ORGANIC STRICTURE OF INFLAMMATORY ORIGIN.
According to conformation, organic acquired stricture occurs in three principal varieties. (1) The first and simplest form is known as the linear stricture, the obstruction corresponding to that which would be produced by tying a narrow cord about the canal.
(2) The second variety is wider, and is known as the annular form, the condition being mechanically similar to that which would result from tying a flat band or piece of tape about the (3) The third form—which is divided by some authorities into several peculiar sub-varieties—involves. a considerable extent of the urethra in an irregular contraction, and is known as tortuous stric ture. For practical purposes these three varieties are sufficiently distinctive.
As regards their clinical features, strictures may be described as (a) simple and readily dilatable ; (b) irritable, involving local hy permsthesia and (c) resilient or elastic; (d) recurrent. This classification necessarily depends largely upon the behavior of the stricture under treatment.
The number of strictures is variable. It has most generally been accepted that stricture is usually single, but it will be found in by far the larger number of cases, if the urethra be carefully explored, that more than one stricture exists.
The amount of contraction in cases of stricture varies greatly, be tween those of large calibre, in which there is but superficial thick ening with loss of elasticity of the mucous membrane, and those severe forms of long-standing stricture in which the lumen of the ure thra is so contracted as to resist the introduction of a fine bristle, even when the stricture is exposed post-mortem. The contraction is sel dom sufficient to completely prevent the passage of urine.
The explanation of the rarity of strictures impermeable to urine is a very simple one. Every intelligent practitioner knows how diffi cult it is to heal a fistula in the tissues which communicates with secreting strictures or with a cavity containing materials which escape and enter the lesion. Urinary fistula, fistula in ano, and sali vary fistula are familiar illustrations. The patency of urethral stric ture is not only facilitated by the passage of the urine, but also by the fact that the mucous membrane is usually intact, or at least in part.
Strictures impermeable even to instruments are also very rare, particularly in the practice of surgeons who exhibit sufficient pa tience, gentleness, and skill in instrumentation.
The location of stricture has been the subject of much contro versy. Dr. Otis' investigations in particular have modified in certain quarters the existing ideas of the relative frequency of stricture at different points in the urethra.
Until recently the dicta of Sir Henry Thompson and others of his school as to the location of stricture have been universally ac cepted. Thompson found in 320 cases of stricture, examined clini cally, 212 which were located at the bulbo-membranous junction, 51 in the spongy portion of the canal, at variable points between one inch anterior to the opening of the triangular ligament, and two and one half inches posterior to the meatus, and 54 at the meatus or within two and one-hall inches posterior to it. In 270 cases examined post
mortem, he found a decided preponderance of stricture in the bulbo membranous region, which he described as the space included be tween a point one inch anterior to the triangular ligament, and another three-fourths of an inch posterior to it. H. Smith examined 98 preparations of stricture in the London museums, and found only 21 in the membranous urethra, the other 77 being anterior to it. The majority of the latter were situated in the bulbous urethra or just in front of it. Otis claims that the condition is most frequently found in the penile portion of the canal. It is obviously impossible for the Thompson and Otis schools to arrive at harmonious conclusions as long as their standards of stricture and methods of exploration re main so widely different. Post-mortem evidence is only relatively valuable. The surgeon who reasons from clinical experience and skil fully uses the urethrometer and bulbs, can never agree with Thomp son, and must acknowledge the accuracy of Otis' methods even though he may consider the conclusions of the latter somewhat over drawn. It has been my experience that the most frequent site of stricture appears clinically to be at the meatus or just within it, most of these,cases, however, being congenital. The next most fre quent point is the junction of the bulb and fossa navicularis, or just posterior to it, i.e., two and one-half to three inches from the mea tus. The next most frequent location is the bulbo-membranous junction, and the next about one inch anterior to it. It seems to oc cur with varying frequency in the intermediary portions of the canal.
From a clinical standpoint, the author has come to regard stric ture as any condition of the urethra which is capable of producing friction, by obstructing the flow of urine, to however slight an ex tent, providing said obstruction and friction • are productive of pathological disturbances, or—if the latter have already begun—tend to perpetuate them. A point of normal contraction, or relative in elasticity, becomes a stricture only when the urethra assumes a patho logical state; the previously normal lack of distensibility is then of great pathological and surgical importance, and its removal may be imperatively necessary.
Believing then that any point of contraction or inelasticity in the urethra, in the presence of a pathological condition of the mucous membrane, constitutes a stricture, the author unhesitatingly reiterates his firm conviction that stricture of the urethra is most frequent in the pendulous portion of the canal. If care be taken to exclude the ele ment of deep urethrismus—which exclusion is not so easy as some authors would have us believe—the proportion is, the writer believes, at least 10 to 1.
The prostatic portion of the urethra is never involved in acquired stricture as far as known. This immunity is due to (1) the rarity of extension of the acute inflammation to its mucous membrane, and (2) the distance of the part from the primary point of infection.