RESUME OF THE EXPERIENCE OF 
SEVENTEEN TEARS 
IN THE 
OPERATION 
OF 
DILATING URETHROTOMY 
BY 
FESSENDEN N. OTIS, M.D. 
CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE COLLEGE OF PHYSICIANS AND 
SURGEONS, NEW YORK ; CONSULTING SURGEON TO CHARITY HOSPITAL, 
ST. ELIZABETH’S HOSPITAL, THE MANHATTAN EYE 
AND EAR HOSPITAL, ETC. 
Reprinted from The Medical Record, July 20, 1889 
NEW YORK 
TROW’S PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1889 RESUME OF THE EXPERIENCE OF 
SEVENTEEN TEARS 
IN THE 
* 
OPERATION 
OP 
DILATING IIEETHROTOMY 
BY 
FESSENDEN N. OTIS, M.D. 
CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE COLLEGE OF PHYSICIANS AND 
SURGEONS, NEW YORK ; CONSULTING SURGEON TO CHARITY HOSPITAL, 
ST. ELIZABETH’S HOSPITAL, THE MANHATTAN EYE 
AND EAR HOSPITAL, ETC. 
Reprinted from The Medical Record, July 20, 1889 
NEW YORK 
TROW’S PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1889 WORKS BY THE SAME AUTHOR. 
Gleet and its Relations to Urethral Stricture. 
No. X. American Clinical Lectures. 8vo, paper, $0.25 
Clinical Lectures on the Physiological Pathology 
and Treatment of Syphilis. Svo, cloth, - 1.00 
Stricture of the Male Urethra : Its Radical Cure. 
8vo, cloth, very fully illustrated, - - - 2.00 
Also, by the same, “ Practical Clinical Lessons on 
Syphilis and the Genito-Urinary Diseases.” 
Birmingham & Co., 28 Union Square, 1883. Svo, 
600 pages, cloth, ----- 4.50 
Students’ Edition, of the above, from the original 
plates, printed for the Author by G. P. Putnam’s 
Sons, March, 1886, - 2.00 
On Some Important Points in the Treatment of 
Stricture, 1887. Svo, paper. 
On the Perfected Evacuator for the Removal of 
Debris after Litiiotrity, 1889. 8vo, paper. 
G. P. PUTNAM’S SONS, NEW YORK AND LONDON. r£sum£ of the experience of seventeen years 
IN THE OPERATION OF 
DILATING URETHROTOMY.1 
The operation of dilating urethrotomy, for the removal of 
urethral stricture, as devised and practised by myself, has 
now been before the medical profession for nearly seventeen 
years. The first dilating urethrotome, with a brief report of 
six cases upon which it had been used, having been presented 
at a meeting of the New York Medical Journal Association, 
November 24, 1871. 
Previous to that time, internal urethrotomy, as a rule, was 
performed only as a last resort, in cases when gradual dilata- 
tion was for some grave reason deemed impracticable, or 
when only very temporary relief had been obtained by that 
method. 
In the performance of internal urethrotomy, at that time, 
there were no fixed principles established for the guidance of 
the surgeon, as to the extent of the incisions. 
The standard urethral calibre accepted by all authorities, 
was then 21 mm. circumference (French scale), or No. 9 of 
the English scale, beyond which sizes no necessity for inter- 
ference, on account of symptoms, was recognized. The indi- 
viduality of the urethra had not been discovered, and urethral 
instruments for the most extreme dilatation, as for the over- 
distention of stricture, did not exceed 30 mm. in circumfer- 
ence ; while 21 mm. was considered sufficiently large for use 
in all ordinary practice. The permanent cure of stricture by 
dilatation, by divulsion, or by division was not effected nor 
expected, and even the possibility of a radical cure, by any 
1 Read before the Association of Genito-Urinary Surgeons, Washington, Sep- 
tember, 1888. 4 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
method, was denied by all accepted authorities. Under this 
condition of things, dilating urethrotomy was proposed. It 
was based upon the acceptance, 1st, of an individual calibre 
for every urethra ; 2d, upon the alleged necessity 
(in order to secure the best results) for complete 
division of all presenting stricture up to the nor- 
mal urethral calibre ; this point to be ascertained 
by actual measurement in each case. 
This was at first determined with difficulty, 
and only approximately, by means of accurately 
graded metallic bulbous sounds. 
Subsequently, however, with increased ease and 
precision, through the urethrometer which was 
presented by me to the profession in 1874. 
Through the use of this instrument, after a 
time it became apparent that a proportionate re- 
lation existed between the size of the flaccid penis 
and the normal urethra in any given case, and this 
fact was subsequently found of much value in 
estimating the normal urethral calibre, in cases 
where no instruments for actual measurement 
were attainable. 
Through the use of the urethrometer, also, the 
external urethral orifice, which had early proved 
a serious obstacle in ascertaining or estimating 
the normal urethral calibre (especially as it had 
been previously accepted as a guide to that cali- 
bre), was found to be of varying size (indepen- 
dently of the urethra associated with it), except 
in its perfect development, when it was found 
to correspond completely in size with that of 
the canal behind it. Further observations soon 
made it evident that contractions of the orifice 
were capable of producing troubles similar to those 
caused by stricture further down the urethra. 
The importance of recognizing the various degrees of con- 
traction between the previously accepted standard (i.e., 21 F. 
or 9 E.) and the normal calibre, as ascertained by actual 
measurement, was made more evident as the study of strict- 
Original Form 
of Otis’s Ure- 
thrometer. OPERATION OF DILATINO URETHROTOMY. 
5 
lire troubles under these new conditions was proceeded with. 
It was found, notably, that gleet, which had from time im- 
memorial been considered the opprobrium of medicine and 
surgery, was, in certainly a large proportion of instances, 
dependent on the presence of urethral strictures, usually of 
large calibre, not readily detected in ordinary examinations. 
The urethrometer, which was the outcome of a necessity for 
definite measurements (in order to use the dilating urethro- 
tome with accuracy), thus broadened its own field to an extent 
little expected when its use was initiated. Through the di- 
vision of strictures, often but slightly diminishing the normal 
urethral calibre (previously recognized as frequent in cases 
of gleet), it was found that in some cases the gleet disap- 
peared without other treatment, and thus its dependence 
upon the stricture for its continuance was finally demon- 
strated. It was also found that the method of operation 
upon a stricture made tense and thinned by dilatation, re- 
quired a much less extensive incision for its complete division 
than when flaccid, and that in thus dividing it there was a 
marked immunity from serious hemorrhage, from urethral 
fever, from abscess, pyaemia, etc., which had been considered 
sources of danger in internal urethrotomy when complete di- 
vision of the stricture was contemplated. 
In the experimental experience of the first years (1871, 
1872, and 1873) with the dilating urethrotome, the grave re- 
sponsibility of so radical a departure from previous methods 
was not under-estimated. The attention of eminent surgeons 
was invited to the procedure, and their presence secured at 
many of the operations. 
Frequent reports of progress "were made to societies, and 
every available opportunity wTas accepted to demonstrate in 
public and in private, at home and abroad, the method of 
operating, and from time to time to present for examination 
cases upon which the operation had been performed. 
The new instruments, which at first were of necessity more 
or less crude in design, as well as in manufacture, were studi- 
ously modified and simplified, until, by 1874, it may be said 
that they were brought to a condition of satisfactory effi- 
ciency, and the operation of dilating urethrotomy—already 6 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
having received much attention, and some practical accept- 
ance, from surgeons in our own country, as well as in various 
parts of Europe—was now fairly launched into the field of 
genito-urinary surgery. The approval and the adoption of 
the operation, necessarily implied abandonment of the old 
views of urethral proportions, and an acceptance of the indi- 
viduality of the urethra with a normal calibre of from 30 to 
40 mm. in circumference, and an average of about 32 mm. 
After the experience of another year, with the operations 
and its results (a report of one hundred tabulated cases, com- 
prising division of two hundred and fifty-eight strictures, 
having been presented by me at a meeting of the New York 
State Medical Society, in March, 1875), it was thought not 
too soon to make a distinct statement of the claims of dilat- 
ing urethrotomy for precedence over the usual methods of in- 
ternal urethrotomy for the treatment of urethral stricture; 
as well as those by divulsion, and (in the greatest majority 
of cases) over the plans of gradual dilatation, for all strictures 
anterior to the bulbo-membranous junction. In this state- 
ment I insisted, 1st, upon a necessity for acquiring knowledge 
of the normal urethral calibre before any operative measures 
were instituted, and of the exact locality and size of every 
stricture in a presenting urethra ; 2d, that there should be an 
accurate adaptation of all procedures to the individual strict- 
ures, with intent to remove them through complete sunder- 
ing at some one point. Claiming this to result (when the 
division was completely effected), 1st, in the greatly dimin- 
ished total risks of operative measures, as compared with at- 
tempts at more or less complete removal of strictures by any 
other method ; 2d, in the ultimate complete removal, by ab- 
sorption, of strictures so divided. 
In my first report of one hundred tabulated cases, compris- 
ing two hundred and fifty-eight strictures operated on, it was 
shown that no deaths or grave accidents had occurred, and 
that in thirty-one re-examined, two over three years, and 
three over one year after operation, freedom from every trace 
of stricture was demonstrated. From this fact, the possibil- 
ity of a radical cure of stricture was then asserted. Since 
that time, March, 1875, the claims which were then squarely OPERATION OF DILATING URETHROTOMY. 
7 
and earnestly made in favor of dilating urethrotomy, have 
found full corroboration and steadily increasing favor, so that 
here to-day there is no necessity of citing specific evidence of 
its general acceptance by the surgeons of America as a valua- 
ble surgical procedure. From what has come to my own per- 
sonal knowledge, 1 am led to believe that many hundred op- 
erations upon strictures, by dilating urethrotomy, are per- 
formed in public hospitals, and also in private practice, in 
America, every year, and that the favor extended to it is 
steadily increasing ; but, perhaps from the fact that it is no 
longer a novelty, and that there is but little credit to be gained 
from statistics which offer no new subjects for contemplation 
or discussion, the reports of these operations or their results 
do not find their way into the medical journals. It is because 
of this and also from the fact that, within the present year, al- 
ready over sixty complete cases of instruments for the scien- 
tific diagnosis of stricture, and for the performance of dilating 
urethrotomy by my method, have been ordered for use at the 
military posts of the United States Army alone ; and further, 
that prominent surgical instrument-makers have claimed in- 
creasing sales of my instruments to the profession at large ; 
chiefly on these accounts, I have concluded that perhaps some 
of the results of a studious experience of my own in the use 
of these instruments might not be unacceptable. Especially 
has this seemed to me desirable for those whose previous op- 
portunities have not been favorable for observation and com- 
parison of results by different instruments, or of various modi- 
fications in the details of operations and after-treatment, and 
also who have not had opportunities of testing results after a 
long period from the date of operation. 
In pursuance of this design, I also beg leave, first, to speak 
of some of the changes and improvements which have been 
made in instruments for diagnosis of stricture and operations 
by dilating urethrotomy, up to the present time. After much 
experimentation the urethrometer, made originally (1874) with 
jointed metallic bars,1 was superseded in great measure, in 1875, 
by one made with steel springs, which latter had the advantage 
of giving a better-shaped bulb, and could be made 5 or 6 mm. 
1 See page 4. 8 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
less iii size than the former. It proved a 
very efficient instrument, and when well 
made, seemed to fulfil all the necessary re- 
quirements ; hut the difficulty of having 
it well made, especially as to the strength 
and temper of the springs, and its liability 
to rust and breakage, proved a source of 
much annoyance, besides involving much 
care and expense to keep it in good work- 
ing order. A little more than a year 
ago, especially urged by the necessity of 
having a more enduring instrument for 
use in the military and naval service, I 
succeeded, through a competitive contest 
between the prominent instrument- 
makers of .New York, in having a per- 
fectly satisfactory instrument made, 
without springs and with a compass of 
from 18 to 45 mm. This, when well 
made, should last for many years, without 
the necessity for repair. 
Next, in regard to the dilating ure- 
throtome. Since its first presentation to 
the profession in 1872, this instrument, 
through continued efforts for increased 
simplicity in construction and increased 
directness and accuracy in application, 
has necessarily undergone many modi- 
fications. One of these was fully twelve 
inches long, and cui'ved, with especial 
design of securing its more easy adapta- 
tion for the division of strictures at or 
bejrnnd the bulbo-membranous junction. 
It was soon found, however, that while 
introduction into the curved portion of 
Fi cr. 2. 
Present Form of the Urethrometer.1 
Fia. 1. 
Fij3. 
1 Messrs. George Tiemann & Co. and Messrs. Hazard, 
Hazard & Co., of New York, have been chiefly in- 
strumental, under my direction, in bringing the ure- 
thrometer to its present satisfactory form. OPERATION OF DILATING URETHROTOMY, 
9 
the urethra was facilitated, the dilata- 
tion by it, thus curved, was unequal, 
and could not he correctly indicated on 
the dial, thus rendering it unreliable. 
And what was a still stronger reason 
for condemning it, a further experience 
with dilating urethrotomy proved that 
division of stricture, by any form of 
urethrotome, beyond the bulb, was un- 
safe, and, in my opinion, distinctly not 
within the legitimate province of di- 
lating urethrotomy. I have repeatedly 
condemned this long, curved, dilating 
urethrotome, in public and in private, 
to surgeons, students, and instrument- 
makers, for the last ten years ; but in 
spite of my efforts it continues to be 
called for, and consequently to be made 
and sold; for which reason 1 take this es- 
pecial opportunity again to condemn ut- 
terly this form of dilating urethrotome. 
The one, and the only dilating, ure- 
throtome I use and recommend for all 
operations of dilating urethrotomy, is 
the short, straight instrument which I 
now exhibit, inches in length, cir- 
cumference.of shaft, 16 mm., and capa- 
ble of being expanded to 45, with a 
blade running 2 to 2£ mm. above the 
groove. I desire here to advise against 
the use of this instrument as a divulsor. 
When, in dilating strictures during op- 
eration, any undue strain is felt, it 
should be at once relieved by passing 
the blade through the stricture, then 
continuing the dilatation, and if nec- 
essary cutting again in a similar way, 
until a dilatation of two or three mil- 
limetres may be made without marked 
Otis’s Dilating Urethrotome. % actual size. 
Knife. 
Dilating Shaft. 10 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
resistance,, a fact which, as a rule, indicates the complete 
sundering of the stricture. In cases where there is some 
uncertainty as to the exact point of binding during the op- 
eration, the use of the bulbous sound will define it, saving 
unnecessarily long incisions. In regard to the locality of the 
incision, I do not hesitate to reiterate my former opinion 
in the strongest terms, that it should be always and only su- 
periorly, i.e., on the roof of the urethra, and as nearly as pos- 
sible, exactly in the median line. A more generous vascular 
distribution in the peri-urethral tissues below will account for 
the fact that hemorrhage is more liable to be severe when the 
incisions are made inferiorly, and is a sufficient reason why 
inferior incision should be avoided. 
Again, when the tissues on the inferior surface are sub- 
jected to the tension necessary to secure the complete sun- 
dering of more than usually deep or resilient strictures, when 
the knife is drawn through them, the incision may extend 
even through the fibrous sheath of the corpus spongiosum, 
and make an infiltration of urine into the adjacent cellular 
tissue quite possible. A number of cases of this, always 
grave, accident, have occurred within my personal knowledge. 
One within the past year. This case I saw in consultation, 
on account of unusual hemorrhage, which continued after the 
operation. Much swelling had followed, which it was thought 
might be from blood extravasation. Two incisions were said 
to have been made with the dilating urethrotome, one on 
either side of the urethra, for the division of several strict- 
ures. The urine was first drawn by catheter, but during the 
night following the operation, it was passed voluntarily. In- 
crease in the size of the penis wras immediately noticed, and 
when I saw the case it was about two inches or more in di- 
ameter, and considerably distorted. Escape of urine into the 
cellular tissue had evidently taken place. 
Immediate free incisions through the integument and su- 
perficial fascia, and release of the imprisoned urine, saved 
from extensive sloughing, but when I saw the patient, several 
weeks after, he had an urinary fistula on the side of his penis, 
while several prominent points of stricture still remained in 
the urethra. In dividing the strictures superiorly, and in the median 
line, the knife, if penetrating to a point beyond the sheath of 
the corpus spongiosum, comes in contact with the fibrous tis- 
sue joining it to the corpora cavernosa, which barrier affords 
the greatest security against accidents from incision in the 
median line, but to which deep incisions in all other directions 
are always liable. 
I believe that one important reason why the operation of 
dilating urethrotomy, in my hands, has been so uniformly suc- 
cessful, and so uniformly free from untoward results, lies in 
the fact that I always divide the stricture on the superior sur- 
face of the urethra, and as nearly as possible in the median 
line. Up to the present time, as I have stated, dilating ure- 
throtomy has, in my hands, proved an eminently safe opera- 
tion. 
At the meeting of the International Medical Congress, held 
in London in 1881, I reported six hundred and sixty-four op- 
erations of my own without a death, or permanent disability 
of any sort. My operations since that date will swell that 
number to more than one thousand, and not only have I 
never yet had a death resulting, when the dilating urethro- 
tome alone was used (that is, when it was not preceded by 
the use of the urethrotome of M. Maisonneuve, or its equiva- 
lent), but I have never yet seen an abscess, nor an escape of 
urine into the tissues, nor an attack of pyaemia follow the op- 
eration. I believe another prominent reason for the safety 
from accidents which has attended my operations will be 
found in the scrupulous care of instruments, securing absolute 
cleanliness and asepsis as far as possible, and in the use of all 
available antiseptic precautions, for patients and instruments, 
both before and after operation. Washing the parts exter- 
nally with a solution of the bichloride of mercury 1 to 1,000, 
and using injections of boric acid internally, two or three 
times a day, until healing is complete. Using the catheter 
for emptying the bladder, for the first few days after opera- 
tion, whenever it is well borne, chiefly as a preventive of 
urethral fever; but in certain cases where the urethra is very 
sensitive and intolerant of its use, allowing the patient to pass 
his own urine from the outset. I am a believer in the power 
OPERATION OF DILATING URETHROTOMY. 
11 12 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
of quinine and morphine to prevent urethral fever, in many 
cases, when contact of urine with freshly made urethral 
wounds cannot be avoided, and am accustomed, in such cases 
especially, to administer a suppository composed of 10 grains 
of quinine with \ grain qf morphine, immediate- 
ly after operation. 
And now, in regard to the accident of hemor- 
rhage. When incisions are made beyond three 
inches, I take the precaution of having the peri- 
neal crutch1 in position immediately after opera- 
tion, so that, should hemorrhage occur subse- 
quently, the patient can readily bear down upon 
it, and thus be promptly secured from any leak- 
age back into the bladder. Effective pressure 
may be made at any desired point anterior, and 
thus always prevent any considerable loss of blood 
in any case. In cases where hemorrhage is not 
completely controlled by temporary pressure I 
have found nothing better than the introduction 
of my hard-rubber endoscopic tube, formerly rec- 
ommended, any necessary counter-pressure being 
made by bandage. This may remain, if necessary, 
for two or three days, removing the tube only 
for cleansing, urination being readily effected or 
catheter passed through it on removal of the ob- 
turator. Cases requiring these unusual measures 
have not occurred, in my experience, in more 
than one-half of one per cent, of cases operated 
on. As a rule, to which there are very few ex- 
ceptions, but slight inflammatory action follows 
even the most extensive incisions of dilating ure- 
throtomy, although there is, as a rule, a pre-exist- 
ing more or less acute urethritis in every case 
operated on; on the contrary, this is usually 
lessened and the sensitiveness diminished. There is, how- 
ever, in some instances where there is much sexual irritability, 
increased tendency to erection, and more or less plastic exuda- 
Author’s 
Endoscopic Tube. 
1 Bee Otis on Stricture of the Urethra: its Radical Cure, p. 283. 13 
OPERATION OF DILATING URETHROTOMY. 
tion in the immediate vicinity of the incisions, resulting in 
more or less troublesome chordee. The exudation causing 
this, as in gonorrhoea, usually passes off in a few days, unless 
the irritation is kept up and increased by some extraneous in- 
fluence, such as a previously existing acrid discharge, sexual 
excitement, or too frequent or rude introduction of sounds. 
In such cases adhesions between the mobile layers of the peri- 
urethral fascia may occur, which, unless accidentally broken 
up by strong erections, may remain for weeks, and even in 
some cases for many months ; sometimes becoming a source 
of great annoyance, but finally passing off completely without 
any special treatment. In a former account of such cases’ I 
recommended a diagonal incision across the superior wall of 
the urethra at the most salient point of incurvation, an opera- 
tion which at my hands met with success in several instances. 
Subsequently, however, I adopted the plan of a mercurial in- 
unction at the point of adhesion, which gave slow but finally 
satisfactory results. Within the past year, however, I have 
combined this with systematic, gentle massage, on a short 
sound, for ten or fifteen minutes once or twice daily, always 
falling short of producing tenderness. The results of this 
plan have already proved its capacity to remove the most 
pronounced troubles of this sort within a few weeks. Ex- 
tension of the penis upon the sound, to as nearly as possible 
its full length, every day or two after the operation, has 
seemed to me serviceable in preventing such adhesions. 
One point in connection with the operation of dilating 
urethrotomy which has been the source of much discussion 
and of some animadversion may, perhaps, be briefly con- 
sidered to advantage at this time. This is in regard to 
division either of congenital or acquired contractions of the 
meatus urinarius externus. The experience and the study 
given to this matter, since my early discussion and advocacy 
of this procedure in 1875, have only confirmed the views then 
presented. The necessity of repeated passage of sounds of 
the full normal calibre of the urethra, subsequent to the com- 
plete division of stricture, in order to secure a permanent 
1 Otis on Stricture, pp. 290, 291. Putnam’s Sons, New York. 14 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
cure, renders enlargement of the orifice to that extent essen- 
tial. This can rarely be done without unwarrantable violence, 
except by incision. Contractions of the meatus, congenital 
or acquired, have been also proven to initiate and prolong 
gleety discharges, and to be a source of various more or less 
important reflex difficulties throughout the genito-urinary 
tract, and not infrequently involving some of the spinal cen- 
tres. Anything short of a complete division of the contracted 
orifice, up to the full normal urethral calibre, is usually in- 
sufficient to give the desired relief in such cases ; but if skil- 
fully and judiciously performed, the operation is, in my belief, 
absolutely free from all reasonable objection, and its results 
are productive of more prompt, complete, and lasting benefit 
to the patient, and more satisfaction to the surgeon, than any 
operation of like gravity in the entire range of surgery. 
The charge that has been made against it, that it dimin- 
ishes the sexual power, I believe my experience with the 
operation justifies me in asserting is wholly groundless. The 
fact being, on the contrary, that in cases of sexual weakness 
I have not infrequently found strictured meatus to be a prom- 
inent factor in inducing it, and the judicious division of the 
contraction one of the most potent measures in its relief or 
cure. That occasional irregularity of the stream has resulted 
from unskilful division is true, and that the apparent force of 
the stream has been diminished, in rare cases, is also quite 
true. There is no excuse for the former with a fairly skilful 
surgeon, and in the latter case, when it is remembered that 
the propelling force is in the bladder, and not in the urethra, 
it will be seen that such division could only affect the stream 
slightly, except where the propelling power of the bladder 
was, by a previously existing atony, reduced to the minimum. 
I have reported a case where the urethral orifice was divided, 
for the relief of grave reflex troubles, to 40, in a urethra of 
normal calibre 34, giving complete relief to those troubles, 
which had resisted repeated lesser incisions, and where sub- 
sequently the patient (now an eminent medical man) became 
the father of several children ; and with the meatus of this 
enormous size he is still able to propel his urine in an un- 
broken steady stream fully three feet. In this connection I OPERATION OF DILATING URETHROTOMY. 
15 
would suggest that the dilating urethrotome should, in my 
opinion, never be used for the division of contractions within 
half an inch of the orifice, and that incisions for that purpose 
should be made with a straight, blunt-pointed bistoury, and 
always on the inferior aspect or floor of the urethra, except 
where the meatus is placed so low that it is impossible to get 
sufficient room for the passage of the proper-sized sound with- 
out incising the superior also. This for the reason, chiefly, 
that incisions sujperioiiy in the glans recontract quickly, or if 
they do not, absorption of the tissue of the glans may occur 
in the line of the incision, if at all extensive, which may re- 
sult possibly in a distinct cleft, as occurred in one such case 
that came under my observation, some years since, giving 
it the appearance of a bifid glans. The enlargement of the 
orifice should never be made by a sudden, quick stroke of the 
knife, as it is sometimes the custom of surgeous to do, but 
under cocaine or ether, very deliberately, and by repeated 
careful incisions, always downward and exactly in the median 
line, until by repeated trial with the bulbous sound the pre- 
cise size required is attained. Should the fraenum be in the 
way, if broad and flat, the incision may be carried through 
its centre as far as its base ; if narrow, it should be first snip- 
ped away to the same extent. When the meatus is situated 
too low to allow sufficient room, the surgeon must content 
himself with an inferior incision that shall not encroach upon 
the true floor of the canal, and will have to use the uretlirom- 
eter, or its equivalent, instead of the sound, for keeping the 
sundered ends of the strictures from uniting until healing of 
the incision is complete. If, in addition to the contraction 
of the orifice, bands of stricture are found immediately ad- 
jacent ; unless within one half or two-thirds of an inch, they 
should be divided superiorly with the dilating urethrometer. 
Incisions on the inferior aspect beyond the latter point 
may be followed by urinary infiltration. And now I wish 
to speak, lastly, of my experience and belief in regard to 
the permanence of results in dilating urethrotomy ; that 
is, as to the validity of the claims which have been made 
for the radical cure of stricture of the urethra by this 
method of treatment. It is not unusual for surgeons to 16 
SEVENTEEN YEARS5 EXPERIENCE IN THE 
infer that cases treated by various methods, and apparently 
cured, are really so when they do not return to them for 
treatment. This proof, however, will not suffice where the 
radical cure of stricture is claimed. 
A re-examination, with the bulbous sound, of the full size 
of the pre-determined normal urethral calibre, or with the 
urethrometer, after many years, will alone give 
the necessary proof upon which such a claim can 
be sustained. The acknowledged failure of all 
methods, except that of dilating urethrotomy, to 
wholly and permanently remove the stricture 
tissue, is accepted by those without an ample ex- 
perience in this, as a sufficient evidence that radi- 
cal cure of stricture is impossible by any method. 
Even Sir Henry Thompson says,1 the more freely 
he divides stricture the more permanent are the 
results ; that he has never had trouble from cut- 
ting stricture too freely, while he has often had 
occasion to regret having cut too little ; and that 
he has frequently seen cases where relief has con- 
tinued for years after internal urethrotomy. Yet 
he says, “ I question very much if I have ever 
seen a case which has been completely cured by 
any treatment whatever.” Under such a weight 
of testimony adverse to the probability of the 
radical cure of stricture, proof of facts claiming 
this for dilating urethrotomy must be full and 
conclusive. Preliminary to the production of 
such proof it may not perhaps be out of place to 
call attention to the important fact that by no 
other method than dilating urethrotomy is com- 
plete sundering of the stricture, at some one point, 
insisted on; that upon the accomplishment of this, 
whether by means of the dilating urethrotome 
or by any other instrument, by one or by repeated operations, 
possibilities of a radical cure solely depends. Occasional fail- 
ure to secure against the return of stricture, after the operation 
Otis’s Bulbous 
Sounds. 
1 Some Important Points connected with the Surgery of the Urinary Organs. 
Students’ Edition, 1884, OPERATION OF DILATING URETHROTOMY. 
17 
of dilating urethrotomy, does not disprove this position, but 
simply indicates a miscalculation on the part of the surgeon as 
to the depth and extent the incision required, resulting in a fail- 
ure to completely sunder the stricture. The exceptions I have 
met have been very rare, and apparently due to the extension 
of the stricture-tissue beyond the reach of any incisions which 
could be safely made. The first really confident claims for 
the capacity of dilating urethrotomy to bring about the com- 
plete and permanent cure of stricture were made in 1875, 
and were based upon the results of thirty-six re-examinations 
with the bulbous sound of the full size of the normal urethra, 
at periods varying from six months to three years after the 
operation, during which interval no use of sounds had been 
resorted to. In 31 of these cases, or about eighty per cent., 
complete freedom from the former strictured condition was 
demonstrated by the unobstructed passage, to and fro, 
throughout the entire urethra anterior to the bulbo-mem- 
branous junction, of a metallic bulbous sound of the full 
normal size of the urethra, as determined at the time of 
operation. In a second series, consisting of 136 tabulated 
cases, presented in 1878, 82 re-examinations were reported, 
out of which 67 were found entirely free from stricture. In 
3 of these cases six years and six months had intervened be- 
tween the date of operation and the re-examination ; in 2 
cases, over five years; in 3 cases, over four years ; in 10 cases, 
over three years; in 7 cases, over two years; in 20 cases, 
over one year ; in 10 cases, over six months. 
Besides these, 2 cases were reported in the second edition 
of my work on “ Stricture of the Urethra,” operated on in 
1872 and in 1880 re-examined, and then, over eight years 
from date of operation, found to be free from stricture. In 
the first case five strictures were originally present, the small- 
est of a calibre of 22 French. In the second, there were also 
five bands of stricture operated on, the smallest 16 French. 
In addition to these cases was one operated on in March, 
1875, for four strictures, defined by a bulb of 24 mm. in cir- 
cumference, in a urethra of normal calibre, 36 French. This 
case was re-examined in May, 1880, and found completely 
free from all stricture by the easy passage of a No. 36 bul- 18 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
bous sound, five years from the date of operation, and no sound, 
bougie, or other instrument of any sort introduced during the 
interval. Again, in 1881, 2 cases presenting a long interval 
between operation and re-examination were met—the first 
seven years, the second eight years—the first, whose strict- 
ures, four in number, were divided from 27 to 36 French; 
the second, where there were six strictures, ranging from 24 
to 30, were divided to 38. 
Another case, operated on in May, 1871, re-examined in 
1883, the longest interval then on record, showed complete 
cure of stricture, by dilating urethrotomy, over twelve years 
after the date of operation. During the past summer 1 have 
had extracted from my case-books, and carefully tabulated, a 
third series of operations in 420 cases, in which .the normal 
calibre of the urethra, the size, number, and locality of the 
strictures are recorded, with the results of re-examination in 
62 cases. 
Recontractions were found to have taken place in 7 cases 
of stricture situated posterior to one inch, while at or near 
the meatus recontractions had occurred in 11 cases. I have 
recently had an opportunity of re-examining the case first 
operated on by dilating urethrotomy, and for the complete 
division of whose strictures the dilating urethrotome was 
originally designed. Extensive stricture was present, which 
had failed to be permanently relieved by several years of 
treatment by gradual dilatation. Divulsion with the instru- 
ments of both Ilolt and Yollemier had been practised to the 
fullest capacity of those instruments, and recontractions from 
that point to 24 of the French scale had taken place, asso- 
ciated, as the chief source of annoyance, with a persistent 
gleet. By means of the dilating urethrotome the strictures 
were all divided up to 32 French. Subsequent re-examina- 
tions, on several occasions, at intervals of three or four years, 
were made with the bulbous sound Ho. 32, without at any 
time detecting a trace of former stricture, and the gleet which 
disappeared within a few weeks after the operation did not 
recur. Ho instrument of any sort was introduced for dilata- 
tion or any other purpose, except by myself at the intervals 
just mentioned, for the purpose of examination alone. On OPERATION OF DILATING URETHROTOMY. 
19 
the last occasion, May, 1888, Mr. A (whose case is fully 
described in my book on “ Stricture of the Male Urethra: Its 
Uadical Cure ”) came to me for consultation concerning a 
difficulty quite independent of stricture, but was induced to 
permit me again to examine his urethra. I at first intro- 
duced, as on previous occasions, a 32 bulbous sound, and was 
struck with the complete freedom from any holding at any 
point. I then introduced the urethrometer, and turning it 
up to 34, two millimetres above the previously estimated nor- 
mal calibre, found that gentle traction enabled me to draw it 
out at this size, thus demonstrating in the most perfect man- 
ner the complete absence of the former strictures and the 
radical cure of the case, as shown by entire absence of every 
trace of stricture fifteen years and ten months from the date 
of operation (May, 1871), New York, September, 1888. 
In issuing a reprint of the foregoing article it has occurred 
to me that a few words in further consideration of the claim 
for the radical cure of anterior urethral stricture by dilating 
urethrotomy, and also in regard to deep urethral stricture, 
may not be without value in connection with the foregoing. 
At the risk of being charged with egotism I will venture to 
quote from a well-known American authority on genito-urin- 
ary diseases, viz., Professor Edward L. Keyes, author of 
“ Genito-urinary Diseases and Syphilis,” etc. In a discussion 
before the American Association of Genito-urinary Surgeons, 
at its last meeting (Newport, May 21, 1889), in opening his 
paper on the question of the “ Uadical Cure of Deep Urethral 
Stricture,” he says : “ Strictures lying in the pendulous ure- 
“ thra have been demonstrated to be capable of radical cure, 
“ chiefly by the unceasing efforts of Professor Otis. I think 
“ that we may all accept it as a demonstrated fact that internal 
“ urethrotomy, preferably performed with the dilating urethro- 
“ tome, will, if the incision be deep enough to extend entirely 
“ beyond the outer limit of the stricture tissue, radically cure 
“ organic stricture of the anterior urethra.” Dr. Keyes, how- 
ever, draws a distinct line between the curability of anterior 
strictures and that of deep urethral stricture, which latter his 
paper was chiefly presented to show were rarely susceptible of 
radical cure by any method. It is tolerably well understood 20 
SEVENTEEN YEARS’ EXPERIENCE IN THE 
by the profession that Professor Keyes lias not come to his 
present opinion in regard to the curability of anterior strict- 
ure without previous active dissent from my claims, nor with- 
out a large experience in all methods of treating urethral 
stricture. 
Fortunately, the greatest proportion of strictures which call 
for treatment have been shown to be in the pendulous por- 
tion of the urethra. I have long held that strictures beyond 
the bulbo-membranous junction were not within the province 
of dilating urethrotomy, chiefly for the reason that the depth 
of the incisions necessary for complete division was likely to 
be followed, in this region, by hemorrhage not readily con- 
trolled, and because drainage of the wound was rendered diffi- 
cult by the action of the compressor urethrae muscles. I have 
therefore practised and advised the adoption of external peri- 
neal urethrotomy in all cases posterior to the bulb. Even in 
strictures at five or five and a half inches, while I believe 
that, in the majority of cases, dilating urethrotomy is safe, 
yet if constitutional disturbance supervened, I do not hesitate 
in such case to make a perineal opening for the purpose of 
securing freedom from irritation through passage of urine 
over the urethral wound, as well as to bring all the parts with- 
in more easy reach of antiseptic applications. 
I have demonstrated in a very considerable number of 
cases that such a procedure does not add very materially to 
the risks of urethrotomy nor to the time required for recov- 
ery, ten days to two weeks being a fair average in the great 
majority of cases. My first published case of external and 
internal urethrotomy combined was done in 1873, and cited 
at length in the first edition of my work on the “ Radical 
Cure of Stricture” (Putnam’s Sons, 1878). Since that time 
I have practised and publicly taught, and repeatedly demon- 
strated at my clinic at Charity Hospital (in connection with 
the College of Physicians and Surgeons) the advisability, in 
all cases not complicated with organic disease contra-indicat- 
ing surgical interference, of combining external and internal 
urethrotomy 'where strictures of the anterior and posterior 
urethra were present; and my experience has shown that the 
inclusion of anterior strictures, many or few, in the scope OPERATION OF DILATING URETHROTOMY. 
21 
of a perineal urethrotomy, does not add materially to the 
risk of the operation nor prolong the recovery in the least 
degree. 
The operation of “ External and Internal Urethrotomy 
Combined,” as I originally termed it, has somewhat recently 
been brought to the notice of the profession abroad by my 
friend Mr. Reginald Harrison, of Liverpool, and I am quoted 
by him as approving it. 
The foregoing statement of my connection with this impor- 
tant surgical procedure will show that my approval has not 
been given without ample consideration. 
In my opinion, one of the prominent reasons why internal 
urethrotomy in deep urethral stricture has so often failed of 
permanent results is that in such cases there are, as a rule, to 
which I have never seen an exception (save in stricture of 
traumatic origin), one or more anterior strictures, which pre- 
vent the occasional passage of an instrument of the full natu- 
ral calibre of the urethra, until healing has taken place ; 
without which no radical cure is probable, even if it may be 
possible. 
5 West Fiftieth Street, July 30, 1889.