The following diagrams are further explanatory of the stricture in its amplified forms.
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The dark marginal line denote the calibre of the urethra, and the inner lines the actual diameter of the obstructed passage. Figure 1 shows the stricture to be on the lower part of the urethra. Figure 2 the upper part. Figure 3 exhibits a stricture of some length, and a somewhat contracted state of the whole canal. Figure 4 denotes a very common form of stricture, which resembles a flour-bag tied in the middle; it is the least difficult to cure of any, because it signifies that the seat of irritation is limited; but these cases are generally precursory to severer forms, if not promptly attended to. Figure 5 represents a stricture of considerable length, and of course very difficult of removal.
There are many provocatives to stricture, and when once mischief is progressing, it makes up for its slow initiation by giant strides. A patient may have a trifling stricture for years without experiencing much inconvenience. He takes cold, fatigues himself, commits some stomachic or other excess, may possibly have fever, all of which more or less disturb the general economy, alter the character of the urine, and in that manner doubly accelerate the disorganization going on in the urethra. A small abscess may spring up in the urethra, or below it among the cellular membranes and integuments. In either case, it chances now and then to burst an opening and create a communication externally with the urinary passage, constituting what is called fistula. A person laboring under stricture is always liable to these occurrences. As much mischief is done oftentimes by mismanagement as by neglect. The clumsy introduction of a bougie, or, in other instances, the unjustifiable introduction of one, is likely to, and very frequently does, lacerate the delicate and irritable membrane, and make a false passage. Figure 6 exhibits an instance at Nos. 1 and 2; the upper numerical shows a false passage made by a bougie, and an obliteration of the ordinary passage of the urethra, the result of inflammation, constituting an impassable stricture; the lower figure exhibits a false opening made, in the first instance, by a fruitless effort at passing an instrument, when inflammation completed the process. No urine escaped from it of course, because communication was cut off from the bladder by the impassable stricture; the outlet for the discharge of that fluid being through a sinuous opening marked No. 2, the No. 3 denoting the closed end of the urethra. The case happened to a man in very ill health, who was prone to ulceration, and he gradually sunk under exhaustion from debility and premature old age. Figure 7 exhibits a stricture where the posterior part was enlarged by the constant pressure of the urine to escape through the narrowed part of the urethra; ulceration ensued, and a fistulous opening was the consequence; the stricture was seated high up, and the fistulous canal was several inches long, terminating in the upper and posterior part of the thigh; the urine used to dribble through it as well as through the urethra. The patient had been a seafaring man; he was in exhausted health from hot climates and intemperate living, and he died at last of consumption. I have the parts showing the stricture and the fistulous opening by me, in a state of good preservation. In Figure 8 is presented an illustration of extensive ulceration producing two fistulous openings; the state of the urethra was only discovered after death, the patient having concealed his infirmity for many years; he died suddenly from apoplexy, being found dead in his bed by the people of the house where he lodged. Figure 9 portrays irregular and extensive ulceration. The patient died from syphilis, having gonorrhœa at the same time. I have the preparation. Figure 10 shows an impervious urethra, and a fistulous opening through which the urine flowed. The urinary passage was blocked up within two inches from the orifice, and the length of the obstruction was perhaps a quarter of an inch. It was perforated successfully by the lanceted stilette, and the passage thereby rendered continuous; the catheter was worn for several days, and the false opening soon healed after a slight application or two of nitric acid. Numerous other illustrations might have been given, but the preceding convey a passable notion of the simplest, and most confirmed, and most severe forms, of the malady in question.
It is melancholy, notwithstanding the resisting and reparative power of nature to avoid so saddening a disease as stricture, that it is so very prevalent, and that it is occasioned by so many causes. Where it is not destructive to life, it is very injurious. It involves, where it is severe, other important organs beside the seat of its abiding; the repeated calls upon the bladder, through sympathy of the irritation, created so near to that viscus, the efforts which at all times it is obliged to make, although assisted by the muscles of the abdomen and contiguous parts to void its contents, at last, and very frequently end in paralysis, and total inability to pass water ensues, except through the aid of the catheter. Independently of which, where so much disease exists as in the urethra, the urine also constantly pressing against ulcerating and irritable surfaces, extravasation of that secretion takes place, and the most formidable and alarming consequences ensue. In the simplest form of stricture, many important functions are disturbed. A very frequent consequence is permanent irritability of the bladder, so that the patient is obliged, ten or twelve times a day, to micturate, and is unable to pass through the night without suffering nearly the same inconvenience. Besides which, the natural sensitiveness of the genital organs becomes speedily and much impaired. I am satisfied that where disorganization of the testicles does not exist, and where the patient is young, or even middle-aged, if he be impotent, he will in nine cases out of ten be found to have stricture. There are exceptions, which shall be named when speaking on the infirmities of the genital system, but in nearly all cases of impuissance there will be found, if not stricture, at least some morbid irritability of the urethra. During the existence of stricture, there is generally a vitiated secretion from the seat of mischief, constituting a gleet; therefore a gleet at all times should be regarded, lest it be an indication of something more than a mere weeping from enfeebled vessels.
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On the Treatment of Stricture.—Having fully described the symptoms and progress of stricture, I proceed to the more pleasing part of treatment. Stricture, if early attended to, is a disease easy remediable: if neglected, its horrors accumulate, and sufferings the most acute close the scene. Such, however, is the progress of science, that it is almost possible to cure the most inveterate case, at all events to relieve it; but that is no reason why the initiatory notices should be disregarded. Stricture, as must be perceived, is of two kinds, spasmodic and permanent: the treatment of the first is chiefly medical, the treatment of the latter chiefly mechanical. The principal agents I rely upon in the cure of the former, are the warm bath, rest, sedatives, and certain dietetic restrictions; for the removal of the latter, I place unbounded confidence in the practice of dilatation; and I am of opinion that the other methods, namely, the application of caustic or the scalpel, might be dispensed with altogether, if the dilating method be not delayed too long.
Before commencing the cure of stricture, I need hardly observe, that we ought to be fully satisfied of its existence. Symptoms are not always unerring guides; and, therefore, our reliance should not wholly depend on them.
——“to be once in doubt