If the instrument be arrested at about six inches and a half, the complaint, in all probability, is seated in the transverse portion of the prostate, and requires very cautious treatment.
When the obstruction is at the very entrance of the bladder, a resistance will be perceived, which, on yielding, will impart a peculiar sensation as the sound enters the bladder. When stricture is thus situated, there is a frequent desire, with almost total inability, to micturate; and when once formed, it is productive of the most serious mischief, unless relieved.
In cases of permanent stricture, the passing of the sound conveys the sensation of going over a ridge. Where it meets with a temporary stoppage, and then passes on, it has probably hitched to a fold of the urethra. Sometimes it will enter the orifice of a dilated follicle; and if much pressure is used, it will occasion considerable bleeding.
The nature and situation of the disease being ascertained, the cure may now be proceeded in, recollecting that no force is to be used, and that too much be not attempted at one essay. Now without entering into an inquiry as to the laws on which contraction and elasticity of certain animal structures depend, it is enough for our purpose to know, that the urethra possesses both properties; it may contract so as to oppose the exit or entrance of the smallest stream, and it may be dilated to admit the introduction of an instrument an inch in circumference. The urethra maintains these properties in disease as well as in health, and upon the strength of this fact, is the practice of dilatation in the cure of permanent stricture founded, permanent stricture, it will be recollected, is a positive narrowing of the urethric canal; and as it is the nature of all organic diseases to progress, unless prevented by art, it needs no stronger argument than necessity to show how imperative it is to set about their removal.
The cure by dilatation is as follows:—the seat and size of the stricture being ascertained (both of which can be easily done by the passing of the sound as directed, and the observance of the stream of urine), a bougie in circumference somewhat larger than the calibre of the urinary current, warmed and dipped in an oleaginous mixture combined with some sedative (Forms [22], [23], [24]) or stimulant (Form [25]) according to circumstances, is to be passed to the stricture, and the gentlest pressure is to be employed for the space of five, ten, or twelve minutes, according to the irritation it produces, removing it as soon as any uneasiness is felt.
Even in this very simple operation, a certain dexterity is requisite; for the direction of all urethræ is not alike, and the mere pushing a bougie against a contracted part is not the only likely method of effecting a free passage. Much also depends upon the nature of the bougie—the elastic ones, although assisted in their attempted passage to the bladder, by the smooth and well lubricated sides of the urethra, have a tendency to straighten; and unless considerable rotatory motion be observed, are apt to hitch in a fold of the urethra, especially if the case befall a person of relaxed fibre, and he be much worn down by suffering. The bougies that I employ are constructed upon an improved plan to those in general use, being prepared of a material that will preserve the shape I adapt them to, previously to introducing them, but at the same time sufficiently soft to yield to any accidental tortuosity of the tube they are intended to explore. The bougie then is to be pressed softly, but steadily, against the obstruction, now and then withholding for a minute the bearing, so as to allow a respite to the stretched membrane; then renewing by, what is better done than expressed, an “insinuating” pressure for the space of the time advised above. The patient should not be dispirited, even if the bougie do not perforate the stricture at the first trial; it would doubtless do so, if longer time were employed, but that is rarely advisable, except in cases where the urine can scarcely escape, or much expedition be requisite. Should the operation even be unsuccessful in this first attempt, the patient will find his ability to micturate much greater than before the introduction; but, save in long-standing and obstinate strictures, I rarely find myself foiled, nor do those who practise the same method, if they have patience and skill enough, in overcoming the difficulty at the first interview. A great advantage of the cure by dilatation, independently of its safety and efficacy, is the insignificant pain it occasions; the sensation produced being only like a pressing desire to make water, which immediately subsides on withdrawing the bougie.
Another method of dilating a stricture, where it happens to be of chronic existence, is the passing a plastic catheter into the bladder, and suffering it to remain all night, or even for several nights, stopping up the handle end with a cork or wooden peg, which the patient can remove when he desires to urinate. The urethra, by this means, becomes quickly dilated, and much beyond the size of the instrument. It necessarily confines the patient to his room and couch; but where an expeditious cure is the object, as much may be effected in this manner in six days, as by the ordinary method in as many weeks. Time, however, it must be remembered, is the working material of nine tenths of strictured invalids, and a week’s lay-up may cost a twelve-month’s salary—a purchase too dear to be generally incurred.
Several other plausible methods have been suggested for the cure of stricture—one by means of an instrument, that the operator could enlarge when it was passed into the urethra, through turning a screw; another, which was to introduce a tube made of some thin skin, and then to distend it with wind or water; a third, and oftentimes, in reality, a very useful and available one, is to compress the penis around the glans, and suffer the urine, as it accumulated, to distend the anterior part of the urethra before the bandage was removed and the urine suffered to escape. But they have their several disadvantages: the processes, with the exception of the last, are complicated and uncertain in their result; the instrument is not so manageable, or so useful, as an ordinary sound; and the gut, instead of distending the strictured part, enlarges the healthy portions of the urethra. The bougie, in proper hands, notwithstanding it is a simple instrument, is the most positive and effectual method of curing stricture as yet, or likely to be, discovered. An entrance, then, having by this means been gained, a bougie of a larger size is to be selected on the next occasion, and the same process repeated. It is never advisable to repeat the operation oftener than once in two days, and when the urethra is irritable, only every three or four days.
By continuing in this manner, the stricture gradually yields, and a bougie as large as the orifice will permit to enter will at last proceed through the whole passage without meeting any obstacle. The operation, notwithstanding this apparent success, should not be wholly laid aside, but continued until the disposition for contraction is entirely removed; and the patient should never rest without occasionally examining his urethra, say once a month (at least once a quarter), lest he encounter a relapse.