Operation. —Extensive experience has demonstrated to the author that the method of dilating urethrotomy, as perfected by Otis and per formed with the instrument which he has devised, is upon the aver age the simplest, safest, and most successful method of treatment of penile strictures. Tho author has devised a series of bulbs with a cutting blade, which are often preferable to the dilating urethrotome iu slight linear strictures ; but the stand-by of the surgeon is the in strument of Otis. In the performance of the operation the strictest asepsis should be maintained. The surgeon should be as careful of his instruments and hands as though he were about to enter the ab dominal cavity. The urethra should be flushed with a 1-10,000 to 1-20,000 solution of bichloride of mercury as a preliminary step in the operation. The operation may bo done under cocaine in most instances. The author uses a solution of two per cent. cocaine and one per cent. carbolic acid. This appears to be safe and is quite as efficient as stronger solutions. It is not best to lay clown any arbi trary rules for the performance of the operation. The size to which the urethra should be enlarged is to be determined by the personal equation. The largest-sized instrument which the meatus will admit, when incised to the fullest capacity possible without the production of serious deformity, is in a general way a safe criterion of the size of the instrument which the rest of the urethra will admit. It is the custom with some surgeons to use the retained catheter after internal urethrotomy. This, however, is not necessary in the majority of in stances. Systematic dilatation is necessary after the operation in order to prevent recontraction and to secure smooth healing of the wound. The instrument should not be passed, as a rule, the third day, and when there is much inflammation it is perfectly safe to allow the urethra to remain undisturbed for from five to seven days. It should be dilated thereafter at intervals of three or four days, which interval is gradually increased. Dilatation should be persisted in for from four to six weeks or longer, according to the exigencies of the case. The author desires to lay special emphasis upon the fact that sounding is usually performed too soon and too fre quently after urethrotomy.
In the author's monograph upon stricture of the urethra, the treatment of strictures of the penile urethra is summed up as follows : 1. Those located within two and one-half inches from the meatus cannot possibly be cured by dilatation, and must be cut.
2. Pronounced cases in any portion of the penile urethra must be cut either immediately or after preliminary dilatation, in by far the majority of cases.
3. The treatment of marked cases of small calibre may be begun by continuous or gradual dilatation with soft instruments up to the size of 15 or 16 French, or even larger, and in some cases it may be advisable to continue the dilatation with soft instruments beyond this point, until the stricture shows irritability.
4. Strictures of large calibre, strictures of recent formation, and those consisting of points of normal inelasticity which are perpetuat ing gleet, may be treated by dilatation, the patient being forewarned that the treatment may prove unsuccessful, and that urethrotomy will probably be required either within a short time, or later on, on account of a recurrence of urethritis dependent upon the contraction. In other words, the patient should be informed that the treatment by dilatation, although it may prove efficacious in temporarily relieving the gleet and other symptoms of stricture, may at the same time fail to produce a permanently satisfactory result, and that he will con stantly be predisposed to attacks of inflammation from the slightest indiscretion. Should the patient be satisfied with treatment of this kind, it is hardly wise for the surgeon to insist upon an operation.
Respecting the prognosis after internal urethrotomy, the author desires to express his faith in the permanency of the result in the majority of cases, if the operation be properly performed.
Stricture of the Deep condition implies those stric tures which involve the bulbo-membranous region. They are generally the most serious form, the gravity of the stricture being directly pro portionate to its distance from the meatus. In selecting the method
of treatment for deep stricture, it should be remembered that no method has yet been generally accepted as affording a prospect of a permanent cure. Inasmuch, therefore, as radical operations do not promise a great deal, we should lean toward conservatism. It is to be understood, however, that many cases occur in which conserva tism may be dangerous. The author holds that perineal section offers a better prospect of radical cure than is generally believed, and that should be oftener performed.
Simple, soft, uncomplicated stricture of the deep urethra should be treated by dilatation. If the stricture be of small calibre, con tinuous dilatation with soft instruments may be practised at first.
As soon, however, as it is possible to introduce moderately large steel instruments they should be used. Continuous dilatation may be practised for from twenty-four to forty-eight hours in very tight strictures, and intermittent dilatation by soft instruments may be practised daily, or every second or third day thereafter. Sys tematic dilatation by steel instruments should not be practised as a rule oftener than once in every three or four days, an interval of from five to seven days being often advantageous. Traumatic stric ture of the deep urethra generally demands perineal section.
_Irritable this form of the disease the patient is usually of a strongly nervous and highly irritable temperament, and the ure thra extremely hypenesthetic. Dilatation produces severe pain and spasm, and is often followed by chill and perhaps fever. Such stric tures require urethrotomy. Resilient and elastic stricture is a con dition in which the obstruction is apparently dilated quite readily, but the symptoms are not relieved, and on exploration with the bulb the coarctation is found to be still present. Urethrotomy is the sine qua non in this condition also. Recurrent stricture is really a variety of resilient stricture in which the property of resiliency is not imme diately manifested, the symptoms, however, recurring very soon after apparently successful dilatation. The cutting operation is the only means of relief in this condition. The hard, so-called nodular stric tures of cartilaginous consistency and long duration which are occa sionally met with in the deep urethra, require, as a rule, perineal section. The same is true of hard and tortuous strictures with com plications, and in cases in which economy of time is necessary, or in which the condition of the patient is such as urgently to demand re lief. Traumatic stricture can rarely be relieved, save by urethrotomy. The author desires to place himself upon record as opposed to in ternal urethrotomy and divulsion of deep urethral strictures. Peri neal section is much more surgical, quite aseptic by comparison, and places the field of operation under approximately perfect control. There are, to be sure, occasions when both divulsion and internal urethrotomy may be justifiable, but these instances are certainly rare.
Electrolysis has received considerable attention as a method of treat ment for urethral stricture. • It is the opinion of the author that this method of treatment has a very limited application. It is not to be condemned in Coto, but the claims which are made for it by some of its enthusiastic advocates are certainly very much exaggerated. That it will in certain instances relieve what the author has termed plus con ditions of stricture, viz., congestion, spasm, and oedema, is probable. When these conditions are removed, however, we are still confronted with the presence of adventitious tissue constituting the true element of the stricture. Upon this the author firmly believes the electrolytic current has very little effect within the limits of safety.
Further discussion of the eminently surgical topic of the treat ment of urethral stricture is hardly warrantable in a work intended primarily for the physician. The author will, therefore, sum up the treatment of the disease by presenting the following resume which has appeared in his monograph upon urethral stricture :