A CASE 
OF 
REFLEX NEURALGIA, 
ASSOCIATED WITH URETHRAL CONTRACTIONS 
AND A RARE FORM OF URINARY SINUS. 
WITH A DESCRIPTION OF THE 
COLD-WATER C OIL 
BY 
FESSENDEN N. OTIS, M. D., 
CLINICAL PROFESSOR OF GENITO-URINARY DISEASES, COLLEGE OF PHYSICIANS AND 
SURGEONS, NEWYORK. 
[.REPRINTED FROM THE NEWYORK MEDICAL JOURNAL, FEB., 1875 ] 
(Illustrated.) 
D. APPLETON & COMPANY, 
NEWYORK: 
54 9 & 55 1 BROADWAY. 
1875. THE POPULAR SCIENCE MONTHLY, 
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Conducted by Prof. E. L. TO UMAE'S. 
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JD. APPLETON 8f CO., Publishers, 
549 & 561 Broadway, New York. RARE FORM OF URINARY SINUS, ABSCESSES, Etc. 
(Reversed from original drawing.) 
A, Stump of cedeinatons prepuce. B, Urinary abscess. C\ Urethral fistulsc. A CASE 
OF 
REFLEX NEURALGIA 
ASSOCIATED WITH URETHRAL CONTRACTIONS 
AND A RARE FORM OF URINARY SINUS. 
WITH A DESCRIPTION OF THE 
COLD-WATER COIL. 
BY 
FESSENDEN N. OTIS, M. D., 
CLINICAL PROFESSOR OP GENITO-URINARY DISEASES, COLLEGE OF PHYSICIANS AND 
SURGEONS, NEW YORK. 
{REPRINTED FROM THE NEWYORK MEDICAL JOURNAL, FEB., 1875.] 
(Illustrated.) 
NEW TOEK: 
D. APPLETON & COMPANY, 
549 & 551 BROADWAY. 
1875. A CASE OF REFLEX NEURALGIA, ASSOCIATED WITH 
URETHRAL CONTRACTIONS, AND A RARE FORM OF 
URINARY SINUS; WITH SUBJOINED DESCRIPTION OF 
THE “COLD-WATER COIL.” 
X. Y., physician, aged fifty-seven years; has never had 
any form of venereal disease; no vicious habits from early 
childhood. Had a very redundant prepuce, which, from fre- 
quent attacks of balanitis, became more or less adherent to the 
glans penis. Up to the age of nineteen years could only un- 
cover one-half the glans. By systematic effort, however, dur- 
ing a period of six months, the adhesions between the glans 
and the internal reflexion of the prepuce were completely 
broken up. He had no further trouble up to the age of twenty- 
two years, when married. On first intercourse, the frenum 
(which was very long and attached at the inferior edge of the 
meatus) was ruptured, occasioning severe haemorrhage, and a 
considerable degree of soreness for several days. He remem- 
bered no further annoyance up to the year 1857, when, at the 
age of fifty years, he had what was then supposed to have been 
an attack of “ dumb ague ” (irregular chills and fever), which, 
in spite of the usual antiperiodic remedies, continued for a 
space of two months. To this a jaundice succeeded, and, at 
about the same time, the left side of the scrotum became swol- 
len, red, and heavy; not sore to the touch, except on firm 
pressure. Heavy aching pain felt in the tumor at times, 
without apparent cause. Xo treatment resorted to except 4 
that of supporting the mass with an ordinary suspensory band- 
age. This condition of things remained, without any marked 
change, for five and a half years, when (in September, 1873, 
being in low condition from overwork) a small carbuncle made 
its appearance on his nose, and was soon followed by another, 
three inches in diameter, on the left side of the neck, which 
lasted, with much suffering and debilitation, for about three 
weeks. At this time a circumscribed cellulitis occurred at 
the most dependent portion of the swollen and indurated scro- 
tum. After a few days’ poulticing an opening occurred in the 
integument, which discharged pus, and was filled with shreds 
of disorganized tissue, similar in appearance to those which 
had characterized the debris of the antecedent carbuncles. For 
this reason the scrotal lesion was considered by the patient 
and his attending surgeon to be of a carbuncular nature; there 
was, however, but a single opening. Under simple treatment 
this supposed carbuncular abscess was discharged fully in 
about a week, and, by the close of the third day following, 
had filled and perfectly cicatrized. In about a week from this 
time, another circumscribed cellulitis appeared on the scrotum, 
about an inch above the first, passing through the same phases, 
and healing completely in about the same time. Another in- 
terval of a week, and a third abscess, precisely like the previous 
ones in accession and course, occupied the superior portion of 
the scrotum, after the complete healing of which, the entire 
scrotum was left quite free from inflammation, induration, or 
any abnormal appearance. During the yext week, another 
lesion apparently of the same nature occurred on the corre- 
sponding side of the penis, three-quarters of inch from the 
root, giving more pain than any of the previous abscesses. 
This, after opening, did not heal, but ran along under the in- 
tegument of the dorsum anteriorly for about an inch, when 
it there “ broke through and discharged carbuncular debris.” 
O o 
The two openings were united by a division of the intervening 
integument, which was thin and red. The burrowing of pus 
continued along the dorsum penis to the fossa glandis, when 
the prepuce became completely phimosed. An opening into 
the preputial cavity in the vicinity of the fossa glandis soon 
occurred, and pus was freely discharged from the preputial 5 
orifice. In trying to wash out the prepuce with a syringe, it 
was found that the injected fluid traversed the entire length 
of the dorsum penis, and emerged at the first opening. A 
small collection of pus was found on the right side, which 
likewise opened into the preputial cavity. At this time the 
prepuce was very oedematous, and urination was difficult and 
painful; the pain extended beyond the penis, into the thighs, 
the calves of the legs, and even occupying the entire heels, not 
only when urination was attempted, but at night when the 
patient was endeavoring to sleep. Opiates were given, Mc- 
Munn’s elixir of opium or chlorodyne, but in small doses, from 
ten to thirty drops, two or three times during the night; 
larger doses were not well borne, aggravating the unrest. 
After some weeks the doctor took a sea-voyage, hoping for 
benefit from change, as his general health had become greatly 
impaired. After being at sea for some twenty days, with no 
perceptible benefit, the swelling of the prepuce suddenly in- 
creased, and a purple spot appeared on the integument of the 
dorsum, just behind the glans. The tissues at this point soon 
gave way, exhaling a fetid odor, and an opening occurred 
about the size of a dime, which became permanent. The 
tension of the tissues was now somewhat relieved, but urina- 
tion continued difficult, and the pains in the thighs, legs, and 
heels, which had hitherto been felt chiefly at night, now con- 
tinued throughout the day, and were severe, almost beyond 
endurance, notwithstanding the use of opiates internally and 
various local appliances. Returning from the voyage after 
an absence of forty-four days (March, 1814), his surgeon di- 
vided the prepuce superiorly from border to base, the incision 
terminating at the gangrenous opening before mentioned. 
This gave great relief to the dysuria, and somewhat mitigated* 
the pains in the thighs, etc., which were described as of a 
heavy, aching character, as from cramp, or excessive muscu- 
lar tension. An aggravation of his trouble now occurred 
from the performance of duties which devolved upon him (as 
the presiding officer of a State medical convention), which in- 
duced him to submit to further surgical procedure. A por- 
tion of the swollen prepuce was removed; as much as was 
thought essential to completely relieve constriction, and to get 6 
at the bottom of the sinuses, for treatment. The cut surfaces 
of the prepuce were left open and healed kindly, with the 
exception of a small opening under the base of the glans, 
through which, finally, a communication was established with 
the urethral canal. This fistula was followed in the course of 
three or four days by a second, from within outward, and 
alongside the first, on the opposite side of the median line. 
After the second opening was established there was some 
relief to the passage of urine, but none to the aching pain of 
the extremities- The supposed carbuncular troubles on the 
scrotum and on the penis were each preceded by a distinct cir- 
cumscribed induration, involving the thickness of the integu- 
ment and not movable over the cellular tissue. Similar in- 
durations, smaller in size, now appeared on the under surface 
of the penis, to the number of three, which each resulted in 
a urethral fistula, through which urine passed at every urina- 
tion. These were about half an inch from the junction of 
the penis with the anterior border of the scrotum, and just to 
the right of the median line. Nothing further was done in 
the way of surgical interference, and no improvement occurred 
either in the urinary difficulty or the pains in the inferior ex- 
tremities. Consultations, with more than a dozen surgeons to 
whose notice the case was brought, failed to afford the patient 
any relief. Not one had ever seen any thing like it. The 
general opinion was opposed to the idea of malignant trouble. 
The difficulty was considered of furuncular origin and to have 
arisen from poverty of the blood, dependent upon overwork. 
No treatment was advised, except that addressed to the gen- 
eral building up of the system. One surgeon advised ampu- 
tation of the penis. The patient then decided to come to New 
•York for relief, arriving on September 17, 1871, with letters 
to the principal surgeons of this city. lie was seen by several. 
The opinions which an examination of his condition elicited, 
were in perfect accord with those already mentioned, viz., a 
disease “ resulting from poverty of the blood from malaria, 
etc., and excessive use of opium ”—causing the neuralgic 
pains, etc., from which the patient continued to suffer night 
and day, and so severely and constantly that a complete de- 
moralization of the patient was imminent. 7 
Priapism added a new element of distress, and -with only 
the hope of obtaining a possible relief from this new complica- 
tion, by means of the cold-water coil {see note at p. 11, descrip- 
tive of tin’s apparatus of my own contrivance), he was referred 
to me. An examination of the penis revealed the condition 
represented in the woodcut Ho. 1 on the frontispiece, executed 
from a drawing which I made at the time of the patient’s first 
visit. I found the glans exceedingly sensitive to touch. The 
patient was passing his water chiefly through a fistulous open- 
ing at the base of the glans, interiorly. The meatus urinarius 
was contracted to 13 f. Bulbous sound 13 f. was passed with 
much pain, hugged closely for one inch until it emerged from 
the first fistulous opening. This opening was also terribly sen- 
sitive ; an attempt to examine it causing a profuse perspiration 
and much complaint. It admitted with difficulty Ho. 26 f., 
and then passed down without force 2j inches, where it 
wTas arrested by a stricture. Bulb Ho. 23 f. passed through, 
and was felt to be free at 2f inches. My own view of the 
case, based upon the experience acquired from previously 
observed cases, where exactly the same character and locality 
of pain had been found to be dependent upon urethral contrac- 
tions, determined me to advise complete division,of all urethral 
contractions as the best and only means of relief. The doctor 
after becoming fully cognizant of my views and reasons for 
operation, consented to submit himself wholly to whatever 
was deemed necessary to carry out the proposed operative 
procedure. The operation was set down for the following 
day, October 2T, 18T4, By my invitation, Prof. Thos. M. Mar- 
ine and Dr. Geo. A. Peters were present. The patient was put 
under the influence of chloroform (which he had often taken 
for relief of his pains, and with perfect impunity) by my 
assistant, Dr. Fox ; and I proceeded first to divide, fully and 
freely, the contraction from the meatus urinarius to the first 
fistulous opening, which was of calibre 13 f. This was done 
so that 31 f. bulbous sound could be easity passed. I then 
divided the orifice of the main fistulous opening, so that the 
same bulb could readily enter. An examination of the deeper 
urethra was now instituted, and it was found that adarge- 
sized probe passed down for one and a half inch, and 8 
thence out of the urethra, to the right, until it entered easily 
the urinary abscess situated at the root of the penis (marked 
in the cut), and which had existed for several months. (The 
patient complained that he always felt pain on urinating, in 
this locality.) The stricture at 2J inches was then defined by 
23; and by aid of my small urethrotome this stricture was 
dilated to 30 f., and divided; 31 solid-steel sound was then 
passed from the meatus, through the entire urethra, and into 
the bladder, without force. When the patient came out 
from the influence of the anaesthetic, he expressed himself as 
feeling better than for a long time. Bleeding was slight. 
The first attempt at urinating was painful, but urine was passed 
more freely than for years. Without opium or any other nar- 
cotic, he passed a comfortable night, sleeping for nine hours. 
On the following morning he stated that he had entire free- 
dom from all the pains so long endured, and that for a similar 
night’s rest he “ would be willing to submit to a similar opera- 
tion every night of his life.” There was no return of his 
pains in the thighs, legs, etc. After two days, I attempted to 
pass an instrument for the purpose of keeping open the 
divided strictures; but the pain was so great that I desisted, 
believing it better to wait until the sensitiveness had subsided, 
even at the risk of speedy contraction of the deeper stricture. 
In a week, the patient was out. Went to Brooklyn on a visit. 
A pair of tight pantaloons, and an evening spent in playing 
billiards, caused some return of his nervous disturbance in the 
inferior extremities; but applications of warm cloths to the 
penis soon relieved him. I then proposed to examine the con- 
dition of the urethra, and found, as I had expected, a recon- 
traction of the deeper stricture. On Sunday, November Bth, 
Drs. Peters, Mcßirney, and Fox present, I again divided the deep 
stricture under chloroform. From that time to the patient’s 
departure to his home, December Ist, he had no further trou- 
ble. His recovery seemed to have been complete. He left 
with the promise to communicate with me at once if he had 
any return of his trouble. I have not since heard from him. 
Among the other results of the operation, the urinary abscess 
on the right side of the root of the penis disappeared entirely, 
and this within ten days after the first operation. 9 
My own view of the origin of the trouble in this case is 
that, from some unrecognized cause, a follicle in the scrotal por- 
tion of the urethra became the subject of inflammatory action; 
that this follicular inflammation finally resulted in ulceration 
and the formation of a fine and somewhat tortuous sinus, ex- 
tending, from the follicular point of exit in the urethra, down 
to the bottom of the scrotum ; that the “ dumb ague,” which 
the patient complained of as occurring at about this time, 
was a urethral fever, and marked the progress of the sinus, 
Diagbam showing the Locality of the Deep Stbictueb, Course of the Ukinabt 
Sinus, and Locality of the Abscesses. 
A, Deep stricture. 1, First abscess, connected wi’tb 2, 3, 4, and 5, the succeeding abscess- 
es, by the sinus, which commenced at A, the point of stricture, and extended down to 
7, the bottom of the scrotum. 
which, after reaching the most depending portion of the scro- 
tum, remained in great degree quiescent for five and a half 
years; and that the depressed condition of health, resulting 
from general causes, finally brought about an active inflam- 
mation, terminating in a primary abscess at the bottom of the 
sinus ; that when the urinary abscess, occurring at the bottom 
of the scrotum, supervened, the cellulitis accompanying it 
closed the sinuous tract for an inch, and, after the first abscess 
had healed, a second cellulitis occurred at the point to which 
the sinus had been closed by the previous inflammation, and 10 
the second abscess resulted. The inflammation attendant 
upon this, closing the sinus for another inch or so, after a brief 
period the third abscess occurred. In the same time and in 
the same manner a fourth; finally the integument of the body 
of the penis became involved in the ulcerative process, pro- 
ceeding to the anterior portion of the organ. Inflammatory 
paraphymcteis, and the consequent tension of all the tissues at 
this point, naturally gave rise to the urethral fistulse which 
appeared in this vicinity. 
The dependence of urinary sinus upon antecedent inflam- 
mation and ulceration of urethral follicles is claimed by Dittel 
(Pitha and Billroth’s “ Handhuch der allgemeinen und spe- 
ciellen Chirurgie,” Band iii., Ahtheilung ii., Lief, vi., p. 191), 
and several cases are reported by him, illustrating, in their 
course, and also in post-mortem examination, the follicular 
origin of small urinary sinuses. Two such cases were reported 
by me under the title of “Urethral Follicular Sinuses” in a 
paper on “Chronic Urethral Discharges,” which appeared in 
the New York Medical Journal of June, 18JO. 
The reflex troubles in this case appear to me to he in ex- 
act accordance with those often found associated with urethral 
stricture, especially at or near the meatus urinarius. They are 
dependent, possibly upon implication and irritation of nerve- 
fibres in the cicatricial tissue, or upon long-continued interfer- 
ence with the discharge of urine, in persons debilitated by in- 
fluences calculated to depress the sympathetic nervous sys- 
tem.1 
1 In a paper read before the New York Academy of Medicine in Feb- 
ruary, 1874 (not yet published), entitled “Reflex Irritation of the Genito- 
urinary Tract resulting upon Urethral Contractions, congenital or acquired,” 
nineteen cases are reported, and the very scanty literature of the subject is 
noted. Some space is also devoted to a consideration of the various ways 
in which such reflex irritations are produced. A tolerably full abstract of 
this paper may be found in the Charleston Medical Journal and Review, 
July, 1874. 11 
The Cold-water Coil in Inflammation of the External 
Male Genital Apparatus, and as an Antiphlogistic after 
Operations on the Penis.I—The1—The apparatus which I have des- 
ignated the “Cold-Water Coil” is formed of a line of the 
small-sized India-rubber tubing of one-sixteenth of an inch 
calibre, and six or seven yards in length. At the middle por- 
tion this tubing is coiled upon itself, so that, by half a dozen 
turns or more, it presents sufficient capacity to loosely encircle 
the entire penis or scrotum. 
This coil, with the length of tubing proceeding from it, 
forms an apparatus through which, on placing one extremity 
of the tubing in a bowl or tumbler of ice-water, exhausting 
OTTO-REYNDERS N.Y. 
its contained air (by suction, or by drawing the tube through 
the finger), a siphonic current is established through the coil. 
The discharge-pipe being placed on a lower plane than the 
water-supply, the current may be kept up until the vessel is 
emptied. 
The rapidity of the flow can be regulated either by raising 
or lowering the end of either tube, which is the simpler plan ; 
but the more convenient one is by a tapering, double silver 
tube, attached to the discharge-pipe, a sponge being fitted to 
the inner tube. This sponge, when the inner tube is pushed 
down into the smaller end of the outer tube, becomes com- 
pressed and gradually obstructs the flow of water, until not a 
1 Reprinted from the New York Medical Record, January 9, 1875. 12 
drop will exude. This contrivance may be regulated so that 
either a free stream can pass, or that the single drops shall 
follow each other, more or less rapidly, with the regularity 
and precision of a timepiece. 
By means of tfyis arrangement, I have been able to apply 
cold to the penis or scrotum continuously and conveniently 
both to the patient and myself. The coils of tubing are re- 
tained in position by a band of cotton or linen cloth. A ready 
method of constructing this apparatus is by placing a strip of 
thin cloth, six inches in length and two in breadth, length- 
wise, upon a large speculum or a four or six ounce vial. The 
tubing, taken at the middle of a piece six or seven yards long, 
is wound around the vial, and, after the requisite number of 
turns are made, the projecting ends of the cloth are doubled 
over the coils and stitched to the under layer between the 
turns of tubing. If, after completion, the turns are found too 
small, they may be readily enlarged by drawing the tubing 
through the cloth to any desired extent. 
I have found this simple contrivance of essential service in 
the acute form of gonorrhoea, reducing inflammatory action 
promptly, and thus giving relief to painful micturition and 
erections. 
It has proved of great value in keeping down inflammation 
and in preventing erections after the operation of circumcision. 
I habitually use it for the same purpose in operations for 
stricture, and with results more prompt and satisfactory than 
those hitherto attained by any medication or application with 
which I am familiar. 
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