ADDRESS IN SURGERY.

THE RATIONAL TREATMENT OF STRICTURE

OF THE URETHRA.

BY SAMUEL W. GROSS, A.M., M.D.,

OF PHILADELPHIA.

GENTLEMEN OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA:

AT your last meeting, when you did me the honor to appoint me to deliver the Address in Surgery, you adopted a resolution that all addresses, in their delivery, should be limited to thirty minutes, in order that they might be open to debate. Instead then of occupying your time with a retrospect of what has been accomplished in this department of the healing art during the past twelve months, I take it that I will best meet your wishes by selecting a topic with which, from ample experience, I am practically familiar, and which will furnish you the occasion for instructive discussion.

Of the various surgical affections in the treatment of which real and substantial progress has been made of late years, none is more commonly met with than organic stricture of the urethra; and it is gratifying to note that much of the success of operative measures is due to American innovations. Having myself fully tested the different methods of managing this most troublesome disease, and having arrived at certain conclusions as to the proper practice to be resorted to for its relief, I am induced to lay them before you, the more especially as I can in this way answer the inquiries which I constantly receive in regard to this class of cases.

The only rational treatment of stricture is to restore the normal calibre, or distensibility, of the urethra at the affected portion. This is a self-evident truth; but, strange to say, it is generally lost sight of, or, if it be recognized, the means usually adopted are certainly inadequate to meet the end proposed. Lest I may be accused of indulging in groundless assertion, let me ask how many of you ascertain, as a preliminary measure, the calibre of the urethra with the view of bringing the narrowed portion up to that standard?

In the process of gradual dilatation, which the majority of you, in common with the profession at large, adopt, how often do you obtain a satisfactory result, to say nothing of a permanent cure? In the application of this method, bougies are introduced at stated intervals and in gradually increasing sizes, until the meatus refuses to take a larger instrument, so that the extent to which the dilatation is carried is gauged by the size of that orifice, which, it need scarcely be remarked, is the narrowest portion of the canal, although in exceptional instances it is as large as the urethra behind it. In these rare cases-and I have only met with two-particularly if the stricture be soft and recent, and does not contain elastic fibres, relief may be obtained, but, as a rule, some symptoms will only be palliated. Even in strictures of large size, and these are the ones most commonly met with, after the cessation or even intermission of instrumentation, the prominent symptoms-which are a gleety discharge and dribbling of the last few drops of urine, with perhaps irritability of the bladder, prostatic or involuntary seminal discharges, painful testis, or disturbances of the sexual powers-are sure to recur. In these cases the bulbous explorer will define the coarctation just as clearly as before the treatment was begun, and afford convincing proof that little progress has been made towards

a cure.

If it be assumed that dilatation is the best and most generally applicable method in properly selected cases, it is very certain that disappointment will ensue if the process ceases with the largest bougie that comfortably stretches the meatus, for the simple reason that the entire urethra is many millimetres larger in circumference than that opening. Hence it is impossible to restore the urethra to its natural capacity unless it be acted upon by an instrument which corresponds to that capacity. My measurements, which confirm those of other observers, show that the average meatus is equal to 24 mm., or nearly one inch in circumference, or to a No. 14 English catheter; while the circumference of the spongy portion, which is itself smaller than the bulbous division, is equal to 32 mm., being a difference which would be represented by a No. 3 English or a No. 8 French catheter. From a consideration of these anatomical points, it is evident that a stricture seated in the urethra, the distensibility of which corresponds to a No. 32 French bougie, cannot be efficiently acted upon by an instrument which merely stretches the meatus. A No. 24 bougie cannot by any posibility restore the stricture to the normal calibre of the urethra; and it is to this fact that the unsatisfactory results of this mode of treatment are to be asscribed.

Surgeons of the present day, who are most experienced in the management of this affection, and believe that dilatation is capable of effecting a cure, reject it in coarctations of the pendulous or antescrotal urethra, in which situation they are very contractile, in traumatic very irritable, and resilient strictures, in cases in which it cannot be carried beyond a certain point, and in strictures complicated by fistulous openings. Hence the field of its usefulness is limited by simple narrowing of the bulbous portion of the urethra, and the prognosis should be the more favorable if the new tissue be soft and of recent formation. Recurring again to the common practice, in a case of uncomplicated stricture in this locality, where organic contractions are most frequent, bougies are used until the meatus resents their further insertion. If the meatus be of the average capacity, permitting the passage of a No. 24 French, without particular discomfort, the stricture can only be made to correspond to that number, whereas it should be dilated to 35 millimetres, which represent the normal average distensibility of the bulbous urethra. While it is true that we may succeed in diminishing or relieving some of the more urgent symptoms in such cases, it is obvious that a cure has not been even approached; and that to effect a good result the meatus should be enlarged to admit of the passage of an instrument of the size adapted to restoring the constricted part to its original dimensions as determined by previous measure

ment.

In my teachings I advise that this practice be adopted, since if it be omitted we cannot advance beyond a certain point. With a divided orifice and the employment of bougies up to the full size of the normal urethra, dilatation becomes a judicious procedure, and if it be capable of affording complete relief, it certainly should do so under these circumstances. What results may have been attained by others under this improved method of gradual dilatation, I have no means of determining; but I can conscientiously say that I myself have never effected a radical cure, although many patients have been greatly benefited and rendered temporarily comfortable.

From these considerations I have reached the conclusion that dilatation is powerless to effect a permanent cure; but that it is not, on that account, to be discarded from the therapeutics of stric ture, since many cases arise in which, from the disinclination on the part of the patient, or from the existence of contraindicating disease of other portions of the urinary apparatus, it is the only recourse at our command.

Of late years, whenever I have been allowed to act upon my own judgment, I have employed dilatation only as an adjunct to other

methods, the object of which is to restore the urethra to its original calibre by inserting a splice of new tissue between the divided sides of the cicatricial tissue upon which the narrowing of the pas sage depends. This may be accomplished either by divulsion or internal urethrotomy, or by both methods combined, in accordance with the indications presented by each individual case. Previous

to the performance of any operation there are, however, certain points to be considered, the observance or neglect of which will tend to hasten or delay the cure. According to my observations too little attention is paid to the fact that a stricture is something more than a mere mechanical obstacle to the free passage of the urine or the introduction of instruments. In every case there is associated with it a chronic or subacute urethritis, which is a source of spasm and irritability, to the latter of which most of the reflected symptoms of stricture may be traced. Hence, in the rational treatment of this affection, the indications are first, to allay congestion, spasm, and tenderness, whereby the urethra will be placed in the best possible condition for an operation; secondly, to bring the coarctation up to the normal calibre of that portion of the urethra in which it is seated; and thirdly, to prevent or mitigate an attack of urethral fever.

To fulfil the first indication, it is important that the patient. should avoid exercise in a carriage, a railway car, or on horseback; refrain from sexual indulgence and stimulating food and drinks; maintain his bowels in a soluble condition; be careful as to exposure to wet and cold; in a word, abstain from everything which tends to increase plethora of the hemorrhoidal and prostatic plexus of veins. By the observance of these hygienic measures, and the internal exhibition of remedies calculated to correct the acidity of the urine and diminish the sensibility of the urethra, of which I have found bromide of potassium to be the best, the future use of instruments will be greatly facilitated.

Of direct measures to subdue the spasm and tenderness of the urethra, the most reliable is the conical steel sound, commencing with a number which corresponds with the calibre of the stricture, and progressively increasing the size as the hyperesthesia diminishes. For the first few insertions, which should be practised at intervals of forty-eight hours, it should be at once withdrawn; but it should afterwards be retained for several minutes, and its use be continued until the sensibility is entirely obtunded. In the event of the meatus being the seat of a stricture, or being much smaller than the rest of the urethra, it should be cut, as a preliminary measure, in order that it may correspond with the size of the largest

instrument that will be demanded in the subsequent treatment. By observing this precaution the length of time required to overcome the inflammatory complications will be greatly shortened. Should the passage of the sound be accompanied with much pain, sedative and astringent injections may prove useful as adjuncts; but if the irritability be so great that each passage of the bougie is followed by chills, further efforts in this direction must be abandoned, and the case be subjected to operation.

The urethra having thus been placed in the best possible condition for operation, the size of that portion of the canal in which the stricture is located should be ascertained with the urethrometer, of which one of the best and cheapest is that devised by myself, and

Fig. 1.

6.TIEMANN&.00.

shown in Fig. 1. As it is also an efficient explorer, it will be found useful in confirming the results of the first examination as to the number, location, and calibre of the stricture. These points, along with the normal size of the urethra to which the constriction is to be restored, having been determined, the surgeon is in a position to select the operation which he may deem best calculated to meet the requirements of the case.

Before proceeding to a radical cure, however, there is a point of great practical importance with which you should be familiar, as it. has a direct bearing upon the diagnosis and treatment. It is-and I believe I was the first to call special attention to it-that when a stricture is seated within the first inch of the urethra, or at the meatus and in the navicular fossa, it is rarely confined to that locality. Thus my notes show that, of 180 cases, representing 322 strictures, in 67, or more than one-third, was a coarctation found in this region. Of these only 7 were solitary, 34 were double, 20 triple, 3 quadruple, 2 quintuple, and 1 multiple; the last having been an instance of 11 contractions in the first two inches and a half of the urethra, to which references will again be made. In other words, in 100 examples of stricture within the first inch of the urethra, in only 10 will it be found to be single, while in 50 an additional one will be detected, in 30 two more will be detected, and in 9 several more will be discovered.

A knowledge of the foregoing facts will lead the surgeon to