ON 
REFLEX IRRITATIONS 
THROUGHOUT THE GENITO-URINARY TRACT, 
RESULTING FROM 
CONTRACTION OF THE URETHRA, 
Fessenden N. Otis, M.D., 
Clinical Professor of Genito-TJrinary Diseases in the College of Physicians and Sur- 
geons, Yew York. 
READ BEFORE THE NEW YORK ACADEMY OF MEDICINE. 
Reprinted from the Ohio Medical and Surgical Journal for February, 1877. 
COLUMBUS: 
NEVINS & MYEES, BOOK AND JOB PRINTERS. 
1877. REFLEX IRRITATIONS. 
By Fessenden N. Otis, M.D., 
Clinical Professor of Genitourinary Diseases in the College of Physicians and 
Surgeons, New York. 
READ BEFORE THE NEW YQRK ACADEMY OF MEDICINE. 
Mr. President and Fellows of the Academy: The influ- 
ence of the irritation of peripheral nerves in producing cen- 
tric disturbance in the spinal cord, which may thence be 
transmitted to distant parts of the animal economy (first 
claimed by Dr. Marshall Hall more than twenty years ago), 
has found corroboration in the testimony of every medical 
scientist since his time ; and besides, so much clinical proof 
has been accumulated by the medical profession at large in 
support of this proposition that it is no longer a matter for 
discussion. Morbid reflex disturbances are now accepted as 
occupying an important place in the recital of human suf- 
fering. 
Varied and grave disturbances, influencing the entire nerv- 
ous system, are often ascertained to be dependent upon as 
apparently significant a cause as a decayed tooth, an indi- 
gestion, a simple erosion upon the cervix uteri, ceasing at 
once on the cessation of the cause. Dr. D. Campbell Black, 
of Glasgow, in his very interesting and valuable work on the 2 
renal and urinary organs, cites cases of retention of urine 
from reflex irritation, the result of an operation for hoemor- 
rhoids. Trousseau has recorded cases of incontinence of urine 
dependent solely upon the irritation caused by a preputial 
contraction. Dr. Sigismund Waterman, of New York, has 
shown me a case of this sort which was promptly relieved 
by division of the prepuce. I have seen other similar cases, 
and also one marked case of retention of urine in an infant 
nine months old, which, after lasting four days, was com- 
pletely relieved within one hour by slitting up the prepuce. 
Seminal emissions are well known to occur as a result of 
phyniosis, relief occurring promptly on ablation of the pre- 
puce. 
Dittel relates a case where a man twenty-six years of age 
had a slight phyniosis, and was the subject of incomplete 
erections, nocturnal emissions, frequent desire to urinate, 
and also of many hypochondriac symptoms, all of which 
were promptly and completely cured by removal of the pre- 
puce. 
A similar case is related by Pitha. Sweigger-Seidel cites a 
case where the simple introduction of a catheter caused com- 
plete syncope, and yet no urethral disease was present. I 
have the record of a similar case where complete uncon- 
sciousness instantly followed the introduction of a bulbous 
sound through the meatus urinarius. Every surgeon of 
much experience has recognized the tendency to syncope in 
a considerable proportion of nervous patients, on the first 
introduction of instruments through the meatus. 
Spasm of the bladder is noted by Dr. D. C. Black as occur- 
ring from sympathetic irritation, and to such a degree that 
complete closure of the uretral orifices results, producing re- 
tention of urine in the ureteis and pelves of the kidney. 
Such a case I believe I have seen, resulting in death from 
uraemia, and caused by the rude introduction, by the patient, 
of a catheter, through a narrow stricture at the posterior 3 
border of the fossa navicularis. Forcible and painful contrac- 
tion of the bladder followed immediately, with complete sup- 
pression of urine. The patient died uraemic twenty-four 
hours after. The bladder was found empty (with the excep- 
tion of a few drams of grumous blood and mucous), closely 
contracted and free from disease. The ureters were normal, 
the kidneys highly engorged with blood, but presenting no 
evidence of disease. The case was accepted as one of acute 
suppression at the time. The ureters are known to contract 
vigorously under the influence of the galvanic current. The 
above case,* it now seems to me, was one of spasm of the 
ureters and bladder, reflected from the irritation of the end 
of the penis. 
A few days since Dr. Brown-Sequard related to me the fol- 
lowing case: 
“ While in London, during the past year, a gentleman 
was brought to me who presented all the rational signs of 
advanced cerebral ramollissement. I had looked upon the case 
as quite a hopeless one, until noticing that the patient fre- 
quently applied his hand, in an absent sort of way, to his 
genital apparatus. Permission being accorded, examination 
of the parts revealed an aggravated inflammatory phymosis, 
complicated with acute balanitis. On making this dis- 
covery,” said Dr. Brown-Sequard, “ I expressed to the med- 
ical gentleman accompanying and in charge of the patient 
my belief of the possibility that the apparent ramollissement 
might be due to reflex irritation, caused by the evidently 
chronic and severe irritation of the glans penis. I advised 
complete division or ablation of the prepuce, and treatment 
of the balanitis, as the best and only hope for the patient’s 
recovery from the brain trouble from which he was suffer- 
ing.” 
The operation was performed, and the effect upon the men- 
* Reported to the New York Pathological Society, March, 1872. 4 
tal and physical condition of the patient was almost imme- 
diate. “ So rapid was his recovery,” said Dr. Brown-Sequard, 
“ that within six weeks from the date of the operation he pre- 
sented himself at my office perfectly well in every respect.” 
Dr. Sayre, of New York, in the Transactions of the Ameri- 
can Medical Association for 1870, has reported several inter- 
esting cases of partial paralysis of the lower extremities, 
associated and evidently dependent upon adherent and con- 
tracted prepuce. One was of a boy five years of age, unable 
to walk without assistance, or to stand erect — his knees 
being flexed at an angle of forty-five degrees. The operation 
of circumcision was performed on this lad by Dr. Sayre, and 
“from the very day of the operation the child began to 
improve,” and without other treatment made a rapid and 
complete recovery. In a second case, a lad of fourteen years 
had been under treatment for paralysis of his legs for several 
months without firiarked improvement, when it was found 
that a contracted and adherent prepuce was present, causing 
great local irritation, dvsuria, and painful erections. The 
preputial contraction was recognized as a possible important 
factor in causing the paralytic trouble. Circumcision was 
performed, resulting in complete recovery from the paralysis 
in six weeks. 
Sir Henry Thompson says:* “ I have given complete relief 
to distressing symptoms of very long continuance, the cause 
of which was not suspected, by dividing an external meatus, 
which, nevertheless, admitted a No. 6 English catheter. I 
have met,” he further states, “ with three marked examples 
of a similar kind, in which the very simple operation neces- 
sary was followed by complete disappearance of urinary difficulties, 
which had been long regarded as of an extremely obscure character. ”f 
He cites a single case: “ J. J., aged thirty-four, a gentleman 
* Stricture of the Urethra, second edition, page 249. 
t Page 253, op. cit. 5 
whom I had visited at the request of his medical attendant, 
in the spring of 1857, had been suffering from painful, pro- 
longed, and frequent micturition for five years previous. He 
was compelled to pass water from three to five times every 
night, and every two hours during the day; experienced 
severe pains in the back and loins, and general ill health. 
Urine was purulent, foetid, alkaline; results of habitual re- 
tention and partial engorgement of the bladder. He had 
been treated for renal disease without any good effect. On 
examination I found a simple narrowing of the urethral 
orifice, and marks of previous ulceration in a small cicatrix. 
I learned,” says he, “ that he had had chancre seven years be- 
fore, which involved a large portion of the meatus, after the 
healing of which his present symptoms almost imperceptibly 
appeared. A probe only passed through the opening. I 
divided the contraction so as to make a free opening. A No. 
10 catheter was passed easily into the bladder, demonstrating 
that there was no other obstruction, and twelve ounces of 
urine were drawn off, although he had passed water just be- 
fore. The relief was almost instantaneous—in a week it was 
complete. He has had perfect immunity from his urinary 
complaints ever since. 
By the cases already cited, and many others scattered 
through the periodical literature of the past few years, it is 
sufficiently proved that paresis, more or less pronounced, may 
result from irritations reflected through peripheral nerves, 
without any coincident morbid change in the structure of the 
spinal cord, and that incontinence of urine, retention of urine, 
suppression of urine, involuntary seminal emissions, may, in 
the same manner, result from irritation at the extremity of the 
glans penis. The case of simulated cerebral ramollissement, re- 
lated by Brown-Sequard, occurring as a direct sequence of like 
irritation, indicates the wide range of sympathetic disturb- 
ances which may be initiated by simple inflammatory action 
at this point. Now, aside from the fact that the glans penis 6 
is known to be extraordinarily rich in sympathetic nerve 
cells, that it is the recognized initial point from "which the 
physiological sexual excitement is transmitted throughout 
the male genitalia, the records of clinical experience abound 
with evidences of the capacity and proneness of this especial 
region to produce reflex disturbances, often of a grave and 
lasting character, throughout the entire nervous system. 
Notwithstanding these facts, I believe that the full signifi- 
cance of this locality as a source of reflex irritations along 
the genito-urinary tract has not yet been appreciated; and, 
further, I am convinced that many heretofore obscure diffi- 
culties and diseases of the genito-urinary organs may be dis- 
tinctly traced to the locality of the meatus urinarius as the 
source of their initiation and continuance. In pursuance of 
this idea, permit me, gentlemen, to present for your consid- 
eration the following cases: 
Case 1.—A. Y., physician, aged twenty-eight, contracted 
first gonorrhoea November 20, 1873. Severe—lasted four 
weeks; treatment by alkalies’, internally; continued appli- 
cation of cold, mild injections. Was under my care. I no- 
ticed, on examination, that his penis was large and the 
meatus small, and called patient’s attention to this fact when 
he first presented for advice, and assured him if he did not 
have a fair recovery it would be necessary to enlarge the 
meatus. 
January 19. Patient presents, with gleety discharge with- 
out known cause, great irritation at the neck of the bladder, 
and frequent desire to urinate; is certain that his former 
disease was imperfectly cured, and that it has come forward 
from the deep urethra to which it had extended in his 
original clap. I reminded him of his contracted meatus; he 
is certain he needs deep injections, but submits to operation 
for enlargement of meatus. Cut it to 30/, after which 30/ 
bulb passes throughout the canal with ease: to keep the in- 
cision open until healing is complete. January 24. Patient -reports immediate cessation of irri- 
tation in the perineal portion of the urethra on division of 
the contraction. The discharge ceased within forty-eight 
hours, and he has had no trouble since. 
Case 2.—September 10, 1872, Mr. W., a Swede silk-wTeaver, 
was brought to me by his medical attendant, complaining of 
pain and general discomfort about the perineum, and espe- 
cially of a nervous uneasiness in that region and in the 
glans penis, which prevented him from pursuing his avoca- 
tion; he could not sit still. Had had a gonorrhoea several 
years previous. Had been treated for stricture by dilatation 
for several months, but without relief. Examination showed 
a narrow meatus, No. 20/. Stricture at two and a half inches, 
defined by 18/. A free division of the meatus was made with 
Civiale’s bistourie cache, and of the stricture with the dilating 
urethrotome; 27/ passed readily through: to be kept open 
by daily introduction of sound until healed. 
September 20. Patient reports entire cessation of the irri- 
tation and nervous feeling immediately following the opera- 
tion, but this returned yesterday. Examination shows re- 
contraction of the meatus to 20. Cut again freely. 
November 16. Patient again called, with the statement 
that he had been able to work until the day previous, when 
the irritation again returned, and he desired to be cut again. 
Examination showed a recontraction at the meatus to 24. 
Cut again, and inroduced 80/, which passed easily through 
the site of stricture at two and a half inches, and down to 
the bulbo-membranous junction. This patient called two 
months’after (January 20), and had had no return of his 
trouble—no recontraction of meatus. 
Case 3.—Mr. W., aged twenty-seven, had gonorrhoea in 
1870, lasting one month, when a fresh exposure resulted in 
another attack, which lasted, under a sharp fire of injections, 
for six months longer. Since that time has always had a re- 
turn of the discharge after connection. Has been under 8 
treatment for stricture by several physicians, but none suc- 
ceeded in entering the bladder. His last medical attendant, 
after treating him for a couple of months, said that he had 
no instruments small enough to pass, and advised him to put 
himself under my care. Examination (April 16) showed 
organs unusually well developed, meatus contracted to 24/, 
and red and pouting, and bathed in a muco-purulent dis- 
charge. Twenty-four sound is arrested at five inches; only 
fine filiform will pass, and that is closely hugged. 
April 19. Pass filiform with ease, follow with No. 10, and 
then, with some effort, with No. 16/; after this the filiform 
is again closely hugged in the membranous portion; divided 
the meatus freely, and introduced No. 30 steel sound, which 
passed literally by its own weight down through into the 
bladder, thus proving not only the spasmodic character of 
the deep obstruction in this case, but its entire dependence 
upon irritation caused by the stricture at the meatus. 
Case 4.—October 30, 1873. J. W., aged thirty-two, had 
gonorrhoea ten years ago, very severely, lasting, with pain 
and difficulty of micturition, fully six months. After being 
apparently well for three a gleety discharge appeared 
without new exposure. Masturbated daily from fourteen 
years of age to twenty, when he abandoned the habit. At 
twenty-six began to have nocturnal emissions, which, grow- 
ing gradually more frequent since the last two years, have 
occurred almost nightly. He has had occasional sexual in- 
tercourse. Erections have been imperfect for last eighteen 
months, ejaculation taking place before the erection was com- 
plete. He has suffered much from despondency and nervous- 
ness. Has had no treatment except for general health, which 
much of the time has been indifferent. Examination shows 
genitals well developed and apparently normal, with the ex- 
ception that while the circumference of the flaccid penis is 
three inches, the meatus is contracted to 22/ (the size of 9 
urethra in a penis three inches in circumference is, as a rule, 
fully 30/).* See note. 
November 1. Divided meatus thoroughly, and passed 31 
bulbous sound readily through contraction. 
November 11. Has had no emission since date of opera- 
tion. 
December 1. Found himself getting so much better in 
spirits and feelings generally, that he ventured to marry on 
the 25th. Since that time has had no trouble of any sort. 
Considers himself a well man. 
Case 5.—Mr% W\, aged twenty-five, came under my care 
December 1,1872. Contracted first gonorrhoea early in June, 
1872. Was treated by the use of injections locally, and alka- 
lies internally, until August 1, during which time he had 
no freedom from the discharge nor from acute suffering. 
About this time the vesical neck became involved, and he 
suffered much from frequent painful micturition. Came 
then under the care of a skilled endoscopist, who discovered 
numerous spots of granulations in the course of the canal, 
extending quite into the prostatic portion, and applications 
of a strong solution of nitrate of silver were made through 
the endoscope, which gave temporary relief; urination still 
painful every hour. 
By September 1, after the use of pencils of tannin and 
glycerine, discharge decreased to a slight mucous. A spell 
of damp weather brought back the purulent discharge, with 
return of perineal pain and frequency of micturition. Tan- 
Note. — I have recently operated for congenital contraction of the 
meatns in a child ten years old, where the circumference was two inches. 
After the operation 22/ was passed easily through the urethra. 
* 3J inches indicates urethral caliber 32/. 
3| “ “ “ “ 34/. 
3f “ “ “ “ 36/. 
4 “ “ “ “ 38/. 
4i “ “ “ “ 40/ 10 
nin pencils again used, but after continuing for four weeks, 
and no improvement, patient was put to bed, and hot hip- 
baths every two hours, etc. 
After five weeks of this treatment, and various other, local 
and general, he came from his bed to mo, December 1, 1872. 
On examination I found no difficulty in introducing No. 
20/ bulbous sound, and discovered a firm cartilaginous 
stricture, extending from just within the meatus one-half 
inch back. This I cut freely with Civiale. Immediately 
following the operation, he expressed himself as feeling 
“like a new man.” In his written report of the case (he 
was a physician), he stated that “on the division of the 
stricture the relief was wonderful.” The discharge ceased 
within twenty-four hours, the perineal pain and frequency 
of micturition, and the ardor urina3 also ceased, and he re- 
turned to his duties, which were most active, on the follow- 
ing day (after having been laid up for over five months), 
and has continued on duty up to the present date, although 
he still suffers occasionally from prostatic pain. The pros- 
tate, which I found double its normal dimensions on his 
first visit, is now found to be reduced in size fully one-third. 
Case 6.—Mr. B., aged forty, from early boyhood has had 
more or less irritation of the urethra, usually referred to the 
vicinity of the meatus urinarius. Twelve years since he 
had an attack of gonorrhoea, which continued for nearly a 
year, in spite of a variety of treatment. Suffered much 
during this attack, especially with pain in the glans penis. 
After a continence of several months, on having sexual in- 
tercourse, found the act of seminal emission was accompa- 
nied by an intense burning pain, extending through the 
perineum and lasting for half an hour, described like red- 
hot lava running over a raw surface. On subsequent similar 
occasions, finding the same result, his physician, being con- 
sulted, called it a sexual weakness, and treated him by in- 
troduction of bougies. This failing to afford relief, he 11 
eschewed sexual indulgence entirely. Occasional nocturnal 
emissions were accompanied and followed by the same pain 
previously referred to, but less severe than in connection. 
In June, 1873, after seven years of continence, he noticed a 
slight gleety discharge from his urethra, with pain in the 
glans penis, aggravated by motion, walking or riding. After 
a variety of opinions by various surgeons, as to the nature 
of his complaint, it was finally decided to be a stricture of 
the urethra, and was treated by the semi-weekly introduc- 
tion of bougies. His strcture was supposed to be in the deep 
portion of the canal, and after six months of treatment his 
urethra was said to have been raised in calibre from 8 to 11 
E. He then had an attack of acute cystitis, lasting two or 
three weeks, and since that time he has been subject to fre- 
quent trouble in micturition, frequency, and pain along the 
urethra, especially at the glans penis, and 11 a feeling of wet- 
ness,” as the patient describes it, “that is depreseing in the 
extreme.” He also had weekly seminal emissions. Exam- 
ination in this case showed full development of penis. 26/ de- 
fined stricture one-third of an inch from the meatus. Exam- 
ination of bladder fails to detect any calculus. No evidence 
of contraction at any other point in the urethra with No. 
21/ bulb. I divided the stricture at the meatus, and passed 
30/’ solid steel sound, easily drawn through the urethra and into 
thebladder. This was in July, 1873. The operation was fol- 
lowed by immediate relief from pain and frequency of mic- 
turition. The discharge soon ceased, a gradual improvement 
took place in regard to the pain after emission, for several 
months, when it began to return, and also some of his vesical 
irritation. Examination revealed a recontraction of the 
stricture. This was again divided, and a few days ago the 
patient wrote me that he has done since the last opera- 
tion (which was performed in November), and is entirely 
relieved of all his most troublesome difficulties, but an occa- 
sional feeling of irritation in the perineal region in duces him 
to think that slight recontraction may have again recurred, 12 
and he proposed to return, at some convenient time, for ex- 
amination upon this point. 
Case 7.—Mr. S., aged forty-five, has had gonorrhoea twice, 
followed each time by a gleet lasting many months, finally 
cured by introduction of steel sounds. Has had several at- 
tacks of irritability of the bladder since first attack of 
gonorrhoea, and long ago noticed that this was affected by 
the use of any alcoholic stimulant, and also that he did not 
completely empty his urethra after micturition. To effect 
this, he was in the habit of pressing his finger along the 
urethra from the perineum; unless he did this, a sense of 
irritation in the canal, and a desire to urinate, would come 
on in a few moments. Complained of feebleness in making 
water after a week or two of continence. On having con- 
nection, the stream is at once greatly improved. Any sexual 
excess is followed by pain in the perineum. His trouble 
was now thought to depend upon spasmodic stricture, and 
large sounds advised. In order to admit them it became 
necessary to incise the meatus. This done, 18E. was easily 
introduced, but not continued as contemplated, as all trouble 
passed off in a few days. A few months subsequently, how- 
ever, his old troubles returned, and were not relieved by the 
u#e of the sound. At this point he came under my care. 
Penis found to be four inches in circumference, which would 
indicate a capacity of urethra of 38 of the French scale. No. 
28 bulbous sound detects contraction at the meatus. This 
was freely divided, with the immediate result of relieving 
the irritation of the bladder, and in a short time pain follow- 
ing connection had almost entirely disappeared, and the 
stream of uripe was increased in force, and the ability to 
empty the canal much improved. The patient is still under 
observation. 
Case 8.—Mr. Z., aged forty-six. Regular and chaste in 
habits until going to China, twenty years since. Following 
the custom of foreigners in that cou'ntry, he indulged ex- 
cessively in sexual intercourse for several years. Had a 13 
single attack of gonorrhoea, from which he recovered com- 
pletely in a few weeks. For the last few months he has been 
troubled with involuntary emissions as frequently as once a 
week, and, latterly, in his attempts at sexual intercourse he 
has failed, on account of the seminal discharge having oc- 
curred before the erection was complete. He feels quite cer- 
tain that his genital apparatus is less in size than formerly. 
Examination shows penis of normal size, three inches in 
circumference and three in length ; some enlargement of the 
left spermatic veins; testes soft, full size, left largest; 
meatus urinarius contracted to 22/ On introduction of the 
bulbous sound through it, as it was quite unyielding, it re- 
quired some slight pressure, and as it suddenly slipped into 
the fossa navicularis, a regular spasmodic retraction of the 
penis occurred at intervals of three or four seconds (retrac- 
tion about a quarter inch), and continuing during the half 
minute that the instrument was retained, and continuing 
with rhythmical regularity for three or four minutes after 
its withdrawal. This result of the introduction of the sound 
was repeated several times at that sitting, the intervals be- 
tween the contractions gradually lengthening, until an in- 
terval of five or six seconds occurred, when it ceased. These 
movements, so evidently of reflex origin, suggested the de- 
pendence of his seminal troubles on the same cause. I 
therefore divided the meatus thoroughly, and introduced 
thirty-one sound without difficulty through the urethra. 
After the operation, the introduction of the thirty-one bulb 
failed to excite the spasmodic contraction of the penis, nor 
in frequent subsequent experiments was I able to reproduce 
this phenomenon. An immediate improvement in the gen- 
eral condition of the patient occurred. His involuntary 
emissions ceased without other treatment, and six weeks 
after the operation he informed me that he had entirely re- 
covered his sexual powers. 
Case 9.—I. W., aged thirty-four, came to me in Septem- 
ber, 1873, complaining of frequent seminal emissions, one or 14 
two every week, pains in the lower part of the back, in the 
hypogastric region, in the groins, running into the testicles 
and extending down the inner aspect of the thighs to the 
knees. He was of chaste habits up to some four or five 
months previous, when he became engaged to be married. 
After this time he was the subject of frequent and prolonged 
venereal excitement and ungratified desire. In a few weeks 
involuntary emissions became frequent and finally painful, 
with suffering for some time after. Gradually the previously 
described pains of the back, hypogastrium, groins, testicles, 
etc., came on, resisting all treatment by his family physician 
until the present time. I prescribed for him absolute ab- 
stinence from sexual contact, general care of diet, position 
in sleep, cold ablutions, etc., and a mixture of bromide of 
potassium with the bromide of ammonium and tincture of 
ergot. December 3, three months after (living several hun- 
dred miles distant), he came again to see me, with the re- 
port of an entire relief from the seminal emissions, but had 
had swelling of testicles, and still suffers from almost constant 
pain in the back, over pubes, in the groins, and, especially 
of late, in the testicles, extending down the thighs. Exam- 
ination revealed a serous effusion into the tunica vaginalis of 
of both sides; in the left some three or four drams of fluid; 
in the right rather more, and which backed well up to the 
external abdominal ring. The light test showed this fluid 
to be quite transparent. I at first thought of treating it as 
an ordinary hydrocele, by withdrawing the fluid; but on 
finding a meatus, situated on the superior aspect of the 
glans, contracted to 15/, and holding the bulb for fully one- 
third of an inch, and further finding that he had long been 
troubled with dribbling after micturition, I explained to 
the patient the possibility of all his trouble arising from 
this congenital deformity. He promptly consented to an 
operation, and I divided the contraction thoroughly, passing 
afterwards a thirty-four steel sound through the urethra. 15 
(Circumference of penis three and a half inches.) Several 
sensitive points were recognized by the patient during the 
passage of the sound, indicating a granular condition of the 
mucous membrane. Immediate relief of the pain in the 
testicles and down the thighs followed the operation. With- 
in a month all trace of fluid in the tunica vaginalis had dis- 
appeared; he had had a single nocturnal emission without 
pain, and with the exception of a feeling of nervous anxiety 
through the hypogastrium (which came on occasionally), 
and some pain in his back, after general fatigue, he was 
quite recovered from his troubles. No internal remedies 
were made use of subsequent to the operation. 
Case 10.—-Mr. De F., aged forty-three, came under my care 
in March, 1867, suffering from retention of urine following a 
debauch. As no great amount of urine was present in the 
bladder, I gave him mur. tr. ferri, advised a hot bath, and 
left him. On the following morning he expressed himself 
free from any trouble, and declined an examination of the 
condition of his urethra. In December, 1871, he again pre- 
sented, complaining of incontinence of urine. He was also 
suffering from intermittent fever (which I suspected was due 
to his urinary trouble.) Said he “ made his water freely, but 
could not hold it.” I found some accumulation in the blad- 
der. As the patient lived out of town, I made no examina- 
tion, but advised him to make arrangements to come in town 
on the following day for treatment. 
He did not present again until November 80, 1872, when 
he came with the statement that he had then lost all control 
of his urine, had had none for the past year. On the day 
previous, while riding, he noticed a swelling in the perineum, 
aud “wished it looked after.” Examination revealed a firm 
elevation on the left of the raphe, one and a half inches in 
diameter at the base, and about an inch in elevation, ex- 
tending from just behind the anterior border of the anus to 
the junction of the scrotum with the perineum; solid, resi- 16 
lient, and painless; no constitutional disturbance; temper- 
ature, 98£°. On examination of the'urethra, expecting to 
find a deep, tight stricture. I was surprised to find myself 
able to pass No. 18/ catheter into the bladder, and to draw 
off a full pint of fetid uripe, although he had just urinated. 
During the day the swelling increased, and interfered with 
the calibre of the urethra, so that I could only pass a No. 1 
catheter into the bladder, and that with difficulty. Attach- 
ing this to Dienlafoy’s aspirator, I drew offia pint and a half 
of urine. This, on examination, was found to be free from 
any evidence of organic disease of the kidney. 
I then incised the tumor down through the superficial pe- 
rineal fascia, and gave exit to a thin layer of pus, in quan- 
tity about a drachm. 
It was only on the fourteenth day after (the swelling grad- 
ually subsiding) that urine was found flowing through the 
wound. In the mean time, the patient suffering from cys- 
titis, his bladder was washed out with a double-channeled ca- 
theter, No. 20/ which was passed without difficulty, although 
a perceptible clinging was recognized near the meatus—his 
bladder trouble increasing so that he made his water every 
hour, and was loaded with pus. I urged an operation on the 
stricture, which, from the easy passage of the catheter, I had 
not before considered of much importance. Introducing bul- 
bous sound No. 20/ I could not detect any stricture; on its 
withdrawal it was arrested at a point half an inch from the 
meatus, incising the stricture with the dilating urethro- 
tome, which (No. 23/) I introduced with some difficulty; I 
then passed No. 30 sound, without obstruction, down into 
the bladder. On the following day I found that the fre- 
quency of evacuation of the urine had decreased from one 
hour to six between the acts; that the purulence had de- 
creased, and that much less urine flowed through the opening 
in the perineum. From that time the patient continued to 
improve; his control of the flow of urine was restored; the 17 
purulence gradually disappeared, and within a week his pe- 
rineal incision had healed, and he left for his home appar- 
ently well, not having had any treatment whatever since the 
healing of the wound at the point of stricture. Circumfer- 
ence of penis in this case, three inches. 
Case 11.—February 12, 1872, Mr. A., aged fifty, came under 
my care, through the courtesy of a professional friend, with 
the statement that he had been suffering from chronic irri- 
tation of the bladder, accompanied by a slight urethral dis- 
charge, more or less troublesome, for a period of five years. 
He was thought by his physicians to be the subject of 
“gravel,” and for a long time had been much treated, and 
was finally sent abroad, in the hope that entire change of 
habit and climate might afford relief. He returned some- 
what benefited. Soon after (about three months previous 
to his visit to me), subsequent to a season of prolonged ex- 
ertion, physical and mental, acute irritation of the bladder 
recurred, with reestablishment of the urethral discharge, 
the latter quite like gonorrhoea, and was treated as such, al- 
though he had lived in the odor of marital sanctity for more 
than twenty years. Anti-blennorrhagics were administered 
with no benefit. Injections afforded only temporary relief. 
The patient presented to me in usual general health, di- 
gestion good. He gave a history of an attack of gonorrhoea 
twenty-five years previovs, which was treated solely by in- 
ternal remedies. A profuse muco-purulent discharge was 
present. On urination the stream was irregular and con- 
tracted. Meatus of average size, and admitted No. 18/ bul- 
bous sound; this was passed slowly and with some pain for 
half an inch, when it suddenly slipped into a capacious ure- 
thra beyond. On withdrawal, it was firmly held at half an 
inch from the meatus. On the same day I incised the stric- 
ture freely with Civiale’s bistourie cache and passed No. 26/, 
and sent him home with directions to his professional attend- 
ant to have dilatation practiced daily until healing of the 18 
wound was complete. Returning July 2d, he reported himself 
as having had entire relief from his bladder trouble, and from 
the discharge, since the healing of the incision. For a few 
days previously, however, he had suffered with some vesical 
irritation. Examination revealed some contraction still re- 
maining on the site of the stricture; this I at once relieved 
by the use of the dilating urethrotome, and passed 30/ down 
into the bladder. 
Case 12.—T. W., aged thirty-five, had gonorrhoea fifteen 
years ago; has had it several times since. The last time, 
four years ago, coming on forty-eight hours from date of ex- 
posure. After the discharge had existed ten or twelve days, 
he states that he “ stopped it with a powerful quack injec- 
tion.” Three or four days subsequent to this he began to 
suffer with a neuralgic pain in the left testicle, the scrotum 
became tender and red, testicles moved up and down alter- 
nately much of the time, and the penis was greatly con- 
tracted; there was likewise pain in the groins, described as 
drawing and sickening, which extended down into his knees 
and the bottoms of his feet. This continued with varying 
severity almost without cessation up fo February 22d, when 
he came to New York for treatment, and fell) into the hands 
of an endoscopist, who discovered numerous granular spots 
deep in his urethra. Applications made at regular inter- 
vals for about three months without benefit. An applica- 
tion of carbolic acid to the scrotum gave some relief to his 
nervous feelings, but this caused vesication, and the relief 
was but temporary. About May 1st he sought the advice of 
a surgeon skilled in genito-urinary diseases. Slight stric- 
ture was discovered near the meatus, and several indurated 
points farther down. 28/ solid steel sound was introduced, 
and after some repetition during one month was given to 
the patient to be regularly used once in three days until his 
trouble ceased. 
Went back to his home, some eight hundred miles distant, 19 
and pursued the plan laid out for him, but received no 
benefit. The motion of his testicles was almost constant, 
and the nervous feelings this induced drove him almost 
frantic—compared with it the pains in his groins, knees, 
and feet were a positive relief. He became very low-spirited 
and despondent. Early in October his physician (who had 
accidentally met with an article of mine in the second num- 
ber of Dr. Brown-Sequard’s Archives on “Reflex Irritations 
of the Genito-Urinary Apparatus, resulting from Stricture”) 
advised him to return to New York and put himself under 
my care. Examination discovered a penis of normal size, 
three inches in circumference; scrotum greatty relaxed and 
covered with eczematous scales produced by the carbolic acid; 
testicles hanging very low. My attention was at once 
drawn by the patient to the rhythmical contraction of the 
cremaster muscles, through which a see-saw motion of the 
testicles was kept up, and which constituted his chief annoy- 
ance. 30f bulbous sound passed the meatus, but was arrested 
at one-half inch, a point to which his greatest sensitiveness, 
during passage of instruments, had always been referred. 
28/ passes through and detects another stricture at two 
inches, and still another at two and a half. 
On Friday, October 17, at my invitation, the patient was 
examined by Dr. Coldham, of Toledo, Dr. J. DeForrest Wood- 
ruff and Dr. Frank Howe, of New York, especially in refer- 
ence to the spasmodic action of the cremasters. This was 
very marked and constant, and continued until the patient 
was placed under the influence of ether by Dr. Howe. I 
then demonstrated the size and locality of the strictures 
before mentioned, and divided them in succession with the 
(my) large dilating urethrotome, after which I passed with 
ease a 30f steel sound through all and into the bladder. As the 
patient emerged from the influence of the ether, it was ob- 
served that there was no longer any of the spasmodic action 
of the cremasters. When he became conscious, he stated 20 
that he already felt less of his nervous feelings than for 
many months. He was “ certain that the right chord had 
been struck.” 
October 8. Improvement continues—no return of spas- 
modic motion. 
October 20. Examination with 30/ bulb shows a slight 
clinging at one-fourth inch from the external orifice. Cut 
this at once, and freely, with straight bistoury, and pass 31/. 
The patient, on the following day, expressed his belief that a 
complete cure had been effected; that since the final division 
of the meatus he had not had the slightest return of the ab- 
normal sensations and pain with which he had, in some 
degree, constantly suffered for the previous four years. Daily 
introduction of the bulb was kept up, in this case, until all 
bleeding ceased, when the, patient was dismissed with the 
promise on his part to inform me by post if he had any re- 
turn of his trouble. 
Case 13.—Mr. H. D., aged fifty-one, had been under my 
professional care for several years; suffered from renal colic 
on twro occasions—once in 1869, and again in 1871. (Was not 
conscious of having passed any stone through the urethra. 
Came to me in February, 1872, complaining of a sense of 
irritation at the glans penis, and a frequent desire to urinate 
Careful exploration of the bladder failed to discover any cal- 
culus, but the meatus urinarius was red and tender, and con- 
tracted to 20f. This contraction was at once divided freely; 
size not noted. The relief from the irritation was immedi- 
ate and complete. In May, 1873, Mr. D. called, stating that 
his old irritation had returned. Examination showed that 
the meatus had recontracted to 23. This was again divided, 
with relief equally prompt as on the first occasion; but in 
the subsequent daily introduction of a glass tube, size, 30/, 
an unnecessary degree of violence was used by the patient, 
setting up an inflammation, which extended back as far as 
the prostate, and threatened to culminate in an abscess of 21 
that organ. This inflammation was accompanied by a dis- 
charge which did not differ from an ordinary gonorrhoea in 
the declining stage. After two months of treatment the dis- 
charge still continued, with more or less irritation of the 
vesical neck. Meatus contracted to 24. Again cut to 30/. 
This operation was followed by immediate relief from the 
vesical irritation. The discharge ceased without other treat- 
ment, and up to January, 1874, the cure has remained per- 
manent. 
Cass 14.—Mr. M., aged twenty-seven, had a history of 
seminal weakness, following self-indulgence from fourteen to 
seventeen. Has never had venereal disease. Began to notice 
a lack of virility a year ago. Seminal emissions weekly. 
Erections imperfect. Frequent desire to urinate, which is 
promptly relieved by tr. ferri. mur.; but this soon causes 
constipation (in spite of any thing short of brisk cathartics), 
and increased seminal discharges result. Has a constant 
and annoying sense of wetness about the glans. Always 
dribbles in his clothes after urination. Microscopic exam- 
ination of urine shows nothing abnormal but a few shreds 
of mucous. Prescribed mixture of bromid. potass, and bromid. 
ammonium, which arrested seminal emissions for a full 
month. He returned in better spirits. Has much less sex- 
ual desire than formerly, and occasional imperfect erections. 
Has not been obliged to urinate more than three or four 
times a day since taking the bromides. When he came to 
me he described the desire to urinate as unceasing. After 
a month he returned with some measure of his urinary irri- 
tation, although still taking the bromides. Great annoyance 
at the dribbling after urination, and says that the constant 
sense of wetness is depressing to the last degree. Examined 
meatus critically; 30/passes, but hugs slightly on return; 
31 will not pass. Size of flaccid organ three and one-half 
inches in length, and four in circumference. From this I 
estimate the normal caliber of the urethra at 38/ at least. 22 
As the dribbling seemed to indicate some retention at meatus, 
I concluded to divide it freely. This was done without pain, 
under the influence of local anaesthesia, when bulbous sound 
No. 38/ was passed with ease through the length of the 
urethra, detecting several small sensitive granular points in 
its course. The relief from the dribbling in this case was 
immediate and complete, and the sense of wetness (as the 
patient always expressed it), which gave him so much an- 
noyance, was completely removed. Although taking no 
internal remedies, he has had no return of emissions; the 
irritation of the bladder also disappeared, and up to the 
present, one month from the date of operation, it has not 
returned. In this case the difference between 30f, which 
measured the size of the evidently contracted and unresilient 
meatus, and 38/, which "was easily passed after division of 
the stricture, viz., six millimeters, shows the extent of the 
contraction. 
Case 15.—A. W., aged twenty-seven, seventeen years ago 
had first attack of gonorrhoea. Afraid and ashamed to 
speak of it, he suffered greatly for four or five months with- 
out any treatment whatever. Has had several attacks since, 
which were treated solely with injections. About six months 
ago had an attack of sub-acute prostatitis, which caused him 
much pain, both in urination and defecation. This lasted 
several weeks. Since that time he has had desire to urinate 
more frequently than natural—several times during the day, 
and also disturbed frequently at night. For the last five 
days he has been obliged to pass water almost every hour 
during the day, and at least every hour during the night, 
suffering great pain in the perineum, also in the rectum, at 
each act of micturition. He has, besides, a constant desire 
to defecate. January 10,1874, examination, per rectum, re- 
veals a tender and enlarged prostate fully double the normal 
size. External genital organs normal, except the meatus uri- 
narius, which was contracted to 20. Circumference of penis 23 
three and one-fourth inches. On passage of 20 bulbous 
sound, a distinct, unyielding fibrous ring was detected, which 
held the bulb firmly at one-fourth inch on its return. 19 
detects second stricture at one inch, and a third at one and 
three-fourths. 
For the patient’s immediate relief, half a dozen Swedish 
leeches were ordered to be applied to the perineum at the 
anterior border of the anus. Morphia suppositories every 
four hours. Under this treatment, with rest in bed, the 
rectal discomfort abated. Frequency of micturition, with 
pain in the perineum and rectum, remained without much 
amelioration until January 16. On this date the patient 
was etherized, and with the assistance of Dr. Beach Jones 
and Dr. Wiesfelder, 1 first divided the stricture at the meatus 
freely with Civiale’s bistoury cache; then, introducing the 
small dilating urethrotome, I dilated to 30/, and cut the sec- 
ond stricture at one inch; readjusted and cut the third at 
one and three fourths, after which 31 steel sound was passed 
readily into the bladder. 
The relief from pain and irritation in the rectum and at 
the neck of the bladder followed the operation almost imme- 
diately. By the following day the desire to urinate was re- 
duced to the normal standard, and the patient was disturbed 
only once during the night. February 10, twenty-six days 
after the operation, he reports himself as having had no 
further trouble, and as passing his water two or three times 
during the day, and once at night. Examination per rec- 
tum shows the prostate free from tenderness, but fully double 
its normal size. Thirty-one steel sound passes through the 
urethra without the slightest trouble. 
Case 16.—Mr. X., agpd fifty-four, seen in consultation with 
Dr. Ives, his family attendant. Had a history of first gonor- 
rhoea twenty-eight years previous; severe, lasting two months. 
Second attack eight years ago; not severe, subsiding entirely 
in ten or twelve days under the use of injections of acetate 24 
of lead alone. Three years ago he began to be troubled with 
frequent micturition during the day, and four or five times 
at night, associated with pain extending from the end of the 
penis to the neck of the bladder; also pain in the testicles 
and perineum, and extending down the thighs. Water 
occasionally stopped, and required to be drawn off with a 
fine catheter. Was taught to do this himself, and has often 
required relief in that way. About the first of August last, 
after using the catheter, he discovered a small bit of gravel 
in the eye of the instrument. Since that time he has voided 
a large quantity of the same sort, with fine, whitish sand, 
mucus, pus, and blood. Was under the care of a prominent 
surgeon in Brooklyn last summer, who, after careful exam- 
ination, assured the patient that he had no stone in the 
bladder. This surgeon treated him at first by frequent wash- 
ings out of the bladder; afterwards he used the galvanic 
current, with one pole in the bladder and one on the back. 
This was continued daily (?) for six weeks, but no improve- 
ment was manifest, and as the patient was much debilitated 
he was sent into the country to recruit. Since that time he 
has had no treatment except the use of Lee’s lithontriptic 
pills, and the use of the catheter when required by attacks 
of retention of urine. 
November 24, 1873. Present condition: Is in feeble gen- 
eral health. Has an expression of great and constant pain; 
is very restless and moans frequently, although evidently 
attempting control; skin pale and yellow; says his weight 
is 130; weight formerly 160. Genital apparatus well de- 
veloped. Bight testicle invaded interiorly by a mass of 
fibrous feel, involving one-half the body of that organ. Left 
much the same, but softer. Passes urine in my presence in 
a small, divided, uncertain stream. Urine of strong, stale 
dor, thick, and muddy in appearance. Coagulum under- 
heat, which is not dissolved by nitric acid. Cursory micro 
scopic examination shows cells of pus and blood. Epithe- 25 
lium from urethra, bladder, and pelves of kidneys, but no 
casts. Meatus urinarius apparently normal. Twenty-nine 
bulbous sound passes to the depth of one-third of an inch; 
it is, however, abruptly arrested at this point, and only 20/ 
will pass. This (No. 20) found no farther obstruction in the 
deeper portion of the canal, but on return was firmly held at 
three-fourths of an inch, thus defining a stricture more than 
one-third of an inch in breadth. Visiting the residence of 
Mr. X., November 26, he was found walking the floor with 
constant moans, begging to have the operation done at once 
to relieve his agony. Assisted by Dr. Ives, the patient was 
promptly anaesthetized. The stricture near the meatus was 
then thoroughly divided, and No. 30/ bulbous sound passed 
through to one inch—here it was abruptly arrested; 24/only 
would pass, and was held firmly on return at one and one- 
third inches. I then introduced the dilating urethrotome, 
turned up to 30/, and cut; 30/ bulb was passed down to two 
inches, where it was again arrested; 28/ only will pass, and 
on withdrawal is held at two and one-fourth inches. Re- 
adjusting the urethrotome, this band was also divided, when 
31/ steel sound was passed without force through the entire 
urethra. Ferguson’s short-beaked sound was then introduced 
into the bladder and thorough search made for stone, but 
without success. Hemorrhage slight, ceasing entirely within 
fifteen minutes after the operation. Dr. Ives remains in 
charge. 
November 29, three days subsequent to the operation, Dr. 
Ives called, reporting that the patient had no pain of any 
kind following the operation, up to his visit of yesterday. 
Under the influence of ten grains of quinine and a quarter 
grain of morphia he had slept for six hours, and on waking 
passed water with freedom, with slight smarting, but no 
pain. After this the intervals between the acts of micturi- 
tion averaged about four hours. Passed the steel sound 31 
with ease. Purulence in the urine greatly decreased. 26 
December 16. Dr. Ives reports Mr. X. as having suffered 
for a day or two past with pain in the penis. Purulence in 
the urine has entirely disappeared; 30 steel sound drops 
through the urethra into the bladder by its own weight. 
The possibility of slight recontraction of the stricture at the 
meatus as cause of trouble was suggested. 
December 23, Mr. X. called with Dr. Ives. He reports, 
personally, that while he passed his water every half hour 
with great straining and pain before the operation, that 
since then he has not been called to urinate oftener than 
once in three or four hours, up to within a week since, when 
it has been once in two hours. All the pains in the back 
and lower part of the abdomen, in the testicles, and extend- 
ing down the thighs, passed off entirely within a few days 
after the operation. During the last ten days he has had 
pain referred to in the vicinity of the prostate when urinat- 
ing, and the stream has been small and weak; could void it 
only by straining. He had himself passed 30/ steel sound 
the day previous. 
Examination of the prostate, per rectum, reveals no en- 
largement or tenderness; 30/sound passes without difficulty 
into the bladder, except a little hugging near the meatus; 
29/ bulb is arrested at one-fourth of an inch, and holds on 
return at three-fourths. I introduced a straight bistoury 
and cut through the contraction, so that No. 34/ bulb passed 
in and out without obstruction, to keep this well open until 
healing is complete. 
Case 17.—October 9, 1873, I was called to see a gentleman 
aged sixty-four, whose general health had always been good; 
he had lived generously, but regularly. He stated that for 
the ten years previous he had occasion to urinate on an aver- 
age every hour during the day, and through the night even 
more frequently; for the previous six months he was confi- 
dent that he had micturated every half hour, unless some 
necessity prevented, when he always suffered from the delay. 27 
At no other time had he any pain; the frequency of micturi- 
tion was simply an inconvenience. He stated that he had 
never had any gonorrhoeal trouble. Several years previ- 
ously he had consulted an eminent surgeon in regard to his 
urinary trouble, and was said to have “stricture just beyond 
the middle of the penis.” For this he was treated by the 
occasional introduction of bougies for a couple of months, 
at the end of which time, no benefit being apparent, he 
ceased bestowing any attention to the matter. About three 
months ago he began to notice a creamy sediment in the 
urine, which would cling to the floor of the pot de chambre. 
It was not, however, until about three weeks ago that he 
began to suffer actual pain and straining on passing his 
water. To this was soon added pain in the testicles, through the 
hypogastrium, and also in the perineum, and extending down the 
inner aspect of the thighs to the knees. The stream of urine was 
subject to frequent sudden arrest, and the straining which 
followed was severely painful, and pain extended through- 
out the regions previously mentioned. The urine soon 
became of a deep reddish brown color, with occasional strings 
of blood and mucous mixed with the copious creamy sedi- 
ment, which was now persistently deposited. Notwithstand- 
ing all this, he continued to ride daily, a distance of some 
three miles, to his office. About a week since, finding the 
motion of his carriage greatly aggravating his pains, he con- 
sulted an eminent medical personal friend of his, who in- 
formed him that he had a grave cystitis, and commended 
him to my care. I found him sitting on a hop poultice, 
which had been prescribed for him by his wife’s medical at- 
tendant (a homoeopath), and ascertained that he had been 
taking frequent doses of a homoeopathic preparation of bella- 
donna. 
Present condition : Constitutional disturbance very slight, 
pulse 80/, temperature 93f. Inspection of urine in the potde 
chambre (which was about one-third filled, and had been 28 
standing for several hours) showed a deposit of mucous and 
pus, stained and streaked with blood, fully one and a half 
inches in depth. Examination per rectum determined the 
prostate to be of even less than the normal size, and free 
from tenderness. 
The introduction of Ferguson’s short beaked sound (No. 20/) 
into the bladder was effected with great gentleness, but with 
ease, and without meeting with any abnormal impediment 
in its passage. The bladder was then thoroughly explored 
for calculus, but with a negative result. Confident, at first, 
from the history and condition of the case, that it would 
prove to be one of stone in the bladder, I had, thus far, only 
cursorily examined the meatus urinarius. Ferguson’s sound 
(No. 20/) had passed through it easily. 22/ and 23/ bulbous 
sound were now passed with ease, but 24/ was held at one- 
third of an inch. After slight pressure for a few seconds it 
slipped suddenly through a ring of fibrous tissue and passed, 
without obstruction, down to the bulbo-membranous junc- 
tion. The patient was then put upon a free use of infusion 
of triticum repens, and suppositories of belladonna and 
hyoscyamus every six hours. 
A subsequent microscopical examination of the urine 
showed pus and blood in abundance, some urethral and ves- 
ical epithelium, none from the ureters, or pelves of the kid- 
neys, no casts. Albumen slight; specific gravity 10.20. 
On suggesting to the patient that division of the strictured 
meatus was likely to be a necessity before much relief would 
occur, he desired tnat his friend, Dr. J. Marion Sims, should 
be called in consultation. 
On Thursday, the 14th, after an exhaustive consideration 
of the case, Dr. Sims coincided with me as to the possibility, 
nay (in the absence of calculus and prostatic disease), of the 
probability, that the well-defined contraction at the meatus 
was the original cause of the cystitis, and might be justly 
held responsible for its continuance. The operation was at 29 
once decided upon, and the patient placed under the influ- 
ence of ether by Dr. Harry Sims. I then thoroughly divided 
the contraction—first by the use of Civiale’s bistoury cache— 
completing the division of some remaining elastic fibres with 
a straight blunt bistoury, until the opening admitted bulb- 
ous sound 31. This was then carried easily down to the 
membranous urethra, without discovery of any farther ob- 
struction. The bladder was again thoroughly explored for 
calculus by both Dr. Sims and myself. It was found to be 
much contracted and thickened, but contained no stone. 
On the 15th (the day following the operation) I ascertained 
that, since the division of the contraction, our patient had 
not had the necessity of passing his water more than once 
in two hours, and that the pains in the testicles, the hypo- 
gastrium, the perineum, and down the thighs, which had 
previously been his chief points of suffering, had entirely dis- 
appeared. There was manifestly less blood in the urine. By 
the 16th the pus had diminished one-half in quantity, the 
blood had entirely disappeared, and the intervals between 
the acts of urination had increased to two hours and a half. 
From this date the only treatment to which the patient was 
subjected was the daily introduction through the meatus, 
into and not beyond the fossse navicularis, of a No. 31 bulb- 
ous sound. By the 26th (twelve days from the date of opera- 
tion) the purulent sediment in the urine had entirely disap- 
peared ; riding or walking no longer gave him discomfort, 
and he had resumed Iris business. The intervals between 
acts of urination now vary from two to three hours. There 
is an occasional occurrence of spasm during the act, which 
causes the sudden stoppage of the stream, and the urine is 
voided slowly, and with but little more force than before the 
operation, but he is not conscious of any other abnormality 
remaining. He expresses himself as feeling and being in 
better condition than for years. A few days subsequent to 
this interview with the patient he went abroad to remain 
during the winter, and I have not since heard from him. Case 19.—Aaron, aged sixty-eight. History of a first gon- 
orrhoea at twenty-one. Married at twenty-seven; had seven 
children, and no trouble with genito-urinary apparatus until 
four years ago, when he contracted another gonorrhoea. This, 
after a month, subsided into a gleet, and to this, in about 
three months after, catarrhal cystitis was added. The cystitis 
resisted every treatment, and has continued, in a greater or 
less degree of severity, up to the present time. About a year 
since he began to suffer with neuralgic pains in the groins 
and in the perineum, and he experienced a very uneasy 
sensation in his testicles, one of which became suddenly en- 
larged. 
November 26, 1874. Penis pnly two inches in length, 
flaccid, three and one-fourth in circumference. Meatus 18/. 
Left testicle half usual size; right normal, but with a greatly 
enlarged and soft epididymis, almost entirely covering in the 
glandular structure, and forming a swelling above it as large 
as a Madeira nut, and described as the seat of long-standing 
and very troublesome irritation. Some muco-purulent secre- 
tion from urethra. Has been treated for some time by use 
of soft bougies, with pain and no relief. Complains of pains 
in back and groins, extending down along inner aspect of 
thighs ;* urination every half hour, day and night; freshly 
voided urine, loaded with pus and mucous; reaction alkaline; 
strong urinaceous odor; no renal epithelium or casts; albu- 
men slight; is uneasy and restless in manner, and full of 
anxiety, quite like a confirmed hypochondriac. Examina- 
tion with 18/ bulbous sound detects a stricture at the meatus, 
extending back for half an inch, after which it slips down 
the urethra without giving evidence of any farther obstruc- 
tion. 
December 22. Saw the patient in consultation with Dr. 
Willard Parker. Division of the stricture at the meatus 
agreed upon. Ether administered by Dr. Charles Turnbull. 
The stricture at the meatus was first divided. Dense cica- 31 
trical tissue, extending for fully one-half inch. Bulbous 
sound 32/ was then passed to two and three-fourth inches, 
when it was arrested by a second stricture. 29/ defined its 
calibre. The dilating urethrotome was then introduced, 
turned to 34, and the stricture divided. 31 solid steel sound 
then passed without obstruction through into the bladder. 
Relief to the neuralgic pains followed the operation almost 
immediately. Within forty-eight hours the intervals be- 
tween acts of micturition had increased from one-half hour 
to four or five hours. Purulence in urine greatly decreased. 
Irritation in the scrotum ceased, swelling of epididymis 
gradually went down, and*the patient made a complete re- 
covery, without other treatment, within four weeks. 
In the foregoing cases, presenting features more or less 
grave in their conditions and consequences, a point of sig- 
nificant interest is common to all, viz., an abnormal contrac- 
tion at or near the meatus urinarius, the well determined 
sequel in the majority of instances of antecedent inflamma- 
tory action. Abnormal spasmodic muscular action plays a 
prominent part in every case. Spasm of the urethral walls, 
of the accelerator urinal muscles, of the cremasters, of the 
vesical neck, and of the seminal ducts, etc.; spasm, as in 
Case 10, so firm and persistent that the urethral walls finally 
gave way behind it; spasm that for months resisted the in- 
troduction of the smallest instrument, as in Case 3; spasm 
so persistent that the bladder was not allowed to completely 
empty itself for years (as in Cases 17, 18, and 19), and thus 
producing the chronic catarrh, which finally became so grave 
an element in these cases; spasm, as in Case 12, where the 
testicles played at see-saw for nearly three years, and until 
the poor wretch who owned them was driven to the verge of 
suicide. 
Some one or several of these conditions appear as a per- 
sistent feature in each. Spasm, a well recognized result of 
irritation, is equally significant of debility. Most of the 32 
cases, if not all, were subjects of sexual excess. Irritation 
supervening upon nervous debility, spasm naturally results. 
Irritations which are known to give rise to reflex disturb- 
ance are not of necessity painful irritations, or which by any 
special sensation invite attention at once to the source of 
trouble. Dr. Hanfield Jones (in his work on Functional 
Nervous Disorders, page 704), says: “ It seems to be well 
ascertained that unfelt irritation may give rise to very vari- 
ous morbid phenomena, affecting both the motor and sensory 
nervous organs. Dr. Brown-Sequard maintains that various 
forms of insanity, of vertigo, chorea, hysteria, tetanus, etc., 
may be due to irritations, starting from a centripetal nerve, 
and frequently slightly felt or unfelt, and that the suppression 
of these irritations may promptly cure the patient.” He 
cites a case where a married lady suffered for a considerable 
time with a uterine neuralgia, which ceased completely on 
the extraction of a tooth that had not caused any considera- 
ble annoyance. 
In the excellent little brochure on Stricture of the Urethra, 
by Samuel R. Wilmot, London, he says: “It is easy to con- 
ceive with what ease morbid irritation in the urethra may 
elude detection, and which, though slight, may be capable 
of exciting perfect reflex action, particularly in systems of 
high nervous mobility, and, where the slightest irritation 
exists within the urethra, the mere influence of the mind, 
derangement of the digestive organs, and various other re- 
mote causes will lead to spasm.” What, then, in these cases 
of evident reflex nervous trouble, is suggested as the cause 
of the irritation? Division of a contracted meatus, as has 
been shown, relieves the reflex disturbance; and yet simple 
contraction of the meatus can not be sufficient to produce 
such morbid nervous actions as cited; for it is well known 
that congenital contractions at this point are frequent, and 
yet no irritation ensues. In congenital contractions, how- 
ever, the muscular surroundings of the urethral orifice are 33 
in a normally supple condition, and able efficiently to play 
their part in completely emptying the urethra after mictu- 
rition. Let this delicate muscular structure become infiltra- 
ted with plastic material, and the complete discharge of the 
last drops of urine, through its action, is rendered impossi- 
ble. A dribbling after the act is the necessary consequence, 
and this is also an unvarying feature in all the foregoing 
cases. It is this inevitable retention of a few drops of urine 
which I believe to be the starting-point of the irritation. 
As time goes on, and the resulting plastic exudation becomes 
organized, cicatricial tissue forming and necessarily con- 
densing, a permanent contraction results, which adds to the 
muscular inefficiency, especially when it occurs in an ori- 
fice congenitally insufficient. It is this condition which 
often prolongs a gonorrhoea, and is the most fruitful source 
of chronic urethral discharge following a gonorrhoea. That 
the retained urine causes the irritation I am led to believe 
still farther, inasmuch as behind structures at the meatus 
granular spots of inflammation occur, sometimes extending 
throughout the urethra, and on relief of the stricture 
promptly disappear without other treatment, as in the third 
case cited. I have seen many such. Local points of tender- 
ness were present in almost, if not quite all the cases of re- 
flex urethral irritation that I have met. 
Then, as the urethral orifice becomes permanently con- 
tracted and unyielding, a distinct and sudden arrest of the 
stream of urine repeatedly occurs during the forcible acts of 
urination. Is it too much to believe that the force of this 
blow at the point of arrest will add to the irritation, and 
that the effect of its recoil should be felt back even to the 
vesical neck? It seems to me that this may, after long years 
of such constant irritating influence, prove an important 
element in disturbing the harmonious action of the complex 
sensory, motor, and sympathetic nerve distribution, in the 
deeper parts of the urethra. 34 
Considering the force and persistence of the spasm in cer- 
tain cases, the idea of its tetanic nature has suggested itself, 
induced by pressure and irritation of the nerves of the glans, 
in the cicatricial contraction. The treatment of the con- 
tractions by complete division, resulting in prompt and not- 
able relief in all the cases, is equally suggestive of simple 
mechanical obstruction, urinary retention, or cicatricial ir- 
ritation. To be effectual, however, the division must be ab- 
solute and entire. It is not sufficient that the meatus be en- 
larged up to the normal urethral caliber. The incision must 
reach down through all cicatricial tissue, and so completely that 
the largest sized bulbous sound which can be passed through 
the opening shall pass in and return without the slightest sense 
of resistance. If it is less than this, the contraction is abso- 
lutely certain to return within a few weeks, often within a 
few days, in spite even of every possible effort to keep the 
parts dilated. Once, however, the stricture tissue is com- 
pletely divided, it is then only requisite that the edges of 
the wound be kept asunder by the occasional introduction of 
a sound, until granulation is established throughout its ex- 
tent. After this (if no new inflammatory action is set up) 
not only will no recontraction take place, but the old ab- 
normal fibrous material will in time become wholly absorbed. 
This important statement, applying virtually to all stric- 
tures of the urethra wherever located, I do not make with- 
out the ability to prove it by the results of this plan, as pre- 
sented in many cases thus treated, in over thirty of which 
examination has been had at periods varying from two years 
and three months to six months from the date of operation. 
During the last month I presented before the members of 
the New York Medical Journal and Library Association a 
case where originally six urethral strictures were present 
(including-one at the meatus) of a size of 24f. These stric- 
tures were operated on (completely divided) with the dilat- 
ing urethrotome in January, 1871, more than two years pre- 35 
vious. Examination with the bulbous sound No. 30/, in the 
hands of a committee, consisting of Prof. Alfred C. Post, 
James M. Miner, and Dr. J. DeForrest Woodruff, failed to de- 
tect the slightest stricture, either at the meatus or at any other 
point. In order to demonstrate the complete restoration of 
this urethra to its normal resilience, by gentle pressure, I 
introduced, in the presence of the members of the Journal 
Association, a bulbous sound, 34 M. in circumference, through 
the meatus, and down to the bulbo-membranous junction. 
Prof. Alfred C. Post, after expressing his thanks for the 
very interesting and valuable paper presented by Dr. Otis, 
said there was a single point which had been made concern- 
ing which he had some personal knowledge, viz., that one 
part of the body may be the seat of a painless affection, and 
yet cause distressing symptoms in some other part. Twenty 
years ago he suffered with a neuralgic affection for several 
days, when he discovered that a wisdom-tooth was the of- 
fending cause. This removed, the pain was at once and en- 
tirely relieved. Afterward, on relating the case to a dentist, 
he remarked that it was nothing new; that he had often met 
with similar cases. Dr. Post had also met with several cases 
of incontinence of urine in children, associated with phy- 
mosis, and which, treated by removal of the prepuce, resulted 
in cure without other remedial means. He had not met 
with the class of cases referred to in the paper just read, but 
he considered them analagous to those above related by him. 
Dr. Richards had observed the association of varied reflex 
phenomena with stricture of the oesophagus and trachea, and 
could not but be struck by the coincidence in the character 
of the troubles with those described by Dr. Otis. 
Prof. Detmold remarked that the facts presented by Prof. 
Otis were not surprising, if we stop a moment to consider 
that the sensitive point of all the tubes of the body is at the 
DISCUSSION. 36 
opening?. Normally there was no sensation in the cavities. 
If there was stone in the bladder the pain would be felt at 
the glans penis; and, besides, the most sensitive region of 
the human body—that with which the entire individual most 
thoroughly sympathizes—is that of the sexual organs. In 
connection with the feeling of wetness which is alluded to in 
some of Dr. Otis’s cases, he had noticed that the feeling of 
cold was complained of by patients suffering from stricture 
and the resulting irritation, and was rather surprised that 
it was not mentioned among the cases related by Dr. Otis. 
Dr. Otis remarked that he had not unfrequently met with 
cases suffering from seminal debility where the feeling of 
cold was complained of, but it was not present in any of the 
cases referred to. 
Dr. J. G. Adams Avould like to ask if Dr. Otis had any faith 
in dilatation for the relief of such cases as he had described. 
Dr. Otis replied that he had none; that complete division 
was the only remedy he had any confidence in. One of the 
most aggravated of the cases presented had been subjected 
to careful and persistent efforts at dilatation, the effect of 
which had only been to aggravate the troubles of the pa- 
tient. He had, however, seen a number of cases where the 
difficulties had been temporarily relieved by a division 
which was not complete. These cases had occurred at his 
clinique, where the daily attendance necessary to prevent 
recontraction could not be secured. 
Dr. Detmold stated that a patient of Dr. Otis’s, whose 
meatus had been divided for a slight stricture, had come to 
him for treatment, and that he was the subject of an intense 
and painful orchitis; that he had refused the case, and had 
sent him back to Dr. Otis’s clinique. He would like to know 
if this was the result of the operation, and if cutting 
stricture at this point had ever brought about troubles else- 
where. 
Dr. Otis said he would not attribute the orchitis to the in- cision; that if not the result of extending urethral disease, 
it was probably caused by the introduction of a sound 
through the curved portion of the urethra; that the simple 
division of stricture had never in his experience produced 
inflammatory trouble at any point, but that on several occa- 
sions the forcible attempts, by the patients, to keep the in- 
cision open, had resulted in inflammation of the glans, and 
in one instance had extended down the urethra, simulating 
an ordinary sub-acute urethritis, until it involved the pros- 
tate gland. It should have been remarked that several of 
the cases of reflex irritation reported were associated with 
an enlarged and sensitive epididymis, and that these con- 
ditions, as in Prof. Parker’s case, were relieved by dividing 
the stricture at the meatus. 
Dr. Detmold remarked that in a certain proportion of 
strictures there was also enlarged epididymis; but in the 
case he had referred to it was not a chronic condition, but an 
acute inflammatory swelling of the body of the testicle. I 
Dr. Otis ascribes this condition to the dilatation, does he be- 
lieve that dilation after or before cutting the stricture will 
bring about an orchitis? It must have been a combination 
of the incision with the injudicious dilatation, for he had 
never seen dilatation alone produce an orchitis. 
Dr. Otis had quite a different experience, and considered 
that the simple passage of an instrument through the 
urethra (sound bougie or catheter) was capable of produc- 
ing such an accident, and this, too, when the introduction 
had been effected in the gentlest and most judicious manner. 
Dr. Otis referred to two cases published by him, he believed, 
in the Medical Record, in July, 1871, when the introduction 
of a soft bougie through a deep, but not very close stricture, 
was followed in both instances by an inflammation which 
could be distinctly traced, by the sensation of the patients, 
as it gradually extended through the entire course of the 38 
vas deferens, terminating within forty-eight hours in an 
acute epididymitis. 
Prof. Fordyce Barker spoke of several cases that had come 
under his observation, where disease of the orifice of the fe- 
male urethra had simulated uterine disease, and that he 
could readily understand the possibility of such results as 
had been described by Dr. Otis as resulting from contraction 
of the male urethral orifice. 
Prof. A. Jacobi remarked that he had no experience in 
such cases as those described, but that he would say a word 
concerning some of the symptoms alluded to. First, that of 
the sensation of cold. He thought Dr. Detmold had stated 
that this symptom was associated with partial or complete 
impotence. In such cases we had the symptom of cold from 
partial or complete paralysis of the vaso-motor nerves, and 
that in the cases related by Dr. Otis this symptom was neces- 
sarily absent, as the cases he recited were all those of nerve 
excitation, and not paresis. Then the feeling of wetness 
spoken of. There was no moisture in reality. The function 
of the urethra was to allow urine to pass; the brain identi- 
fied this sensation with wetness. When the stomach is 
empty there is a feeling of hunger. When the mucous 
membrane is diseased, as in chronic catarrh, there is a feel- 
ing of hunger. In the same manner when we have trouble 
with the mucous membrane of the urethra we had the feel- 
ing of wetness. 
Dr. Chamberlain spoke of a case which he had recently 
seen with Dr. Learning, where a reflex irritation set up by a 
deep fissure of the anus had given rise to conditions which 
simulated locomotor ataxia, and which, on divulsion of the 
sphincter ani, was almost immediately and completely re- 
lieved from symptoms which had been said to indicate well- 
pronounced sclerosis of the anterior column of the spinal 
cord.