The symptoms of this disease are, inability to ex pel all the urine at once, there being always a few drops remaining between the stricture and the blad der, so that when the patient imagines he has fin ished, he finds his clothes wet, and on pressing the penis more urine is expelled; the stream soon be comes wiry, spiral, forked, or scattered, and there is straining with an uneasy feeling in the perineum and anus after voiding the urine; there is a greater desire to make water in the evening and during the night, being seldom able to lie longer than four hours, and occasionally making it involuntarily, with now and then a nocturnal emission. A gleety and even a purulent discharge is present from the beginning, so that it is liable to be mistaken for gonorrhoea. As the disease advances, the urine is voided in drops, great pain is experienced extending to the loins, the urinary bladder is thrown into vio lent action, and discharges mucus and pus, and the patient penis. These symptoms, with retention of urine from time to time, either gradu ally exhaust the patient, or the urethra behind the stricture bursts, and the urine is effused into the cellular substance in the vicinity, as described under retention, or the bladder ruptures, and the same event occurs, or lastly, the urine escapes, and forms fistula in perineo, and the patient survives. The slightest excess in drinking aggravates the symp toms, and often produces the spasmodic stricture, as well as retention of urine; and so also does the change from a warm to a cold atmosphere. These causes, together with the insertion of the bougie, often produce a febrile paroxysm resembling ague. The simple spasmodic stricture is rarely met with in consequence of the patient disregarding it until a permanent state has been induced by the inflam mation excited from repeated attacks. When the violence of the spasm is present, the treatment is by bloodletting, a dose of nitrous ether and lauda num, the warm bath, an enema of warm water, or one combined with laudanum, and warm opiate fomentations.
The treatment of the permanent, is by catheters or bougics, the latter of which are made of wax, cat-gut, horse-skin, elastic gum, silver and steel; but the wax, elastic gum, and steel, are those chiefly employed. One of elastic gum or steel, as large as the meatus will admit of, is to lie conducted along the urethra down to the seat of the stricture, and the point marked with the nail of the finger, when va rious ones of smaller dimensions are to be inserted, until one enters the stricture, which if of short ex tent, or the ring stricture, may be treated with the caustic bougie, which is merely one of wax, having a small portion of the nitrate of silver inserted in the point, and which is to be conducted to the stric ture, and kept there with a slight degree of press ure for a few seconds at first, but at each applica tion longer and longer, previously however insert ing a common bougie of the ordinary size of the canal for a few seconds, to remove any mucous or spasmodic irritability of the urethra. If the caustic produces so large an eschar as to plug up the ure thra, a small common bougie will remove it; and the application of the caustic ought only to be repeated every second day. When there is so great a degree of irritability of the urethra and bladder that the caus tic produces a febrile paroxysm, the pure potassa should be used instead of the nitrate of silver, and the warm bath combined, together with the inter nal exhibition of the muriate of mercury and nitrous ether. The caustic occasionally produces hemor rhage, which may be easily suppressed by compres sion. The caustic is very liable to make a false passage, especially if the stricture be beyond the bulb of the urethra, and consequently ought never to be employed excepting in this ring stricture. A false passage is to be apprehended if the bougie makes progress towards the bladder, while the dif ficulty of voiding the urine continues as at first.
In the lengthened stricture, the common or me tallic bougie is to be preferred, beginning with one the size of the stricture, and gradually increasing them in size, and retaining them each time for a longer period: indeed, even when a cure is estab lished, the patient should be taught the insertion of an ordinary sized catheter, which he ought to use at least once a week. If irritability follows the em
ployment of this bougie, the same mode of relief is to be adopted as recommended when using the caustic one. The metallic bougie acts by disten tion, absorption, ulceration, and again absorption. A more expeditious and safe way of curing either the short or long stricture, if the patient will con fine himself to bed, is by the insertion into the blad der of a series of elastic gum or silver catheters, beginning with one the size of the stricture, and progressively increasing them. They can generally be enlarged every second day. This is also pre ferable to Mr. Arnot's method or Mr. Stafford's lancetted stilettes.
The stricture, if of some length, and so small that the bougie cannot overcome it, ought to be cut down upon, and a larger urethra made by the introduction of the flexible gum catheter. A sound is inserted in the urethra down the length of the stricture, and an incision made with a scalpel to its point, when the strictured portion is to be discovered with a probe and laid open, the sound withdrawn and a catheter inserted in the bladder. When the stric ture is situated opposite the scrotum, a free incis ion should be made in the cellular tissue of the lat ter to prevent the urine from diffusing itself in it. The French use a sonde conique and force the ob struction. Mr. Amussat, however, employs the in jection of warm water as described under retention of urine. In many instances of strictured urethra, it is advisable to puncture the bladder, and after wards restore the continuity of the canal.
When the canal ruptures behind the stricture, a free incision should be made to allow the urine to flow by the wound, and the contiguous infiltrated cellular tissue ought to be freely punctured. When the surgeon makes a false passage by the bougie, which is known by the rough feeling communicated to the fingers, by a tearing sensation, and by the instrument being in a degree grasped, he should immediately withdraw it, and desire the patient to retain his urine if possible, that it may not irritate the wound, and diffuse itself in the contiguous cel lular tissue, but allow a clot of blood to form, and a slight degree of inflammation to heal the wound. If he persists, either with the bougie or the cathe ter, he will only aggravate the evil, for the false passage being distended with blood, presses on the urethra, and prevents him from conducting it on wards to the bladder, the urine flows into this pas sage, is extravasated in the contiguous parts, and forms an abscess which commonly ends in fistula in perineo, or urinary fistula. This disease also en sues from ulceration of the urethra behind a stric ture, which is sometimes involved in the ulceration. If there be only an abscess, it ought to be most freely cut open. In this affection, a sound should first be passed into the bladder, and then a flexible gum catheter,which must be worn and progressively enlarged until the fistula is healed. When a stric ture has been the cause, either this should be de stroyed with caustic or cut down upon, and the lat ter ought to be preferred. In some rare instances no trace of the original canal can be discovered, in consequence of the urine rendering the substance in the contiguity of the fistula (for there is often more than one aperture) purely cartilaginous; and then the operator must make a urethra according to his anatomical knowledge. In the healing of such a wound considerable difficulty is experienced, and may be best accomplished by treating it, as recom mended in hare-lip, or by the actual cautery. Stricture of the urethra rarely occurs in the female, and only in consequence of maltreatment in partu rition, or in the insertion of the catheter; and when it is present, its treatment is the same as recom mended in man.