URETTIROTOMT. — Gradual dilatation having failed, or being impossible, some form of cutting operation will be neces sary.
Internal Urelhrotony. — Strictures of the meatus and first inch and a half of the urethra may be divided either by a convex, blunt-pointed tenotome or by one of the various forms of tomes. Strictures situated from an inch and a half to four or four and a half inches from the meatus may be divided by a urethrotome, the dilating instru ment being the best for this purpose. If the calibre is below 15 French, it may be necessary to employ a urethrotome of the Maisonneuve variety to prepare for the dilating urethrotome. The division should be made in the floor of the ure thra. After having cut the stricture a bougie a boule of appropriate size should be passed to be sure that the proper calibre has been obtained, and, if not, a second division should be made.
A soft-rubber catheter should be passed and retained for from three days to a week. After its removal, full-sized metal boogies should be passed as di rected under gradual dilatation, and continued at less frequent intervals for some years.
A urethra which is about to be incised should be made sterile, if this is possible, and the urine of such a patient should always be sterilized at least twenty-four hours before the operation, and should be kept sterile during the time of treat ment. The administration of 20 drops of a mixture of 1 drachm of salol and 2 drachms of oil of gaultheria, three or four times a day, will sterilize the urine within twenty-four hours. In addition to this the urethra should be irrigated with permanganate of potash (1 to 3000) for five minutes before the operation, or it should be thoroughly "ballooned" with this antiseptic solution by using the or dinary conical syringe introduced at the meatus, and the canal thoroughly dis tended with the fluid. This should be repeated three or four times, and a suffi cient pressure employed to overcome the resistance of the cut-off muscle, in this way reaching the entire canal.
The vast majority of all strictures of the urethra can be treated practically without pain with cocaine amusthesia.
The susceptibility of every new patient to this agent should be carefully studied.
When the entire urethra is injected, 1 drachm of a 2-per-rent. solution should first be employed, and the degree or the susceptibility of the patient, as well as the anmsthetic effect produced, can be ascertained in five or ten minutes. If the anaesthesia is incomplete and the patient shows no susceptibility to the drug, an other drachm of the same or a stronger solution may be injected.
Ansthesia of the membranous portion of the urethra may be obtained by carry ing the Keyes-Ultzmann syringe-point down to the cut-off muscle, pushing it slightly within, and injecting 10 to 15 minims of a 4-per-cent. solution. Arms
thesia beyond the cut-off muscle is prac tically impossible.
In meatotomy a few crystals applied just within the meatus, or 10 minims of a 6-per-cent. solution injected, limiting the application by digital closure of the canal one inch behind the opening, will effect complete anaesthesia in division of the meatus or of an organic stricture here. J. A. Wyeth (New England Med. Monthly, Jan., '07).
The very conditions that make cocain ization of the urethra desirable also make it difficult. If, however, the ure thra is filled with hydrogen dioxide (1 part to 3 of water), and the canal thoroughly cleansed of pus, mucus, shreds, etc.; then washed out with plain sterilized water, and a 4-per-cent. sterile solution of cocaine injected, it takes a much shorter time for the cocaine to act, and the anesthesia is. much more com plete than when the cocaine is injected as usual. E. Walter Brierly (Med. Brief, Feb., 'OS).
In the treatment of deep urethral strictures by internal urethrotomy, per sonal method is as follows: The urine is rendered antiseptic by giving 5 grains of salol and 5 grains of boric acid, three or four times daily, beginning several days before the operation, if possible. An anresthetie having been given, the penis is washed with weak bichloride solution (1 to 2000) and the urethra injected with boric solution followed by iodoform and glycerin, 10 per cent. A filiform bougie is then introduced, and over it a Couley tunneled staff. This being withdrawn, a Maisonneuve or Teevan urethrotome is inserted and the stricture cut on the roof of the urethra. A Teevan, which cuts to about a No. 26 French, is used. On its withdrawal Nos. 26, 29, and 30 sounds are passed. A new English catheter, about No. 26, is introduced and the blad der and urethra are syringed out with a boric-acid or very weak bichloride solu tion, and the catheter tied in. Sometimes a couple of drachms of iodoform and glyc erin are injected, part of which flows away. After the operation the boric acid and salol are continued three times daily, or 3 grains of methylene-blue are given in capsules three times daily. The cathe ter is allowed to remain in the urethra until the third day, and sounds passed on alternate days thereafter. The patient is allowed to get up on the fifth to the seventh day, and is usually ready to leave the hospital to attend at the dispensary on the ninth. G. Davis (Univ. Med. )lag-, Aug., '98).