[Reprinted from the Transactions of the Medical and Chirurgical Faculty 
of Maryland, April, 1878.] 
URETHRAL STRICTURE 
1JY 
THOMAS R. BROWN, M. D., 
Professor Clinical and Operative Surgery and Diseases of the Qenito- Urinary 
Organs, College of Physicians and Surgeons, Baltimore, Md. 
BALTIMORE: 
Innes & Company, Printers and Binders. 
1878. [Reprinted from the Transactions of the Medical and Chirurgical Faculty of Maryland, 
April, 1878.] 
URETHRAL STRICTURE. 
THOMAS R. BROWN, M. D., 
Prof. Ulinicul and Operative Surgery and Diseases of the Genito- Urinary Organs, College of 
Physicians and Surgeons, Baltimore, Md. 
My contribution from the Section of Surgery includes the 
subject of “Urethral Stricture/’ more especially its treatment. 
Quoting from an address very kindly sent to me by Mr. Teevan, 
F. R. C. S., which he lately delivered before the Medical Society of 
London, I submit a question equally as appropriate to my audience 
as to his: “How is it that the treatment of stricture in this 
country is at present, to some extent, a matter of opinion? Is it 
because the complaint is rare, and that but few facts present them- 
selves to our notice? Not at all,” he answers. “ The disease is 
very common and facts abound.” That the treatment of stricture 
is a mere matter of opinion, no one will dispute. Neither can it 
be disputed that these opinions take wide range of difference, and 
that this contrariety evidences more or less dissatisfaction with all 
the remedies within our reach. No less than eleven different 
methods are offered for the relief of the same disease; and for each 
of these there is a strenuous advocate, who verily believes that his 
favorite remedy is the one par excellence, and all others fail of 
their purpose at least more than his. Fadet suggests, in speaking 
of eclampsia, that when a great number of remedies is vaunted 
against a given disease, it simply shows the poverty of the thera- 
peutics on that subject. With a certain qualification, this is true 
in every department of our science; and of however much 
narrowness it may presume, I take it that precision of knowledge 
of the means at our command for the relief of disease, both 
medical and surgical, keeps close companionship with the much 
despised routinism. In enumerating the different methods of 2 
treating stricture, I include only those, of course, which are in 
actual use more or less at the present day. These are : 
1st. The purely expectant plan, which involves forced rest in 
the recumbent position through a more or less considerable period 
of time. 
2d. The plan of gradual dilatation by sounds of an ascending 
series, with variable intervals, not less than 24 hours usually, 
between the introduction of the smaller and the next size larger 
instrument. A strict observance of the French system of gradua- 
tion is, as a rule, necessary to the proper carrying out of this plan, 
which is simply to dilate or stretch. 
3d. The plan of rapid gradual dilatation with the same instru- 
ments, used in the same manner as in the above but with shorter 
intervals of rest, the whole or one-half of the object of the treat- 
ment being accomplished at one sitting, usually under some 
anaesthetic. The probability of the tissue rupturing under this 
method is not so great as we would suppose. This depends much 
upon the exact character of that tissue. In both of these methods 
the treatment is without retention of the sound. 
4th. The plan of what is styled “ continuous dilatation,” in 
which the instrument is retained for some time, the urine finding 
its way out between the sound and urethra, thus aiding in the 
dilatation. (Furneaux Jordan). The length of this time is deter- 
mined by such circumstances as the nature of the stricture, the 
irritability of the urethra, convenience of the patient, &c., &c. 
5th. The plan of internal urethrotomy. 
6th. The plan of external urethrotomy, generally in the perineum. 
7th. The plan of subcutaneous section of the urethra. 
8th. The plan of electrolysis, or that method by which the dis- 
appearance of the cicatricial tissue is effected by a process of 
“ galvano-chemical absorption.” The agent employed is the 
constant current of galvanism, with the negative pole applied to 
the neoplasm ; the positive, according to Newman, leaving a “hard 
retractile cicatrix,” and therefore too severe to justify its use. 
9th. The plan of “ immediate dilatation,” or more properly, 
rupturing of the stricture. Under this caption we include all 
those procedures which involve the splitting, divulsing, or instanta- 3 
neous dilatation, so called, of the constriction, and exclude all 
which merely stretch. 
10. The plan of treatment by “ the application of caustics for 
one of two purposes/’ according to Teevan, who regards the 
method too sweepingly condemned, “ either to cause sloughing of 
the affected part, or merely to open up the mouth of the stricture 
when impassable to instruments.” 
11th. The plan of introducing a guide through the obstruction, 
and afterwards sliding over it (the guide) another instrument, 
generally a tube properly apportioned so as to glide easily over the 
first instrument, and still not too large to be impeded at the point 
or points of constriction. This is, in fact, another mode of dilata- 
tion. 
These make up the armamentarium at the disposal of the surgeon 
in the treatment of urethral stricture. As just stated, they are all 
more or less in use at the present time. Anything like an exhaust- 
ive examination of the merits of each of these is, of course, 
impossible in a single essay. It would require more time and 
patience than this occasion would permit, or I am disposed to 
exact. In the outset of my inquiry with a view to the preparation 
of this article, it occurred to me that an ascertainment of the views 
of certain eminent surgeons, upon a few of the vexed questions 
connected with stricture, might be of use. It would at least reflect 
the present status of the subject. I accordingly wrote to the 
following gentlemen:—Drs. Gross, Agnew, Van Buren, McGuire, 
C. II. Mastin, Gouley, Bumstead, Dawson of Ohio, Pease of 
the University of Syracuse, Bigelow, McGraw, Yandell, Toland, 
Maclean, Hodgkin, and Otis, of this country; Barwell, Lister, 
Timothy Holmes, Bryant, Berkley Hill, Christopher Heath, 
Teevan, Coulson, Humphrey of Cambridge, Furneaux Jordan, and 
Sir James Paget, of England. I must take this opportunity of 
expressing my grateful acknowledgments to the large number who 
saw fit to respond, and especially to Prof. Martin, of the Johns 
Hopkins University, for aiding me in my English correspondence. 
The questions submitted to each were these, and the answers 
were requested with a view to publication : 
1st. “ What is your opinion as to there being such a condition 
as spasmodic urethral stricture? ” 4 
2d. “ What, in your opinion, is the best method of treating 
organic stricture: by dilatation, gradual and forcible; by 
urethrotomy, internal and external; or by divulsion, granting that 
the health of the patient is otherwise good ? ” 
3d. “ Would the existence of renal disease, such as might be 
instanced by the presence of granular or hyaline casts, influence 
you in the selection of your mode of treatment, or would you 
esteem any one of the above methods to be equally safe? ” 
4th. “ To what extent has your observation confirmed the views 
of Prof. F. N. Otis, of New York, as to the relation which the 
calibre of the urethra bears to the size of the flaccid penis, and as 
to the ability of that gentleman’s method of operating to effect a 
radical cure ? ” 
5th. “ In what proportion of your cases, treated by any of the 
methods in common use, would you be willing to state that such a 
complete relief has been afforded as to secure to the patient an 
entire immunity from the after-introduction of the sound? ” 
6th. “ Does the seat of the stricture influence the nature of your 
treatment ? ” 
To the first question, as to there being such a condition as 
spasmodic stricture of the urethra, the answers in the affirmative 
and negative were about equally divided. Nearly all agree with 
Profs. Otis and Barwell, that if a slight organic narrowing of the 
canal exists, such a condition as spasm of the urethra can and does 
take place. This is especially true if the life of the individual is 
one of such errors and indiscretions as to lead to the secretion of 
irritating urine. Assuming that the word stricture applies 
entirely to the organic variety—the reason for which I certainly 
fail to apprehend—Prof. Holmes, of London, writes as follows : 
“ As to there being such a thing as spasmodic stricture, I never 
heard it questioned that there is such a thing as spasmodic reten- 
tion. I have seen a great many cases, one in which the surgeon 
was led to puncture the bladder when there certainly was no 
organic stricture.” In his further comments he refers me to his 
Surgery, where I find that he proposes to substitute the words 
“spasmodic retention,” or “spasm of the urethra,” for those in 
common use. Prof. Humphrey, of Cambridge University, after 5 
citing that he had seen many cases of supposed spasmodic retention, 
“ and many in which other surgeons have failed to pass instru- 
ments,” and after stating that he had “never found any difficulty 
in passing a fair-sized catheter into the bladder,” concludes with 
the remark, “ I have long doubted the correctness of the term 
1 spasmodic/ as applied to the affection.” He “believes that the 
obstacle is usually seated at the neck of the bladder in these cases, 
and is usually dependent upon congestion of the mucous or sub- 
mucous tissue in that region.” Prof. Van Buren refers it to per- 
verted action in his “cut-off muscle.” Mr. Teevan says that it 
is “ secondary to but not idiopathic.” Mr. Furneaux Jordan says 
that “ it does not exist except in conjunction with organic stric- 
ture.” Profs. Bigelow, McGraw and McLean are of like opinion, 
and Sir Henry Thompson deals with the subject in this rather 
sarcastic and summary manner: “I will tell you,” he writes, 
“ what stricture is. It is an exceedingly useful excuse for the 
of instruments. It is a ‘ refuge for incompetence.’ 
When you cannot pass a catheter, when you find it exceedingly 
difficult to get anything in, and in fact wish to desist, it is a con- 
venient thing, and has always been so recognized, for the doctor to 
say, ‘ There is spasm.’ There is spasm, says the doctor, now in 
the muscles, and it will be prudent at present to desist from 
further attempts to pass an instrument. And no doubt when this 
is said it is so.” Prof. Hodgen is confident that he has seen a 
“ number of cases of ‘ spasmodic stricture,’ ” and Prof. D. Hayes 
Agnew has no doubt of its existence, always of very temporary 
duration, and not inconsistent with a perfectly healthy urethra, 
the constriction being caused “ by some irritant.” 
There is another, and perhaps increasingly numerous group of 
surgeons to-day, who trace “ urethral spasm ” in any part of the 
canal, to contractions at or very near the meatus, and in this compara- 
tively unexplored region some brilliant successes have been won. 
I present the following illustrative case from my own practice: 
Mr. X , residing in a neighboring county, while visiting the 
city is seized with retentio urince, which had been preceded for 
some months by progressive diminution in the size of his stream. 
For the relief of present distress he consulted a prominent physician, 6 
who, failing to pass a catheter beyond the membranous portion, 
invited me to meet him. When seen by me his bladder was 
enormously distended. All attempts to catheterize failed. Supra- 
pubic aspiration* was then practised without a bad symptom, and 
with instant relief. Five hours after the bladder had refilled 
without ability to void the urine. The obstruction was encount- 
ered at the same spot (in the membranous urethra), which became 
passable under ether carried to complete relaxation. The meatus, 
which was found of less calibre than the urethra, was divided with 
the meatome. This was followed by the frequent after-insertion 
of sound until the parts had healed. From that day to this, 
nearly one year, I am advised that the patient has continued well, 
with good stream, and without any recurrence of trouble. 
Dr. Mastin has very kindly given me an account of a similar 
case. He says : “ I had a young man come to me from the 
interior of this State (Alabama), who had a close organic stricture 
at about four inches down the urethra. I opened his meatus and 
then divided the stricture freely. To my astonishment, in the 
course of a week I found, that although I could pass a large-sized 
sound beyond the site of stricture, yet it was impossible to pass it 
through the membranous urethra. Here I found a firm spasm 
which would not permit the smallest sound to enter. I was at a 
loss to understand the case, never having met with anything of 
the sort before. I concluded that it must depend upon some reflex 
irritation. I opened the meatus to the full calibre of the urethra. 
The result was the spasm at the bulb and membranous urethra 
vanished as if by magic, and my patient left soon after for his 
home, cured.” 
* In an article on “ Urethral Fever,” recently published, I have noted the 
great advantage of aspiration over catheterization in relieving retention. It 
is comparatively harmless and saves the urethra, which, in this condition, is 
very liable to be injured. The avoidance of urethral fever and shock, which so 
often succeed to the passage of any instrument, are among the risks of catheter- 
ization from which aspiration provides exemption. The plan proposed by Mr. 
Cock, as communicated by Prof. Barwell, is, “ When a patient passes urine 
only in drops and no passage into the full bladder can be obtained, a fine aspi- 
rator-needle may be passed through the linea alba into the bladder—opium 
given, a couple of leeches applied to the perineum—after this a flexible catheter 
may nearly always be introduced, or if not at first successful, and the bladder 
again becomes full, the aspiration may be repeated, and then when the flexible 
catheter is introduced, and be left in for two or three days, the difficulty is over- 
come ” for the time. 7 
Prof. R. W. Pease, of the Syracuse University, in his address 
before the New York State Society, which includes a narration of 
forty-five cases treated by the Otis method, opens as follows: 
“ In 1874 a gentleman whom I had treated for stricture of the 
urethra at the membranous portion, for several months, and who, 
prior to coming under my care, had been treated by two most 
capable physicians, one a world-known surgeon, drifted away from 
me because I, like those who preceded me, had failed to give him 
any relief by the stereotyped method of treatment, the use of 
bougies. His symptoms, in brief, were a desire to frequently 
micturate flocculent urine, and a constantly recurring gleet. The 
protracted malady had sadly undermined his health, as evidenced 
by great nervous irritability, induced by his disturbed rest. For- 
tunately he came under the care of Prof. Otis, of New York. The 
diagnosis made by Prof. O. was a stricture one-half an inch from 
the meatus, and none at the membranous portion. The meatus was 
cut to 40 F., that being the capacity of his urethra, and in a few 
days he returned to Syracuse, every symptom mitigated, and in a 
few weeks all evidence of contraction of the urethra was removed, 
the urine cleared up, the nervous symptoms dissipated, and, in short, 
the patient cured.” 
In a recent number of the Lancet, Mr. Berkley Hill, of the 
University College Hospital, London, offers the case of “ J. B , 
set. 43, admitted July 11th, 1876. Had gonorrhoea at 14 and 16 
years of age. Each attack lasted twelve months. For the past 
six years he had had frequent calls to make water, with straining 
and small streams. An instrument had never been passed to the 
bladder, though three years ago ineffectual attempts had been made 
by a medical man. From December, 1875, to April, 1876, he had 
attended as out-patient at one of the London Hospitals for the 
stricture and difficulty in passing his motions (fecal). On admis- 
sion the patient complained of pain and straining in micturition 
and difficulty in defecation. The foeces were small and flat. The 
urethra measured by the urethrometer was equal to 22 F. through 
the meatus, beyond that point No. 35 F. passed easily up and 
down the penile part. In the rectum found no induration or con- 
traction of the gut, and the lower part was free from foeces, but 8 
the base of the bladder was distended. There was a dull note on 
percussing the supra-pubic and left inguinal regions. The meatus 
was incised until No. 35 French bullet sound could be passed in 
and out freely. A flexible conde-catheter was passed and more 
than a pint of urine drawn off. When the bladder was empty, a 
soft irregular mass behind it became distinct. The patient was 
ordered to remain in bed and take a sharp purge, which acted copi- 
ously. Henceforth he was much relieved, and by July 18th had 
lost his old symptoms altogether. He passed urine without strain- 
ing, and could hold it all night; his bowels acted easily ; the 
tumor of the rectum was no longer there. Patient discharged. 
On October 3 the patient called at the hospital. He was quite 
free from the troublesome straining, and otherwise well.” 
I have preferred to give these cases at length, from the practice 
of different men of unquestioned ability and integrity, to confining 
the quotations from my own observation, or from the experience 
of Prof. Otis, who, as the pioneer in this line of inquiry, might be 
accredited with partiality. From what has been said, and from the 
very much more that could have been added, I am free to confess that 
in locating strictures in the deeper parts of the urethra I believe 
that we have often incorrectly heretofore assumed the existence of 
organic contractions there in the place of urethral spasm, itself the 
product of reflex irritation at or near the end of the organ. For my 
own part, despite the criticism of Sir Henry Thompson, I feel com- 
pelled to assert my belief in the existence of genuine urethral spasm, 
sufficiently decided to entirely occlude that canal to both instruments 
and urine when no organic lesion exists. How else to explain what 
I am sure is known to every other surgeon, those cases of agonizing 
retention resulting from immoderate indulgence in alcohol, I am 
at a loss to say. To my mind the disclaimer as to “ spasmodic 
stricture ” in one breath, and the admission in another of its ex- 
istence as a consequence of some structural change, carries with it 
all that any of us claim, namely, that given an urethral irritation, 
whether it be induced by a genuine stricture, vice in eating and 
drinking, exposure to cold or what not, closure of the urethra will 
often result, and that closure is due chiefly to spasm. I claim, there- 
fore, that it has an actual existence, and is by no means always, 
though it may be sometimes, a mere “ refuge for incompetence.” 9 
The answers to ray question as to what would be the means of 
relief should serious renal disease be detected are varied, some con- 
tending for dilatation, some for divulsion, some for urethrotomy, 
some that the risks are so great as to forbid any operation, and 
others for the promptest and most thorough interference. Upon 
this point Dr. Mastin, who, up to May 26, 1877, had performed 
internal section 280 times without a death, claims that, with 
uraemic intoxication always imminent, and the necessity for provid- 
ing against any obstacle to the entire discharge of the urine, the 
“ process of gradual dilatation is too slow.” Believing, as he does, 
that the speedier the relief the better, he recommends free division, 
and that the urethra be at once restored to its normal calibre. 
“ Inasmuch as the renal disease,” says the distinguished surgeon to 
St. Peter’s Hospital, “ is secondary to the local obstruction, an 
operation would in such a case become all the more imperative.” 
In only two instances have I operated in Bright’s disease; once by 
dilatation and once by cutting. At no time have I seen better 
recoveries. As to the kidney trouble there was neither aggravation 
nor the least improvement. In case 26 of his series, Prof. Pease 
notes “ relief of diabetes,” and in case 42 disappearance of “ albu- 
men and casts ” (not defined), probably epithelial, after the cure of 
the strictures, both of which are to be classed with those of large 
calibre. By far the majority of my respondents, however, pre- 
ferred to treat stricture with renal disease, either by gradual, con- 
tinuous dilatation or divulsion, rather condemning, at the same 
time, any operative procedure, except under the clearest necessity. 
The answers which were received to the question relating to 
immunity from the sound were such as I fully expected. Nearly 
all admitted their ignorance of the practical use of any means 
which proposes to accomplish this end of cure, and it is, therefore, 
not surprising that, in their opinion, the sound could not be dis- 
pensed with for an indefinite period, if at all. Wade, of London, 
in his book on Stricture, only too correctly describes the views of 
surgeons when he says, “ After the patient is pronounced cured by 
his surgeon, lie is obliged to continue the systematic use (always 
repulsive and often hazardous) of a sound or flexible bougie for 
the rest of his life.” The utter impropriety of applying the word 10 
“cure” to such a result is manifest. He may be pronounced re- 
lieved, but certainly not cured, if he cannot lay aside his treatment 
without the fear of immediate relapse. This being the state of 
the case, we can administer but faint praise of the progress which 
surgery has attained in this, one of its most fertile fields. I 
respectfully submit, therefore, if any method well authenticated 
comes to us which proposes to do away with this “ repulsive and 
often hazardous ” incubus, is it not our duty to give it a judicial and 
dispassionate trial ? The cases reported by Otis, by Pease, and the 
remark by Mastin “ that in a majority of them (280 cases) I have 
found no recontraction,” offer us abundant encouragement to make 
the effort. While not prepared to submit my own experience in 
tabulated form at present, I can state that out of over one hun- 
dred individuals operated upon to date, only one has returned for 
treatment. Whether recontraction has taken place in any of the 
rest I am unable to say. When inquired of by me they have not 
invariably, though nearly so, spoken of themselves as well, but 
lacked sufficient scientific interest to undergo the much or little 
pain and inconvenience of re-examination, being content to let well 
enough alone. Some of these cases are old enough to come within 
the range of Mr. Foster’s remark at the Clinical Society, “ I do not 
care to see the man now, but I should much like to examine him two 
years hence.” In those cases where the great part of the urethral 
surroundings are made up of dense, thick connective tissue proli- 
ferations, especially in the perineum, completely closing the canal, 
I seriously question the ability of this or any other method to effect 
a radical cure. My own cases are too recent on this point, however, 
for me to be willing to give any opinion, and I think that in these 
cases exceptional care must be taken in pronouncing them cured. 
To the fourth question, as to how far the individual observations 
had confirmed the views of Prof. Otis as to the relation between 
the size of the urethra and the flaccid penis, the majority had no 
answer to make, for the reason that they had had no experience in 
the matter. Prof. Van Buren says that there is a germ of truth 
in the theory, but at the same time adds that the size of the flaccid 
penis is subject to such variations, in the young and old for example, 
as to make it an unsafe standard. Mr. Teevan says that Dr. Otis 
failed to “satisfy him (me) as to the rationale of his operations.” 11 
Prof. Pease gives unqualified endorsement; the title of whose 
address already referred to is “ Improved Methods of Diagnosis and 
Treatment of Strictures of the Urethra.” Dr. Mastin believes 
that the operation of Otis is “ based upon sound principles, and is 
a very great advance in genito-urinary surgery.” In a foot-note 
in the last edition of “Gross on the Urinary Organs,” it appears 
“ from a number of measurements made upon private and hospital 
cases that the editor is enabled to add additional confirmatory 
evidence of the correctness of the estimates of Dr. Otis,” though 
in his letter to me Prof. Gross condemns the practice of measuring 
the penis. As to the result of my own experience in this matter, 
covering a very large number of cases, I have not been satisfied 
that the exact relationship claimed did exist. In the vast majority 
the relative size of the urethra was rather larger than that laid 
down by Prof. Otis, and especially was this true of the negro, xlt 
my clinic at the College of Physicians and Surgeons many illus- 
trations of this fact, as applied to the urethrae of negroes, occurred. 
In a large number my measurements corresponded exactly with 
those made by Dr. O., whilst in not a single one did I find the 
capacity of the urethra less than the given size of the penis would 
call for. In consequence therefore of these differences, I have 
learned to attach less and less importance to the measurements of 
the penis and more and more to the indications of the urethrometer, 
an instrument which to my mind is of great use, and without 
which urethral surgery must be very inexact. 
In the answers to the sixth question there was an almost unani- 
mous sentiment in favor of treating close strictures of the penile 
urethra by internal section, and all the rest by gradual dilatation 
or by divulsion. Those who preferred internal urethrotomy were 
decidedly in the minority. 
In answering the second question, some curious, not to sa}T 
amusing, differences were brought out. Prof. Barwell regards 
divulsion, especially with Holt’s instrument, with great disfavor, 
whilst Prof. Bigelow prefers divulsion, and Prof. McGraw particu- 
larly, using Holt’s instrument. From what has been written, it is 
clear that the great drift is towards what is known as the treatment 
by bougies or gradual dilatation, with an exception in favor of 
internal urethrotomy when the tissue of the stricture is resilient, 12 
is in the pendulous urethra, or when it is dense as in the case of 
traumatic strictures. Whenever referred to, perineal section is 
quite generally recommended for the relief of urinary fistula de- 
pendent upon stricture. It would seem then that the old dictum 
of Mercier is still the guide, “ Dilate if you can, cut if you cannot.” 
Mr. Timothy Holmes writes: “I entertain the strongest opinion 
that the old method by gradual dilatation is in general the best 
and safest way of treating stricture, and the more so the more 
reason there is for suspecting renal disease, or other organic 
diseases of the urinary organs.” In fact, the entire English 
sentiment, as judged by my correspondence, gives the preference 
to gradual dilatation. Prof. Humphrey is equally as emphatic as 
Prof. Holmes. In France on the other hand, and to an increasing 
extent in this country, the method by urethrotomy is the most 
popular; a popularity which I think is deserved, and is founded 
upon a more rational, a more scientific basis than is the case with 
any of the others. If this be so, it may well be asked, “ how is it 
that it has been supplanted to so great an extent by the less rational 
means?” In the first place, the operation of internal section seems 
to have been considered as involving more risk to the organ and 
the life of the individual than is compensated for by any supposed 
advantage it may possess over the other milder forms of treatment. 
It, like every other treatment of a given disease, has been injured 
by special advocacy. Its friends, as usual, in endeavoring to 
establish for it too great a claim for success, and for freedom from 
danger, have been absolutely reckless in using it. Reybard, for 
example, who was a most vigorous advocate of internal urethroto- 
my, believed that its success was in proportion to the depth of the 
cut, which should extend as a rule, he said, through the entire 
thickness of the spongy substance. Prof. Gouley is my authority 
for the statement that an eye-witness at one of Reybard’s clinics, 
“saw the blade protrude through the skin.” Under such practice 
it is not surprising that much carelessness and indifference to its 
perils arose; and that many unnecessary complications, such as 
serious shock, hemorrhage, violent urethral fevers, abscess, persist- 
ing chordee, and the like were produced. It is quite needless to 
condemn such practice, and to urge the injustice of measuring the 
value of any system by its abuse. Sir Hy. Thompson says that 13 
internal urethrotomy is “ safe, efficient, certain,” and yields 
more lasting results than any other treatment — an opinion to a 
certain degree shared by Van Buren, who, in his letter to me, 
states that, “ in a general way, the more thoroughly a stricture is 
divided, the better the chance of permanent cure.” 
Inasmuch as the dangers are chiefly the result of damage done 
by too deep incisions to the perio-urethral tissues involving 
extravasations of urine and blood, it must occur to every one that 
the relative safety of the operation depends upon our ability to 
prevent these untoward accidents. This I believe to be almost 
invariably attainable by a close attention to the normal capacity of 
the particular urethra which we have to treat. The necessity for 
carefully constructed instruments has been duly appreciated, and 
in my judgment that necessity has been more fully met by Otis’ 
urethrotome and urethrometer, than any other instruments in use. 
Combined with this there must be great delicacy and skill, with 
tact in manipulation, otherwise our object will not be reached, and 
worse than all, a very valuable suggestion may fall into disrepute. 
This can only be obtained by long and careful experience. If a 
new departure is worthy of our consideration at all, it is incumbent 
upon us to use every precaution in testing its merits, so that 
failure to accomplish its promised success cannot be accredited to 
either incompetence or neglect. 
In regard to that matter of the normal calibre, and the facilities 
for determining it, we must never lose sight of those expansions 
directly behind the obstruction. If we do, we will surely insist 
upon the opening of the urethra to a larger extent than the nature 
of things would justify, and will certainly be liable to censure for 
having done too much. Under such a condition as this we have 
to use external in connection with internal measurement, to enable 
us to ascertain the proper extent of the incision necessary to 
completely and entirely divide the band of tissue which constitutes 
the coarctation. For after all this is the whole thing in a nut- 
shell, to see to it that this peculiar cicatricial tissue, so called, with 
its known tendency to contract, shall be thoroughly divided. No 
matter by what instrument we accomplish it, the important thing 
for us is to be sure that we do it. After all the known methods, 
cases have been reported in which no recontraction occurred, which 14 
perhaps is to be explained upon the ground that the entire stricture 
was separated at the time. 
Now as to the matter of danger, which is a vitally important 
point to the proper settlement of the question. This is intended 
to refer, not only to the mortality which follows, but also to what 
are entitled the “ surgical accidents.” Neither of these, of course, can 
exactly be gotten at any more completely after this than after any 
other operation, but records, which now and then are open to our 
inspection, will give us some approximate idea on the subject. In 
a recent number of the Lancet there is a report of 68 cases treated 
by internal section, at the University College Hospital, London, 
with a death of four cases, one of which, from surgical kidney and 
pyelitis, might have followed any other procedure with equal 
certainty. Among the accidents were abscesses, rigors, hemor- 
rhage, chordee, cystitis, extravasations of urine, and orchitis. 
Many of these were most probably due to too free cutting. In 
49 cases of gradual dilatation, there were 3 deaths, accompanied by 
abscesses, rigors, hemorrhage, chordee and orchitis, in less pro- 
portion than in the former. In 87 cases treated by divulsion, a 
method that cannot be condemned too severely, there were 6 
deaths with the same results as appeared after internal section, 
but more numerous, both as to relative mortality and accident. I 
have already referred to the experience of Dr. Mastin covering 280 
cases without a single death, to which 1 may be permitted to add 
my own of over 100 cases with a similar result. The most fre- 
quent accident occurring with me was urethral fever. Abscess 
occurred but once, hemorrhage of a. serious character but four 
times, one of these cases being a confirmed and broken-down 
alcoholist who died some months after with spinal sclerosis, 
retention of urine in 2 cases, and chordee in about one dozen cases, 
with a promise of permanency in one. None of the other 
accidents referred to above have occurred with me. For the 
purpose of showing the extent of the injury inflicted in one of the 
cases where abscesses occurred, I might append brief notes of a 
case, but a want of time forbids. As a result of careful and more 
recent observation, I feel justified in saying that this extensive 
suppuration would most probably not have occurred if external 
incisions had been made in the perineum so soon as those signifi- 15 
cant swellings which indicate free internal bleeding were seen. 
The necessity for such a course is evident, and the dangers of such 
incisions, which should be on either side of the raph& and suffi- 
ciently deep and long to provide a free escape for the infiltrated 
blood, are so trifling as not to be considered. In the vast majority 
of my cases absorption of the blood has taken place readily, but 
this applies to a moderate effusion. When this is considerable such 
a happy issue is unlikely, and if we do not let it out early, nature 
will select a means of her own, generally speaking suppuration. 
The damage which this suppuration can inflict, when the pus con- 
tained within those compact perineal tissues begins to make for 
itself an outlet, is very great. 
In further comment upon the dangers of internal section, Prof. 
Otis, in an article belonging to the Seguin Series, entitled 
“ Stricture of the Male Urethra—its Radical Cure,” reports 100 
cases without a single death, “ hemorrhage in four cases,” pros- 
tatic abscess in three cases, curvatures of penis during erection in 
three cases, persisting in one, urethritis in two cases, diphtheritic 
deposit at wound in three cases, urethral fever in seven cases, re- 
tention in one. In conversation with this surgeon some months 
ago, at least two years after the above publication, he informed me 
that he had not yet had a death. In the forcible address by Prof. 
Pease already referred to, and which I commend to your perusal 
as one of the fairest expositions of the subject I have read, he notes 
“a remarkable immunity from accidents.” His 45 cases yield one 
case of urethral fever and two of severe hemorrhage. 
In further proof of the little risk of this operation when 
performed with due care, I extract the following from an address 
delivered before the Section of Surgery, at the annual meeting of 
the British Medical Association, in Manchester, in August 1877, 
by Mr. Teevan, himself a strong advocate for treatment by gradual 
dilatation, and who still quotes approvingly the doctrine of Mercier; 
“Now for statistics. I think they will be found to be eminently sat- 
isfactory, and will carry conviction. They are the largest, I believe, 
which have ever been placed before the profession, and show what 
internal urethrotomy can accomplish. No other operation for 
stricture with which I am acquainted,” he says, “ can produce such 
favorable results. I consider that no operation can be performed 16 
on the urethra without a certain amount of risk, but how slight 
that risk is you will immediately see. I find that the operation 
has been performed by six surgeons in London, Paris, Mobile and 
New York, one thousand and ninty-five times with but ten deaths,” 
and he adds in conclusion, “ there would probably have been two 
deaths less had it not been for the crowded state of the wards in 
the Necker Hospital during the Commune.” 
We cannot resist the conclusion in the face of such testimony as 
has been presented, that internal urethrotomy is the safest and the 
most intelligent way of relieving the obstruction, fraught chiefly 
with those dangers which have been imposed by partisanship on 
the one hand, and prejudice or unwillingness to disestablish an 
old practice on the other. As to the liability of the longitudinal 
slit—the cicatricial splice of the Americans, the “ piece d’allonge- 
ment” of the French—to contract and become an element of com- 
plication, I can invoke the experience of lithotomists to disprove. 
It seems to me, moreover, that the treatment by splitting, or by 
divulsion as accomplished by Holt’s instrument, involving as it. 
does lacerations of the urethra as well as the stricture; engenders 
a condition as bad as, if not worse than, the disease which it seeks 
to remedy. 
As to the question, all-absorbing with some, of the propriety of 
employing the “ sonde a deineure.” It is my almost invariable 
habit to reject it. The reasons for its use must be urgent to 
induce me to incur those grave consequences from its presence, of 
“ inflammation and ulceration ” of the mucous membrane for the 
sake of preventing consecutive hemorrhage. As to the matter of 
the retained catheter insuring against the flow of urine (only dan- 
gerous when ammoniacal and extravasated into the cellular tissue) 
over the recently cut surface, it needs no discussion. No matter 
how snugly the instrument may fit the urethra at the time of the 
operation, we may rest assured that in a few days, and some- 
times hours, the urethra will so expand as to admit the passage of 
urine outside the catheter. This soon becomes charged with 
calcareous incrustations, and secures the presence of a foreign body 
in the urethra of a very irritating character. I am not unaware 
of the claim that there are certain gum instruments to which this 
exception cannot be taken.