a scissors-like shut-off (Fig. 9) which allows, when in use, the opening and closing of the inflow tube by means of which the urethra is alternately filled and emptied with the irrigating fluid. This is accomplished by having a urethral nozzle, with one opening at the penile and two at the other extremity (Fig. 8). One of the latter is connected with the irrigator inflow tube, and the other with a short tube for outflow. In operating this apparatus, the patient stands over the basin or sits upon the operating-table with thighs reflexed. By alternately opening and closing the inflow tube, the urethra is flushed out with as much of the fluid contents of the jar as may be desired, and during this process all of the folds of the canal are opened and the mouths of the follicles cleaned.

Posterior urethral and bladder lavage without the catheter (Fig. 11) may be conducted at the same time as irrigation of the anterior canal by raising the tank the sufficient height (2 to 2.5 meters or 7 to 8 feet), with or without local anesthesia of the antero-posterior urethra, by distending the front section of the canal until the fluid escapes by the cut-off muscle through the posterior portion. Great care should be exercised not to inflict undue irritation by this procedure, and pressure should be relieved at once by reversing the flow with the alternating cut-off, or by withdrawing the nozzle if the patient complains unduly. This method of deep urethral irrigation without the catheter cannot always be successfully performed without producing irritation, sometimes to an extent that unnecessary pain results and even such complications as swollen testicle or greater activity of the inflammation in the deep urethra and neck of the bladder. It requires cooperation on the part of the patient, or his passive assistance, which means relaxation of the parts and total absence of resistance. This is best accomplished by having the patient in a comfortable semi-recumbent position, with the knees bent and feet supported on properly adjusted stirrups (Fig. 11). By employing one of the methods of anesthetizing the urethra before a cystoscopic examination (see page 18), the treatment is more easily accomplished and the element of resistance being removed thereby, there is much less likelihood of causing irritation and harm. In suitable cases this procedure is capable of exceptional benefit, especially when the patient as well as the operator becomes trained in its use by gradual progression. In irritable patients it is

Fig. 11. — Deep urethral and vesical irrigation, without catheter.

well for the first one or two treatments to desist when only a small quantitj' of fluid passes into the bladder, and it will be found on subsequent trial that a gradually increasing amount will pass the cut-off muscle and that by such patient persistence the entire quantity (250 to 500 c.c. — 8 to 16 ounces) will enter with little difficulty.

The soft-rubber nozzle of the ordinary anterior urethral syringe attached to a 100 c.c. bladder syringe is sometimes used for forced vesical irrigation, but this plan should not be adopted in irritable conditions, as the force that can be exerted in this manner to overcome the resistance is very great.

The catheter is often a safer means of deep urethral and bladder irrigation, in which case, before the introduction of the catheter, the anterior urethra should be cleansed, either by irrigation or by gently

Fig. 12. — Vesical irrigation with catheter.

flushing out the canal with a bulbous or piston urethral syringe. When the bladder is the part to be irrigated, the catheter is introduced all the way, and after the contents are evacuated, the irrigating fluid is allowed to flow in from an irrigator jar (Fig. 12), or is injected by means of the 100 c.c. or 150 c.c. syringe, until the bladder is comfortably filled, when it is emptied and refilled as often as may be necessary to cleanse it; or, in some forms of treatment, the catheter is withdrawn and the patient is told to retain the fluid for a few minutes, or an hour or more. When it is intended to irrigate the posterior urethra, after injecting a small amount of fluid into the bladder, the catheter is withdrawn about 2.5 cm. (1 in.), or until the fluid does not return through the catheter, showing that the eye is in the posterior urethra and not in the bladder; then the desired amount of fluid is introduced, and after the catheter is withdrawn, the patient is told to pass the fluid out voluntarily, or it is retained for a variable period, according to the object of the treatment and the nature of the fluid.

Exploratory and Dilating Instruments

Sounds are inflexible solid instruments, used for exploration and dilatation of the urethra. Those made of nickled copper are superior to those of steel, the former being less likely to rust. The solid metal sounds (Figs. 13 and 14) are blunt or conical at the extremity. The former are used for diagnostic purposes, the latter for dilatation. The reasons for this are obvious; the shoulder of a blunt instrument can more readily detect the presence of urethral obstruction, while the tapered sound can be more easily engaged in a narrowing of the canal and is therefore better for dilating purposes. In dilating the urethra, it is preferable to employ a sound which is tapered in both directions, toward the handle as well as toward the extremity, the object of which is to avoid the continued distention of the meatus, especially when this part is constricted, while the deeper portion of the canal is being subjected to the required amount of distention. Careful calculation has been used in the development of the curve and taper of the metal sound. The larger sizes, therefore (above 24 or 25 F.), should taper in size toward the handle. The blunt sound has its full size at the tip, which is maintained for 7.5 cm. (about 3 inches), when it tapers down several sizes toward the handle. The conical sound should taper in both directions, toward the handle and tip (Fig. 14). At the beginning of the straight portion the full size is reached, and continued for 4.5 cm. (about 1 3/4 inches) (Fig. 14-Y). Thence it tapers toward the handle about six sizes French. From the straight portion to the tip it tapers 7 cm. (2 3/4 inches) about fourteen sizes French scale. The curve from straight portion to tip should be short, with an extra shortness of the curve near the beak (Fig. 14-X), since this extra curve greatly facilitates introduction, especially at the hole in the triangular ligament, by keeping the point of the instrument against the roof of the canal. In sizes smaller than 20, the sound, unless in the hands of an expert, does not compare in safety with an olivary bougie.

The single-curved sound is largely used, although the double-curved or so-called B^niqu^ type of instrument is preferred by some urologists.

Both styles of instruments have their uses. I find that it is better to adopt the form which seems suited to the individual case according to the facility of introduction. The B^niqu^ sound (Fig. 15) is intended on account of the pitch given to it by the double curve to find readily the entrance to the posterior urethra and surmount any obstacle in the prostatic portion or at the bladder orifice.

t N

Fig. 13.— Blunt steel sound.

Fig. 14. — Double taper conical steel sound.

Fig. 15. — Conical steel sound B^niqu^ curve.

Woven conical bougies are made with flexible neck, and should be olivary tipped. Tliey are used both for diagnostic purposes and for dilatation. Thoss Instruments serve the purpose of dilating strictures up to tho limit where steel sounds may be used. There should be a complete set, from 10 to 25 French size, in every urological equipment (Fig. 16).

Bulbous bougies, Bougie k Boule, as they are called, appear in both types, flexible and metallic (Fig. 17). The French flexible bougies are preferable and quite durable enough. This bougie has two parts, a cylindrical rod of uniform size and a knob that tips one ft

Fig. 16.

Olivary bougie.

Fig. 17.

Bulbous bougie.

Fig. 18.

Filiform bougie.

end of the staff. These instruments are called "stricture searchers" because they detect the presence of strictured areas on entering the canal, and upon withdrawal will carry upon the shoulder a drop of blood or pus as evidence of the inflamed area behind the constriction. It may be demonstrated, however, that even in a perfectly healthy urethra, resistance is felt on the passage of the knob from the bulbous into the narrower membranous part. Such a perfectly normal condition is unfortunately sometimes treated as stricture by those who are too prone to regard every point of narrowing as unwarranted.

Filiform bougies (Fig. 18) are made of woven silk or whalebone, with tiny bulbous tips and straight or cork-screw ends. They are the smallest instruments (sizes 1 to 4 French) employed for urethral investigation. The greatest care must be exercised in regard to the

Fig. 19. — Guyon sound with conductor.

Fig. 20.— a, Filiform catheter. B, Filiform bougie. (Philips modification of Banks,)

condition of these instruments, for whether of whalebone or woven silk, they are fragile, and the possibility of the bougie breaking oflF in the urethra must always be borne in mind. An imperfect filiform should never be used. Bougie iortHUe is a type of filiform bougie, which, although originally straight, has been bent at one end. In

INSTRUMENTS AND GENBBAL TECHNIC

Fig. 21. — Author's urethral clamp.

order to make this curve practical for use, the tip is soaked in collodion and then dried. This bent extremity will sometimes find the aperture of a tortuous stricture better than the straight variety. The introduction of the filiform bougie is often the beginning of a satisfactory and complete dilatation of the urethra, even though at first it cannot be passed through the strictural area at all, or only after great

patience. The passage of one filiform may be followed up by the introduction of one or several others alongside of the first, or it may be used as a guide for a tunneled sound (Fig. 123, p. 288), an instrument that has been used largely for this purpose, but which cannot always be handled with that facility and gentleness which are so important in urethral investigation. Indeed, it is far better to desist after the passage of a single filiform and to resume a day or so later, than to subject the canal to rough handling. And, often, by such conservative course, it will be found at the subsequent sitting, that the reintroduction of the filiform is much easier, and increase in the size and number of the instruments can then be accomplished by gradual progression.