CASES OF SUCCESSFUL OPERATION FOR CLOSE STRICTURE BY INTERN AI^tfRETHROTOMY.* By E. R. PALMER, M. D„ Louisville, Ky. MR. HARRISON in his Lettsomian lectures, Dr. Keyes in his ad- mirable text-book, and a number of our best writers, among them Dr. Stein, of this association, have declared in the matter of operative treatment in stricture of the urethra of close caliber, and espe- cially where such obstruction is somewhat deeply situated, that perineal sec- tion should be done along with internal urethrotomy, and that not because of its offering any greater assurance of permanent cure, but rather as a precautionary measure against infiltration of urine and urine fever. With exceeding deference to the opinions of the gentlemen named, I desire to present a brief resume of twenty-two cases coming under this head where- in internal urethrotomy alone was done, detailing a few of the cases, and giving the sum of results obtained in the whole number. Case I.—W. D., youth of nineteen, presented with a narrow meatus and two close strictures—one at two inches and a half, another at five inches. Urine passed by hair-like stream. Etherized, meatotomy done, then a slender Mai- sonneuve staff passed over a filiform that had been introduced with much diffi- culty, and the blade pushed its entire length and withdrawn. An Otis then passed as far as it would go, dilated to 34, its knife pulled all the way out, and the instrument further dilated to 37. Slight haemorrhage only. A catheter passed into bladder, and it filled with l-to-20,000 hot bichloride solution, which, after withdrawal of catheter, the patient voided voluntarily. Ether caused much nausea. Whisky, followed by a hypodermic of morphine, was given and the patient put to bed. No medicine. Complete recovery; 32 F. sound used for months afterward. Patient lost sight of. * Read at the fourth annual meeting of the American Association of Genito- urinary Surgeons, at Altoona, Pa., June 3, 1890. 2 Successful Operation for Bulbo-Membranous Close Stricture. Case II.—Chris D., colored, aged twenty-six. Circumcised for extreme phimosis; had an almost impermeable strictured condition of the entire penile urethra. Operated on in colored ward, City Hospital, under ether. Filiform passed after nearly an hour of ineffectual striving. Chief obstacle at bulbo-membranous junction. Maisonneuve blade carried to the bladder, followed by the Otis back as deep as possible, cutting to 32. Silk ca- theter tied in bladder, and warm washing with weak bichloride and boric- acid solution ordered. Ordered ten grains of boric acid every three hours. Catheter withdrawn second day, and 28 F. curved sound passed. A severe chill followed, but fever subsided with no ill effect, and patient left hospital able to pass 26 F. curved easily. I found on inquiry that the boric acid had not been given. Case III.— C. S., middle-aged, a drunken German shoemaker. First seen in bed, his clothing and bedding reeking with the odors of the urine that dripped continually from his penis. Inquiry brought out that this condition had been gradually developing for thirteen years. Examination externally showed the entire penile urethra the seat of a series of fibrous stricture rings. Boric acid, fifteen grains every three hours, was given for twenty-four hours, and then, without anaesthesia and after repeated failures, a filiform was carried into the bladder. The Maisonneuve-Otis back to bulb to 33, dilating afterward to 36'5 ; hot bichloride and boric-acid washing, with boric acid internally; no fever; result perfect. Last fall, three years after opera- tion, passed 29 F. curved into bladder with perfect ease. Case IV.—T. E., aged twenty-six, nickel-plater. Close stricture at bulb; boric acid internally. Maisonneuve, followed by Otis, washing, and rest in bed. No haemorrhage of any amount; no fever. Four weeks later passed 28 F. curved easily into bladder. Case V.—John W., aged twenty-six, tobacco handler. Same conditions of urethra as in previous cases, and same series of operations, cutting finally to 32 and dilating to 38. Left my office at once for his home in a coupe, and urinated before I reached there. Had previously been in the habit of trying to urinate every half-hour day and night. Could not take boric acid ; com- plained that it nauseated him. Second day a chill, with temperature of 105°. Bladder immediately distended with the warm antiseptic wash, the patient being required to void it after withdrawal of catheter. A hot rectal enema was also given ; fever rapidly subsided. Quinine given freely, followed by five-drop doses of oil gaultheria. On the fourth day passed 29 curved easily its entire length. Another chill followed. Four days later discharged well, passing a full stream. Two years and a half later his brother, on casual inquiry, reports him all right. Case VI.—Young man, a roustabout, came into my office one night, with retention. Examination showed close stricture five inches back ; filiform, Maisonneuve and a washout, a gift of a handful of boric-acid tablets, and the case never seen afterward. Case VII.—N. J., aged twenty-four. Close stricture five inches and three quarters back, cut over filiform with Maisonneuve ; haemorrhage slight. On second day passed 29 F. curved, followed by little haemorrhage. Two days later—that is, the fourth day—the same sound was followed by quite profuse Original Communications. haemorrhage, as was also each succeeding urination for twenty-four hours. No more sounding done ; each washing followed by some bleeding. Eight days after operation a chill ; quinine given ; no more haemorrhage. Eleven days after operation sent home well. Little less than two years subsequent reports at office absolutely well. Case VIII.—W. E., bricklayer, aged thirty-five. Close stricture six inches back. Cocaine, four-per-cent, solution, used ; cut with big blade of Maisonneuve only. Can now pass 27 F. curved easily into bladder. Case IX.—B. P., drummer, aged forty-six. Habits bad ; constitution delicate. Close stricture of penile urethra anterior to bulb. Maisonneuve only. Five months returned recontracted ; cut again moderately with Otis, given a 24 F. sound straight, and discharged. Prospects of cure not good, owing to habits, etc. Case X.—Gf. Q., railroad switchman. Called, passing urine guttatim; history of long standing, stricture growing steadily worse. Exploratory examination ; finally got a filiform into bladder. Rather than postpone, emergency so great, did full operation at once. No trouble afterward. Six months later returned with a twenty-dollar bill as a token of gratitude for cure. Case XI.—J. S., aged twenty-nine, tobacco stemmer. Stricture close to bulb, of nine years’ standing ; had been cut in St. Louis in 1880, with recon- traction to almost impermeability at the bulb. Usual treatment by me, De- cember 29,1888 ; April 15, 1890, nearly fifteen months after operation, passed 29 F. curved without any difficulty or pain. Case XII.—B. W., aged twenty-eight, dry-goods packer. Circumcised for obstinate phimosis ; urine passed as a delicate spiral thread. After three quarters of an hour trial under cocaine got a filiform into bladder ; partially divulsed anterior urethra over this with a slender Thompson, and then passed the stall of Maisonneuve with some force and much difficulty into the blad- der. Was obliged to stop here, and have chloroform administered. The operations, as before detailed, including meatotomy, were now done; boric acid and quinine were both given; care as to washing and diet closely observed; the case conducted to the end without any fever or noticeable feature, and discharged, passing a full stream. Eighteen months later reported by brother-in-law as likely to have to come back; no par- ticulars. Case XIII.—Delicate man of thirty-five, a journalist. Found one morn- ing that my assistant had, after long effort in the night previous, passed a filiform for extreme retention, leaving it in, and ordering rapid boric-acid saturation. On my arrival next morning, half a water-bucketful of urine was shown as having trickled out around the whalebone. Operated at once, as in other cases ; had series of furious chills ; urine showed no albumin ; result excellent, but general health bad. Treated for some time afterward for pulmonary tuberculosis, as he had all the usual symptoms, including cough. Patient went home to northern Ohio, and died nearly two years later. Autopsy showed both lungs sound, but kidneys almost wholly de- 4 /Successful Operation for Bulbo- Membranous Close Stricture. stroyed by disease. This latter report made to me by a lay kinsman of the patient. Case XIV.—W. S., aged thirty-five ; country school-teacher. This is a case that would alone require a half-dozen pages to fully report. A purple, engorged glans penis ; a cartilaginous meatus ; a sallow, broken subject, passing as high as eight pints four ounces of urine, of specific gravity 1‘005 to l'OOO, free of albumin, in twenty-four hours, devoting almost his entire time to the discharge of this fluid, that escaped most tediously through a urethra closely strictured almost its entire length. Every operation in the category of internal urethral manipulation was done, not at once, but from time to time, over a period of three months, beginning in January, 1889. No fever of any amount ; two weeks one time and one another in bed, and a full re- covery, with disappearance of the polyuria among the results. Fourteen months later, 29 F. curved passed easily into bladder, the man being now wholly well. I will not detain you with a further recital in detail. Twenty-two such cases in all comprise my list without a single death, with hardly a failure, and without in any case an external urethrotomy. A Maisonneuve grooved on the top, yet no serious haemorrhage in any case, several of the cases of the most urgent type, many of the worst not going to bed for more than two days, and some—as in H. R., a medical student, candidate for the degree—not laying up at all; and urine fever, for escape from which the perineal section is demanded, playing practically no part in the history of the entire group of cases. During the time that these cases have been accumulating I have done perineal section without a guide for impermeable stricture four times, with three successes and one death from pelvic phlegmon.