Gradual dilatation is advised in all cases of stricture of the deep urethra if a No. 12 French or larger instrument can be passed. It should also be tried in recent soft, large strictures of the pendu lous urethra, excepting those of the first inch and a half of the urethra. This method is carried out as follows: Sup pose a No. 16 French bougie a boule has demonstrated a stricture, a No. 17 or 18 metal urethral bougie should be passed and allowed to remain a few moments, after which a 19 or 20 may be intro duced. The next treatment should be three to five days later, depending upon the case, at which time probably an 18, 20, and 22 bougie may be passed, and so on, increasing one or two sizes at each visit, until the normal calibre of the pa tient shall have been reached. Occa sionally a stricture will be so dense and inelastic that the same sizes must be used at two or more successive seances before a larger size will pass. In ing out this procedure the general rule should be to "coax" the stricture rather than to employ force. After the full calibre of the urethra has been obtained a bougie of the proper size should be passed at gradually increasing intervals for two to three years, and, if any tend ency to recontract is observed, through out the patient's life.
The less force is used, the more certain are the results in the dilatation of strict ure. The general rule should he to pass two soft bougies, differing by one-third of a millimetre, or two to four metallic bougies, differing by one-sixth of a milli metre, at a time; to leave them in but a minute or two, or even to withdraw them at once; to pass them not oftener than upon alternate days, and always to begin with a lower number. Thus, and thus only, will one successfully treat a dilatable stricture—that is to say, the great majority of strictures. If one has in hand a "bad" stricture, one may try "prolonged dilatation," but only with soft bougies that enter easily—with, in deed, a bougie that seems "too small." Clinical experience shows that it is the dynamical, not the mechanical, use of dilating instruments that will give last ingly-good results, without inconven ience and without danger to the patients.
If a11 the resources of this method are fairly tried without achieving sufficient dilatation, there is but one resource—in ternal urethrotomy in one form or an . other. A. A. Warden (Glasgow Med. Jour., Sept., '07).
In all cases of old stricture the treat ment must be conducted in carefully regulated stages, and the urine submitted to frequent examination. In some cases, in which the introduction of any instru ment has been attended with very con siderable difficulty, a capillary catheter has been successfully used.
The capillary catheter must always be handled with great delicacy and patience. After injecting the urethra with warm oil, the penis is drawn forward with the left hand, and the instrument gently passed down to the stricture. As soon as its progress is arrested it must be withdrawn two or three inches, rotated between the thumb and finger, and again twisted down upon the obstruction. Dur ing the repetition of these manipulations it often slips into the bladder, at the same time its free and easy movement in the urethra, together with the sensa tions experienced by the patient, clearly indicate to the operator that the stricture has been overcome.
The instrument is generally retained in position for about thirty-six hours. When the operation of dilatation after prolonged rest and many patient efforts proves unsuccessful, and the patient re mains exposed to the risk of complica tions, the operation of external ure throtomy, followed by bladder drainage through the perineum, is recommended as the very best surgical procedure that can be practiced. J. W. Cousins (Brit. Med. Jour., Jan. S, '9S).
In every case of urethral stricture the surgeon should first try gradual dilata tion before recommending a cutting op eration. The results are quite as per manent and the duration of treatment (from 3 to 12 months) is actually no longer than had urethrotomy been per formed. S. T. Howland (Med. News, Apr. 9, '9S).
A special method of rapid dilatation is recommended in the treatment of certain cases of advanced urethral stricture, espe cially those complicated by some degree of retention of urine and calling for sur gical aid. The instrument employed is constructed on the lines of a Holt dilator, and is provided with a pilot guide, as well as with a screw-top, in case the former proves useless. It con tains a fine test-catheter on which the dilators run, and is fed with a series of 7 rods by which dilatation can be car ried from a No. 3 to a No. 12 (English scale). The dilatation is effected under and must be done deliber ately, so as to stretch and not to lacerate the stricture, the operation usually last ing about from 10 to 20 minutes. When the stricture has been fully dilated the instrument is quietly withdrawn, and the urine that remains is evacuated with a full-sized silver catheter. Reginald Har rison (Lancet, Aug. 6, '9S).
Notwithstanding the unfavorable re sults in a few cases, electrolysis is a valuable method in the treatment of the glandular form of chronic urethritis. From a study of 17 cases, the following conclusions are reached: 1. In all cases of suspected urethral disease (excluding cases of acute ure thritis) a careful urethroscopical exam ination should precede treatment.
2. As a rule, all forms of chronic ure thritis can be cured by regular dilata tions and urethral injections of a sil•er nitrate solution.
3. Electrolysis is indicated only in the glandular form of chronic urethritis.
4. Electrolysis will cure the larger pro portion of chronic glandular urethritis.
5. If electrolysis fails, the dilatation treatment is indicated.
6. In some cases of chronic urethritis, dilatation treatment preceding electroly sis will prove beneficial.
7. In those cases in which firm and dense cicatrices have developed in conse quence of electrolysis, regular dilatations should be proceeded with.
S. During treatment endoscopical ex aminations of the urethra should be regu larly made, controlling thereby, under the direct guidance of the eye, the progress of the disease, and, according to the con ditions found. modifying the treatment. G. T. Mundorf (Med. Record. Aug. 20, '9S).
After four years' experience of elec trolysis in urethral stricture. its results considered superior to those obtained from internal urethrotomy. Chassaignac (New Orleans Med. and Surg. Jour., May, 1900).