The Use and Abuse of Instruments in 
. the Male Urethra. 
f 
g 
BY 
WILLIAM B. VAN LENNEP, M.D., 
PHILADELPHIA, PA. 
Reprinted from The Hahnemannian Monthly, 
December, 1885. THE USE AND ABUSE OF INSTRUMENTS IN THE 
MALE URETHRA. 
WILLIAM B. VAN LENNEP, M.D., PHILADELPHIA, PA. 
There is perhaps no branch in the whole domain of surgery 
in which more brilliant and gratifying resultscan be obtained 
than in the treatment of ailments of the male urethra and 
bladder. And yet nowhere are our efforts at times more una- 
vailing, and even productive of more positive harm. 
This may be largely due to routinism or ruts, a clinging 
with fond tenacity on the part of teachers and practitioners to 
old-time theories and methods of treatment, although they are 
known to be incomplete or even wrong. As in every branch 
of medicine, new departures are looked upon with distrust, but 
here especially this would seem to spring from lack of inquiry 
and original research. So long as the names of Otis and 
Bigelow live, we shall, as a nation, always take a front rank 
in genito-urinary surgery, but aside from a few such men, those 
who have given time and thought to this line of study are the 
exception. 
Our French brethren have an immense literature bearing 
on the subject, devoted chiefly, however, to originating and 
combating fanciful theories, while their ingenuity has given 
birth in the main to the most elaborate and often unpractical 
instruments. The Germans, too, in this particular, seem to 
have fallen short in logic and research. For instance, when 
looking over the armamentarium of an eminent Vienna 
specialist, he remarked that he was the only man in that city 
who had a sound over No. 30 charriere; while, at the largest 
genito-urinary clinic in their hospital, cases of retention, etc., 
from strictures, and deep-seated ones, too, are treated with 
conical silver catheters running down to Nos. 8, 7, and below 
of the same scale. 
During conversation with a friend, a gynecologist, a short 
time since, I remarked on the size of his library ; he answered 
that he had but a small portion of the literature bearing on 
1 2 
his specialty. He might have added that he was but one 
among thousands who are earnestly devoting themselves to the 
same line of study. It is fashionable with us, and we are 
proud to be looked upon as the gynecologists of the world; a 
man too need not hesitate to say anywhere that he is a " lady's 
doctor," while, on the other haijd, he is not over-anxious to 
proclaim himself a " gentleman's doctorworking beside with 
speculum, and the erudite finger goes ahead of groping in the 
dark at the end of a steel rod or silver tube. Lastly, it is 
natural, perhaps, that a male profession should feel for a 
suffering female laity, but while treating the mothers, we must 
not neglect to look after the fathers, past, present and future. 
It will be my task to point out some of the ruts we are in, 
and some of the mistakes we are most prone to make, and to 
endeavor to show, where and how we can, in my humble 
opinion, improve on and correct them. 
First, then, a few words concerning the surgical and 
pathological anatomy of the male urethra. I say surgical ad- 
visedly, on account of the importance of distinguishing between 
the urethra viewed from a surgical and from an anatomical 
standpoint. We have surgically a urethra proper, extending 
from the meatus to the triangular ligament, all behind that, i.e., 
membranous and prostatic urethra, forming a cervix or neck 
of the bladder, and belonging surgically and pathologically to 
the latter. This neck has, at its outer end, a more powerful 
voluntary sphincter, and,-at the inner, a weaker involuntary 
one. A familiar example will illustrate: As the bladder 
becomes distended, the uncomfortable feeling of fulness is 
supplanted by one of urging, and, stooping over to bring into 
play the voluntary muscles of the perineum which bear on 
the compressor urethrae, the unfortunate man, in Philadelphia 
at least, seeks in vain for a public urinal. The weaker 
involuntary sphincter has given way, the urine has entered 
the vesical neck, and voluntary action is required to hold it. 
So when disease has impaired the action of the latter muscle, 
the moment the urine has passed the first barrier, the urging 
is irresistible. 
It is just here that so-called spasmodic stricture will be 
usually found, either holding the instrument fast, when once 
within the muscle, or preventing the entrance of the same. In 
the latter instance, however, the trouble often is that we do not 
find the opening in the triangular ligament. 
Ultzmann was, I think, the first to demonstrate the action 
of these two sphincters. He is wont to impress it on his class 3 
by the following simple experiment: Passing a catheter, to 
which is attached a syringe, as far as the triangular ligament, 
the water injected flows out of the meatus. This point is 
reached with a curved metal instrument at an angle of about 
45 degrees. With the beak in the membranous urethra, the 
stream presses open the weaker sphincter, and enters the 
bladder, but, on removing the syringe, no fluid will flow out 
of the catheter unless the viscus be overdistended. Depressing 
the handle still more, the vesical contents are readily drawn 
off. 
He has ingeniously made use of these facts in locating 
urethral troubles, and in applying treatment for the same. To 
the latter we shall have occasion to return later on. 
Again, the introduction of an instrument will cause a 
stinging at the meatus increasing as the same is stretched. 
Beyond that to the bulb it will scarcely be felt, presupposing 
of "course an absence of lesion, but the moment it enters the 
membranous portion, a peculiar sickening sensation is experi- 
enced, resulting at times in syncope. This pain is severe in 
proportion to the susceptibility of the individual and to the 
size of the instrument. 
Further, once this boundary is passed, especially if the canal 
be roughly handled or unduly dilated in the bargain, we have 
reason to fear urethral chill, catheter fever, and the long list 
of names given to the groups of symptoms we ascribe to 
instrumentation in the urethra. Gynecologists tell us that, in 
the absence of the hymen, the use of instruments in the vagina 
is both painless and devoid of danger, but that we dare not 
enter the uterus without the greatest caution. So here, barring 
the orifice, which can be enlarged at will, we can treat the true 
surgical urethra without undue pain or complication, but once 
in the deep urethra, considered by many analogous in some 
parts and respects to the uterus, we must exhibit a like 
solicitude. 
This brings me to my first point, namely: Never, without 
good reason, to pass this boundary between anterior or true 
and deep or vesical urethra; if we do so, always to use the 
smallest and softest instruments possible. 
Such a statement may seem contrary to the teaching of 
Bigelow, and to disagree with the results of "rapid lithotrity" 
as practiced to-day. In this operation complete anaesthesia 
brings about an entire relaxation of all the muscular fibres of 
the deep urethra, while the removal of every vestige of the 
concretion does away with the cause of all previous irritation. 4 
Thus the two main drawbacks to lithotrity as formerly 
practiced, urethral reaction from instrumentation, and cystitis 
from fragments left behind, are obviated. Further, the mass 
of conservative authority leans to the use of smaller evacuators, 
and requires the acquisition of a greater skill in crushing,-in 
other words, instruments adapted to the size of the urethra, 
rather than the over-distension of some canals to bring them 
up to a standard calculated to lighten the labors of the 
operator. 
Statistics show that the vast majority of strictures resulting 
from urethritis are situate anterior to the triangular ligament. 
In fact, this may be laid down as an absolute rule for practice. 
On the other hand, those of traumatic origin, as well from 
blows or falls as from the misuse of instruments, will be found 
at or behind the bulbo-membranous junction,-from external 
violence, because rupture usually occurs at this the weakest 
spot; from instrumentation, because it is just here that we are 
most liable to go astray. 
How then are we to treat stricture after urethritis? 
First, ascertain the normal calibre of the urethra ; then, 
the exact size, character and location of the constriction or 
constrictions; freely enlarge the meatus and posterior border 
of the fossa navicularis, and pass into the stricture steel sounds, 
gradually increasing in size, until it is entirely obliterated ; 
continue the use of these instruments at long intervals over an 
extended period of time. Should the constriction prove hard 
and resisting, should it prove resilient (this trait seems to 
belong more particularly to traumatic stricture), incise it freely, 
and to the uttermost fibre, by an internal urethrotomy. 
Is this, however, routine practice? A urethritis runs its 
course leaving the lingering " drop in the morning." Sounds 
are passed into the bladder, until the limit of the meatus is 
reached, usually overstepped; it is enlarged, perhaps, and the 
treatment continued until the capacity of the urethra is filled. 
Let us examine a little more in detail the course of treatment 
mapped out. There would seem to be no need of further 
comment on the desirability of ascertaining the normal calibre 
of the urethra, and diagnosing, accurately locating and meas- 
uring the stricture or strictures. These steps are indispensable 
to an intelligent treatment, especially since the demonstration 
of the existence of strictures of large calibre, and since the 
theory has been exploded that when the canal is large enough 
to pass a good-sized stream, it is sufficiently restored to be left 
alone. This is not such an old theory either, being taught 5 
by one of England's most eminent authorities, and accepted, 
practically if not theoretically, by alas! too many. Otis' 
method of external measurement will give the size of the canal 
approximately, but for accuracy in diagnosing and locating, 
we need his urethrometer. In cases of tight stricture, the 
smaller-sized bulbs are preferable, because they will readily 
enter the urethra, and because his instrument, as a rule, 
registers incorrectly the lower numbers of the scale, besides 
losing its shoulder so to speak. In strictures of large calibre, 
however, it is invaluable, as it can be enlarged to fit the lumen 
of the urethra after passing the 'meatus. Once treatment is 
well under way, and the orifice freely cut, the firmer solid 
bulbs come into use again. 
These data obtained and noted, it becomes necessary, in most 
cases, to enlarge the entrance to the canal. I dwell on this 
because, though apparently a trivial step, it but too often 
proves a stumbling-block. Had we a sound working on the 
principle of the urethrometer, one the size of which we could 
increase when within the urethra, we might leave the orifice 
alone. However, I have repeatedly met with cases where no 
stricture could be detected, and a free incision at this point was 
followed by complete cessation of all discharge. The term 
"cutting the meatus" seems to me decidedly wrong; it leads 
many astray, and has given rise to the very prevalent method 
of snipping the same with a pair of scissors to avoid haemor- 
rhage and pain. I followed the advice given me only to find, 
in my first case, a "stricture" at the other end of the fossa 
navicularis. Introducing the urethrometer, and screwing it 
up to the capacity of the urethra, we will find, on withdrawing 
it, either, that it comes out without a catch; this is rare, but 
if the case, no interference is necessary; or, it catches just 
within the lips of the meatus; if so, by all means let us use 
the scissors; but in most instances it will catch a short distance 
down. Be this a stricture or a normal contracture, the treat- 
ment is the same. Dilatation at this point is very painful, 
hence the meatus stretchers are not desirable, and nothing but 
a free incision, with a blunt pointed bistoury or meatotome 
passed in a half inch or more, will open the door, and obviate 
reclosure by healing. 
A word next concerning the dilatation ; the sound should 
not be passed into the deep urethra or bladder. Normally the 
narrowest parts of the canal are the vicinity of the meatus and 
the membranous portion; the former is enlarged and admits 
instruments, in consequence, which stretch the latter, cause 6 
pain and suffering more or less intense, and often set up a 
most serious train of symptoms. Treatment must needs be 
stopped, or, if carried out without such complications, we 
justify the criticism made to me by a well-known German 
syphilographer, who disapproved of using large instruments 
" on the American plan," because he had observed that, in such 
cases, subsequent inflammations set up, and that at an early 
stage, trouble in the deep urethra, bladder, etc. Again the 
sound should be passed into the stricture only, and if there are 
several, the dilatation of the first should be complete before the 
second is touched and so on. As to the first point, when once 
in the stricture our end is accomplished, and there is no need of 
dilating any other portion. Having once accurately located 
the lesion, this is of course easy. As to treating more than 
one constriction at a time, there is this serious drawback : with 
the instrument tightly held, we lose the sensations conveyed 
in its onward journey, and can no longer guide it intelligently, 
or, using the amount of power necessary to force it through, 
we may do incalculable damage beyond. This is especially 
true of constrictions near the orifice of the canal, and hence 
another reason for their early and complete obliteration. 
Further, the old-time sound is to my mind a snare. The 
temptation is almost irresistible to pass it beyond the angle of 
45 degrees, or "all the way in;" the beak must needs be 
fully two inches beyond the stricture to give the same the full 
size of the instrument; pressure is made throughout the canal, 
when it is only needed at the point of constriction, and there 
is no scale to show just how far the beak has gone. A straight 
instrument will reach every point of the urethra proper, and, 
with a little practice, can be passed farther on if necessary. 
Dr. F. D. Weisse, of New York, published in the Medical 
Record of December 20th, 1884, the description of some bulbs 
and sounds which seem to fill a long-felt want. He has, too, 
in the accompanying article, emphasized the distinction between 
the urethra proper and the deep or vesical urethra. I have 
had a full set of his sounds and bulbs made for me, and I 
present them to the society for examination. He describes 
them as follows: The bulbs are "Otis' metal bougie & boule 
with a non-flexible, ruled staff, and with a bulb at either end- 
giving two sizes to the one instrument. Its length 
is six and one-quarter inches from the apex of one bulb to the 
base of the otherThe staff, smaller than the bulbs, has 
two flattened sides, which are ruled in one-quarter inch spaces, 
etc." These are useful, as before stated, in conjunction with 7 
the Otis urethrometer, the advantage over the original 
instrument being the scale on the staff. With these go "a set 
of urethral sounds with ruled staffs." They consist of " a 
sound portion at either end-two sizes to one instrument- 
and an intervening staff portion. The sound portion is two 
inches in length ; the middle, for an inch, presents the full 
circumference or size of the sound in millimetres (French 
scale); the ends (for half an inch each) taper through several 
sizes. The staff portion has much less circumference than the 
sound portions, and it is four and a quarter inches in length ; 
it is flattened on two sides (one for each of the end sounds), 
which are ruled in inches, with the quarter inch divisions." 
The taper is abrupt, the sound or stretching portion is short, 
but fully long enough, while the scale, by comparison with 
the bulbs or urethrometer, tells exactly how far the instrument 
should be passed. Lastly, after giving them a fair trial, I feel 
they have enabled me to take a step in the right direction. 
. How and when are we to cut for stricture? As before 
stated, should we find a hard, resisting band or ring, into 
which an instrument enters with difficulty, causing pain and 
often more or less bleeding, a continuance of gradual dilatation 
is useless, and I sincerely hope the day is not far distant when, 
under these circumstances, cutting will be the rule, not the 
exception. Further, I do not see how any instrument but the 
one devised by Otis can do any permanent good. I once met 
with a stricture a short distance from the meatus, and, intro- 
ducing an ear-speculum, I tried to cut it with a blunt-pointed 
tenotome. I was converted to the dilating urethrotome! 
The key-note seems to be complete division of every fibre, and 
when this is done, in the vast majority of instances, there will 
be no recurrence and no necessity for further instrumentation. 
In the above category we ought to include resilient stric- 
tures, but as they are usually of traumatic origin and are found 
in the membranous urethra, they deserve separate mention. 
In this location, beside the tendency they show to recontraction, 
there is the danger of reaction from continued instrumentation 
and the stretching process, and sooner or later cutting must be 
resorted to. The enthusiasts on the subject of internal ure- 
throtomy would carry that operation into this region. I would 
enter a most emphatic protest against such practice. The cases 
of death, whether from haemorrhage, or shock, or urethral reac- 
tions, have been almost invariably after deep urethrotomies, and 
besides, the operation is exceedingly difficult of execution. I 
feel quite safe in saying that we may lay down the rule: 8 
internal urethrotomy to the bulb, external urethrotomy or 
perineal section at or beyond that point. Here, too, when the 
section has been complete, there is no fear of recurrence. 
There are inflammatory conditions of the urethra, granula- 
tions, erosions, etc., which often yield to pressure and topical ap- 
plications, but when occurring in the deep urethra, where they 
are most obstinate, long lasting, and dangerous, we lose what 
is, perhaps, our most potent weapon. Pressure will stretch, 
will cause pain, and will sooner or later set up serious mischief. 
Our instruments then must be small and, if possible, soft. A 
Nelaton catheter, carried to a point where the fluid does not 
run out of the meatus, will irrigate the whole deep urethra, 
while the small-sized silver catheter of Ultzmann, with capil- 
lary perforation and syringe attachment (hypodermic size), or 
the porte remede of Dittel, will allow concentrated fluids and 
solids, respectively, to be accurately placed anywhere between 
the triangular ligament and the true vesical sphincter. 
Passing to the bladder, I cannot refrain from a word con- 
cerning catheterization. There are here two flagrant abuses, 
the use of hard instruments and the desire to " put these in," 
not " let them find their way in." Simple as this caution may 
seem, it is none the less too often forgotten, and to this fact, 
with what abomination the metal catheter, are due, not only 
most cases of failure in retention, but all the false passages that 
so often complicate such failure. Nelaton and Mercier deserve 
the eternal thanks of suffering mankind, and alongside of them 
among the immortals should be seated the inventor of the 
filiform. With these three instruments, a syringeful of sweet 
oil, and a limitless supply of patience, at least no harm can be 
done. 
The last resort, too, in such cases should, I think, often be 
a much earlier one, viz.: aspiration, a harmless operation, easy 
of execution, one that can be indefinitely repeated, but usually 
postponed until irreparable harm has been done. 
In conclusion I would say a word concerning the treatment 
of acute urethritis. 
May we not discard that, to my mind, more than useless 
instrument, the syringe? Was there ever a man who could 
properly inject his urethra? and, as a rule, how little do the 
two or three squirts a day avail him I Will not internal 
medication take the place of the syringe? In some cases, 
perhaps, yes; in some, perhaps, nature will come to the rescue; 
but a form of efficient local treatment must yet be found. This 
will supplant the syringe in the inflammatory stage, when hot 9 
water, pure or slightly medicated, is used to cleanse and keep 
down inflammation, and in the stage of decline when as- 
tringents are substituted. 
Irrigation has been highly lauded and severely criticised, 
but in it, I think we have, for the present, a solution of the 
problem. The main difficulty seems to be the pain caused by 
the instruments used. My attention was called some three 
years ago to an article by Whitehead, of Manchester, I believe, 
in the Lancet, describing a catheter for irrigation. It was of 
hard rubber, with a bulbous point from which " eyes" looked 
backward to prevent, forsooth, the passage of the water 11 into 
the bladder;" the shank was made up of three cords arranged 
spirally and forming three grooves for the ready egress of the 
water, and to insure its washing more of the surface. I sent 
for it, and used it-once. Thinking over the surgical anatomy 
of the urethra, I ventured to substitute a Nelaton cathe- 
ter with the eye in the point, and found it worked perfectly 
well. 
The course I pursue with an acute urethritis is as follows, 
and while there is no claim to originality in the method, I 
have used it long enough to heartily recommend it. 
In a bath-room adjoining my office, I have a Betts' bucket 
and pan, such as he uses for the vaginal douche. The patient 
sits on the latter, as I found that in some individuals there 
was a tendency to faintness at first. . In the bucket is warm 
water which is made hotter as desired; this is medicated 
slightly during the early stages with antiseptics, for which 
astringents are substituted later on. From the bucket runs a 
rubber-tube with stop-cock and adjustable tip at the extremity, 
and to this is attached a soft catheter with the eye at or as near 
the point as possible, and of a size to suit the meatus. 
The patient having passed his urine, the instrument is 
lubricated with carbolized glycerin, and introduced beyond 
the limit of the inflammatory process, or to any point short of 
the triangular ligament; the water is turned on and flows 
forcibly out of the meatus. The sittings are daily and at first 
of short duration, the guide being the patient's feelings and 
face, and are gradually lengthened to one-half hour at the 
outside, while the temperature of the water can be raised by 
degrees to such a point that the hand can hardly be held in it. 
The average case requires about two weeks before the discharge 
becomes thin and watery, when irrigation is of no more avail. 
In some instances this stage is reached in a few days ; in others, 
the average given is surpassed, but the most striking point is 10 
the immunity from pain, dysuria, and chordee. With a meatus 
markedly swollen, a urethral mucous membrane deeply con- 
gested, and a discharge copious, thick, and of a greenish hue, 
we might expect such trouble, but it is absent, and when these 
symptoms present, irrigation quickly dispels them. Once the 
stage of decline is well advanced, I substitute for irrigation 
medicated bougies ; any preparation can be ordered or obtained 
at Mitchell's, but I prefer pretty strong astringents with opium 
added. I order the long size (six inches), and have them cut in 
two and introduced, after lubrication with glycerin, three times 
daily for the first two days. If they are well borne, they can 
be lengthened as seen fit and-introduced after each micturition. 
The discharge once stopped, or reduced to a minimum, it but 
remains, after a short wait, to carefully examine the urethra 
for sensitive spots or constrictions. 
Of course, local and general hygiene are not forgotten, and 
remedies are administered as considered indicated. They will 
often materially hasten the end they do not seem readily to 
bring about alone. 
Further, it is not always the remedies considered most potent 
in such cases that do the work. It is well to have a group of 
drugs to look to in any disease, but the empiricism this has 
led to has undoubtedly had much to do with the falling into 
disrepute of internal medication. 
We have then, it seems to me, in irrigation a rational method 
of treatment, one that gives better results than we have been 
able to obtain thus far, but one which, at present, involves 
considerable time and trouble for the physician, as well as 
annoyance for the busy patient. It is most certainly worth 
our while to devote thought to the matter, and I confidently 
expect to see the day, and that shortly, when it will be so 
simplified and perfected as to become the routine treatment.