Conclusions based upon the results ob tained in 1500 internal urethrotomies: In cases of chronic urethral discharge, in ternal urethrotomy should be practiced after all other methods of treatment have failed, and even when the urethra will admit a 26 French or possibly a 30 French, the cutting operation often ef fects a cure. The operation is followed only in very few cases by any untoward symptoms; occasionally slight dribbling of urine may continue, but never any worse than that caused by the stricture for the relief of which the operation was instituted. Among a few other sequels may be mentioned continuance of ure thral discharge, pseudo-impotency, per manent chordee (this last very rare) ; sometimes hremorrhage following either immediately or shortly after the opera tion gives considerable annoyance to the surgeon. Fatal results have been per sonally had from internal urethrotomy and the large majority Gf patients are permanently cured. G. Frank Lydston (Med. News, Mar. 4, '99).
External Urethrotomy.—This is usu ally required at the deep urethra, in which situation it is called external per ineal urethrotomy. It is required for strictures of the bulbo-membranous and membranous urethra that cannot be cured by gradual dilatation.
A staff is passed into the bladder, the urethra exposed by an incision in the middle line of the perineum and the stricture divided upon the staff. If the staff will not pass the obstruction the urethra should be opened on the tip of the instrument just anterior to the strict ure. By carefully holding the divided edges of the urethra apart a filiform may be passed which will act as a guide in dividing the contracted portion.
In the operative treatment of urethral stricture, Kiinig includes in the technic of external urethrotomy the excision of all cicatricial tissue. At times as much as 3 or 4 centimetres have been ex cised. If possible the divided ends of the urethra should be united with fine cat gut or silk sutures; not in its entire cir cumference, however, the floor of the ure thra being allowed to remain patulous. In Kiinig's experience in cases in which it is impossible to approximate the cut urethral surfaces the interspace is event ually filled in by regeneration of tissue analogous to that in the urethra. This
has been found to take place despite the fact that the urine is evacuated through the fistula. The precaution is taken, after each urination, to carefully cleanse the parts, At the expiration of three weeks the fistula is usually closed. Reinhardt (Phila. Med. Jour., Oct. 15, '93).
Attention is called to certain points in performing external urethrotomies for strictures which may prevent recurrences and annoying complications. The roof of the urethral canal should always be divided as well as the floor. In order to ascertain whether all of the stricture-tis sue has been divided, the index finger, with the palmar surface directed upward, should be passed into the perineal wound and down to healthy urethra, well in front of the stricture, and then backward on the roof of the canal into the bladder. The posterior urethra should be dilated with the index finger, a measure which prevents post-operative tenesmus. Drain age is best attained by a large perinea' tube, which is withdrawn in two to four days to be cleansed and then replaced; it should be removed permanently on the fifth to seventh clay. Post-operative dila tation should be begun as early as the second day. J. R. Hayden (Amer. Jour. Med. Sci., Feb., '99).
External urethrotomy is applicable in resilient and rapidly contractile strictures in the deep urethra; in cases in which the wound made by an internal ureth rotome is out of proportion to the natural drainage possibilities of the ure thra: in stricture complicated with uri nary fistulce and in eases of stricture with extravasation; in some rare eases of stricture in which operative treatment is rapidly followed by acute symptoms of impending death. Impor tance is attached to the use of a guide, the utility of the internal operation as immediately preliminary to the external, and the more efficient provision for urine and wound drainage. R. Harrison (Lan cet, Mar. 17, 1900).
The after-treatment is the same as that given for perineal section.