Our first object in treating strictures is to ascertain the number and situation of the contractions. The bougie should be curved to the requisite degree (which is necessary in all cases where these instru ments are introduced) and oiled before its introduction. The surgeon holds the glans penis lightly with the fore-finger and thumb of the left hand, just under the corona glandis, and introduces the bougie with the right hand, carrying it forwards gently, and drawing the penis upwards, so as to make the urethra tense. When he meets with an obstruction, he waits a little, and tries again. He should make a mark with the nail on the bougie, oppo site to the end of the urethra, if he cannot pass a stricture ; and then try a smaller instrument The same plan must be pur sued, until all the contractions are ascer tained. If he makes this examination with a soft white bougie, he may get an im pression of the stricture by pressing gen. tly, which will be of servicetin the subse quent treatment. For the cure of the complaint common bougies may be used ; or they may be armed with caustic.
The common bougie acts mechanically by dilating the contracted portion. The largest instrument that the urethra will admit should be passed into the bladder daily, and left there for ten minutes at first, gradually lengthening the time It should be secured by tying it to the end of the penis. The size of the bougie should be increased, as the strictures di late.
Where caustic is used, a small piece of argentum nitratum is inserted in the end of a bougie, and surrounded laterally by its substance. This is termed an armed bougie. In using this method, we ascer tain first ho‘v large a common bougie will pass to the stricture, and mark accurately the distance of the contraction ; then take a caustic bougie of the same size, and mark the distance on this also. We then carry it pretty quickly down to the stric ture, against which we hold it steadily, at first for a short time (less than a mi nute) but afterwards longer. 'fills is to be repeated every other day, and to be practised successively with the different strictures that are met with Mr. Whate ly has recommended a peculiar mode of employing caustic. He breaks a piece of kali purum, with a hammer, into bits, of which the largest should not exceed a pin's head, and keeps these in a phial with a ground stopper. He passes a ban gle through the stricture, and marks the situation of the contraction. In the end Of this he makes a small hole with a pin, inserts a bit of the kali, smaller than a pin's head, and covers it with lard. He passes his bougie, properly curved, down to the stricture, and lets it rest for a few seconds, that the kali may dissolve ; he then urges it about one-eight of an inch forwards, allows it to rest, and then passes it on about as much further. He now withdraws it to the beginning of the stric ture, and passes it through again once or twice. This is to be repeated every
seven days, the size of the boogie being increased as much as the stricture will ad mit. Mr. Whately adopts this plan, from supposing that the membrane of the ure thra is diseased for some extent.
A new passage is sometimes formed by the use of boogies. Here all instruments should be laid aside, if the circumstances admit, to give an opportunity for the parts to recover.
notulain perineo. When the urethra is very much obstructed, nature often en. deavours to procure relief by ulceration on the inside of that part of the urethra, which is between the stricture and the bladder. Hence the urine insinuates it self into the cellular substance of the pe rineum, scrotum, &c. causing suppuration and mortification. if the patient survive, the sloughs are detached, leaving a free communication between the urethra and the external surface : and the openings thus produced, by which urine is evacu ate, are called fistula in perineo. The treatment consists in removing the stric ture, which is the cause of the complaint ; and this must be attempted both by the caustic and common bougie. If the fistu la does not heal, when the urethra is per fectly restored to its natural dimensions, it should be laid open like any other sinus which does not seem disposed to heal. A catheter, or staff, having been passed into the bladder, a director is introduced along the sinus, until it meet the former instrument ; then it will be easy to divide the sinuses with the crooked knife. An elastic catheter should be worn until the wound is healed, which should be dress ed from the bottom. The treatment of the complaint, which terminates in a fis tula in perineo, will be considered under the next head.
Retention of urine. When the evacua thin of urine is prevented by any particu lar cause, the bladder becomes remarka bly distended. Its fundus ascends towards the navel, and forms a hard circumscribed swelling above the pubes, while the low er portion of the vacua bulges towards the rectum. Violent pain and straining, tension of the abdomen, cold sweats, anxiety, &c. are attendant symptoms. 'When the cause of the retention does not close the urethra, and it has proceeded to a considerable extent, the urine comes away by drops through the natural pas sage, leaving the bladder still distended. If the canal, through which the urine ought to flow, be obstructed, inflammation and ulceration or sloughing ensue. When this happens in the urethra, fistula in pe rineo are the consequence. But the blad der itself may slough and burst. Reten. tion of urine arises from the following causes. Weakness, or paralysis of the bladder, inflammation of this viscus or of the adjacent parts, a spasmodic affection of the urethra, or some actual contraction of the passage.