r011ii71710115 Dilatation,--This method is suitable for narrow and irrit able strictures, and consists in passing a small gum-elastic catheter through the constriction into the bladder, and tying it in for 2,1 to 36 hours, after which it is to be withdrawn and the next sized catheter, which readily passes is likewise to be maintained in situ for a similar period, and so on till the urethra is dilated to a moderate degree, when the inter mittent method may he resorted to. The danger of sepsis is always a real one in carrying out this method, and hence it will not be enough to trust alone to the most scrupulous sterilisation of the instruments employed, since micro-organisms may find their way into the bladder from without. Urinary antiseptics by the mouth must therefore he administered, as 5 to ro grs. Urotropine or 3 mins. Creosote in capsule ter in die, and the urethra should he flushed out by a stream of weak Permanganate solution (1 gr. to i oz.) or of concentrated Boric Acid solution before the fresh catheter is tied in each time. The chief objection to the continuous method is that it keeps the patient in bed, but it produces excellent results where the intermittent method for one reason or another cannot be utilised.
As already mentioned, the continuous dilatation may be suspended after the stricture has been fairly opened up and the interrupted method commenced. The steady pressure of the catheter against the face of the cicatricial tissue of the stricture introduces a new element into the treat ment which hastens resolution, acting as hypodermic injections of Fibrolysin are believed to do in all organic strictures, though this plan of treating urethral strictures is seldom resorted to.
Rapid dilatation was formerly much employed; it was carried out by passing, under general a series of graduated metal sounds (Thompson's or Lister's) till at a single seance the urethra was dilated to its fullest normal capacity. Relapses were the rule, and very often dangerous extravasation of urine, permanent fistula and serious complica tions resulted from rupture of the urethra. and this method, like that of Divulsiorr, which consisted in a rapid stretching or tearing of the cicatricial tissue by a double-bladed instrument has been abandoned for safer though less expeditious methods.
has been successfully resorted to in the treat ment of resilient and bridle strictures in the penile portion of the urethra, as this type of narrowing has a marked tendency to contract as soon as dilatation has been suspended. It is the most suitable method of treating very irritable and bleeding strictures. and those in which the passage of a hougie is always followed by rigors and in narrow strictures where the presence of a tied-in catheter cannot he tolerated by an irritable bladder.
The rationale of the method consists in a free division of the cicatricial tissue in the long axis of the stricture, which is then kept open during the healing process by the regular passage of a solid Bougie.
A number of ingenious instruments are in use, each operator selecting one which carries out some requirement that he considers essential to success. These may be divided into two classes—i.e., those designed to sever the stricture from before backwards, and those which are first passed through the stricture, which is then divided from behind forwards as the instrument is withdrawn.
For very narrow strictures of cartilaginous hardness the former kind of instrument is employed. A filiform guide-bougie is first passed through the stricture into the bladder. Upon this the urethrotome is introduced down to the narrowed part, and by means of a spring the concealed blade of the instrument is protruded and the constricted part is divided to the required depth as the blade is pushed against the stricture towards the bladder, cutting from before backwards. Hill's instrument can be used when the stricture only admits a Nro. 2, but Afaisonneuve's and Tevan's instruments are more commonly used.
Where the stricture can be dilated to the size of a No. ; (English) instrument the urethrotome of Civiale or Otis is passed through it. and as the instrument is withdrawn the concealed blade is caused to incise the narrowed part for its entire length, the depth of the incision and the " tautness " of the parts being regulated by various mechanical con trivances designed for the purpose. The stricture must he divided on the floor of the urethra and through its entire depth, but care must be taken to leave intact the healthy vascular or erectile tissue lying external to it. In using Otis's urethrotome the operator gets great assistance by feeling the resistance of the tissues and the progress of the blade. on grasping the penis from the outside with the fingers of the left hand.
After either form of cutting operation a large solid metal sound (No. x4 English) is introduced into the urethra, and permitted to find its own way into the bladder by gravitation. This gives a practical proof of the completeness with which the stricture has been divided, and should the sound fail to enter the bladder without pressure a second incision of the parts, in a plane different to the first, may he considered advisable. Irpon withdrawal of the sound the largest-sized metal catheter is inserted, and the bladder very thoroughly emptied of all urine. It is a mistake to attempt to tic in a catheter unless hemorrhage has been severe. The patient is placed in bed, gets a Morphia suppository and abstains from drinking liquids, and is kept very warm so as to encourage the action of the skin, whilst a few bits of Ice are used to relieve thirst. In 6, S or TO hours, when he can hold his urine no longer, he is placed in a hot bath and permitted to micturate. Rigors are to he anticipated by a full Opiate, Whiskey and Quinine, and the bowels, which should have been purged before operation, are allowed to remain unrelieved for a few days.